Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 1 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0001A NOCOV DEF SYSMAN Description: ADM SARSCOV2 30MCG/0.3ML 1ST Category: Non Covered Services CMS Add: 12/11/2020 CMS Term: 10/31/2023 0001F NOCOV DEF SYSMAN Description: HEART FAILURE COMPOSITE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 0001U NOCOV DEF SYSMAN Description: RBC DNA HEA 35 AG 11 BLD GRP Category: Non Covered Services CMS Add: 02/01/2017 CMS Term: 0002A NOCOV DEF SYSMAN Description: ADM SARSCOV2 30MCG/0.3ML 2ND Category: Non Covered Services CMS Add: 12/11/2020 CMS Term: 10/31/2023 0002M NOCOV DEF SYSMAN Description: LIVER DIS 10 ASSAYS W/ASH Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0002U NOCOV DEF SYSMAN Description: ONC CLRCT 3 UR METAB ALG PLP Category: Non Covered Services CMS Add: 02/01/2017 CMS Term: 0003A NOCOV DEF SYSMAN Description: ADM SARSCOV2 30MCG/0.3ML 3RD Category: Non Covered Services CMS Add: 08/12/2021 CMS Term: 10/31/2023 0003M NOCOV DEF SYSMAN Description: LIVER DIS 10 ASSAYS W/NASH Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0003U NOCOV DEF SYSMAN Description: ONC OVAR 5 PRTN SER ALG SCOR Category: Non Covered Services CMS Add: 02/01/2017 CMS Term: 0004A NOCOV DEF SYSMAN Description: ADM SARSCOV2 30MCG/0.3ML BST Category: Non Covered Services CMS Add: 09/22/2021 CMS Term: 10/31/2023 0004M NOCOV DEF SYSMAN Description: SCOLIOSIS DNA ALYS Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0005F NOCOV DEF SYSMAN Description: OSTEOARTHRITIS COMPOSITE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 0005U NOCOV DEF SYSMAN Description: ONCO PRST8 3 GENE UR ALG Category: Non Covered Services CMS Add: 05/01/2017 CMS Term: 0006M NOCOV DEF SYSMAN Description: ONC HEP GENE RISK CLASSIFIER Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0007M NOCOV DEF SYSMAN Description: ONC GASTRO 51 GENE NOMOGRAM Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0007U NOCOV DEF SYSMAN Description: RX TEST PRSMV UR W/DEF CONF Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 2 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0008M NOCOV DEF SYSMAN Description: ONC BREAST RISK SCORE Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 12/31/2017 0008U NOCOV DEF SYSMAN Description: HPYLORI DETCJ ABX RSTNC DNA Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 0009U NOCOV DEF SYSMAN Description: ONC BRST CA ERBB2 AMP/NONAMP Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 00100 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SALIVARY GLAND Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00102 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH REPAIR OF CLEFT LIP Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00103 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BLEPHAROPLASTY Category: Anesthesia CMS Add: 01/01/1994 CMS Term: 00104 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH ELECTROSHOCK Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0010U NOCOV DEF SYSMAN Description: NFCT DS STRN TYP WHL GEN SEQ Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 0011A NOCOV DEF SYSMAN Description: ADM SARSCOV2 100MCG/0.5ML1ST Category: Non Covered Services CMS Add: 12/18/2020 CMS Term: 10/31/2023 0011M NOCOV DEF SYSMAN Description: ONC PRST8 CA MRNA 12 GEN ALG Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0011U NOCOV DEF SYSMAN Description: RX MNTR LC-MS/MS ORAL FLUID Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 00120 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH EAR SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00124 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH EAR EXAM Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00126 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH TYMPANOTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0012A NOCOV DEF SYSMAN Description: ADM SARSCOV2 100MCG/0.5ML2ND Category: Non Covered Services CMS Add: 12/18/2020 CMS Term: 10/31/2023 0012F NOCOV DEF SYSMAN Description: CAP BACTERIAL ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 3 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0012M NOCOV DEF SYSMAN Description: ONC MRNA 5 GEN RSK URTHL CA Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0013A NOCOV DEF SYSMAN Description: ADM SARSCOV2 100MCG/0.5ML3RD Category: Non Covered Services CMS Add: 08/12/2021 CMS Term: 10/31/2023 0013M NOCOV DEF SYSMAN Description: ONC MRNA 5 GEN RECR URTHL CA Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 00140 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH PROCEDURES ON EYE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00142 ANEST DEF ANESTH 02/01/2015 0.00 4.0 Description: ANESTH LENS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00144 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH CORNEAL TRANSPLANT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00145 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH VITREORETINAL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00147 ANEST DEF ANESTH 02/01/2015 0.00 4.0 Description: ANESTH IRIDECTOMY Category: Anesthesia CMS Add: 01/01/1991 CMS Term: 00148 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH EYE EXAM Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0014F NOCOV DEF SYSMAN Description: COMP PREOP ASSESS CAT SURG Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0014M NOCOV DEF SYSMAN Description: LIVER DS ALYS 3 BMRK SRM ALG Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 0015F NOCOV DEF SYSMAN Description: MELAN FOLLOW-UP COMPLETE Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0015M NOCOV DEF SYSMAN Description: ADRNL CORTCL TUM BCHM ASY 25 Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 00160 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH NOSE/SINUS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00162 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH NOSE/SINUS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00164 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH BIOPSY OF NOSE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 4 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0016M NOCOV DEF SYSMAN Description: ONC BLADDER MRNA 219 GEN ALG Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0016U NOCOV DEF SYSMAN Description: ONC HMTLMF NEO RNA BCR/ABL1 Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 00170 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH PROCEDURE ON MOUTH Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00172 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH CLEFT PALATE REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00174 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH PHARYNGEAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00176 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH PHARYNGEAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0017M NOCOV DEF SYSMAN Description: ONC DLBCL MRNA 20 GENES ALG Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0017U NOCOV DEF SYSMAN Description: ONC HMTLMF NEO JAK2 MUT DNA Category: Non Covered Services CMS Add: 08/01/2017 CMS Term: 0018M NOCOV DEF SYSMAN Description: TRNSPLJ RNL MEAS CD154+CLL Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0018U NOCOV DEF SYSMAN Description: ONC THYR 10 MICRORNA SEQ ALG Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 00190 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH FACE/SKULL BONE SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00192 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH FACIAL BONE SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0019U NOCOV DEF SYSMAN Description: ONC RNA TISS PREDICT ALG Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 00210 ANEST DEF ANESTH 01/01/1900 0.00 11.0 Description: ANESTH CRANIAL SURG NOS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00211 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH CRAN SURG HEMOTOMA Category: Anesthesia CMS Add: 01/01/2009 CMS Term: 00212 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SKULL DRAINAGE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 5 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00214 ANEST DEF ANESTH 01/01/1900 0.00 9.0 Description: ANESTH SKULL DRAINAGE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00215 ANEST DEF ANESTH 01/01/1900 0.00 9.0 Description: ANESTH SKULL REPAIR/FRACT Category: Anesthesia CMS Add: 01/01/1994 CMS Term: 00216 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH HEAD VESSEL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00218 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANESTH SPECIAL HEAD SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0021A NOCOV DEF SYSMAN Description: FEE COVID-19 VAC 3 DOSE 1 Category: Non Covered Services CMS Add: 12/17/2020 CMS Term: 10/31/2023 0021U NOCOV DEF SYSMAN Description: ONC PRST8 DETCJ 8 AUTOANTB Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 00220 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH INTRCRN NERVE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00222 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH HEAD NERVE SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0022A NOCOV DEF SYSMAN Description: FEE COVID-19 VAC 3 DOSE 2 Category: Non Covered Services CMS Add: 12/17/2020 CMS Term: 10/31/2023 0022U NOCOV DEF SYSMAN Description: TGSAP NSM LUNG NEO DNA&RNA23 Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 0023U NOCOV DEF SYSMAN Description: ONC AML DNA DETCJ/NONDETCJ Category: Non Covered Services CMS Add: 10/01/2017 CMS Term: 0024T NOCOV DEF SYSMAN Description: TRANSCATH CARDIAC REDUCTION Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 12/31/2007 0024U NOCOV DEF SYSMAN Description: GLYCA NUC MR SPECTRSC QUAN Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0025U NOCOV DEF SYSMAN Description: TENOFOVIR LIQ CHROM UR QUAN Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0026U LAB L60 MAXFEE 01/20/2023 3600.00 0.0 Y Description: ONC THYR DNA&MRNA 112 GENES Category: Laboratory CMS Add: 01/01/2018 CMS Term: 0027U NOCOV DEF SYSMAN Description: JAK2 GENE TRGT SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 6 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0029U NOCOV DEF SYSMAN Description: RX METAB ADVRS TRGT SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 00300 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH HEAD/NECK/PTRUNK Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0030U NOCOV DEF SYSMAN Description: RX METAB WARF TRGT SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0031A NOCOV DEF SYSMAN Description: ADM SARSCOV2 VAC AD26 .5ML Category: Non Covered Services CMS Add: 02/27/2021 CMS Term: 10/31/2023 0031U NOCOV DEF SYSMAN Description: CYP1A2 GENE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 00320 ANEST DEF ANESTH 01/01/1900 0.00 6.0 1-999years s Description: ANESTH NECK ORGAN 1YR/> Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00322 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH BIOPSY OF THYROID Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00326 ANEST DEF ANESTH 02/01/2015 0.00 7.0 0-364days Description: ANESTH LARYNX/TRACH < 1 YR Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 0032U NOCOV DEF SYSMAN Description: COMT GENE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0033U NOCOV DEF SYSMAN Description: HTR2A HTR2C GENES Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0034A NOCOV DEF SYSMAN Description: ADM SARSCOV2 VAC AD26 .5ML B Category: Non Covered Services CMS Add: 10/20/2021 CMS Term: 10/31/2023 0034U NOCOV DEF SYSMAN Description: TPMT NUDT15 GENES Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 00350 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH NECK VESSEL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00352 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH NECK VESSEL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0035U NOCOV DEF SYSMAN Description: NEURO CSF PRION PRTN QUAL Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0036U NOCOV DEF SYSMAN Description: XOME TUM & NML SPEC SEQ ALYS Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 7 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0037U NOCOV DEF SYSMAN Description: TRGT GEN SEQ DNA 324 GENES Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0038U NOCOV DEF SYSMAN Description: VITAMIN D SRM MICROSAMP QUAN Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0039U NOCOV DEF SYSMAN Description: DNA ANTB 2STRAND HI AVIDITY Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 00400 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH SKIN EXT/PER/ATRUNK Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00402 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SURGERY OF BREAST Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00404 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SURGERY OF BREAST Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00406 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANESTH SURGERY OF BREAST Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0040U NOCOV DEF SYSMAN Description: BCR/ABL1 GENE MAJOR BP QUAN Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 00410 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH CORRECT HEART RHYTHM Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0041A DDWA DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 1ST Category: CIH Waiver CMS Add: 07/13/2022 CMS Term: 10/31/2023 0041A DDWA DEF MAXFEE 07/13/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 1ST Category: CIH Waiver CMS Add: 07/13/2022 CMS Term: 10/31/2023 0041A MEDSV DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 1ST Category: Medical Services CMS Add: 07/13/2022 CMS Term: 10/31/2023 0041A MEDSV DEF MAXFEE 07/13/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 1ST Category: Medical Services CMS Add: 07/13/2022 CMS Term: 10/31/2023 0041A SSFS DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 1ST Category: Family Support Waivr CMS Add: 07/13/2022 CMS Term: 10/31/2023 0041A SSFS DEF MAXFEE 07/13/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 1ST Category: Family Support Waivr CMS Add: 07/13/2022 CMS Term: 10/31/2023 0041A TRANS DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 1ST Category: Transportation CMS Add: 07/13/2022 CMS Term: 10/31/2023 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 8 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0041A TRANS DEF MAXFEE 07/13/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 1ST Category: Transportation CMS Add: 07/13/2022 CMS Term: 10/31/2023 0041U NOCOV DEF SYSMAN Description: B BRGDRFERI ANTB 5 PRTN IGM Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0042A DDWA DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 2ND Category: CIH Waiver CMS Add: 07/13/2022 CMS Term: 10/31/2023 0042A DDWA DEF MAXFEE 07/13/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 2ND Category: CIH Waiver CMS Add: 07/13/2022 CMS Term: 10/31/2023 0042A MEDSV DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 2ND Category: Medical Services CMS Add: 07/13/2022 CMS Term: 10/31/2023 0042A MEDSV DEF MAXFEE 07/13/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 2ND Category: Medical Services CMS Add: 07/13/2022 CMS Term: 10/31/2023 0042A SSFS DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 2ND Category: Family Support Waivr CMS Add: 07/13/2022 CMS Term: 10/31/2023 0042A SSFS DEF MAXFEE 07/13/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 2ND Category: Family Support Waivr CMS Add: 07/13/2022 CMS Term: 10/31/2023 0042A TRANS DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 2ND Category: Transportation CMS Add: 07/13/2022 CMS Term: 10/31/2023 0042A TRANS DEF MAXFEE 07/13/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCOV2 5MCG/0.5ML 2ND Category: Transportation CMS Add: 07/13/2022 CMS Term: 10/31/2023 0042T MEDSV DEF BILL90 Y Description: CT PERFUSION W/CONTRAST CBF Category: Medical Services CMS Add: 01/01/2003 CMS Term: 0042U NOCOV DEF SYSMAN Description: B BRGDRFERI ANTB 12 PRTN IGG Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0043U NOCOV DEF SYSMAN Description: TBRF B GRP ANTB 4 PRTN IGM Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 0044A DDWA DEF MAXFEE 01/01/2023 38.95 0.0 18-999years rs Description: ADM SARSCOV2 5MCG/0.5ML BST Category: CIH Waiver CMS Add: 10/19/2022 CMS Term: 10/31/2023 0044A DDWA DEF MAXFEE 10/19/2022 12/31/2022 36.90 0.0 18-999years rs Description: ADM SARSCOV2 5MCG/0.5ML BST Category: CIH Waiver CMS Add: 10/19/2022 CMS Term: 10/31/2023 0044A MEDSV DEF MAXFEE 01/01/2023 38.95 0.0 18-999years rs Description: ADM SARSCOV2 5MCG/0.5ML BST Category: Medical Services CMS Add: 10/19/2022 CMS Term: 10/31/2023 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 9 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0044A MEDSV DEF MAXFEE 10/19/2022 12/31/2022 36.90 0.0 18-999years rs Description: ADM SARSCOV2 5MCG/0.5ML BST Category: Medical Services CMS Add: 10/19/2022 CMS Term: 10/31/2023 0044A SSFS DEF MAXFEE 01/01/2023 38.95 0.0 18-999years rs Description: ADM SARSCOV2 5MCG/0.5ML BST Category: Family Support Waivr CMS Add: 10/19/2022 CMS Term: 10/31/2023 0044A SSFS DEF MAXFEE 10/19/2022 12/31/2022 36.90 0.0 18-999years rs Description: ADM SARSCOV2 5MCG/0.5ML BST Category: Family Support Waivr CMS Add: 10/19/2022 CMS Term: 10/31/2023 0044A TRANS DEF MAXFEE 01/01/2023 38.95 0.0 18-999years rs Description: ADM SARSCOV2 5MCG/0.5ML BST Category: Transportation CMS Add: 10/19/2022 CMS Term: 10/31/2023 0044A TRANS DEF MAXFEE 10/19/2022 12/31/2022 36.90 0.0 18-999years rs Description: ADM SARSCOV2 5MCG/0.5ML BST Category: Transportation CMS Add: 10/19/2022 CMS Term: 10/31/2023 0044U NOCOV DEF SYSMAN Description: TBRF B GRP ANTB 4 PRTN IGG Category: Non Covered Services CMS Add: 04/01/2018 CMS Term: 00450 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SURGERY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00454 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH COLLAR BONE BIOPSY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0045U NOCOV DEF SYSMAN Description: ONC BRST DUX CARC IS 12 GENE Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0046U NOCOV DEF SYSMAN Description: FLT3 GENE ITD VARIANTS QUAN Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00470 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH REMOVAL OF RIB Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00472 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH CHEST WALL REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00474 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANESTH SURGERY OF RIB Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0047U NOCOV DEF SYSMAN Description: ONC PRST8 MRNA 17 GENE ALG Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0048U NOCOV DEF SYSMAN Description: ONC SLD ORG NEO DNA 468 GENE Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0049U NOCOV DEF SYSMAN Description: NPM1 GENE ANALYSIS QUAN Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 10 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00500 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH ESOPHAGEAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0050U NOCOV DEF SYSMAN Description: TRGT GEN SEQ DNA 194 GENES Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0051A NOCOV DEF SYSMAN Description: ADM SARSCV2 30MCG TRS-SUCR 1 Category: Non Covered Services CMS Add: 01/03/2022 CMS Term: 10/31/2023 0051U NOCOV DEF SYSMAN Description: RX MNTR LC-MS/MS UR/BLD 31 Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00520 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH CHEST PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00522 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH CHEST LINING BIOPSY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00524 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH CHEST DRAINAGE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00528 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANES MEDIASCPY & DX THORSCPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00529 ANEST DEF ANESTH 01/01/1900 0.00 11.0 Description: ANES MEDSCPY&THORSCPY 1 LUNG Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 0052A NOCOV DEF SYSMAN Description: ADM SARSCV2 30MCG TRS-SUCR 2 Category: Non Covered Services CMS Add: 01/03/2022 CMS Term: 10/31/2023 0052U NOCOV DEF SYSMAN Description: LPOPRTN BLD W/5 MAJ CLASSES Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00530 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH PACEMAKER INSERTION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00532 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH VASCULAR ACCESS Category: Anesthesia CMS Add: 01/01/1992 CMS Term: 00534 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH CARDIOVERTER/DEFIB Category: Anesthesia CMS Add: 01/01/1993 CMS Term: 00537 ANEST DEF ANESTH 02/01/2015 0.00 7.0 Description: ANESTH CARDIAC ELECTROPHYS Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 00539 ANEST DEF ANESTH 01/01/1900 0.00 18.0 Description: ANESTH TRACH-BRONCH RECONST Category: Anesthesia CMS Add: 01/01/2003 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 11 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0053A NOCOV DEF SYSMAN Description: ADM SARSCV2 30MCG TRS-SUCR 3 Category: Non Covered Services CMS Add: 01/03/2022 CMS Term: 10/31/2023 00540 ANEST DEF ANESTH 02/01/2015 0.00 12.0 Description: ANESTH CHEST SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00541 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH ONE LUNG VENTILATION Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 00542 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTHESIA REMOVAL PLEURA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00546 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH LUNG CHEST WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00548 ANEST DEF ANESTH 01/01/1900 0.00 17.0 Description: ANESTH TRACHEA BRONCHI SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0054A NOCOV DEF SYSMAN Description: ADM SARSCV2 30MCG TRS-SUCR B Category: Non Covered Services CMS Add: 01/03/2022 CMS Term: 10/31/2023 0054T NOCOV DEF SYSMAN Description: BONE SRGRY CMPTR FLUOR IMAGE Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 0054U NOCOV DEF SYSMAN Description: RX MNTR 14+ DRUGS & SBSTS Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00550 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH STERNAL DEBRIDEMENT Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 0055T NOCOV DEF SYSMAN Description: BONE SRGRY CMPTR CT/MRI IMAG Category: Non Covered Services CMS Add: 01/01/2004 CMS Term: 0055U NOCOV DEF SYSMAN Description: CARD HRT TRNSPL 96 DNA SEQ Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00560 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH HEART SURG W/O PUMP Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00561 ANEST DEF ANESTH 01/01/1900 0.00 25.0 0-364days Description: ANESTH HEART SURG <1 YR Category: Anesthesia CMS Add: 01/01/2005 CMS Term: 00562 ANEST DEF ANESTH 01/01/1900 0.00 20.0 1-999years s Description: ANESTH HRT SURG W/PMP AGE 1+ Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00563 ANEST DEF ANESTH 01/01/1900 0.00 25.0 Description: ANESTH HEART SURG W/ARREST Category: Anesthesia CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 12 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00566 ANEST DEF ANESTH 01/01/1900 0.00 25.0 Description: ANESTH CABG W/O PUMP Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 00567 ANEST DEF ANESTH 01/01/1900 0.00 18.0 Description: ANESTH CABG W/PUMP Category: Anesthesia CMS Add: 01/01/2009 CMS Term: 00580 ANEST DEF ANESTH 01/01/1900 0.00 20.0 Description: ANESTH HEART/LUNG TRANSPLNT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0058U NOCOV DEF SYSMAN Description: ONC MERKEL CLL CARC SRM QUAN Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0059U NOCOV DEF SYSMAN Description: ONC MERKEL CLL CARC SRM +/- Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00600 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH SPINE CORD SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00604 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANESTH SITTING PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0060U NOCOV DEF SYSMAN Description: TWN ZYG GEN SEQ ALYS CHRMS2 Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0061U NOCOV DEF SYSMAN Description: TC MEAS 5 BMRK SFDI M-S ALYS Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 00620 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH SPINE CORD SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00625 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANES SPINE TRANTHOR W/O VENT Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 00626 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANES SPINE TRANSTHOR W/VENT Category: Anesthesia CMS Add: 01/01/2007 CMS Term: 0062U NOCOV DEF SYSMAN Description: AI SLE IGG&IGM ALYS 80 BMRK Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00630 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH SPINE CORD SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00632 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH REMOVAL OF NERVES Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00635 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH LUMBAR PUNCTURE Category: Anesthesia CMS Add: 01/01/2001 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 13 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0063U NOCOV DEF SYSMAN Description: NEURO AUTISM 32 AMINES ALG Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00640 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH SPINE MANIPULATION Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 0064A NOCOV DEF SYSMAN Description: ADM SARSCOV2 50MCG/0.25MLBST Category: Non Covered Services CMS Add: 10/20/2021 CMS Term: 10/31/2023 0064U NOCOV DEF SYSMAN Description: ANTB TP TOTAL&RPR IA QUAL Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0065U NOCOV DEF SYSMAN Description: SYFLS TST NONTREPONEMAL ANTB Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00670 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANESTH SPINE CORD SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0067U NOCOV DEF SYSMAN Description: ONC BRST IMHCHEM PRFL 4 BMRK Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0068U NOCOV DEF SYSMAN Description: CANDIDA SPECIES PNL AMP PRB Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0069U NOCOV DEF SYSMAN Description: ONC CLRCT MICRORNA MIR-31-3P Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00700 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH ABDOMINAL WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00702 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH FOR LIVER BIOPSY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0070U NOCOV DEF SYSMAN Description: CYP2D6 GEN COM&SLCT RAR VRNT Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0071A NOCOV DEF SYSMAN Description: ADM SARSCV2 10MCG TRS-SUCR 1 Category: Non Covered Services CMS Add: 10/29/2021 CMS Term: 10/31/2023 0071T MEDSV DEF MAXFEE 01/01/2005 471.16 0.0 Description: US LEIOMYOMATA ABLATE <200 Category: Medical Services CMS Add: 01/01/2005 CMS Term: 0071U NOCOV DEF SYSMAN Description: CYP2D6 FULL GENE SEQUENCE Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0072A NOCOV DEF SYSMAN Description: ADM SARSCV2 10MCG TRS-SUCR 2 Category: Non Covered Services CMS Add: 10/29/2021 CMS Term: 10/31/2023 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 14 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0072T MEDSV DEF MAXFEE 01/01/2005 471.16 0.0 Y Description: US LEIOMYOMATA ABLATE >200 Category: Medical Services CMS Add: 01/01/2005 CMS Term: 0072U NOCOV DEF SYSMAN Description: CYP2D6 GEN CYP2D6-2D7 HYBRID Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00730 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH ABDOMINAL WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00731 ANEST DEF ANESTH 01/01/2018 0.00 5.0 Description: ANES UPR GI NDSC PX NOS Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 00732 ANEST DEF ANESTH 01/01/2018 0.00 6.0 Description: ANES UPR GI NDSC PX ERCP Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 0073A NOCOV DEF SYSMAN Description: ADM SARSCV2 10MCG TRS-SUCR 3 Category: Non Covered Services CMS Add: 01/03/2022 CMS Term: 10/31/2023 0073U NOCOV DEF SYSMAN Description: CYP2D6 GEN CYP2D7-2D6 HYBRID Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0074A NOCOV DEF SYSMAN Description: ADM SARSCV2 10MCG TRS-SUCR B Category: Non Covered Services CMS Add: 05/17/2022 CMS Term: 10/31/2023 0074U NOCOV DEF SYSMAN Description: CYP2D6 NONDUPLICATED GENE Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00750 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH REPAIR OF HERNIA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00752 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH REPAIR OF HERNIA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00754 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH REPAIR OF HERNIA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00756 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH REPAIR OF HERNIA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0075T NOCOV DEF SYSMAN Description: PERQ STENT/CHEST VERT ART Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0075U NOCOV DEF SYSMAN Description: CYP2D6 5' GENE DUP/MLT Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0076T NOCOV DEF SYSMAN Description: S&I STENT/CHEST VERT ART Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 15 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0076U NOCOV DEF SYSMAN Description: CYP2D6 3' GENE DUP/MLT Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00770 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH BLOOD VESSEL REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0077U NOCOV DEF SYSMAN Description: IG PARAPROTEIN QUAL BLD/UR Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 0078U NOCOV DEF SYSMAN Description: PAIN MGT OPI USE GNOTYP PNL Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00790 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH SURG UPPER ABDOMEN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00792 ANEST DEF ANESTH 01/01/1900 0.00 13.0 Description: ANESTH HEMORR/EXCISE LIVER Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00794 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH PANCREAS REMOVAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00796 ANEST DEF ANESTH 01/01/1900 0.00 30.0 Description: ANESTH FOR LIVER TRANSPLANT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00797 ANEST DEF ANESTH 02/01/2015 0.00 11.0 Description: ANESTH SURGERY FOR OBESITY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 0079U NOCOV DEF SYSMAN Description: CMPRTV DNA ALYS MLT SNPS Category: Non Covered Services CMS Add: 10/01/2018 CMS Term: 00800 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH ABDOMINAL WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00802 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH FAT LAYER REMOVAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0080U NOCOV DEF SYSMAN Description: ONC LNG 5 CLIN RSK FACTR ALG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 00811 ANEST DEF ANESTH 01/01/2018 0.00 4.0 Description: ANES LWR INTST NDSC NOS Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 00812 ANEST DEF ANESTH 01/01/2018 0.00 3.0 Description: ANES LWR INTST SCR COLSC Category: Anesthesia CMS Add: 01/01/2018 CMS Term: 00813 ANEST DEF ANESTH 01/01/2018 0.00 5.0 Description: ANES UPR LWR GI NDSC PX Category: Anesthesia CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 16 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0081A NOCOV DEF SYSMAN Description: ADM SARSCV2 3MCG TRS-SUCR 1 Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 00820 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH ABDOMINAL WALL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0082A NOCOV DEF SYSMAN Description: ADM SARSCV2 3MCG TRS-SUCR 2 Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0082U NOCOV DEF SYSMAN Description: RX TEST DEF 90+ RX/SBSTS UR Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 00830 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH REPAIR OF HERNIA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00832 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH REPAIR OF HERNIA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00834 ANEST DEF ANESTH 01/01/1900 0.00 5.0 0-364days Description: ANESTH HERNIA REPAIR < 1 YR Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 00836 ANEST DEF ANESTH 01/01/1900 0.00 6.0 0-6months Description: ANESTH HERNIA REPAIR PREEMIE Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 0083A NOCOV DEF SYSMAN Description: ADM SARSCV2 3MCG TRS-SUCR 3 Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0083U NOCOV DEF SYSMAN Description: ONC RSPSE CHEMO CNTRST TOMOG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 00840 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH SURG LOWER ABDOMEN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00842 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH AMNIOCENTESIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00844 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH PELVIS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00846 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Y Description: ANESTH HYSTERECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00848 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH PELVIC ORGAN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0084U NOCOV DEF SYSMAN Description: RBC DNA GNOTYP 10 BLD GROUPS Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 17 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00851 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Y Description: ANESTH TUBAL LIGATION Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 00860 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH SURGERY OF ABDOMEN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00862 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH KIDNEY/URETER SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00864 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH REMOVAL OF BLADDER Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00865 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH REMOVAL OF PROSTATE Category: Anesthesia CMS Add: 01/01/1996 CMS Term: 00866 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH REMOVAL OF ADRENAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00868 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH KIDNEY TRANSPLANT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00869 NOCOV DEF SYSMAN Description: ANESTH, VASECTOMY Category: Non Covered Services CMS Add: 01/01/2002 CMS Term: 12/31/2002 0086U NOCOV DEF SYSMAN Description: NFCT DS BACT&FNG ORG ID 6+ Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00870 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BLADDER STONE SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00872 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH KIDNEY STONE DESTRUCT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00873 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH KIDNEY STONE DESTRUCT Category: Anesthesia CMS Add: 01/01/1991 CMS Term: 0087U NOCOV DEF SYSMAN Description: CRD HRT TRNSPL MRNA 1283 GEN Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00880 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH ABDOMEN VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00882 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH MAJOR VEIN LIGATION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0088U NOCOV DEF SYSMAN Description: TRNSPLJ KDN ALGRFT REJ 1494 Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 18 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0089U NOCOV DEF SYSMAN Description: ONC MLNMA PRAME & LINC00518 Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00902 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH ANORECTAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00904 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH PERINEAL SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00906 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH REMOVAL OF VULVA Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00908 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH REMOVAL OF PROSTATE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0090U NOCOV DEF SYSMAN Description: ONC CUTAN MLNMA MRNA 23 GENE Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00910 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH BLADDER SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00912 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BLADDER TUMOR SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00914 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH REMOVAL OF PROSTATE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00916 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BLEEDING CONTROL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00918 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH STONE REMOVAL Category: Anesthesia CMS Add: 01/01/1990 CMS Term: 0091A NOCOV DEF SYSMAN Description: ADM SARSCOV2 50 MCG/.5 ML1ST Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0091U NOCOV DEF SYSMAN Description: ONC CLRCT SCR WHL BLD ALG Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00920 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH GENITALIA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00921 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Y Description: ANESTH VASECTOMY Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 00922 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH SPERM DUCT SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 19 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 00924 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH TESTIS EXPLORATION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00926 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH REMOVAL OF TESTIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00928 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH REMOVAL OF TESTIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0092A NOCOV DEF SYSMAN Description: ADM SARSCOV2 50 MCG/.5 ML2ND Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0092U NOCOV DEF SYSMAN Description: ONC LNG 3 PRTN BMRK PLSM ALG Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00930 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH TESTIS SUSPENSION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00932 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH AMPUTATION OF PENIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00934 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH PENIS NODES REMOVAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00936 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH PENIS NODES REMOVAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00938 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH INSERT PENIS DEVICE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0093A NOCOV DEF SYSMAN Description: ADM SARSCOV2 50 MCG/.5 ML3RD Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0093U NOCOV DEF SYSMAN Description: RX MNTR 65 COM DRUGS URINE Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00940 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH VAGINAL PROCEDURES Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00942 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH SURG ON VAG/URETHRAL Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00944 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Y Description: ANESTH VAGINAL HYSTERECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00948 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH REPAIR OF CERVIX Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 20 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0094A NOCOV DEF SYSMAN Description: ADM SARSCOV2 50 MCG/.5 MLBST Category: Non Covered Services CMS Add: 03/29/2022 CMS Term: 10/31/2023 0094U NOCOV DEF SYSMAN Description: GENOME RAPID SEQUENCE ALYS Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 00950 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH VAGINAL ENDOSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 00952 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH HYSTEROSCOPE/GRAPH Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0095T NOCOV DEF SYSMAN Description: RMVL ARTIFIC DISC ADDL CRVCL Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0095U NOCOV DEF SYSMAN Description: EE&MJ BSC PRTN ELISA EST DEV Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0096U NOCOV DEF SYSMAN Description: HPV HI RISK TYPES MALE URINE Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0098T NOCOV DEF SYSMAN Description: REV ARTIFIC DISC ADDL Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0100T NOCOV DEF SYSMAN Description: PROSTH RETINA RECEIVE&GEN Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0101T NOCOV DEF SYSMAN Description: ESW MUSCSKEL SYS NOS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0101U NOCOV DEF SYSMAN Description: HERED COLON CA DO 15 GENES Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0102T NOCOV DEF SYSMAN Description: ESW PHY ANES LAT HMRL EPCNDL Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0102U NOCOV DEF SYSMAN Description: HERED BRST CA RLTD DO 17 GEN Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0103U NOCOV DEF SYSMAN Description: HERED OVA CA PNL 24 GENES Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0104A NOCOV DEF SYSMAN Description: FEE COVID-19 VAC 11 RES Category: Non Covered Services CMS Add: 04/26/2022 CMS Term: 10/31/2023 0105U NOCOV DEF SYSMAN Description: NEPH CKD MULT ECLIA TUM NEC Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 21 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0106T NOCOV DEF SYSMAN Description: TOUCH QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0106U NOCOV DEF SYSMAN Description: GSTR EMPTG 7 TIMED BRTH SPEC Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0107T NOCOV DEF SYSMAN Description: VIBRATE QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0107U NOCOV DEF SYSMAN Description: C DIFF TOX AG DETCJ IA STOOL Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0108T NOCOV DEF SYSMAN Description: COOL QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0108U NOCOV DEF SYSMAN Description: GI BARRETT ESOPH 9 PRTN BMRK Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0109T NOCOV DEF SYSMAN Description: HEAT QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0109U NOCOV DEF SYSMAN Description: ID ASPERGILLUS DNA 4 SPECIES Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0110T NOCOV DEF SYSMAN Description: NOS QUANT SENSORY TEST Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 0110U NOCOV DEF SYSMAN Description: RX MNTR 1+ORAL ONC RX&SBSTS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01112 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BONE ASPIRATE/BX Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 0111A NOCOV DEF SYSMAN Description: ADM SARSCOV2 25MCG/0.25ML1ST Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0111U NOCOV DEF SYSMAN Description: ONC COLON CA KRAS&NRAS ALYS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01120 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH PELVIS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0112A NOCOV DEF SYSMAN Description: ADM SARSCOV2 25MCG/0.25ML2ND Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0112U NOCOV DEF SYSMAN Description: IADI 16S&18S RRNA GENES Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 22 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01130 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH BODY CAST PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0113A NOCOV DEF SYSMAN Description: ADM SARSCOV2 25MCG/0.25ML3RD Category: Non Covered Services CMS Add: 06/17/2022 CMS Term: 10/31/2023 0113U NOCOV DEF SYSMAN Description: ONC PRST8 PCA3&TMPRSS2-ERG Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01140 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH AMPUTATION AT PELVIS Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0114U NOCOV DEF SYSMAN Description: GI BARRETTS ESOPH VIM&CCNA1 Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01150 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH PELVIC TUMOR SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0115U NOCOV DEF SYSMAN Description: RESPIR IADNA 18 VIRAL&2 BACT Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01160 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH PELVIS PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0116U NOCOV DEF SYSMAN Description: RX MNTR NZM IA 35+ORAL FLU Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01170 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH PELVIS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01173 ANEST DEF ANESTH 01/01/1900 0.00 12.0 Description: ANESTH FX REPAIR PELVIS Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 0117U NOCOV DEF SYSMAN Description: PAIN MGMT 11 ENDOGENOUS ANAL Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0118U NOCOV DEF SYSMAN Description: TRNSPLJ DON-DRV CLL-FR DNA Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0119U NOCOV DEF SYSMAN Description: CRD CERAMIDES LIQ CHROM PLSM Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01200 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH HIP JOINT PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01202 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH ARTHROSCOPY OF HIP Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 23 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0120U NOCOV DEF SYSMAN Description: ONC B CLL LYMPHM MRNA 58 GEN Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01210 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH HIP JOINT SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01212 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH HIP DISARTICULATION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01214 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH HIP ARTHROPLASTY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01215 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH REVISE HIP REPAIR Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 0121A DDWA DEF MAXFEE 04/18/2023 38.95 0.0 12-999years rs Description: ADM SARSCV2 BVL 30MCG/.3ML 1 Category: CIH Waiver CMS Add: 04/18/2023 CMS Term: 10/31/2023 0121A MEDSV DEF MAXFEE 04/18/2023 38.95 0.0 12-999years rs Description: ADM SARSCV2 BVL 30MCG/.3ML 1 Category: Medical Services CMS Add: 04/18/2023 CMS Term: 10/31/2023 0121A SSFS DEF MAXFEE 04/18/2023 38.95 0.0 12-999years rs Description: ADM SARSCV2 BVL 30MCG/.3ML 1 Category: Family Support Waivr CMS Add: 04/18/2023 CMS Term: 10/31/2023 0121A TRANS DEF MAXFEE 04/18/2023 38.95 0.0 12-999years rs Description: ADM SARSCV2 BVL 30MCG/.3ML 1 Category: Transportation CMS Add: 04/18/2023 CMS Term: 10/31/2023 0121U NOCOV DEF SYSMAN Description: SC DIS VCAM-1 WHOLE BLOOD Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01220 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH PROCEDURE ON FEMUR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0122U NOCOV DEF SYSMAN Description: SC DIS P-SELECTIN WHL BLOOD Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01230 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH SURGERY OF FEMUR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01232 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH AMPUTATION OF FEMUR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01234 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH RADICAL FEMUR SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0123U NOCOV DEF SYSMAN Description: MCHNL FRAGILITY RBC PRFLG Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 24 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0124A DDWA DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCV2 BVL 30MCG/.3ML A Category: CIH Waiver CMS Add: 08/31/2022 CMS Term: 10/31/2023 0124A DDWA DEF MAXFEE 08/31/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCV2 BVL 30MCG/.3ML A Category: CIH Waiver CMS Add: 08/31/2022 CMS Term: 10/31/2023 0124A MEDSV DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCV2 BVL 30MCG/.3ML A Category: Medical Services CMS Add: 08/31/2022 CMS Term: 10/31/2023 0124A MEDSV DEF MAXFEE 08/31/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCV2 BVL 30MCG/.3ML A Category: Medical Services CMS Add: 08/31/2022 CMS Term: 10/31/2023 0124A SSFS DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCV2 BVL 30MCG/.3ML A Category: Family Support Waivr CMS Add: 08/31/2022 CMS Term: 10/31/2023 0124A SSFS DEF MAXFEE 08/31/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCV2 BVL 30MCG/.3ML A Category: Family Support Waivr CMS Add: 08/31/2022 CMS Term: 10/31/2023 0124A TRANS DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCV2 BVL 30MCG/.3ML A Category: Transportation CMS Add: 08/31/2022 CMS Term: 10/31/2023 0124A TRANS DEF MAXFEE 08/31/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCV2 BVL 30MCG/.3ML A Category: Transportation CMS Add: 08/31/2022 CMS Term: 10/31/2023 0124T NOCOV DEF SYSMAN Description: CONJUNCTIVAL DRUG PLACEMENT Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 12/31/2013 01250 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH UPPER LEG SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01260 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH UPPER LEG VEINS SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01270 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH THIGH ARTERIES SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01272 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH FEMORAL ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01274 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH FEMORAL EMBOLECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0129U NOCOV DEF SYSMAN Description: HERED BRST CA RLTD DO PANEL Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0130U NOCOV DEF SYSMAN Description: HERED COLON CA DO MRNA PNL Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 25 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0131U NOCOV DEF SYSMAN Description: HERED BRST CA RLTD DO PNL 13 Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01320 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH KNEE AREA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0132U NOCOV DEF SYSMAN Description: HERED OVA CA RLTD DO PNL 17 Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0133U NOCOV DEF SYSMAN Description: HERED PRST8 CA RLTD DO 11 Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01340 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH KNEE AREA PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0134A DDWA DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCV2 BVL 50MCG/.5ML A Category: CIH Waiver CMS Add: 08/31/2022 CMS Term: 10/31/2023 0134A DDWA DEF MAXFEE 08/31/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCV2 BVL 50MCG/.5ML A Category: CIH Waiver CMS Add: 08/31/2022 CMS Term: 10/31/2023 0134A MEDSV DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCV2 BVL 50MCG/.5ML A Category: Medical Services CMS Add: 08/31/2022 CMS Term: 10/31/2023 0134A MEDSV DEF MAXFEE 08/31/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCV2 BVL 50MCG/.5ML A Category: Medical Services CMS Add: 08/31/2022 CMS Term: 10/31/2023 0134A SSFS DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCV2 BVL 50MCG/.5ML A Category: Family Support Waivr CMS Add: 08/31/2022 CMS Term: 10/31/2023 0134A SSFS DEF MAXFEE 08/31/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCV2 BVL 50MCG/.5ML A Category: Family Support Waivr CMS Add: 08/31/2022 CMS Term: 10/31/2023 0134A TRANS DEF MAXFEE 01/01/2023 38.95 0.0 12-999years rs Description: ADM SARSCV2 BVL 50MCG/.5ML A Category: Transportation CMS Add: 08/31/2022 CMS Term: 10/31/2023 0134A TRANS DEF MAXFEE 08/31/2022 12/31/2022 36.90 0.0 12-999years rs Description: ADM SARSCV2 BVL 50MCG/.5ML A Category: Transportation CMS Add: 08/31/2022 CMS Term: 10/31/2023 0134U NOCOV DEF SYSMAN Description: HERED PAN CA MRNA PNL 18 GEN Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0135U NOCOV DEF SYSMAN Description: HERED GYN CA MRNA PNL 12 GEN Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01360 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH KNEE AREA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 26 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0136U NOCOV DEF SYSMAN Description: ATM MRNA SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 0137U NOCOV DEF SYSMAN Description: PALB2 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01380 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH KNEE JOINT PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01382 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH DX KNEE ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0138U NOCOV DEF SYSMAN Description: BRCA1 BRCA2 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 01390 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH KNEE AREA PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01392 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH KNEE AREA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01400 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH KNEE JOINT SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01402 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH KNEE ARTHROPLASTY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01404 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH AMPUTATION AT KNEE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0140U NOCOV DEF SYSMAN Description: NFCT DS FUNGI DNA 15 TRGT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0141A DDWA DEF MAXFEE 04/18/2023 38.95 0.0 0-11years Description: ADM SRSCV2 BVL 25MCG/.25ML 1 Category: CIH Waiver CMS Add: 04/18/2023 CMS Term: 10/31/2023 0141A MEDSV DEF MAXFEE 04/18/2023 38.95 0.0 0-11years Description: ADM SRSCV2 BVL 25MCG/.25ML 1 Category: Medical Services CMS Add: 04/18/2023 CMS Term: 10/31/2023 0141A SSFS DEF MAXFEE 04/18/2023 38.95 0.0 0-11years Description: ADM SRSCV2 BVL 25MCG/.25ML 1 Category: Family Support Waivr CMS Add: 04/18/2023 CMS Term: 10/31/2023 0141A TRANS DEF MAXFEE 04/18/2023 38.95 0.0 0-11years Description: ADM SRSCV2 BVL 25MCG/.25ML 1 Category: Transportation CMS Add: 04/18/2023 CMS Term: 10/31/2023 0141U NOCOV DEF SYSMAN Description: NFCT DS BACT&FNG GRAM POS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 27 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01420 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH KNEE JOINT CASTING Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0142A DDWA DEF MAXFEE 04/18/2023 38.95 0.0 0-11years Description: ADM SRSCV2 BVL 25MCG/.25ML 2 Category: CIH Waiver CMS Add: 04/18/2023 CMS Term: 10/31/2023 0142A MEDSV DEF MAXFEE 04/18/2023 38.95 0.0 0-11years Description: ADM SRSCV2 BVL 25MCG/.25ML 2 Category: Medical Services CMS Add: 04/18/2023 CMS Term: 10/31/2023 0142A SSFS DEF MAXFEE 04/18/2023 38.95 0.0 0-11years Description: ADM SRSCV2 BVL 25MCG/.25ML 2 Category: Family Support Waivr CMS Add: 04/18/2023 CMS Term: 10/31/2023 0142A TRANS DEF MAXFEE 04/18/2023 38.95 0.0 0-11years Description: ADM SRSCV2 BVL 25MCG/.25ML 2 Category: Transportation CMS Add: 04/18/2023 CMS Term: 10/31/2023 0142U NOCOV DEF SYSMAN Description: NFCT DS BACT&FNG GRAM NEG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 01430 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH KNEE VEINS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01432 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH KNEE VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01440 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH KNEE ARTERIES SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01442 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH KNEE ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01444 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH KNEE ARTERY REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0144A DDWA DEF MAXFEE 01/01/2023 38.95 0.0 6-11years Description: ADM SRSCV2 BVL 25MCG/.25ML A Category: CIH Waiver CMS Add: 10/12/2022 CMS Term: 10/31/2023 0144A DDWA DEF MAXFEE 10/12/2022 12/31/2022 36.90 0.0 6-11years Description: ADM SRSCV2 BVL 25MCG/.25ML A Category: CIH Waiver CMS Add: 10/12/2022 CMS Term: 10/31/2023 0144A MEDSV DEF MAXFEE 01/01/2023 38.95 0.0 6-11years Description: ADM SRSCV2 BVL 25MCG/.25ML A Category: Medical Services CMS Add: 10/12/2022 CMS Term: 10/31/2023 0144A MEDSV DEF MAXFEE 10/12/2022 12/31/2022 36.90 0.0 6-11years Description: ADM SRSCV2 BVL 25MCG/.25ML A Category: Medical Services CMS Add: 10/12/2022 CMS Term: 10/31/2023 0144A SSFS DEF MAXFEE 01/01/2023 38.95 0.0 6-11years Description: ADM SRSCV2 BVL 25MCG/.25ML A Category: Family Support Waivr CMS Add: 10/12/2022 CMS Term: 10/31/2023 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 28 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0144A SSFS DEF MAXFEE 10/12/2022 12/31/2022 36.90 0.0 6-11years Description: ADM SRSCV2 BVL 25MCG/.25ML A Category: Family Support Waivr CMS Add: 10/12/2022 CMS Term: 10/31/2023 0144A TRANS DEF MAXFEE 01/01/2023 38.95 0.0 6-11years Description: ADM SRSCV2 BVL 25MCG/.25ML A Category: Transportation CMS Add: 10/12/2022 CMS Term: 10/31/2023 0144A TRANS DEF MAXFEE 10/12/2022 12/31/2022 36.90 0.0 6-11years Description: ADM SRSCV2 BVL 25MCG/.25ML A Category: Transportation CMS Add: 10/12/2022 CMS Term: 10/31/2023 01462 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER LEG PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01464 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH ANKLE/FT ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01470 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER LEG SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01472 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH ACHILLES TENDON SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01474 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH LOWER LEG SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01480 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER LEG BONE SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01482 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH RADICAL LEG SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01484 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH LOWER LEG REVISION Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01486 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH ANKLE REPLACEMENT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01490 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER LEG CASTING Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01500 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH LEG ARTERIES SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01502 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH LWR LEG EMBOLECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0151A DDWA DEF MAXFEE 04/18/2023 38.95 0.0 5-11years Description: ADM SARSCV2 BVL 10MCG/.2ML 1 Category: CIH Waiver CMS Add: 04/18/2023 CMS Term: 10/31/2023 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 29 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0151A MEDSV DEF MAXFEE 04/18/2023 38.95 0.0 5-11years Description: ADM SARSCV2 BVL 10MCG/.2ML 1 Category: Medical Services CMS Add: 04/18/2023 CMS Term: 10/31/2023 0151A SSFS DEF MAXFEE 04/18/2023 38.95 0.0 5-11years Description: ADM SARSCV2 BVL 10MCG/.2ML 1 Category: Family Support Waivr CMS Add: 04/18/2023 CMS Term: 10/31/2023 0151A TRANS DEF MAXFEE 04/18/2023 38.95 0.0 5-11years Description: ADM SARSCV2 BVL 10MCG/.2ML 1 Category: Transportation CMS Add: 04/18/2023 CMS Term: 10/31/2023 01520 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER LEG VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01522 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH LOWER LEG VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0152T NOCOV DEF SYSMAN Description: COMPUTER CHEST ADD-ON Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 12/31/2006 0152U NOCOV DEF SYSMAN Description: NFCT DS DNA UNTRGT NGNRJ SEQ Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0153U NOCOV DEF SYSMAN Description: ONC BREAST MRNA 101 GENES Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0154A DDWA DEF MAXFEE 01/01/2023 38.95 0.0 5-11years Description: ADM SARSCV2 BVL 10MCG/.2ML A Category: CIH Waiver CMS Add: 10/12/2022 CMS Term: 10/31/2023 0154A DDWA DEF MAXFEE 10/12/2022 12/31/2022 36.90 0.0 5-11years Description: ADM SARSCV2 BVL 10MCG/.2ML A Category: CIH Waiver CMS Add: 10/12/2022 CMS Term: 10/31/2023 0154A MEDSV DEF MAXFEE 01/01/2023 38.95 0.0 5-11years Description: ADM SARSCV2 BVL 10MCG/.2ML A Category: Medical Services CMS Add: 10/12/2022 CMS Term: 10/31/2023 0154A MEDSV DEF MAXFEE 10/12/2022 12/31/2022 36.90 0.0 5-11years Description: ADM SARSCV2 BVL 10MCG/.2ML A Category: Medical Services CMS Add: 10/12/2022 CMS Term: 10/31/2023 0154A SSFS DEF MAXFEE 01/01/2023 38.95 0.0 5-11years Description: ADM SARSCV2 BVL 10MCG/.2ML A Category: Family Support Waivr CMS Add: 10/12/2022 CMS Term: 10/31/2023 0154A SSFS DEF MAXFEE 10/12/2022 12/31/2022 36.90 0.0 5-11years Description: ADM SARSCV2 BVL 10MCG/.2ML A Category: Family Support Waivr CMS Add: 10/12/2022 CMS Term: 10/31/2023 0154A TRANS DEF MAXFEE 01/01/2023 38.95 0.0 5-11years Description: ADM SARSCV2 BVL 10MCG/.2ML A Category: Transportation CMS Add: 10/12/2022 CMS Term: 10/31/2023 0154A TRANS DEF MAXFEE 10/12/2022 12/31/2022 36.90 0.0 5-11years Description: ADM SARSCV2 BVL 10MCG/.2ML A Category: Transportation CMS Add: 10/12/2022 CMS Term: 10/31/2023 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 30 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0154U NOCOV DEF SYSMAN Description: ONC URTHL CA RNA FGFR3 GENE Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0155U NOCOV DEF SYSMAN Description: ONC BRST CA DNA PIK3CA GENE Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0156U NOCOV DEF SYSMAN Description: COPY NUMBER SEQUENCE ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0157U NOCOV DEF SYSMAN Description: APC MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0158U NOCOV DEF SYSMAN Description: MLH1 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0159U NOCOV DEF SYSMAN Description: MSH2 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0160U NOCOV DEF SYSMAN Description: MSH6 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 01610 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SURGERY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0161U NOCOV DEF SYSMAN Description: PMS2 MRNA SEQ ALYS Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 01620 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH SHOULDER PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01622 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANES DX SHOULDER ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0162U NOCOV DEF SYSMAN Description: HERED COLON CA TRGT MRNA PNL Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 01630 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH SURGERY OF SHOULDER Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01634 ANEST DEF ANESTH 01/01/1900 0.00 9.0 Description: ANESTH SHOULDER JOINT AMPUT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01636 ANEST DEF ANESTH 01/01/1900 0.00 15.0 Description: ANESTH FOREQUARTER AMPUT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01638 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH SHOULDER REPLACEMENT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 31 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0163U NOCOV DEF SYSMAN Description: ONC CLRCT SCR 3 PRTN ALG Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 0164A DDWA DEF MAXFEE 01/01/2023 38.95 0.0 0-5years Description: ADM SRSCV2 BVL 10MCG/0.2ML A Category: CIH Waiver CMS Add: 12/08/2022 CMS Term: 10/31/2023 0164A DDWA DEF MAXFEE 12/08/2022 12/31/2022 36.90 0.0 0-5years Description: ADM SRSCV2 BVL 10MCG/0.2ML A Category: CIH Waiver CMS Add: 12/08/2022 CMS Term: 10/31/2023 0164A MEDSV DEF MAXFEE 01/01/2023 38.95 0.0 0-5years Description: ADM SRSCV2 BVL 10MCG/0.2ML A Category: Medical Services CMS Add: 12/08/2022 CMS Term: 10/31/2023 0164A MEDSV DEF MAXFEE 12/08/2022 12/31/2022 36.90 0.0 0-5years Description: ADM SRSCV2 BVL 10MCG/0.2ML A Category: Medical Services CMS Add: 12/08/2022 CMS Term: 10/31/2023 0164A SSFS DEF MAXFEE 01/01/2023 38.95 0.0 0-5years Description: ADM SRSCV2 BVL 10MCG/0.2ML A Category: Family Support Waivr CMS Add: 12/08/2022 CMS Term: 10/31/2023 0164A SSFS DEF MAXFEE 12/08/2022 12/31/2022 36.90 0.0 0-5years Description: ADM SRSCV2 BVL 10MCG/0.2ML A Category: Family Support Waivr CMS Add: 12/08/2022 CMS Term: 10/31/2023 0164A TRANS DEF MAXFEE 01/01/2023 38.95 0.0 0-5years Description: ADM SRSCV2 BVL 10MCG/0.2ML A Category: Transportation CMS Add: 12/08/2022 CMS Term: 10/31/2023 0164A TRANS DEF MAXFEE 12/08/2022 12/31/2022 36.90 0.0 0-5years Description: ADM SRSCV2 BVL 10MCG/0.2ML A Category: Transportation CMS Add: 12/08/2022 CMS Term: 10/31/2023 0164T NOCOV DEF SYSMAN Description: REMOVE LUMB ARTIF DISC ADDL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0164U NOCOV DEF SYSMAN Description: GI IBS IA ANTI-CDTB&VINCULIN Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 01650 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH SHOULDER ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01652 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH SHOULDER VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01654 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Description: ANESTH SHOULDER VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01656 ANEST DEF ANESTH 01/01/1900 0.00 10.0 Description: ANESTH ARM-LEG VESSEL SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0165T NOCOV DEF SYSMAN Description: REVISE LUMB ARTIF DISC ADDL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 32 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0165U NOCOV DEF SYSMAN Description: PEANUT ALLG ASMT EPI Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 0166U NOCOV DEF SYSMAN Description: LIVER DS 10 BIOCHEM ASY SRM Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 01670 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH SHOULDER VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0167U NOCOV DEF SYSMAN Description: CHORNC GONADOTROPIN HCG IA Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 01680 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH SHOULDER CASTING Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0169U NOCOV DEF SYSMAN Description: NUDT15&TPMT GENE COM VRNT Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 0170U NOCOV DEF SYSMAN Description: NEURO ASD RNA NEXT GEN SEQ Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: 01710 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH ELBOW AREA SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01712 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH UPPR ARM TENDON SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01714 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH UPPR ARM TENDON SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01716 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BICEPS TENDON REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0171A DDWA DEF MAXFEE 04/18/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 1 Category: CIH Waiver CMS Add: 04/18/2023 CMS Term: 10/31/2023 0171A MEDSV DEF MAXFEE 04/18/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 1 Category: Medical Services CMS Add: 04/18/2023 CMS Term: 10/31/2023 0171A SSFS DEF MAXFEE 04/18/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 1 Category: Family Support Waivr CMS Add: 04/18/2023 CMS Term: 10/31/2023 0171A TRANS DEF MAXFEE 04/18/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 1 Category: Transportation CMS Add: 04/18/2023 CMS Term: 10/31/2023 0171U NOCOV DEF SYSMAN Description: TRGT GEN SEQ ALYS PNL DNA 23 Category: Non Covered Services CMS Add: 04/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 33 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0172A DDWA DEF MAXFEE 04/18/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 2 Category: CIH Waiver CMS Add: 04/18/2023 CMS Term: 10/31/2023 0172A MEDSV DEF MAXFEE 04/18/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 2 Category: Medical Services CMS Add: 04/18/2023 CMS Term: 10/31/2023 0172A SSFS DEF MAXFEE 04/18/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 2 Category: Family Support Waivr CMS Add: 04/18/2023 CMS Term: 10/31/2023 0172A TRANS DEF MAXFEE 04/18/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 2 Category: Transportation CMS Add: 04/18/2023 CMS Term: 10/31/2023 0172U NOCOV DEF SYSMAN Description: ONC SLD TUM ALYS BRCA1 BRCA2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01730 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH UPPR ARM PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01732 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH DX ELBOW ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0173A DDWA DEF MAXFEE 01/01/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 3 Category: CIH Waiver CMS Add: 12/08/2022 CMS Term: 10/31/2023 0173A DDWA DEF MAXFEE 12/08/2022 12/31/2022 36.90 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 3 Category: CIH Waiver CMS Add: 12/08/2022 CMS Term: 10/31/2023 0173A MEDSV DEF MAXFEE 01/01/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 3 Category: Medical Services CMS Add: 12/08/2022 CMS Term: 10/31/2023 0173A MEDSV DEF MAXFEE 12/08/2022 12/31/2022 36.90 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 3 Category: Medical Services CMS Add: 12/08/2022 CMS Term: 10/31/2023 0173A SSFS DEF MAXFEE 01/01/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 3 Category: Family Support Waivr CMS Add: 12/08/2022 CMS Term: 10/31/2023 0173A SSFS DEF MAXFEE 12/08/2022 12/31/2022 36.90 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 3 Category: Family Support Waivr CMS Add: 12/08/2022 CMS Term: 10/31/2023 0173A TRANS DEF MAXFEE 01/01/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 3 Category: Transportation CMS Add: 12/08/2022 CMS Term: 10/31/2023 0173A TRANS DEF MAXFEE 12/08/2022 12/31/2022 36.90 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML 3 Category: Transportation CMS Add: 12/08/2022 CMS Term: 10/31/2023 0173U NOCOV DEF SYSMAN Description: PSYC GEN ALYS PANEL 14 GENES Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 34 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01740 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH UPPER ARM SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01742 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH HUMERUS SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01744 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH HUMERUS REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0174A DDWA DEF MAXFEE 03/14/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML A Category: CIH Waiver CMS Add: 03/14/2023 CMS Term: 10/31/2023 0174A MEDSV DEF MAXFEE 03/14/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML A Category: Medical Services CMS Add: 03/14/2023 CMS Term: 10/31/2023 0174A SSFS DEF MAXFEE 03/14/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML A Category: Family Support Waivr CMS Add: 03/14/2023 CMS Term: 10/31/2023 0174A TRANS DEF MAXFEE 03/14/2023 38.95 0.0 0-4years Description: ADM SARSCV2 BVL 3MCG/0.2ML A Category: Transportation CMS Add: 03/14/2023 CMS Term: 10/31/2023 0174T NOCOV DEF SYSMAN Description: CAD CXR WITH INTERP Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0174U NOCOV DEF SYSMAN Description: ONC SOLID TUMOR 30 PRTN TRGT Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01756 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH RADICAL HUMERUS SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01758 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH HUMERAL LESION SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0175T NOCOV DEF SYSMAN Description: CAD CXR REMOTE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0175U NOCOV DEF SYSMAN Description: PSYC GEN ALYS PANEL 15 GENES Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01760 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH ELBOW REPLACEMENT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0176U NOCOV DEF SYSMAN Description: CDTB&VINCULIN IGG ANTB IA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01770 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH UPPR ARM ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 35 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01772 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH UPPR ARM EMBOLECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0177U NOCOV DEF SYSMAN Description: ONC BRST CA DNA PIK3CA 11 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01780 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH UPPER ARM VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01782 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH UPPR ARM VEIN REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0178U NOCOV DEF SYSMAN Description: PEANUT ALLG ASMT EPI CLIN RX Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0179U NOCOV DEF SYSMAN Description: ONC NONSM CLL LNG CA ALYS 23 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0180U NOCOV DEF SYSMAN Description: ABO GNOTYP ABO 7 EXONS Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01810 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER ARM SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0181U NOCOV DEF SYSMAN Description: CO GNOTYP AQP1 EXON 1 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01820 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER ARM PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01829 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH DX WRIST ARTHROSCOPY Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 0182U NOCOV DEF SYSMAN Description: CROM GNOTYP CD55 EXONS 1-10 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01830 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER ARM SURGERY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01832 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH WRIST REPLACEMENT Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0183T NOCOV DEF SYSMAN Description: WOUND ULTRASOUND Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 12/31/2013 0183U NOCOV DEF SYSMAN Description: DI GNOTYP SLC4A1 EXON 19 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 36 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01840 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH LWR ARM ARTERY SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01842 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH LWR ARM EMBOLECTOMY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01844 ANEST DEF ANESTH 01/01/1900 0.00 6.0 Description: ANESTH VASCULAR SHUNT SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0184T NOCOV DEF SYSMAN Description: EXC RECTAL TUMOR ENDOSCOPIC Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0184U NOCOV DEF SYSMAN Description: DO GNOTYP ART4 EXON 2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01850 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER ARM VEIN SURG Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01852 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH LWR ARM VEIN REPAIR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0185T NOCOV DEF SYSMAN Description: COMPTR PROBABILITY ANALYSIS Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 12/31/2013 0185U NOCOV DEF SYSMAN Description: FUT1 GNOTYP FUT1 EXON 4 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01860 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH LOWER ARM CASTING Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0186T NOCOV DEF SYSMAN Description: SUPRACHOROIDAL DRUG DELIVERY Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 12/31/2013 0186U NOCOV DEF SYSMAN Description: FUT2 GNOTYP FUT2 EXON 2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0187U NOCOV DEF SYSMAN Description: FY GNOTYP ACKR1 EXONS 1-2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0188U NOCOV DEF SYSMAN Description: GE GNOTYP GYPC EXONS 1-4 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0189U NOCOV DEF SYSMAN Description: GYPA GNOTYP NTRNS 1 5 EXON 2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0190U NOCOV DEF SYSMAN Description: GYPB GNOTYP NTRNS 1 5 SEUX 3 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 37 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01916 ANEST DEF ANESTH 02/01/2015 0.00 5.0 Description: ANESTH DX ARTERIOGRAPHY Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0191U NOCOV DEF SYSMAN Description: IN GNOTYP CD44 EXONS 2 3 6 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01920 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH CATHETERIZE HEART Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01922 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH CAT OR MRI SCAN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01924 ANEST DEF ANESTH 02/01/2015 0.00 5.0 Description: ANES THER INTERVEN RAD ARTRL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01925 ANEST DEF ANESTH 02/01/2015 0.00 7.0 Description: ANES THER INTERVEN RAD CARD Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01926 ANEST DEF ANESTH 02/01/2015 0.00 8.0 Description: ANES TX INTERV RAD HRT/CRAN Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 0192T NOCOV DEF SYSMAN Description: INSERT ANT SEGMENT DRAIN EXT Category: Non Covered Services CMS Add: 07/01/2008 CMS Term: 12/31/2013 0192U NOCOV DEF SYSMAN Description: JK GNOTYP SLC14A1 EXON 9 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01930 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANES THER INTERVEN RAD VEIN Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01931 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANES THER INTERVEN RAD TIPS Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01932 ANEST DEF ANESTH 02/01/2015 0.00 6.0 Description: ANES TX INTERV RAD TH VEIN Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01933 ANEST DEF ANESTH 02/01/2015 0.00 7.0 Description: ANES TX INTERV RAD CRAN VEIN Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01937 ANEST DEF ANESTH 01/01/2022 0.00 4.0 Description: ANES DRG/ASPIR CRV/THRC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 01938 ANEST DEF ANESTH 01/01/2022 0.00 4.0 Description: ANES DRG/ASPIR LMBR/SAC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 01939 ANEST DEF ANESTH 01/01/2022 0.00 4.0 Description: ANES NULYT AGT CRV/THRC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 38 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0193U NOCOV DEF SYSMAN Description: JR GNOTYP ABCG2 EXONS 2-26 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01940 ANEST DEF ANESTH 01/01/2022 0.00 4.0 Description: ANES NULYT AGT LMBR/SAC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 01941 ANEST DEF ANESTH 01/01/2022 0.00 5.0 Description: ANES NEUROMD/NTRVRT CRV/THRC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 01942 ANEST DEF ANESTH 01/01/2022 0.00 5.0 Description: ANES NEUROMD/NTRVRT LMBR/SAC Category: Anesthesia CMS Add: 01/01/2022 CMS Term: 0194U NOCOV DEF SYSMAN Description: KEL GNOTYP KEL EXON 8 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01951 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH BURN LESS 4 PERCENT Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 01952 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH BURN 4-9 PERCENT Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 01953 ANEST DEF MAXFEE 05/18/2018 16.26 0.0 Description: ANESTH BURN EACH 9 PERCENT Category: Anesthesia CMS Add: 01/01/2001 CMS Term: 01958 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH ANTEPARTUM MANIPUL Category: Anesthesia CMS Add: 01/01/2004 CMS Term: 0195U NOCOV DEF SYSMAN Description: KLF1 TARGETED SEQUENCING Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01960 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH VAGINAL DELIVERY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01961 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: ANESTH CS DELIVERY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01962 ANEST DEF ANESTH 01/01/1900 0.00 8.0 Y Description: ANESTH EMER HYSTERECTOMY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01963 ANEST DEF ANESTH 02/01/2015 0.00 8.0 Y Description: ANESTH CS HYSTERECTOMY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01965 ANEST DEF ANESTH 01/01/1900 0.00 4.0 Description: ANESTH INC/MISSED AB PROC Category: Anesthesia CMS Add: 01/01/2006 CMS Term: 01966 ANEST DEF ANESTH 11/15/2014 0.00 4.0 Y Description: ANESTH INDUCED AB PROCEDURE Category: Anesthesia CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 39 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 01967 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH/ANALG VAG DELIVERY Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01968 ANEST DEF ANESTH 02/01/2015 0.00 2.0 Description: ANES/ANALG CS DELIVER ADD-ON Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 01969 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Y Description: ANESTH/ANALG CS HYST ADD-ON Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 0196U NOCOV DEF SYSMAN Description: LU GNOTYP BCAM EXON 3 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0197U NOCOV DEF SYSMAN Description: LW GNOTYP ICAM4 EXON 1 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0198T NOCOV DEF SYSMAN Description: OCULAR BLOOD FLOW MEASURE Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0198U NOCOV DEF SYSMAN Description: RHD&RHCE GNTYP RHD1-10&RHCE5 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 01990 ANEST DEF ANESTH 01/01/1900 0.00 7.0 Description: SUPPORT FOR ORGAN DONOR Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01991 ANEST DEF ANESTH 01/01/1900 0.00 3.0 Description: ANESTH NERVE BLOCK/INJ Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 01992 ANEST DEF ANESTH 01/01/1900 0.00 5.0 Description: ANESTH N BLOCK/INJ PRONE Category: Anesthesia CMS Add: 01/01/2003 CMS Term: 01996 ANEST DEF MAXFEE 01/01/1900 41.64 0.0 Description: HOSP MANAGE CONT DRUG ADMIN Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 01999 ANEST DEF ANESTH 02/01/2015 0.00 0.0 Description: UNLISTED ANESTH PROCEDURE Category: Anesthesia CMS Add: 01/01/1989 CMS Term: 0199U NOCOV DEF SYSMAN Description: SC GNOTYP ERMAP EXONS 4 12 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0200T NOCOV DEF SYSMAN Description: PERQ SACRAL AUGMT UNILAT INJ Category: Non Covered Services CMS Add: 07/01/2009 CMS Term: 0200U NOCOV DEF SYSMAN Description: XK GNOTYP XK EXONS 1-3 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0201T NOCOV DEF SYSMAN Description: PERQ SACRAL AUGMT BILAT INJ Category: Non Covered Services CMS Add: 07/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 40 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0201U NOCOV DEF SYSMAN Description: YT GNOTYP ACHE EXON 2 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0202T NOCOV DEF SYSMAN Description: POST VERT ARTHRPLST 1 LUMBAR Category: Non Covered Services CMS Add: 07/01/2009 CMS Term: 0202U NOCOV DEF SYSMAN Description: NFCT DS 22 TRGT SARS-COV-2 Category: Non Covered Services CMS Add: 05/20/2020 CMS Term: 0203U NOCOV DEF SYSMAN Description: AI IBD MRNA XPRSN PRFL 17 Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0204U NOCOV DEF SYSMAN Description: ONC THYR MRNA XPRSN ALYS 593 Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0205U NOCOV DEF SYSMAN Description: OPH AMD ALYS 3 GENE VARIANTS Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0206U NOCOV DEF SYSMAN Description: NEURO ALZHEIMER CELL AGGREGJ Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0207T NOCOV DEF SYSMAN Description: CLEAR EYELID GLAND W/HEAT Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0207U NOCOV DEF SYSMAN Description: NEURO ALZHEIMER QUAN IMAGING Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0208T NOCOV DEF SYSMAN Description: AUDIOMETRY AIR ONLY Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0209T NOCOV DEF SYSMAN Description: AUDIOMETRY AIR & BONE Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0209U NOCOV DEF SYSMAN Description: CYTOG CONST ALYS INTERROG Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 02100 NOCOV DEF SYSMAN Description: ANESTH DIAG NERVE BLK Category: Non Covered Services CMS Add: 10/16/2003 CMS Term: 06/30/2015 02101 NOCOV DEF SYSMAN Description: ANESTH DIAG NRV BLK PRONE Category: Non Covered Services CMS Add: 10/16/2003 CMS Term: 06/30/2015 0210T NOCOV DEF SYSMAN Description: SPEECH AUDIOMETRY THRESHOLD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0210U NOCOV DEF SYSMAN Description: SYPHILIS TST ANTB IA QUAN Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 41 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0211T NOCOV DEF SYSMAN Description: SPEECH AUDIOM THRESH & RECOG Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0211U NOCOV DEF SYSMAN Description: ONC PAN-TUM DNA&RNA GNRJ SEQ Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0212T NOCOV DEF SYSMAN Description: COMPRE AUDIOMETRY EVALUATION Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0212U NOCOV DEF SYSMAN Description: RARE DS GEN DNA ALYS PROBAND Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0213T NOCOV DEF SYSMAN 0-1 Description: NJX PARAVERT W/US CER/THOR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0213U NOCOV DEF SYSMAN Description: RARE DS GEN DNA ALYS EA COMP Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0214T NOCOV DEF SYSMAN Description: NJX PARAVERT W/US CER/THOR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0214U NOCOV DEF SYSMAN Description: RARE DS XOM DNA ALYS PROBAND Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0215T NOCOV DEF SYSMAN Description: NJX PARAVERT W/US CER/THOR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0215U NOCOV DEF SYSMAN Description: RARE DS XOM DNA ALYS EA COMP Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0216T NOCOV DEF SYSMAN 0-1 Description: NJX PARAVERT W/US LUMB/SAC Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0216U NOCOV DEF SYSMAN Description: NEURO INH ATAXIA DNA 12 COM Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0217T NOCOV DEF SYSMAN Description: NJX PARAVERT W/US LUMB/SAC Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0217U NOCOV DEF SYSMAN Description: NEURO INH ATAXIA DNA 51 GENE Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0218T NOCOV DEF SYSMAN Description: NJX PARAVERT W/US LUMB/SAC Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0218U NOCOV DEF SYSMAN Description: NEURO MUSC DYS DMD SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 42 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0219T NOCOV DEF SYSMAN Description: PLMT POST FACET IMPLT CERV Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0219U NOCOV DEF SYSMAN Description: NFCT AGT HIV GNRJ SEQ ALYS Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0220T NOCOV DEF SYSMAN Description: PLMT POST FACET IMPLT THOR Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0220U NOCOV DEF SYSMAN Description: ONC BRST CA AI ASSMT 12 FEAT Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0221T NOCOV DEF SYSMAN Description: PLMT POST FACET IMPLT LUMB Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0221U NOCOV DEF SYSMAN Description: ABO GNOTYP NEXT GNRJ SEQ ABO Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0222T NOCOV DEF SYSMAN Description: PLMT POST FACET IMPLT ADDL Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0222U NOCOV DEF SYSMAN Description: RHD&RHCE GNTYP NEXT GNRJ SEQ Category: Non Covered Services CMS Add: 10/01/2020 CMS Term: 0223U NOCOV DEF SYSMAN Description: NFCT DS 22 TRGT SARS-COV-2 Category: Non Covered Services CMS Add: 06/25/2020 CMS Term: 0224U NOCOV DEF SYSMAN Description: ANTIBODY SARS-COV-2 TITER(S) Category: Non Covered Services CMS Add: 06/25/2020 CMS Term: 0225U NOCOV DEF SYSMAN Description: NFCT DS DNA&RNA 21 SARSCOV2 Category: Non Covered Services CMS Add: 08/10/2020 CMS Term: 0226U NOCOV DEF SYSMAN Description: SVNT SARSCOV2 ELISA PLSM SRM Category: Non Covered Services CMS Add: 08/10/2020 CMS Term: 0227U NOCOV DEF SYSMAN Description: RX ASY PRSMV 30+RX/METABLT Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0228U NOCOV DEF SYSMAN Description: ONC PRST8 MA MOLEC PRFL ALG Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0229U NOCOV DEF SYSMAN Description: BCAT1&IKZF1 PRMTR MTHYLN ALY Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0230U NOCOV DEF SYSMAN Description: AR FULL SEQUENCE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 43 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0231U NOCOV DEF SYSMAN Description: CACNA1A FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0232T NOCOV DEF SYSMAN Description: NJX PLATELET PLASMA Category: Non Covered Services CMS Add: 07/01/2010 CMS Term: 0232U NOCOV DEF SYSMAN Description: CSTB FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0233U NOCOV DEF SYSMAN Description: FXN GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0234T MEDSV DEF BILL40 Description: TRLUML PERIP ATHRC RENAL ART Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0234U NOCOV DEF SYSMAN Description: MECP2 FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0235T MEDSV DEF BILL40 Description: TRLUML PERIP ATHRC VISCERAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0235U NOCOV DEF SYSMAN Description: PTEN FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0236T MEDSV DEF BILL40 Description: TRLUML PERIP ATHRC ABD AORTA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0236U NOCOV DEF SYSMAN Description: SMN1&SMN2 FULL GENE ANALYSIS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0237T MEDSV DEF BILL40 Description: TRLUML PERIP ATHRC BRCHIOCPH Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0237U NOCOV DEF SYSMAN Description: CAR ION CHNLPTHY GEN SEQ PNL Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0238T MEDSV DEF BILL40 Description: TRLUML PERIP ATHRC ILIAC ART Category: Medical Services CMS Add: 01/01/2011 CMS Term: 0238U NOCOV DEF SYSMAN Description: ONC LNCH SYN GEN DNA SEQ ALY Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0239U NOCOV DEF SYSMAN Description: TRGT GEN SEQ ALYS PNL 311+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0240U LAB DEF MAXFEE 12/24/2021 142.63 0.0 Description: NFCT DS VIR RESP RNA 3 TRGT Category: Laboratory CMS Add: 10/06/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 44 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0241U LAB DEF MAXFEE 12/24/2021 142.63 0.0 Description: NFCT DS VIR RESP RNA 4 TRGT Category: Laboratory CMS Add: 10/06/2020 CMS Term: 0242U LAB L60 MAXFEE 07/24/2023 5000.00 0.0 Y Description: TRGT GEN SEQ ALYS PNL 55-74 Category: Laboratory CMS Add: 04/01/2021 CMS Term: 0243U NOCOV DEF SYSMAN Description: OB PE BIOCHEM ASSAY PGF ALG Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0244U NOCOV DEF SYSMAN Description: ONC SOLID ORGN DNA 257 GENES Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0245U NOCOV DEF SYSMAN Description: ONC THYR MUT ALYS 10 GEN&37 Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0246U NOCOV DEF SYSMAN Description: RBC DNA GNOTYP 16 BLD GROUPS Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0247U NOCOV DEF SYSMAN Description: OB PRTRM BRTH IBP4 SHBG MEAS Category: Non Covered Services CMS Add: 04/01/2021 CMS Term: 0248U NOCOV DEF SYSMAN Description: ONC BRN SPHRD CLL 12 RX PNL Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0249U NOCOV DEF SYSMAN Description: ONC BRST ALYS 32 PHSPRTN ALG Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0250U NOCOV DEF SYSMAN Description: ONC SLD ORG NEO DNA 505 GENE Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0251U NOCOV DEF SYSMAN Description: HEPCIDIN-25 ELISA SERUM/PLSM Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0252U NOCOV DEF SYSMAN Description: FTL ANEUPLOIDY STR ALYS DNA Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0253T NOCOV DEF SYSMAN Description: INSERT AQUEOUS DRAIN DEVICE Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: 0253U NOCOV DEF SYSMAN Description: RPRDTVE MED RNA GEN PRFL 238 Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0254U NOCOV DEF SYSMAN Description: REPRDTVE MED ALYS 24 CHRMSM Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0255U NOCOV DEF SYSMAN Description: ANDROLOGY INFERTILITY ASSMT Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 45 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0256U NOCOV DEF SYSMAN Description: TMA/TMAO PRFL MS/MS UR ALG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0257U NOCOV DEF SYSMAN Description: VLCAD LEUK NZM ACTV WHL BLD Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0258U NOCOV DEF SYSMAN Description: AI PSOR MRNA 50-100 GEN ALG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0259U NOCOV DEF SYSMAN Description: NEPH CKD NUC MRS MEAS GFR Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0260T NOCOV DEF SYSMAN Description: HYPTHRM BDY NEONATE 28D/< Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: 12/31/2013 0260U NOCOV DEF SYSMAN Description: RARE DS ID OPT GENOME MAPG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0261T NOCOV DEF SYSMAN Description: HYPTHRM HEAD NEONATE 28D/< Category: Non Covered Services CMS Add: 01/01/2011 CMS Term: 12/31/2013 0261U NOCOV DEF SYSMAN Description: ONC CLRCT CA IMG ALYS W/AI Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0262U NOCOV DEF SYSMAN Description: ONC SLD TUM RT-PCR 7 GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0263T NOCOV DEF SYSMAN Description: IM B1 MRW CEL THER CMPL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0263U NOCOV DEF SYSMAN Description: NEURO ASD MEAS 16 C METBLT Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0264T NOCOV DEF SYSMAN Description: IM B1 MRW CEL THER XCL HRVST Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0264U NOCOV DEF SYSMAN Description: RARE DS ID OPT GENOME MAPG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0265T NOCOV DEF SYSMAN Description: IM B1 MRW CEL THER HRVST ONL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0265U NOCOV DEF SYSMAN Description: RAR DO WHL GN&MTCDRL DNA ALS Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0266T NOCOV DEF SYSMAN Description: IMPLT/RPL CRTD SNS DEV TOTAL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 46 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0266U NOCOV DEF SYSMAN Description: UNXPL CNST HRTBL DO GN XPRSN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0267T NOCOV DEF SYSMAN Description: IMPLT/RPL CRTD SNS DEV LEAD Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0267U NOCOV DEF SYSMAN Description: RARE DO ID OPT GEN MAPG&SEQ Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0268T NOCOV DEF SYSMAN Description: IMPLT/RPL CRTD SNS DEV GEN Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0268U NOCOV DEF SYSMAN Description: HEM AHUS GEN SEQ ALYS 15 GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0269T NOCOV DEF SYSMAN Description: REV/REMVL CRTD SNS DEV TOTAL Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0269U NOCOV DEF SYSMAN Description: HEM AUT DM CGEN TRMBCTPNA 22 Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0270T NOCOV DEF SYSMAN Description: REV/REMVL CRTD SNS DEV LEAD Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0270U NOCOV DEF SYSMAN Description: HEM CGEN COAGJ DO 20 GENES Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0271T NOCOV DEF SYSMAN Description: REV/REMVL CRTD SNS DEV GEN Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0271U NOCOV DEF SYSMAN Description: HEM CGEN NEUTROPENIA 24 GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0272T NOCOV DEF SYSMAN Description: INTERROGATE CRTD SNS DEV Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0272U NOCOV DEF SYSMAN Description: HEM GENETIC BLD DO 60 GENES Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0273T NOCOV DEF SYSMAN Description: INTERROGATE CRTD SNS W/PGRMG Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0273U NOCOV DEF SYSMAN Description: HEM GEN HYPRFIBRNLYSIS 8 GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0274T NOCOV DEF SYSMAN Description: PERQ LAMOT/LAM CRV/THRC Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 47 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0274U NOCOV DEF SYSMAN Description: HEM GEN PLTLT DO 62 GENES Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0275T NOCOV DEF SYSMAN Description: PERQ LAMOT/LAM LUMBAR Category: Non Covered Services CMS Add: 07/01/2011 CMS Term: 0275U NOCOV DEF SYSMAN Description: HEM HEPRN NDUC TRMBCTPNA SRM Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0276U NOCOV DEF SYSMAN Description: HEM INH THROMBOCYTOPENIA 42 Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0277U NOCOV DEF SYSMAN Description: HEM GEN PLTLT FUNCJ DO 40 Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0278T NOCOV DEF SYSMAN Description: TEMPR Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 0278U NOCOV DEF SYSMAN Description: HEM GEN THROMBOSIS 14 GENES Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0279U NOCOV DEF SYSMAN Description: HEM VW FACTOR&CLGN III BNDG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0280U NOCOV DEF SYSMAN Description: HEM VW FACTOR&CLGN IV BNDG Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0281U NOCOV DEF SYSMAN Description: HEM VWD PROPEPTIDE AG LVL Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0282U NOCOV DEF SYSMAN Description: RBC DNA GNTYP 12 BLD GRP GEN Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0283U NOCOV DEF SYSMAN Description: VW FACTOR TYPE 2B EVAL PLSM Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0284U NOCOV DEF SYSMAN Description: VW FACTOR TYPE 2N EVAL PLSM Category: Non Covered Services CMS Add: 10/01/2021 CMS Term: 0285U NOCOV DEF SYSMAN Description: ONC RSPS RADJ CLL FR DNA TOX Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0286U NOCOV DEF SYSMAN Description: CEP72 NUDT15&TPMT GENE ALYS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0287U LAB L60 MAXFEE 01/20/2023 3600.00 0.0 Y Description: ONC THYR DNA&MRNA 112 GENES Category: Laboratory CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 48 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0288U NOCOV DEF SYSMAN Description: ONC LUNG MRNA QUAN PCR 11&3 Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0289U NOCOV DEF SYSMAN Description: NEURO ALZHEIMER MRNA 24 GEN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0290U NOCOV DEF SYSMAN Description: PAIN MGMT MRNA GEN XPRSN 36 Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0291U NOCOV DEF SYSMAN Description: PSYC MOOD DO MRNA 144 GENES Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0292U NOCOV DEF SYSMAN Description: PSYC STRS DO MRNA 72 GENES Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0293U NOCOV DEF SYSMAN Description: PSYC SUICIDAL IDEA MRNA 54 Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0294U NOCOV DEF SYSMAN Description: LNGVTY&MRTLTY RSK MRNA 18GEN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0295U NOCOV DEF SYSMAN Description: ONC BRST DUX CARC 7 PROTEINS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0296U NOCOV DEF SYSMAN Description: ONC ORL&/OROP CA 20 MLC FEAT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0297U NOCOV DEF SYSMAN Description: ONC PAN TUM WHL GEN SEQ DNA Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0298U NOCOV DEF SYSMAN Description: ONC PAN TUM WHL TRNS SEQ RNA Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0299U NOCOV DEF SYSMAN Description: ONC PAN TUM WHL GEN OPT MAPG Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0300U NOCOV DEF SYSMAN Description: ONC PAN TUM WHL GEN SEQ&OPT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0301U NOCOV DEF SYSMAN Description: IADNA BARTONELLA DDPCR Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0302U NOCOV DEF SYSMAN Description: IADNA BRTNLA DDPCR FLWG LIQ Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0303U NOCOV DEF SYSMAN Description: HEM RBC ADS WHL BLD HYPOXIC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 49 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0304U NOCOV DEF SYSMAN Description: HEM RBC ADS WHL BLD NORMOXIC Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0305U NOCOV DEF SYSMAN Description: HEM RBC FNCLTY&DFRM SHR STRS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0306U NOCOV DEF SYSMAN Description: ONC MRD NXT-GNRJ ALYS 1ST Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0307U NOCOV DEF SYSMAN Description: ONC MRD NXT-GNRJ ALYS SBSQ Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0308T NOCOV DEF SYSMAN Description: INSJ OCULAR TELESCOPE PROSTH Category: Non Covered Services CMS Add: 07/01/2012 CMS Term: 0308U NOCOV DEF SYSMAN Description: CRD CAD ALYS 3 PRTN 3 PARAM Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0309U NOCOV DEF SYSMAN Description: CRD CV DS ALY 4 PRTN PLM ALG Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0310U NOCOV DEF SYSMAN Description: PED VSCLTS KD ALYS 3 BMRKS Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0311U NOCOV DEF SYSMAN Description: NFCT DS BCT QUAN ANTMCRB SC Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0312U NOCOV DEF SYSMAN Description: AI DS SLE ALYS 8 IGG AUTOANT Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0313U NOCOV DEF SYSMAN Description: ONC PNCRS DNA&MRNA SEQ 74 Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0314U NOCOV DEF SYSMAN Description: ONC CUTAN MLNMA MRNA 35 GENE Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0315U NOCOV DEF SYSMAN Description: ONC CUTAN SQ CLL CA MRNA 40 Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0316U NOCOV DEF SYSMAN Description: B BRGDRFERI LYME DS OSPA EVL Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0317U NOCOV DEF SYSMAN Description: ONC LUNG CA 4-PRB FISH ASSAY Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0318T NOCOV DEF SYSMAN Description: REPLACE AORTIC VALVE TTHORAC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 12/31/2013 *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 50 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0318U NOCOV DEF SYSMAN Description: PED WHL GEN MTHYLTN ALYS 50+ Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0319U NOCOV DEF SYSMAN Description: NEPH RNA PRETRNSPL PERPH BLD Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0320U NOCOV DEF SYSMAN Description: NEPH RNA PSTTRNSPL PERPH BLD Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0321U NOCOV DEF SYSMAN Description: IADNA GU PTHGN 20BCT&FNG ORG Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0322U NOCOV DEF SYSMAN Description: NEURO ASD MEAS 14 ACYL CARN Category: Non Covered Services CMS Add: 04/01/2022 CMS Term: 0323U NOCOV DEF SYSMAN Description: IADNA CNS PTHGN NEXT GEN SEQ Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0326U LAB DEF BILL90 Y Description: TRGT GEN SEQ ALYS PNL 83+ Category: Laboratory CMS Add: 07/01/2022 CMS Term: 0327U NOCOV DEF SYSMAN Description: FTL ANEUPLOIDY TRSMY DNA SEQ Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0328U NOCOV DEF SYSMAN Description: DRUG ASSAY 120+ RX&METABLT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0329T NOCOV DEF SYSMAN Description: MNTR IO PRESS 24HRS/> UNI/BI Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0329U NOCOV DEF SYSMAN Description: ONC NEO XOME&TRNS SEQ ALYS Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0330T NOCOV DEF SYSMAN Description: TEAR FILM IMG UNI/BI W/I&R Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0330U NOCOV DEF SYSMAN Description: IADNA VAG PTHGN PANEL 27 ORG Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0331T NOCOV DEF SYSMAN Description: HEART SYMP IMAGE PLNR Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0331U NOCOV DEF SYSMAN Description: ONC HL NEO OPT GEN MAPPING Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0332T NOCOV DEF SYSMAN Description: HEART SYMP IMAGE PLNR SPECT Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 51 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0332U NOCOV DEF SYSMAN Description: ONC PAN TUM GEN PRFLG 8 DNA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0333T NOCOV DEF SYSMAN Description: VISUAL EP SCR ACUITY AUTO Category: Non Covered Services CMS Add: 07/01/2013 CMS Term: 0333U NOCOV DEF SYSMAN Description: ONC LVR SURVEILANC HCC CFDNA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0334U NOCOV DEF SYSMAN Description: ONC SLD ORGN TGSA DNA 84/+ Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0335T NOCOV DEF SYSMAN Description: INSJ SINUS TARSI IMPLANT Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 0335U NOCOV DEF SYSMAN Description: RARE DS WHL GEN SEQ FETA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0336U NOCOV DEF SYSMAN Description: RARE DS WHL GEN SEQ BLD/SLV Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0337U NOCOV DEF SYSMAN Description: ONC PLSM CELL DO&MYELOMA ID Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0338T NOCOV DEF SYSMAN Description: TRNSCTH RENAL SYMP DENRV UNL Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 0338U NOCOV DEF SYSMAN Description: ONC SLD TUM CRCG TUM CL SLCT Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0339T NOCOV DEF SYSMAN Description: TRNSCTH RENAL SYMP DENRV BIL Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 0339U NOCOV DEF SYSMAN Description: ONC PRST8 MRNA HOXC6 & DLX1 Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0340U NOCOV DEF SYSMAN Description: ONC PAN CA ALYS MRD PLASMA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0341U NOCOV DEF SYSMAN Description: FTL ANEUP DNA SEQ CMPR ALYS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0342T NOCOV DEF SYSMAN Description: THXP APHERESIS W/HDL DELIP Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 0342U NOCOV DEF SYSMAN Description: ONC PNCRTC CA MULT IA ECLIA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 52 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0343U NOCOV DEF SYSMAN Description: ONC PRST8 XOM ALY 442 SNCRNA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0344U NOCOV DEF SYSMAN Description: HEP NAFLD SEMIQ EVL 28 LIPID Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0345T NOCOV DEF SYSMAN Description: TRANSCATH MTRAL VLVE REPAIR Category: Non Covered Services CMS Add: 01/01/2014 CMS Term: 0345U NOCOV DEF SYSMAN Description: PSYC GENOM ALYS PNL 15 GEN Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0346U NOCOV DEF SYSMAN Description: BETA AMYL AB40&AB42 LC-MS/MS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0347T NOCOV DEF SYSMAN Description: INS BONE DEVICE FOR RSA Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0347U NOCOV DEF SYSMAN Description: RX METAB/PCX DNA 16 GEN ALYS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0348T NOCOV DEF SYSMAN Description: RSA SPINE EXAM Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0348U NOCOV DEF SYSMAN Description: RX METAB/PCX DNA 25 GEN ALYS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0349T NOCOV DEF SYSMAN Description: RSA UPPER EXTR EXAM Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0349U NOCOV DEF SYSMAN Description: RX METAB/PCX DNA 27GEN RX IA Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0350T NOCOV DEF SYSMAN Description: RSA LOWER EXTR EXAM Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0350U NOCOV DEF SYSMAN Description: RX METAB/PCX DNA 27 GEN ALYS Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0351T NOCOV DEF SYSMAN Description: INTRAOP OCT BRST/NODE SPEC Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0351U NOCOV DEF SYSMAN Description: NFCT DS BCT/VIRAL TRAIL IP10 Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0352T NOCOV DEF SYSMAN Description: OCT BRST/NODE I&R PER SPEC Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 53 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0352U NOCOV DEF SYSMAN Description: NFCT DS BV&VAGINITIS AMP PRB Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0353T NOCOV DEF SYSMAN Description: INTRAOP OCT BREAST CAVITY Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0353U NOCOV DEF SYSMAN Description: IADNA CHLMYD&GONORR AMP PRB Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0354T NOCOV DEF SYSMAN Description: OCT BREAST SURG CAVITY I&R Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0354U NOCOV DEF SYSMAN Description: HPV HI RSK QUAL MRNA E6/E7 Category: Non Covered Services CMS Add: 10/01/2022 CMS Term: 0355U NOCOV DEF SYSMAN Description: APOL1 RISK VARIANTS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0356U NOCOV DEF SYSMAN Description: ONC OROP 17 DNA DDPCR ALG Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0358T NOCOV DEF SYSMAN Description: BIA WHOLE BODY Category: Non Covered Services CMS Add: 07/01/2014 CMS Term: 0358U NOCOV DEF SYSMAN Description: NEURO ALYS B-AMYL 1-42&1-40 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0359U NOCOV DEF SYSMAN Description: ONC PRST8 CA ALYS ALL PSA Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0360U NOCOV DEF SYSMAN Description: ONC LUNG ELISA 7 AUTOANT ALG Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0361U NOCOV DEF SYSMAN Description: NEURFLMNT LT CHN DIG IA QUAN Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0362T MENTL DEF BILL90 Y 0-999years s Description: BHV ID SUPRT ASSMT EA 15 MIN Category: Mental Health CMS Add: 07/01/2014 CMS Term: 0362U NOCOV DEF SYSMAN Description: ONC PAP THYR CA RNA 82&10 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0363U NOCOV DEF SYSMAN Description: ONC URTHL MRNA 5 GEN ALG Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0364U NOCOV DEF SYSMAN Description: ONC HL NEO GEN SEQ ALYS ALG Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 54 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0365U NOCOV DEF SYSMAN Description: ONC BLDR 10 PRB BLDR CA Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0366U NOCOV DEF SYSMAN Description: ONC BLDR 10 PRB RECR BLDR CA Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0367U NOCOV DEF SYSMAN Description: ONC BLDR 10 FLWG TRURL RESCJ Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0368U NOCOV DEF SYSMAN Description: ONC CLRCT CA MUT&MTHYLTN MRK Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0369U NOCOV DEF SYSMAN Description: IADNA GI PTHGN 31 ORG&21 ARG Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0370U NOCOV DEF SYSMAN Description: IADNA SURG WND PTHGN 34&21 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0371U NOCOV DEF SYSMAN Description: IADNA GU PTHGN SEMIQ DNA16&1 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0372U NOCOV DEF SYSMAN Description: NFCT DS GU PTHGN ARG DETCJ Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0373T MENTL DEF BILL90 Y 0-999years s Description: ADAPT BHV TX EA 15 MIN Category: Mental Health CMS Add: 07/01/2014 CMS Term: 0373U NOCOV DEF SYSMAN Description: IADNA RSP TR NFCT 17 8 13&16 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0374U NOCOV DEF SYSMAN Description: IADNA GU PTHGN 21 ORG&21ARG Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0375U NOCOV DEF SYSMAN Description: ONC OVRN BCHM ASY 7 PRTN ALG Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0376U NOCOV DEF SYSMAN Description: ONC PRST8 CA IMG ALYS 128 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0377U NOCOV DEF SYSMAN Description: CV DS QUAN ADVSRM/PLSM LPRTN Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0378T NOCOV DEF SYSMAN Description: VISUAL FIELD ASSMNT REV/RPRT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 0378U NOCOV DEF SYSMAN Description: RFC1 REPEAT XPNSJ VRNT ALYS Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 55 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0379T NOCOV DEF SYSMAN Description: VIS FIELD ASSMNT TECH SUPPT Category: Non Covered Services CMS Add: 01/01/2015 CMS Term: 0379U NOCOV DEF SYSMAN Description: TGSAP SL OR NEO DNA523&RNA55 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0380U NOCOV DEF SYSMAN Description: RX METB ADVRS TRGT SQ ALY 20 Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0381U NOCOV DEF SYSMAN Description: MAPLE SYRUP UR DS MNTR QUAN Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0382U NOCOV DEF SYSMAN Description: HYPRPHENYLALNINMIA MNTR QUAN Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0383U NOCOV DEF SYSMAN Description: TYROSINEMIA TYP I MNTR QUAN Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0384U NOCOV DEF SYSMAN Description: NEPH CKD RSK HI STG KDN DS Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0385U NOCOV DEF SYSMAN Description: NEPH CKD ALG RSK DBTC KDN DS Category: Non Covered Services CMS Add: 04/01/2023 CMS Term: 0387U NOCOV DEF SYSMAN Description: ONC MLNMA AMBRA1&AMLO Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0388U NOCOV DEF SYSMAN Description: ONC NONSM CLL LNG CA 37 GEN Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0389U NOCOV DEF SYSMAN Description: PED FBRL KD IFI27&MCEMP1 RNA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0390U NOCOV DEF SYSMAN Description: OB PE KDR ENG&RBP4 IA ALG Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0391U NOCOV DEF SYSMAN Description: ONC SLD TUM DNA&RNA 437 GEN Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0392U NOCOV DEF SYSMAN Description: RX METAB GENRX IA 16 GENES Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0393U NOCOV DEF SYSMAN Description: NEU PRKSN MSFL A-SYNCLN PRTN Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0394T NOCOV DEF SYSMAN Description: HDR ELCTRNC SKN SURF BRCHYTX Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 56 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0394U NOCOV DEF SYSMAN Description: PFAS 16 PFAS COMPND LC MS/MS Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0395T NOCOV DEF SYSMAN Description: HDR ELCTR NTRST/NTRCV BRCHTX Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0395U NOCOV DEF SYSMAN Description: ONC LNG MULTIOMICS PLSM ALG Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0396U NOCOV DEF SYSMAN Description: OB PREIMPLTJ TST 300000 DNA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0397T NOCOV DEF SYSMAN Description: ERCP W/OPTICAL ENDOMICROSCPY Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0398T MEDSV DEF BILL90 Y Description: MRGFUS STRTCTC LES ABLTJ Category: Medical Services CMS Add: 01/01/2016 CMS Term: 0398U NOCOV DEF SYSMAN Description: GI BARET ESPH DNA MTHYLN ALY Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0399U NOCOV DEF SYSMAN Description: NEURO CERE FOLATE DEFNCY SRM Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0400U NOCOV DEF SYSMAN Description: OB XPND CAR SCR 145 GENES Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0401U NOCOV DEF SYSMAN Description: CRD C HRT DS 9 GEN 12 VRNTS Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0402T NOCOV DEF SYSMAN Description: COLGN CRS-LINK CRN&PACHYMTRY Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0403T NOCOV DEF SYSMAN Description: DIABETES PREV STANDARD CURR Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0404T NOCOV DEF SYSMAN Description: TRNSCRV UTERIN FIBROID ABLTJ Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0408T NOCOV DEF SYSMAN Description: INSJ/RPLC CARDIAC MODULJ SYS Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0409T NOCOV DEF SYSMAN Description: INSJ/RPLC CAR MODULJ PLS GN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0410T NOCOV DEF SYSMAN Description: INSJ/RPLC CAR MODULJ ATR ELT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 57 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0411T NOCOV DEF SYSMAN Description: INSJ/RPLC CAR MODULJ VNT ELT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0412T NOCOV DEF SYSMAN Description: RMVL CARDIAC MODULJ PLS GEN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0413T NOCOV DEF SYSMAN Description: RMVL CAR MODULJ TRANVNS ELT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0414T NOCOV DEF SYSMAN Description: RMVL & RPL CAR MODULJ PLS GN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0415T NOCOV DEF SYSMAN Description: REPOS CAR MODULJ TRANVNS ELT Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0416T NOCOV DEF SYSMAN Description: RELOC SKIN POCKET PLS GEN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0417T NOCOV DEF SYSMAN Description: PRGRMG EVAL CARDIAC MODULJ Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0418T NOCOV DEF SYSMAN Description: INTERRO EVAL CARDIAC MODULJ Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0419T NOCOV DEF SYSMAN Description: DSTRJ NEUROFIBROMA XTNSV Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0420T NOCOV DEF SYSMAN Description: DSTRJ NEUROFIBROMA XTNSV Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0421T NOCOV DEF SYSMAN Description: WATERJET PROSTATE ABLTJ CMPL Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0422T NOCOV DEF SYSMAN Description: TACTILE BREAST IMG UNI/BI Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0424T NOCOV DEF SYSMAN Description: INSJ/RPLC NSTIM APNEA COMPL Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0425T NOCOV DEF SYSMAN Description: INSJ/RPLC NSTIM APNEA SEN LD Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0426T NOCOV DEF SYSMAN Description: INSJ/RPLC NSTIM APNEA STM LD Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0427T NOCOV DEF SYSMAN Description: INSJ/RPLC NSTIM APNEA PLS GN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 58 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0428T NOCOV DEF SYSMAN Description: RMVL NSTIM APNEA PLS GEN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0429T NOCOV DEF SYSMAN Description: RMVL NSTIM APNEA SEN LD Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0430T NOCOV DEF SYSMAN Description: RMVL NSTIM APNEA STIMJ LD Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0431T NOCOV DEF SYSMAN Description: RMVL/RPLC NSTIM APNEA PLS GN Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0432T NOCOV DEF SYSMAN Description: REPOS NSTIM APNEA STIMJ LD Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0433T NOCOV DEF SYSMAN Description: REPOS NSTIM APNEA SENSING LD Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0434T NOCOV DEF SYSMAN Description: INTERRO EVAL NPGS APNEA Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0435T NOCOV DEF SYSMAN Description: PRGRMG EVAL NPGS APNEA 1 SES Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0436T NOCOV DEF SYSMAN Description: PRGRMG EVAL NPGS APNEA STUDY Category: Non Covered Services CMS Add: 01/01/2016 CMS Term: 0437T NOCOV DEF SYSMAN Description: IMPLTJ SYNTH RNFCMT ABDL WAL Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0439T NOCOV DEF SYSMAN Description: MYOCRD CONTRAST PRFUJ ECHO Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0440T NOCOV DEF SYSMAN Description: ABLTJ PERC UXTR/PERPH NRV Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0441T NOCOV DEF SYSMAN Description: ABLTJ PERC LXTR/PERPH NRV Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0442T NOCOV DEF SYSMAN Description: ABLTJ PERC PLEX/TRNCL NRV Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0443T NOCOV DEF SYSMAN Description: R-T SPCTRL ALYS PRST8 TISS Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0444T NOCOV DEF SYSMAN Description: 1ST PLMT DRUG ELUT OC INS Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 59 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0445T NOCOV DEF SYSMAN Description: SBSQT PLMT DRUG ELUT OC INS Category: Non Covered Services CMS Add: 07/01/2016 CMS Term: 0446T NOCOV DEF SYSMAN Description: INSJ IMPLTBL GLUCOSE SENSOR Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0447T NOCOV DEF SYSMAN Description: RMVL IMPLTBL GLUCOSE SENSOR Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0448T NOCOV DEF SYSMAN Description: REMVL INSJ IMPLTBL GLUC SENS Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0449T NOCOV DEF SYSMAN Description: INSJ AQUEOUS DRAIN DEV 1ST Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0450T NOCOV DEF SYSMAN Description: INSJ AQUEOUS DRAIN DEV EACH Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0464T NOCOV DEF SYSMAN Description: VISUAL EP TEST FOR GLAUCOMA Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0465T NOCOV DEF SYSMAN Description: SUPCHRDL NJX RX W/O SUPPLY Category: Non Covered Services CMS Add: 01/01/2017 CMS Term: 0469T NOCOV DEF SYSMAN Description: RTA POLARIZE SCAN OC SCR BI Category: Non Covered Services CMS Add: 07/01/2017 CMS Term: 0472T NOCOV DEF SYSMAN Description: PRGRMG IO RTA ELTRD RA Category: Non Covered Services CMS Add: 07/01/2017 CMS Term: 0473T NOCOV DEF SYSMAN Description: REPRGRMG IO RTA ELTRD RA Category: Non Covered Services CMS Add: 07/01/2017 CMS Term: 0474T MEDSV DEF BILL90 Description: INSJ AQUEOUS DRG DEV IO RSVR Category: Medical Services CMS Add: 07/01/2017 CMS Term: 0479T NOCOV DEF SYSMAN Description: FXJL ABL LSR 1ST 100 SQ CM Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0480T NOCOV DEF SYSMAN Description: FXJL ABL LSR EA ADDL 100SQCM Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0481T NOCOV DEF SYSMAN Description: NJX AUTOL WBC CONCENTRATE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0483T NOCOV DEF SYSMAN Description: TMVI PERCUTANEOUS APPROACH Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 60 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0484T NOCOV DEF SYSMAN Description: TMVI TRANSTHORACIC EXPOSURE Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0485T NOCOV DEF SYSMAN Description: OCT MID EAR I&R UNILATERAL Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0486T NOCOV DEF SYSMAN Description: OCT MID EAR I&R BILATERAL Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0488T NOCOV DEF SYSMAN Description: DIABETES PREV ONLINE/ELEC Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0489T MEDSV DEF BILL90 Y Description: REGN CELL TX SCLDR HANDS Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0490T MEDSV DEF BILL90 Y Description: REGN CELL TX SCLDR H MLT INJ Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0494T MEDSV DEF BILL90 Y Description: PREP & CANNULJ CDVR DON LUNG Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0495T MEDSV DEF BILL90 Y Description: MNTR CDVR DON LNG 1ST 2 HRS Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0496T MEDSV DEF BILL90 Y Description: MNTR CDVR DON LNG EA ADDL HR Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0499T NOCOV DEF SYSMAN Description: CYSTO F/URTL STRIX/STENOSIS Category: Non Covered Services CMS Add: 01/01/2018 CMS Term: 0500F NOCOV DEF SYSMAN Description: INITIAL PRENATAL CARE VISIT Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0500T MEDSV DEF BILL90 Description: HPV 5+ HI RISK HPV TYPES Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0501F NOCOV DEF SYSMAN Description: PRENATAL FLOW SHEET Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0501T MEDSV DEF BILL90 Description: COR FFR DERIVED COR CTA DATA Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0502F NOCOV DEF SYSMAN Description: SUBSEQUENT PRENATAL CARE Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0502T MEDSV DEF BILL90 Description: COR FFR DATA PREP & TRANSMIS Category: Medical Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 61 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0503F NOCOV DEF SYSMAN Description: POSTPARTUM CARE VISIT Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 0503T MEDSV DEF BILL90 Description: COR FFR ALYS GNRJ FFR MDL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0504T MEDSV DEF BILL90 Description: COR FFR DATA REVIEW I&R Category: Medical Services CMS Add: 01/01/2018 CMS Term: 0505F NOCOV DEF SYSMAN Description: HEMODIALYSIS PLAN DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0505T NOCOV DEF SYSMAN Description: EV FEMPOP ARTL REVSC Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0506T NOCOV DEF SYSMAN Description: MAC PGMT OPT DNS MEAS HFP Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0507F NOCOV DEF SYSMAN Description: PERITON DIALYSIS PLAN DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 0507T NOCOV DEF SYSMAN Description: NEAR IFR 2IMG MIBMN GLND I&R Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0508T NOCOV DEF SYSMAN Description: PLS ECHO US B1 DNS MEAS TIB Category: Non Covered Services CMS Add: 07/01/2018 CMS Term: 0509F NOCOV DEF SYSMAN Description: URINE INCON PLAN DOCD Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 0509T NOCOV DEF SYSMAN Description: PATTERN ERG W/I&R Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0510T NOCOV DEF SYSMAN Description: RMVL SINUS TARSI IMPLANT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0511T NOCOV DEF SYSMAN Description: RMVL&RINSJ SINUS TARSI IMPLT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0512T NOCOV DEF SYSMAN Description: ESW INTEG WND HLG 1ST WND Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0513F NOCOV DEF SYSMAN Description: ELEV BP PLAN OF CARE DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0513T NOCOV DEF SYSMAN Description: ESW INTEG WND HLG EA ADDL Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 62 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0514F NOCOV DEF SYSMAN Description: CARE PLAN HGB DOCD ESA PT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0515T NOCOV DEF SYSMAN Description: INSJ WCS LV COMPL SYS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0516F NOCOV DEF SYSMAN Description: ANEMIA PLAN OF CARE DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0516T NOCOV DEF SYSMAN Description: INSJ WCS LV ELTRD ONLY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0517F NOCOV DEF SYSMAN Description: GLAUCOMA PLAN OF CARE DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0517T NOCOV DEF SYSMAN Description: INSJ WCS LV PG COMPNT Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0518F NOCOV DEF SYSMAN Description: FALL PLAN OF CARE DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0518T NOCOV DEF SYSMAN Description: RMVL PG COMPNT WCS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0519F NOCOV DEF SYSMAN Description: PLAND CHEMO DOCD B/4 TXMNT Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0519T NOCOV DEF SYSMAN Description: RMVL & RPLCMT PG COMPNT WCS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0520F NOCOV DEF SYSMAN Description: RAD DOS LIMTS B/4 3D RAD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0520T NOCOV DEF SYSMAN Description: RMVL&RPLCMT PG WCS NEW ELTRD Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0521F NOCOV DEF SYSMAN Description: PLAN OF CARE 4 PAIN DOCD Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 0521T NOCOV DEF SYSMAN Description: INTERROG DEV EVAL WCS IP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0522T NOCOV DEF SYSMAN Description: PRGRMG DEV EVAL WCS IP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0523T NOCOV DEF SYSMAN Description: NTRAPX C FFR W/3D FUNCJL MAP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 63 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0524T NOCOV DEF SYSMAN Description: EV CATH DIR CHEM ABLTJ W/IMG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0525F NOCOV DEF SYSMAN Description: INITIAL VISIT FOR EPISODE Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 0525T NOCOV DEF SYSMAN Description: INSJ/RPLCMT COMPL IIMS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0526F NOCOV DEF SYSMAN Description: SUBS VISIT FOR EPISODE Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 0526T NOCOV DEF SYSMAN Description: INSJ/RPLCMT IIMS ELTRD ONLY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0527T NOCOV DEF SYSMAN Description: INSJ/RPLCMT IIMS IMPLT MNTR Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0528F NOCOV DEF SYSMAN Description: RCMND FLW-UP 10 YRS DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0528T NOCOV DEF SYSMAN Description: PRGRMG DEV EVAL IIMS IP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0529F NOCOV DEF SYSMAN Description: INTRVL 3/>YR PTS CLNSCP DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0529T NOCOV DEF SYSMAN Description: INTERROG DEV EVAL IIMS IP Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0530T NOCOV DEF SYSMAN Description: REMOVAL COMPLETE IIMS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0531T NOCOV DEF SYSMAN Description: REMOVAL IIMS ELECTRODE ONLY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0532T NOCOV DEF SYSMAN Description: REMOVAL IIMS IMPLT MNTR ONLY Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0533T NOCOV DEF SYSMAN Description: CONT REC MVMT DO 6-10 DAYS Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0534T NOCOV DEF SYSMAN Description: CONT REC MVMT DO SETUP&TRAIN Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0535F NOCOV DEF SYSMAN Description: DYSPNEA MNGMNT PLAN DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 64 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0535T NOCOV DEF SYSMAN Description: CONT REC MVMT DO REPRT CNFIG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0536T NOCOV DEF SYSMAN Description: CONT REC MVMT DO DL W/I&R Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0537T MEDSV DEF RBRVS 01/01/2019 0.00 Y Description: BLD DRV T LYMPHCYT CAR-T CLL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 0538T MEDSV DEF RBRVS 01/01/2019 0.00 Y Description: BLD DRV T LYMPHCYT PREP TRNS Category: Medical Services CMS Add: 01/01/2019 CMS Term: 0539T MEDSV DEF RBRVS 01/01/2019 0.00 Y Description: RECEIPT&PREP CAR-T CLL ADMN Category: Medical Services CMS Add: 01/01/2019 CMS Term: 0540F NOCOV DEF SYSMAN Description: GLUCO MNGMNT PLAN DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0540T MEDSV DEF BILL90 Y Description: CAR-T CLL ADMN AUTOLOGOUS Category: Medical Services CMS Add: 01/01/2019 CMS Term: 0541T NOCOV DEF SYSMAN Description: MYOCARDIAL IMAGING MCG Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0542T NOCOV DEF SYSMAN Description: MYOCARDIAL IMAGING MCG I&R Category: Non Covered Services CMS Add: 01/01/2019 CMS Term: 0543T NOCOV DEF SYSMAN Description: TA MV RPR W/ARTIF CHORD TEND Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0544T NOCOV DEF SYSMAN Description: TCAT MV ANNULUS RCNSTJ Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0545F NOCOV DEF SYSMAN Description: FOLLOW UP CARE PLAN MDD DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 0545T NOCOV DEF SYSMAN Description: TCAT TV ANNULUS RCNSTJ Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0546T NOCOV DEF SYSMAN Description: RF SPECTRSC NTRAOP MRGN ASMT Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0547T NOCOV DEF SYSMAN Description: B1 MATRL QUAL TST MCRIND TIB Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0552T NOCOV DEF SYSMAN Description: LOW-LEVEL LASER THERAPY Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 65 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0553T NOCOV DEF SYSMAN Description: PERQ TCAT ILIAC ANAST IMPLT Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0554T MEDSV DEF BILL90 Description: B1 STR & FX RSK ANALYSIS Category: Medical Services CMS Add: 07/01/2019 CMS Term: 0555F NOCOV DEF SYSMAN Description: SYMPTOM MGMNT PLAN CARE DOCD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 0555T MEDSV DEF BILL90 Description: B1 STR&FX RSK TRANSMIS DATA Category: Medical Services CMS Add: 07/01/2019 CMS Term: 0556F NOCOV DEF SYSMAN Description: PLAN CARE LIPID CONTROL DOCD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 0556T MEDSV DEF BILL90 Description: B1 STR & FX RSK ASSESSMENT Category: Medical Services CMS Add: 07/01/2019 CMS Term: 0557F NOCOV DEF SYSMAN Description: PLAN CAREMNG ANGNL SYMPTDOCD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 0557T MEDSV DEF BILL90 Description: B1 STR & FX RSK I&R Category: Medical Services CMS Add: 07/01/2019 CMS Term: 0558T NOCOV DEF SYSMAN Description: CT SCAN F/BIOMCHN CT ALYS Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0559T NOCOV DEF SYSMAN Description: ANTMC MDL 3D PRINT 1ST CMPNT Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0560T NOCOV DEF SYSMAN Description: ANTMC MDL 3D PRINT EA ADDL Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0561T NOCOV DEF SYSMAN Description: ANTMC GUIDE 3D PRINT 1ST GD Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0562T NOCOV DEF SYSMAN Description: ANTMC GUIDE 3D PRINT EA ADDL Category: Non Covered Services CMS Add: 07/01/2019 CMS Term: 0563T NOCOV DEF SYSMAN Description: EVAC MEIBOMIAN GLND HEAT BI Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0564T NOCOV DEF SYSMAN Description: ONC CHEMO RX CYTOTOX CSC 14 Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0565T NOCOV DEF SYSMAN Description: AUTOL CELL IMPLT ADPS HRVG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 66 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0566T NOCOV DEF SYSMAN Description: AUTOL CELL IMPLT ADPS NJX Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0567T MEDSV DEF BILL90 Y 21-999years rs Description: PERM FLP TUBE OCCLS W/IMPLT Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0568T NOCOV DEF SYSMAN Description: INTRO MIX SALINE&AIR F/SSG Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0569T NOCOV DEF SYSMAN Description: TTVR PERQ APPR 1ST PROSTH Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0570T NOCOV DEF SYSMAN Description: TTVR PERQ EA ADDL PROSTH Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0571T MEDSV DEF BILL90 Y Description: INSJ/RPLCMT ICDS SS ELTRD Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0572T MEDSV DEF BILL90 Y Description: INSERTION SS DFB ELECTRODE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0573T MEDSV DEF BILL90 Y Description: REMOVAL SS DFB ELECTRODE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0574T MEDSV DEF BILL90 Y Description: REPOS PREV SS IMPL DFB ELTRD Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0575F NOCOV DEF SYSMAN Description: HIV RNA PLAN CARE DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 0575T MEDSV DEF BILL90 Y Description: PRGRMG DEV EVAL ICDS SS IP Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0576T MEDSV DEF BILL90 Y Description: INTERROG DEV EVAL ICDS SS IP Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0577T MEDSV DEF BILL90 Y Description: EPHYS EVAL ICDS SS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0578T MEDSV DEF BILL90 Y Description: REM INTERROG DEV ICDS PHYS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0579T MEDSV DEF BILL90 Y Description: REM INTERROG DEV ICDS TECH Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0580F NOCOV DEF SYSMAN Description: MULTIDISCIPLINARY CARE PLAN Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 67 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0580T MEDSV DEF BILL90 Description: RMVL SS IMPL DFB PG ONLY Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0581F NOCOV DEF SYSMAN Description: PT TRNSFRD FROM ANESTH TO CC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0581T NOCOV DEF SYSMAN Description: ABLTJ MAL BRST TUM PERQ CRTX Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0582F NOCOV DEF SYSMAN Description: NO TRNSFR FROM ANESTH TO CC Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0582T MEDSV DEF BILL90 Description: TRURL ABLTJ MAL PRST8 TISS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0583F NOCOV DEF SYSMAN Description: TRANSFER CARE CHECKLIST USED Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0583T MEDSV DEF BILL90 Y Description: TMPST AUTO TUBE DLVR SYS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0584F NOCOV DEF SYSMAN Description: NO TRANSFERCARE CHKLIST USED Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 0584T NOCOV DEF SYSMAN Description: PERQ ISLET CELL TRANSPLANT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0585T NOCOV DEF SYSMAN Description: LAPS ISLET CELL TRANSPLANT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0586T NOCOV DEF SYSMAN Description: OPEN ISLET CELL TRANSPLANT Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0587T MEDSV DEF BILL90 Y Description: PERQ IMPLTJ/RPLCMT ISDNS PTN Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0588T MEDSV DEF BILL90 Y Description: REVISION/REMOVAL ISDNS PTN Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0589T MEDSV DEF BILL90 Y Description: ELEC ALYS SMPL PRGRMG IINS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0590T MEDSV DEF BILL90 Y Description: ELEC ALYS CPLX PRGRMG IINS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 0591T NOCOV DEF SYSMAN Description: HLTH&WB COACHING INDIV 1ST Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 68 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0592T NOCOV DEF SYSMAN Description: HLTH&WB COACHING INDIV F-UP Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0593T NOCOV DEF SYSMAN Description: HLTH&WB COACHING GROUP Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 0594T MEDSV DEF BILL90 Y Description: OSTEOT HUM XTRNL LNGTH DEV Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0596T NOCOV DEF SYSMAN Description: TEMP FML IU VLV-PMP 1ST INSJ Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0597T NOCOV DEF SYSMAN Description: TEMP FML IU VALVE-PMP RPLCMT Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0598T NOCOV DEF SYSMAN Description: NCNTC R-T FLUOR WND IMG 1ST Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0599T NOCOV DEF SYSMAN Description: NCNTC R-T FLUOR WND IMG EA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0600T NOCOV DEF SYSMAN Description: IRE ABLTJ 1+TUM ORGAN PERQ Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0601T NOCOV DEF SYSMAN Description: IRE ABLTJ 1+TUMORS OPEN Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0602T NOCOV DEF SYSMAN Description: TRANSDERMAL GFR MEASUREMENTS Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0603T NOCOV DEF SYSMAN Description: TRANSDERMAL GFR MONITORING Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0604T NOCOV DEF SYSMAN Description: REM OCT RTA DEV SETUP&EDUCAJ Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0605T NOCOV DEF SYSMAN Description: REM OCT RTA TECHL SPRT MIN 8 Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0606T NOCOV DEF SYSMAN Description: REM OCT RTA PHYS/QHP EA 30D Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0607T MEDSV DEF BILL90 Description: REM MNTR PULM FLU MNTR SETUP Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0608T MEDSV DEF BILL90 Description: REM MNTR PULM FLU MNTR ALYS Category: Medical Services CMS Add: 07/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 69 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0609T NOCOV DEF SYSMAN Description: MRS DISC PAIN ACQUISJ DATA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0610T NOCOV DEF SYSMAN Description: MRS DISC PAIN TRANSMIS DATA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0611T NOCOV DEF SYSMAN Description: MRS DISC PAIN ALG ALYS DATA Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0612T NOCOV DEF SYSMAN Description: MRS DISCOGENIC PAIN I&R Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0613T NOCOV DEF SYSMAN Description: PERQ TCAT INTRATRL SEPTL SHT Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0614T MEDSV DEF BILL90 Description: RMVL&RPLCMT SS IMPL DFB PG Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0615T MEDSV DEF BILL90 Description: EYE MVMT ALYS W/O CALBRJ I&R Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0616T NOCOV DEF SYSMAN Description: INSERTION OF IRIS PROSTHESIS Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0617T NOCOV DEF SYSMAN Description: INSJ IRIS PROSTH W/RMVL&INSJ Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0618T NOCOV DEF SYSMAN Description: INSJ IRIS PROSTH SEC IO LENS Category: Non Covered Services CMS Add: 07/01/2020 CMS Term: 0619T MEDSV DEF BILL90 Description: CYSTO W/PRST8 COMMISSUROTOMY Category: Medical Services CMS Add: 07/01/2020 CMS Term: 0620T NOCOV DEF SYSMAN Description: EVASC VEN ARTLZ TIBL/PRNL VN Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0621T NOCOV DEF SYSMAN Description: TRABECULOSTOMY INTERNO LASER Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0622T NOCOV DEF SYSMAN Description: TRABECULOSTOMY INT LSR W/SCP Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0623T NOCOV DEF SYSMAN Description: AUTO QUANTIFICATION C PLAQUE Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0624T NOCOV DEF SYSMAN Description: AUTO QUAN C PLAQ DATA PREP Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 70 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0625T NOCOV DEF SYSMAN Description: AUTO QUAN C PLAQ CPTR ALYS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0626T NOCOV DEF SYSMAN Description: AUTO QUAN C PLAQ I&R Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0627T NOCOV DEF SYSMAN Description: PERQ NJX ALGC FLUOR LMBR 1ST Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0628T NOCOV DEF SYSMAN Description: PERQ NJX ALGC FLUOR LMBR EA Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0629T NOCOV DEF SYSMAN Description: PERQ NJX ALGC CT LMBR 1ST Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0630T NOCOV DEF SYSMAN Description: PERQ NJX ALGC CT LMBR EA Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0631T NOCOV DEF SYSMAN Description: TC VIS LIT HYPERSPECTRAL IMG Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0632T NOCOV DEF SYSMAN Description: PERQ TCAT US ABLTJ NRV P-ART Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0633T NOCOV DEF SYSMAN Description: CT BREAST W/3D UNI C- Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0634T NOCOV DEF SYSMAN Description: CT BREAST W/3D UNI C+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0635T NOCOV DEF SYSMAN Description: CT BREAST W/3D UNI C-/C+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0636T NOCOV DEF SYSMAN Description: CT BREAST W/3D BI C- Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0637T NOCOV DEF SYSMAN Description: CT BREAST W/3D BI C+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0638T NOCOV DEF SYSMAN Description: CT BREAST W/3D BI C-/C+ Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0639T NOCOV DEF SYSMAN Description: WRLS SKN SNR ANISOTROPY MEAS Category: Non Covered Services CMS Add: 01/01/2021 CMS Term: 0640T NOCOV DEF SYSMAN Description: NCNTC NR IFR SPCTRSC WND Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 71 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0641T NOCOV DEF SYSMAN Description: NCNTC NR IFR SPCTRSC WND IMG Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0642T NOCOV DEF SYSMAN Description: NCNTC NR IFR SPCTRSC WND I&R Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0643T NOCOV DEF SYSMAN Description: TCAT L VENTR RSTRJ DEV IMPLT Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0644T NOCOV DEF SYSMAN Description: TCAT RMVL/DBLK ICAR MAS PERQ Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0645T NOCOV DEF SYSMAN Description: TCAT IMPLTJ C SINS RDCTJ DEV Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0646T NOCOV DEF SYSMAN Description: TTVI/RPLCMT W/PRSTC VLV PERQ Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0647T NOCOV DEF SYSMAN Description: INSJ GTUBE PERQ MAG GASTRPXY Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0648T NOCOV DEF SYSMAN Description: QUAN MR TIS WO MRI 1ORGN Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0649T NOCOV DEF SYSMAN Description: QUAN MR TISS W/MRI 1ORGN Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0650T NOCOV DEF SYSMAN Description: PRGRMG DEV EVAL SCRMS REMOTE Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0651T NOCOV DEF SYSMAN Description: MAG CTRLD CAPSULE ENDOSCOPY Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0652T NOCOV DEF SYSMAN Description: EGD FLX TRANSNASAL DX BR/WA Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0653T NOCOV DEF SYSMAN Description: EGD FLX TRANSNASAL BX 1/MLT Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0654T NOCOV DEF SYSMAN Description: EGD FLX TRANSNASAL TUBE/CATH Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0655T MEDSV DEF BILL90 Y Description: TPRNL FOCAL ABLTJ MAL PRST8 Category: Medical Services CMS Add: 07/01/2021 CMS Term: 0656T NOCOV DEF SYSMAN Description: VRT BDY TETHERING ANT <7 SEG Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 72 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0657T NOCOV DEF SYSMAN Description: VRT BDY TETHERING ANT 8+ SEG Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0658T NOCOV DEF SYSMAN Description: ELEC IMPD SPECTRSC 1+SKN LES Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0659T NOCOV DEF SYSMAN Description: TCAT INTRA-C NFS SUPERSAT O2 Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0660T NOCOV DEF SYSMAN Description: IMPLT ANT SGM IO NBIO RX SYS Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0661T NOCOV DEF SYSMAN Description: RMVL&RIMPLTJ ANT SGM IMPLT Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0662T NOCOV DEF SYSMAN Description: SCALP COOL 1ST MEAS&CALBRJ Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0663T NOCOV DEF SYSMAN Description: SCALP COOL PLMT MNTR RMVL Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0664T NOCOV DEF SYSMAN Description: DON HYSTERECTOMY OPEN CDVR Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0665T NOCOV DEF SYSMAN Description: DON HYSTERECTOMY OPEN LIV Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0666T NOCOV DEF SYSMAN Description: DON HYSTERECTOMY LAPS LIV Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0667T NOCOV DEF SYSMAN Description: DON HYSTERECTOMY RCP UTER Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0668T NOCOV DEF SYSMAN Description: BKBENCH PREP DON UTER ALGRFT Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0669T NOCOV DEF SYSMAN Description: BKBENCH RCNSTJ DON UTER VEN Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0670T NOCOV DEF SYSMAN Description: BKBENCH RCNSTJ DON UTER ARTL Category: Non Covered Services CMS Add: 07/01/2021 CMS Term: 0671T MEDSV DEF BILL90 Description: INSJ ANT SGM AQ DRG DEV 1+ Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0672T NOCOV DEF SYSMAN Description: NDOVAG CRYG RF REMDL TISS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 73 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0673T MEDSV DEF BILL90 Y Description: ABLTJ B9 THYR NDUL PERQ LASR Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0674T MEDSV DEF BILL90 Description: LAPS INSJ NW/RPCMT PRM ISDSS Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0675T MEDSV DEF BILL90 Description: LAPS INSJ NW/RPCMT ISDSS 1LD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0676T MEDSV DEF BILL90 Description: LAPS INSJ NW/RPCMT ISDSS EA Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0677T MEDSV DEF BILL90 Description: LAPS REPOS LEAD ISDSS 1ST LD Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0678T NOCOV DEF SYSMAN Description: LAPS REPOS LEAD ISDSS EA ADD Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0679T NOCOV DEF SYSMAN Description: LAPS RMVL LEAD ISDSS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0680T NOCOV DEF SYSMAN Description: INSJ/RPLCMT PG ONLY ISDSS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0681T NOCOV DEF SYSMAN Description: RLCJ PULSE GEN ONLY ISDSS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0682T NOCOV DEF SYSMAN Description: REMOVAL PULSE GEN ONLY ISDSS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0683T NOCOV DEF SYSMAN Description: PRGRMG DEV EVAL ISDSS IP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0684T NOCOV DEF SYSMAN Description: PERI-PX DEV EVAL ISDSS IP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0685T NOCOV DEF SYSMAN Description: INTERROG DEV EVAL ISDSS IP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0686T NOCOV DEF SYSMAN Description: HISTOTRIPSY MAL HEPATCEL TIS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0687T NOCOV DEF SYSMAN Description: TX AMBLYOPIA DEV SETUP 1ST Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0688T NOCOV DEF SYSMAN Description: TX AMBLYOPIA ASSMT W/REPORT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 74 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0689T NOCOV DEF SYSMAN Description: QUAN US TIS CHARAC W/O DX US Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0690T NOCOV DEF SYSMAN Description: QUAN US TIS CHARAC W/DX US Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0691T NOCOV DEF SYSMAN Description: AUTO ALYS XST CT STD VRT FX Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0692T NOCOV DEF SYSMAN Description: THERAPEUTIC ULTRAFILTRATION Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0693T NOCOV DEF SYSMAN Description: COMPRE FUL BDY 3D MTN ALYS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0694T NOCOV DEF SYSMAN Description: 3D VOL IMG&RCNSTJ BRST/AX Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0695T NOCOV DEF SYSMAN Description: BDY SRF MPG PM/CVDFB TM IMPL Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0696T NOCOV DEF SYSMAN Description: BDY SURF MAPG PM/CVDFB F/UP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0697T NOCOV DEF SYSMAN Description: QUAN MR TIS WO MRI MLT ORGN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0698T NOCOV DEF SYSMAN Description: QUAN MR TISS W/MRI MLT ORGN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0699T MEDSV DEF BILL90 Description: NJX PST CHMBR EYE MEDICATION Category: Medical Services CMS Add: 01/01/2022 CMS Term: 0700T NOCOV DEF SYSMAN Description: MOLEC FLUOR IMG SUS NEV 1ST Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0701T NOCOV DEF SYSMAN Description: MOLEC FLUOR IMG SUS NEV EA Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0704T NOCOV DEF SYSMAN Description: REM TX AMBLYOPIA SETUP&EDU Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0705T NOCOV DEF SYSMAN Description: REM TX AMBLYOPIA TECH SPRT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0706T NOCOV DEF SYSMAN Description: REM TX AMBLYOPIA I&R PHY/QHP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 75 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0707T NOCOV DEF SYSMAN Description: NJX B1 SUB MTRL SBCHDRL DFCT Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0708T NOCOV DEF SYSMAN Description: ID CA IMMNTX PREP & 1ST NJX Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0709T NOCOV DEF SYSMAN Description: ID CA IMMNTX EACH ADDL NJX Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0710T NOCOV DEF SYSMAN Description: N-INVAS ARTL PLAQ ALYS Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0711T NOCOV DEF SYSMAN Description: N-NVS ARTL PLAQ ALYS DAT PRP Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0712T NOCOV DEF SYSMAN Description: N-NVS ARTL PLAQ ALYS QUAN Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0713T NOCOV DEF SYSMAN Description: N-NVS ARTL PLAQ ALYS RVW I&R Category: Non Covered Services CMS Add: 01/01/2022 CMS Term: 0714T NOCOV DEF SYSMAN Description: TPRNL LSR ABLT B9 PRST8 HYPR Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0715T NOCOV DEF SYSMAN Description: PERQ TRLUML CORONRY LITHOTRP Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0716T NOCOV DEF SYSMAN Description: CAR ACOUS WAVFRM REC CAD RSK Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0717T NOCOV DEF SYSMAN Description: ADRC THER PRTL RC TEAR Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0718T NOCOV DEF SYSMAN Description: ADRC THER PRTL RC TEAR NJX Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0719T NOCOV DEF SYSMAN Description: PST VRT JT RPLCMT LMBR 1 SGM Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0720T NOCOV DEF SYSMAN Description: PRQ ELC NRV STIM CN WO IMPLT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0721T NOCOV DEF SYSMAN Description: QUAN CT TISS CHARAC W/O CT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0722T NOCOV DEF SYSMAN Description: QUAN CT TISS CHARAC W/CT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 76 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0723T NOCOV DEF SYSMAN Description: QMRCP W/O DX MRI SM ANAT SES Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0724T NOCOV DEF SYSMAN Description: QMRCP W/DX MRI SAME ANATOMY Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0725T NOCOV DEF SYSMAN Description: VESTIBULAR DEV IMPLTJ UNI Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0726T NOCOV DEF SYSMAN Description: RMVL IMPLT VSTIBULAR DEV UNI Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0727T NOCOV DEF SYSMAN Description: RMVL&RPLCMT IMPLT VSTBLR DEV Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0728T NOCOV DEF SYSMAN Description: DX ALYS VSTBLR IMPLT UNI 1ST Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0729T NOCOV DEF SYSMAN Description: DX ALYS VSTBLR IMPLT UNI SBQ Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0730T MEDSV DEF BILL90 Description: TRABECULOTOMY LSR W/OCT GDN Category: Medical Services CMS Add: 07/01/2022 CMS Term: 0731T NOCOV DEF SYSMAN Description: AUGMNT AI-BASED FCL PHNT A/R Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0732T NOCOV DEF SYSMAN Description: IMMNTX ADMN ELECTROPORATN IM Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0733T NOCOV DEF SYSMAN Description: REM R-T MTN NREHAB THER SPLY Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0734T NOCOV DEF SYSMAN Description: REM R-T MTN NREHAB TX MGMT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0735T NOCOV DEF SYSMAN Description: PREP TUM CAV IORT PRIM CRNOT Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0736T NOCOV DEF SYSMAN Description: COLONIC LAVAGE 35+L WATER Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0737T NOCOV DEF SYSMAN Description: XENOGRAFT IMPLTJ ARTCLR SURF Category: Non Covered Services CMS Add: 07/01/2022 CMS Term: 0738T NOCOV DEF SYSMAN Description: TX PLN MAG FLD ABLTJ PRST8 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 77 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0739T NOCOV DEF SYSMAN Description: ABLTJ MAL PRST8 MAG FLD NDCT Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0740T NOCOV DEF SYSMAN Description: REM AUTON ALG NSLN CAL SETUP Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0741T NOCOV DEF SYSMAN Description: REM AUTON ALG NSLN DATA COLL Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0742T RADIO DEF BILL90 Description: AQMBF SPECT XERS/STRS & REST Category: Radiology CMS Add: 01/01/2023 CMS Term: 0743T RADIO DEF BILL90 Description: B1 STR & FX RSK VRT FX ASSMT Category: Radiology CMS Add: 01/01/2023 CMS Term: 0744T NOCOV DEF SYSMAN Description: INSJ BIOPROSTC VLV FEM VN Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0745T MEDSV DEF BILL90 Description: CAR ABLT RAD ARR N-INVAS LOC Category: Medical Services CMS Add: 01/01/2023 CMS Term: 0746T MEDSV DEF BILL90 Description: CAR ABLT RAD ARR CNV LOC MAP Category: Medical Services CMS Add: 01/01/2023 CMS Term: 0747T NOCOV DEF SYSMAN Description: CAR ABLT RAD ARRHYT DLVR RAD Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0748T NOCOV DEF SYSMAN Description: NJX STM CL PRDCT ANL SFT TIS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0749T RADIO DEF BILL90 Description: B1 STR&FX RSK ASSMT DXR-BMD Category: Radiology CMS Add: 01/01/2023 CMS Term: 0750T RADIO DEF BILL90 Description: B1 STR&FX RSK ASMT DXRBMD1VW Category: Radiology CMS Add: 01/01/2023 CMS Term: 0751T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SLD LEVEL II Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0752T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SLD LVL III Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0753T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SLD LEVEL IV Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0754T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SLD LEVEL V Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 78 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0755T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SLD LEVEL VI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0756T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SLD SPC GRPI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0757T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SL SPC GRPII Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0758T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SL SPC HCHEM Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0759T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SL SP GRPIII Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0760T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SL IMM 1ST Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0761T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SL IMM EA 1 Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0762T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP SL IMM EA M Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0763T NOCOV DEF SYSMAN Description: DGTZ GLS MCRSCP MPHMTRC ALYS Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0764T NOCOV DEF SYSMAN Description: ASSTV ALG ECG RSK ASMT CNCRT Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0765T NOCOV DEF SYSMAN Description: ASSTV ALG ECG RSK ASMT PREV Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0766T NOCOV DEF SYSMAN Description: TC MAG STIMJ PN 1ST TX 1NRV Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0767T NOCOV DEF SYSMAN Description: TC MAG STIMJ PN 1ST TX EA Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0768T NOCOV DEF SYSMAN Description: TC MAG STIMJ PN SBSQ TX 1NRV Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0769T NOCOV DEF SYSMAN Description: TC MAG STIMJ PN SBSQ TX EA Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0770T NOCOV DEF SYSMAN Description: VR TECHNOLOGY ASSIST THERAPY Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 79 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0771T NOCOV DEF SYSMAN Description: VR PX DISSOC SVC SM PHY 1ST Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0772T NOCOV DEF SYSMAN Description: VR PX DISSOC SVC SM PHY EA Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0773T NOCOV DEF SYSMAN Description: VR PX DISSOC SVC OTH PHY 1ST Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0774T NOCOV DEF SYSMAN Description: VR PX DISSOC SVC OTH PHY EA Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0775T NOCOV DEF SYSMAN Description: ARTHRD SI JT PRQ IARTIC IMPL Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0776T NOCOV DEF SYSMAN Description: THER INDCTJ NTRABRN HYPTHRM Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0777T MEDSV DEF BILL90 Description: R-T PRS SENSING EDRL GDN SYS Category: Medical Services CMS Add: 01/01/2023 CMS Term: 0778T NOCOV DEF SYSMAN Description: SMMG CNCRNT APPL IMU SNR Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0779T NOCOV DEF SYSMAN Description: GI MYOELECTRICAL ACTV STUDY Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0780T NOCOV DEF SYSMAN Description: INSTLJ FECAL MICROBIOTA SSP Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0781T NOCOV DEF SYSMAN Description: BRNCHSC RF DSTRJ PULM NRV BI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0782T NOCOV DEF SYSMAN Description: BRNCHSC RF DSTRJ PLM NRV UNI Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0783T NOCOV DEF SYSMAN Description: TC AURICULR NEUROSTIMULATION Category: Non Covered Services CMS Add: 01/01/2023 CMS Term: 0791T NOCOV DEF SYSMAN Description: MOTR COG VR GAIT TRAIN EA 15 Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0792T NOCOV DEF SYSMAN Description: APPL SLVR DIAMN FLUORIDE 38% Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0793T NOCOV DEF SYSMAN Description: PRQ TCAT THRM ABLT NRV P-ART Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 80 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0794T NOCOV DEF SYSMAN Description: PT SPEC ALG RX-ONC TX OPTION Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0795T NOCOV DEF SYSMAN Description: TCAT INS 2CHMBR LDLS PM CMPL Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0796T NOCOV DEF SYSMAN Description: TCAT INS 2CHMBR LDLS PM RA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0797T NOCOV DEF SYSMAN Description: TCAT INS 2CHMBR LDLS PM RV Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0798T NOCOV DEF SYSMAN Description: TCAT RMV 2CHMBR LDLS PM CMPL Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0799T NOCOV DEF SYSMAN Description: TCAT RMVL 2CHMBR LDLS PM RA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0800T NOCOV DEF SYSMAN Description: TCAT RMVL 2CHMBR LDLS PM RV Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0801T NOCOV DEF SYSMAN Description: TCAT RMV&RPL 2CHMBR LDLS PM Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0802T NOCOV DEF SYSMAN Description: TCAT RMV&RPL2CHMB LDLS PM RA Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0803T NOCOV DEF SYSMAN Description: TCAT RMV&RPL2CHMB LDLS PM RV Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0804T NOCOV DEF SYSMAN Description: PRGRMG EVL LDLS PM 2CHMBR IP Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0805T NOCOV DEF SYSMAN Description: TCAT S&IVC PRSTC VL IMPL PRQ Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0806T NOCOV DEF SYSMAN Description: TCAT S&IVC PRSTC VL IMPL OPN Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0807T NOCOV DEF SYSMAN Description: PULM TISS VNTJ ALYS PREV CT Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0808T NOCOV DEF SYSMAN Description: PULM TISS VNTJ ALYS W/CT Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 0809T NOCOV DEF SYSMAN Description: ARTHRD SI JT PRQ TFX&IMPLT Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 81 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 0810T NOCOV DEF SYSMAN Description: SUBRTA NJX RX AGT W/VTRC Category: Non Covered Services CMS Add: 07/01/2023 CMS Term: 10004 MEDSV DEF RBRVS 01/01/2019 37.68 Description: FNA BX W/O IMG GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10005 MEDSV DEF RBRVS 01/01/2019 90.75 Description: FNA BX W/US GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10006 MEDSV DEF RBRVS 01/01/2019 43.63 Description: FNA BX W/US GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10007 MEDSV DEF RBRVS 01/01/2019 202.63 Description: FNA BX W/FLUOR GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10008 MEDSV DEF RBRVS 01/01/2019 114.44 Description: FNA BX W/FLUOR GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10009 MEDSV DEF RBRVS 01/01/2019 330.90 Description: FNA BX W/CT GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 1000F NOCOV DEF SYSMAN Description: TOBACCO USE ASSESSED Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 10010 MEDSV DEF RBRVS 01/01/2019 199.81 Description: FNA BX W/CT GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10011 MEDSV DEF BILL20 Description: FNA BX W/MR GDN 1ST LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10012 MEDSV DEF BILL20 Description: FNA BX W/MR GDN EA ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 10021 26 MEDSV DEF RBRVS 02/01/2015 48.90 Description: FNA BX W/O IMG GDN 1ST LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 10021 MEDSV DEF RBRVS 09/01/2019 104.97 Description: FNA BX W/O IMG GDN 1ST LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 10021 TC MEDSV DEF RBRVS 02/01/2015 12.14 Description: FNA BX W/O IMG GDN 1ST LES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 1002F NOCOV DEF SYSMAN Description: ASSESS ANGINAL SYMPTOM/LEVEL Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 10030 MEDSV DEF RBRVS 09/15/2017 490.96 Description: GUIDE CATHET FLUID DRAINAGE Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 82 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 10035 MEDSV DEF RBRVS 01/01/2016 378.19 0-1 Description: PERQ DEV SOFT TISS 1ST IMAG Category: Medical Services CMS Add: 01/01/2016 CMS Term: 10036 MEDSV DEF RBRVS 09/01/2019 327.77 Description: PERQ DEV SOFT TISS ADD IMAG Category: Medical Services CMS Add: 01/01/2016 CMS Term: 1003F NOCOV DEF SYSMAN Description: LEVEL OF ACTIVITY ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 10040 NOCOV DEF SYSMAN 0-1 Description: ACNE SURGERY Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 1004F NOCOV DEF SYSMAN Description: CLIN SYMP VOL OVRLD ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 1005F NOCOV DEF SYSMAN Description: ASTHMA SYMPTOMS EVALUATE Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 10060 MEDSV DEF RBRVS 09/01/2019 82.16 0-1 Description: DRAINAGE OF SKIN ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10061 MEDSV DEF RBRVS 09/01/2019 145.92 0-1 Description: DRAINAGE OF SKIN ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1006F NOCOV DEF SYSMAN Description: OSTEOARTHRITIS ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 1007F NOCOV DEF SYSMAN Description: ANTI-INFLM/ANLGSC OTC ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 10080 MEDSV DEF RBRVS 09/01/2019 125.34 Description: DRAINAGE OF PILONIDAL CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10081 MEDSV DEF RBRVS 09/01/2019 190.20 Description: DRAINAGE OF PILONIDAL CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1008F NOCOV DEF SYSMAN Description: GI/RENAL RISK ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 1010F NOCOV DEF SYSMAN Description: SEVERITY ANGINA BY ACTVTY Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1011F NOCOV DEF SYSMAN Description: ANGINA PRESENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 10120 MEDSV DEF RBRVS 09/01/2019 106.85 Description: REMOVE FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 83 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 10121 MEDSV DEF RBRVS 09/01/2019 193.76 Description: REMOVE FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1012F NOCOV DEF SYSMAN Description: ANGINA ABSENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 10140 MEDSV DEF RBRVS 09/01/2019 114.95 Description: DRAINAGE OF HEMATOMA/FLUID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1015F NOCOV DEF SYSMAN Description: COPD SYMPTOMS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 10160 MEDSV DEF RBRVS 09/01/2019 91.80 Description: PUNCTURE DRAINAGE OF LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 10180 MEDSV DEF RBRVS 09/01/2019 172.94 Description: COMPLEX DRAINAGE WOUND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 1018F NOCOV DEF SYSMAN Description: ASSESS DYSPNEA NOT PRESENT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1019F NOCOV DEF SYSMAN Description: ASSESS DYSPNEA PRESENT Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1022F NOCOV DEF SYSMAN Description: PNEUMO IMM STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1026F NOCOV DEF SYSMAN Description: CO-MORBID CONDITION ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1030F NOCOV DEF SYSMAN Description: INFLUENZA IMM STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1031F NOCOV DEF SYSMAN Description: SMOKING & 2ND HAND ASSESSED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1032F NOCOV DEF SYSMAN Description: SMOKER/EXPOSED 2ND HND SMOKE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1033F NOCOV DEF SYSMAN Description: TOBACCO NONSMOKER NOR 2NDHND Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1034F NOCOV DEF SYSMAN Description: CURRENT TOBACCO SMOKER Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1035F NOCOV DEF SYSMAN Description: SMOKELESS TOBACCO USER Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 84 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1036F NOCOV DEF SYSMAN Description: TOBACCO NON-USER Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1038F NOCOV DEF SYSMAN Description: PERSISTENT ASTHMA Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1039F NOCOV DEF SYSMAN Description: INTERMITTENT ASTHMA Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1040F NOCOV DEF SYSMAN Description: DSM-5 INFO MDD DOCD Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1050F NOCOV DEF SYSMAN Description: HISTORY OF MOLE CHANGES Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1052F NOCOV DEF SYSMAN Description: TYPE LOCATION ACTIVITYASSESS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1055F NOCOV DEF SYSMAN Description: VISUAL FUNCT STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 1060F NOCOV DEF SYSMAN Description: DOC PERM/CONT/PAROX ATR FIB Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1061F NOCOV DEF SYSMAN Description: DOC LACK PERM&CONT&PAROX FIB Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1065F NOCOV DEF SYSMAN Description: ISCHM STROKE SYMP LT3 HRSB/4 Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1066F NOCOV DEF SYSMAN Description: ISCHM STROKE SYMP GE3 HRSB/4 Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1070F NOCOV DEF SYSMAN Description: ALARM SYMP ASSESSED-ABSENT Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1071F NOCOV DEF SYSMAN Description: ALARM SYMP ASSESSED-1+ PRSNT Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1090F NOCOV DEF SYSMAN Description: PRES/ABSN URINE INCON ASSESS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1091F NOCOV DEF SYSMAN Description: URINE INCON CHARACTERIZED Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 11000 MEDSV DEF RBRVS 09/01/2019 38.75 0-1 Description: DEBRIDE INFECTED SKIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 85 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11001 MEDSV DEF RBRVS 02/01/2015 15.24 0-9 Description: DEBRIDE INFECTED SKIN ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11004 MEDSV DEF RBRVS 02/01/2015 418.91 Description: DEBRIDE GENITALIA & PERINEUM Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11005 MEDSV DEF RBRVS 02/01/2015 560.31 Description: DEBRIDE ABDOM WALL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11006 MEDSV DEF RBRVS 02/01/2015 507.38 Description: DEBRIDE GENIT/PER/ABDOM WALL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 11008 MEDSV DEF RBRVS 02/01/2015 196.44 Description: REMOVE MESH FROM ABD WALL Category: Medical Services CMS Add: 01/01/2005 CMS Term: 1100F NOCOV DEF SYSMAN Description: PTFALLS ASSESS-DOCD GE2>/YR Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 11010 MEDSV DEF RBRVS 01/01/2019 342.62 Description: DEBRIDE SKIN AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11011 MEDSV DEF RBRVS 01/01/2019 378.38 Description: DEBRIDE SKIN MUSC AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11012 MEDSV DEF RBRVS 01/01/2019 500.75 Description: DEB SKIN BONE AT FX SITE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 1101F NOCOV DEF SYSMAN Description: PT FALLS ASSESS-DOCD LE1/YR Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 11042 MEDSV DEF RBRVS 09/01/2019 82.13 Description: DEB SUBQ TISSUE 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11043 MEDSV DEF RBRVS 09/01/2019 162.88 Description: DEB MUSC/FASCIA 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11044 MEDSV DEF RBRVS 09/01/2019 225.84 Description: DEB BONE 20 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11045 MEDSV DEF RBRVS 02/01/2015 29.87 Description: DEB SUBQ TISSUE ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11046 MEDSV DEF RBRVS 02/01/2015 52.28 Description: DEB MUSC/FASCIA ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: 11047 MEDSV DEF RBRVS 02/01/2015 89.07 Description: DEB BONE ADD-ON Category: Medical Services CMS Add: 01/01/2011 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 86 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11055 MEDSV DEF RBRVS 02/01/2015 33.51 Description: TRIM SKIN LESION Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11056 MEDSV DEF RBRVS 02/01/2015 41.18 Description: TRIM SKIN LESIONS 2 TO 4 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11057 MEDSV DEF RBRVS 02/01/2015 46.61 Description: TRIM SKIN LESIONS OVER 4 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11102 MEDSV DEF RBRVS 01/01/2019 70.00 0-1 Description: TANGNTL BX SKIN SINGLE LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11103 MEDSV DEF RBRVS 01/01/2019 37.79 Description: TANGNTL BX SKIN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11104 MEDSV DEF RBRVS 01/01/2019 88.03 0-1 Description: PUNCH BX SKIN SINGLE LESION Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11105 MEDSV DEF RBRVS 01/01/2019 43.30 Description: PUNCH BX SKIN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11106 MEDSV DEF RBRVS 01/01/2019 106.49 0-1 Description: INCAL BX SKN SINGLE LES Category: Medical Services CMS Add: 01/01/2019 CMS Term: 11107 MEDSV DEF RBRVS 01/01/2019 51.09 Description: INCAL BX SKN EA SEP/ADDL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 1110F NOCOV DEF SYSMAN Description: PT LFT INPT FAC W/IN 60 DAYS Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1111F NOCOV DEF SYSMAN Description: DSCHRG MED/CURRENT MED MERGE Category: Non Covered Services CMS Add: 07/01/2007 CMS Term: 1116F NOCOV DEF SYSMAN Description: AURIC/PERI PAIN ASSESSED Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 1118F NOCOV DEF SYSMAN Description: GERD SYMPS ASSESSED 12 MONTH Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 1119F NOCOV DEF SYSMAN Description: INIT EVAL FOR CONDITION Category: Non Covered Services CMS Add: 01/01/2008 CMS Term: 11200 MEDSV DEF RBRVS 02/01/2015 61.75 0-1 Description: REMOVAL OF SKIN TAGS 2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11305 MEDSV DEF RBRVS 01/01/2016 69.06 Description: SHAVE SKIN LESION 0.5 CM/< Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11306 MEDSV DEF RBRVS 01/01/2016 84.58 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11307 MEDSV DEF RBRVS 01/01/2016 99.95 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11308 MEDSV DEF RBRVS 01/01/2016 105.78 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 1130F NOCOV DEF SYSMAN Description: BK PAIN & FXN ASSESSED Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 88 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11310 MEDSV DEF RBRVS 01/01/2016 78.55 Description: SHAVE SKIN LESION 0.5 CM/< Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11311 MEDSV DEF RBRVS 01/01/2016 77.45 Description: SHAVE SKIN LESION 0.6-1.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11312 MEDSV DEF RBRVS 01/01/2016 111.39 Description: SHAVE SKIN LESION 1.1-2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 11313 MEDSV DEF RBRVS 01/01/2016 129.61 Description: SHAVE SKIN LESION >2.0 CM Category: Medical Services CMS Add: 01/01/1993 CMS Term: 1134F NOCOV DEF SYSMAN Description: EPSD BK PAIN FOR 6 WKS/< Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 1135F NOCOV DEF SYSMAN Description: EPSD BK PAIN FOR >6 WKS Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 1136F NOCOV DEF SYSMAN Description: EPSD BK PAIN FOR 12 WKS/< Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 1137F NOCOV DEF SYSMAN Description: EPSD BK PAIN FOR >12 WKS Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 11400 MEDSV DEF RBRVS 02/01/2015 85.70 Description: EXC TR-EXT B9+MARG 0.5 CM< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11401 MEDSV DEF RBRVS 02/01/2015 103.67 Description: EXC TR-EXT B9+MARG 0.6-1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11402 MEDSV DEF RBRVS 02/01/2015 115.34 Description: EXC TR-EXT B9+MARG 1.1-2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11403 MEDSV DEF RBRVS 02/01/2015 133.66 Description: EXC TR-EXT B9+MARG 2.1-3CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11404 MEDSV DEF RBRVS 02/01/2015 151.65 Description: EXC TR-EXT B9+MARG 3.1-4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11406 MEDSV DEF RBRVS 02/01/2015 219.10 Description: EXC TR-EXT B9+MARG >4.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11420 MEDSV DEF RBRVS 02/01/2015 85.72 Description: EXC H-F-NK-SP B9+MARG 0.5/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11421 MEDSV DEF RBRVS 02/01/2015 110.10 Description: EXC H-F-NK-SP B9+MARG 0.6-1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 89 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11422 MEDSV DEF RBRVS 02/01/2015 122.84 Description: EXC H-F-NK-SP B9+MARG 1.1-2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11423 MEDSV DEF RBRVS 02/01/2015 141.64 Description: EXC H-F-NK-SP B9+MARG 2.1-3 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11424 MEDSV DEF RBRVS 02/01/2015 163.49 Description: EXC H-F-NK-SP B9+MARG 3.1-4 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11426 MEDSV DEF RBRVS 02/01/2015 234.58 Description: EXC H-F-NK-SP B9+MARG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11440 MEDSV DEF RBRVS 02/01/2015 94.60 Description: EXC FACE-MM B9+MARG 0.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11441 MEDSV DEF RBRVS 02/01/2015 117.74 Description: EXC FACE-MM B9+MARG 0.6-1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11442 MEDSV DEF RBRVS 02/01/2015 131.70 Description: EXC FACE-MM B9+MARG 1.1-2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11443 MEDSV DEF RBRVS 02/01/2015 157.25 Description: EXC FACE-MM B9+MARG 2.1-3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11444 MEDSV DEF RBRVS 02/01/2015 198.75 Description: EXC FACE-MM B9+MARG 3.1-4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11446 MEDSV DEF RBRVS 02/01/2015 276.44 Description: EXC FACE-MM B9+MARG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11450 MEDSV DEF RBRVS 09/01/2019 263.96 Description: REMOVAL SWEAT GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11451 MEDSV DEF RBRVS 09/01/2019 338.09 Description: REMOVAL SWEAT GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11462 MEDSV DEF RBRVS 09/01/2019 257.72 Description: REMOVAL SWEAT GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11463 MEDSV DEF RBRVS 09/01/2019 346.18 Description: REMOVAL SWEAT GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11470 MEDSV DEF RBRVS 09/01/2019 290.57 Description: REMOVAL SWEAT GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11471 MEDSV DEF RBRVS 09/01/2019 360.77 Description: REMOVAL SWEAT GLAND LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 90 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1150F NOCOV DEF SYSMAN Description: DOC PT RSK DEATH W/IN 1YR Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1151F NOCOV DEF SYSMAN Description: DOC NO PT RSK DEATH W/IN 1YR Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1152F NOCOV DEF SYSMAN Description: DOC ADVNCD DIS COMFORT 1ST Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1153F NOCOV DEF SYSMAN Description: DOC ADVNCD DIS CMFRT NOT 1ST Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1157F NOCOV DEF SYSMAN Description: ADVNC CARE PLAN IN RCRD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1158F NOCOV DEF SYSMAN Description: ADVNC CARE PLAN TLK DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1159F NOCOV DEF SYSMAN Description: MED LIST DOCD IN RCRD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 11600 MEDSV DEF RBRVS 02/01/2015 134.62 Description: EXC TR-EXT MAL+MARG 0.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11601 MEDSV DEF RBRVS 02/01/2015 159.41 Description: EXC TR-EXT MAL+MARG 0.6-1 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11602 MEDSV DEF RBRVS 02/01/2015 172.96 Description: EXC TR-EXT MAL+MARG 1.1-2 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11603 MEDSV DEF RBRVS 02/01/2015 197.56 Description: EXC TR-EXT MAL+MARG 2.1-3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11604 MEDSV DEF RBRVS 02/01/2015 220.26 Description: EXC TR-EXT MAL+MARG 3.1-4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11606 MEDSV DEF RBRVS 02/01/2015 315.71 Description: EXC TR-EXT MAL+MARG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1160F NOCOV DEF SYSMAN Description: RVW MEDS BY RX/DR IN RCRD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 11620 MEDSV DEF RBRVS 02/01/2015 136.13 Description: EXC H-F-NK-SP MAL+MARG 0.5/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11621 MEDSV DEF RBRVS 02/01/2015 160.42 Description: EXC S/N/H/F/G MAL+MRG 0.6-1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 91 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11622 MEDSV DEF RBRVS 02/01/2015 179.03 Description: EXC S/N/H/F/G MAL+MRG 1.1-2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11623 MEDSV DEF RBRVS 02/01/2015 210.72 Description: EXC S/N/H/F/G MAL+MRG 2.1-3 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11624 MEDSV DEF RBRVS 02/01/2015 237.72 Description: EXC S/N/H/F/G MAL+MRG 3.1-4 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11626 MEDSV DEF RBRVS 02/01/2015 287.44 Description: EXC S/N/H/F/G MAL+MRG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11640 MEDSV DEF RBRVS 02/01/2015 140.16 Description: EXC F/E/E/N/L MAL+MRG 0.5CM< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11641 MEDSV DEF RBRVS 02/01/2015 166.39 Description: EXC F/E/E/N/L MAL+MRG 0.6-1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11642 MEDSV DEF RBRVS 02/01/2015 189.71 Description: EXC F/E/E/N/L MAL+MRG 1.1-2 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11643 MEDSV DEF RBRVS 02/01/2015 225.33 Description: EXC F/E/E/N/L MAL+MRG 2.1-3 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11644 MEDSV DEF RBRVS 02/01/2015 277.95 Description: EXC F/E/E/N/L MAL+MRG 3.1-4 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11646 MEDSV DEF RBRVS 02/01/2015 364.30 Description: EXC F/E/E/N/L MAL+MRG >4 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1170F NOCOV DEF SYSMAN Description: FXNL STATUS ASSESSED Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 11719 MEDSV DEF RBRVS 02/01/2015 9.93 Description: TRIM NAIL(S) ANY NUMBER Category: Medical Services CMS Add: 01/01/1998 CMS Term: 11720 MEDSV DEF RBRVS 01/01/2019 22.97 Description: DEBRIDE NAIL 1-5 Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11721 MEDSV DEF RBRVS 01/01/2019 32.01 Description: DEBRIDE NAIL 6 OR MORE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 11730 MEDSV DEF RBRVS 09/01/2019 70.51 0-1 Description: REMOVAL OF NAIL PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11732 MEDSV DEF RBRVS 02/01/2015 25.45 0-10 Description: REMOVE NAIL PLATE ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 92 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11740 MEDSV DEF RBRVS 09/01/2019 34.96 Description: DRAIN BLOOD FROM UNDER NAIL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11750 MEDSV DEF RBRVS 09/01/2019 159.57 Description: REMOVAL OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11755 MEDSV DEF RBRVS 09/01/2019 94.98 Description: BIOPSY NAIL UNIT Category: Medical Services CMS Add: 01/01/1994 CMS Term: 1175F NOCOV DEF SYSMAN Description: FUNCTION STAT ASSESSED RVWD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 11760 MEDSV DEF RBRVS 09/01/2019 163.11 Description: REPAIR OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11762 MEDSV DEF RBRVS 09/01/2019 200.62 Description: RECONSTRUCTION OF NAIL BED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 11765 MEDSV DEF RBRVS 09/01/2019 117.33 Description: EXCISION OF NAIL FOLD TOE Category: Medical Services CMS Add: 01/01/1989 CMS Term: 11770 MEDSV DEF RBRVS 09/01/2019 194.42 Description: REMOVE PILONIDAL CYST SIMPLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 11771 MEDSV DEF RBRVS 09/01/2019 400.53 Description: REMOVE PILONIDAL CYST EXTEN Category: Medical Services CMS Add: 01/01/1986 CMS Term: 11772 MEDSV DEF RBRVS 09/01/2019 486.57 Description: REMOVE PILONIDAL CYST COMPL Category: Medical Services CMS Add: 01/01/1986 CMS Term: 1180F NOCOV DEF SYSMAN Description: THROMBOEMB RISK ASSESSED Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 1181F NOCOV DEF SYSMAN Description: NEUROPSYCHIA SYMPTS ASSESSED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1182F NOCOV DEF SYSMAN Description: NEUROPSYCHI SYMPT 1+PRESENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1183F NOCOV DEF SYSMAN Description: NEUROPSYCHIATRIC SYMP ABSENT Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 11900 MEDSV DEF RBRVS 09/01/2019 38.66 0-1 Description: INJECT SKIN LESIONS 7 Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 93 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 11920 MEDSV DEF RBRVS 01/01/2019 120.30 0-1 Description: CORRECT SKIN COLOR 6.0 CM/< Category: Medical Services CMS Add: 01/01/1982 CMS Term: 11921 MEDSV DEF RBRVS 01/01/2019 139.88 Y 0-1 Description: CORRECT SKN COLOR 6.1-20.0CM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 11922 MEDSV DEF RBRVS 01/01/2019 43.22 Y Description: CORRECT SKIN COLOR EA 20.0CM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 11950 NOCOV DEF SYSMAN 0-1 Description: TX CONTOUR DEFECTS 1 CC/< Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 11951 NOCOV DEF SYSMAN 0-1 Description: TX CONTOUR DEFECTS 1.1-5.0CC Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 11952 NOCOV DEF SYSMAN 0-1 Description: TX CONTOUR DEFECTS 5.1-10CC Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 11954 NOCOV DEF SYSMAN 0-1 Description: TX CONTOUR DEFECTS >10.0 CC Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 11960 MEDSV DEF RBRVS 09/01/2019 666.75 Description: INSERT TISSUE EXPANDER(S) Category: Medical Services CMS Add: 01/01/1985 CMS Term: 11970 MEDSV DEF RBRVS 09/01/2019 437.91 Description: RPLCMT TISS XPNDR PERM IMPLT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 11971 MEDSV DEF RBRVS 09/01/2019 331.08 Description: RMVL TIS XPNDR WO INSJ IMPLT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 11976 MEDSV DEF RBRVS 01/01/2019 102.90 Description: REMOVE CONTRACEPTIVE CAPSULE Category: Medical Services CMS Add: 01/01/1992 CMS Term: 11980 MEDSV DEF RBRVS 02/01/2015 73.62 Description: IMPLANT HORMONE PELLET(S) Category: Medical Services CMS Add: 01/01/2000 CMS Term: 11981 MEDSV DEF RBRVS 02/01/2015 97.07 Description: INSERTION DRUG DLVR IMPLANT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 11982 MEDSV DEF RBRVS 02/01/2015 110.33 Description: REMOVE DRUG IMPLANT DEVICE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 11983 MEDSV DEF RBRVS 02/01/2015 155.30 Description: REMOVE/INSERT DRUG IMPLANT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 12001 MEDSV DEF RBRVS 09/01/2019 63.11 Description: RPR S/N/AX/GEN/TRNK 2.5CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 94 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 12002 MEDSV DEF RBRVS 09/01/2019 76.71 Description: RPR S/N/AX/GEN/TRNK2.6-7.5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12004 MEDSV DEF RBRVS 09/01/2019 90.55 Description: RPR S/N/AX/GEN/TRK7.6-12.5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12005 MEDSV DEF RBRVS 09/01/2019 117.91 Description: RPR S/N/A/GEN/TRK12.6-20.0CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12006 MEDSV DEF RBRVS 09/01/2019 141.75 Description: RPR S/N/A/GEN/TRK20.1-30.0CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12007 MEDSV DEF RBRVS 09/01/2019 164.62 Description: RPR S/N/AX/GEN/TRNK >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1200F NOCOV DEF SYSMAN Description: SEIZURE TYPE& FREQU DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 12011 MEDSV DEF RBRVS 09/01/2019 77.05 Description: RPR F/E/E/N/L/M 2.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12013 MEDSV DEF RBRVS 09/01/2019 84.47 Description: RPR F/E/E/N/L/M 2.6-5.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12014 MEDSV DEF RBRVS 09/01/2019 99.82 Description: RPR F/E/E/N/L/M 5.1-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12015 MEDSV DEF RBRVS 09/01/2019 121.90 Description: RPR F/E/E/N/L/M 7.6-12.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12016 MEDSV DEF RBRVS 09/01/2019 150.86 Description: RPR FE/E/EN/L/M 12.6-20.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12017 MEDSV DEF RBRVS 09/01/2019 111.95 Description: RPR FE/E/EN/L/M 20.1-30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12018 MEDSV DEF RBRVS 09/01/2019 126.64 Description: RPR F/E/E/N/L/M >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12020 MEDSV DEF RBRVS 09/01/2019 201.71 Description: CLOSURE OF SPLIT WOUND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 12021 MEDSV DEF RBRVS 09/01/2019 118.16 Description: CLOSURE OF SPLIT WOUND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 12031 MEDSV DEF RBRVS 09/01/2019 165.13 Description: INTMD RPR S/A/T/EXT 2.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 95 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 12032 MEDSV DEF RBRVS 09/01/2019 210.64 Description: INTMD RPR S/A/T/EXT 2.6-7.5 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12034 MEDSV DEF RBRVS 09/01/2019 217.78 Description: INTMD RPR S/TR/EXT 7.6-12.5 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12035 MEDSV DEF RBRVS 09/01/2019 269.75 Description: INTMD RPR S/A/T/EXT 12.6-20 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12036 MEDSV DEF RBRVS 09/01/2019 297.54 Description: INTMD RPR S/A/T/EXT 20.1-30 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12037 MEDSV DEF RBRVS 09/01/2019 335.08 Description: INTMD RPR S/TR/EXT >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12041 MEDSV DEF RBRVS 09/01/2019 168.56 Description: INTMD RPR N-HF/GENIT 2.5CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12042 MEDSV DEF RBRVS 09/01/2019 201.54 Description: INTMD RPR N-HF/GENIT2.6-7.5 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12044 MEDSV DEF RBRVS 09/01/2019 251.27 Description: INTMD RPR N-HF/GENIT7.6-12.5 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12045 MEDSV DEF RBRVS 09/01/2019 281.51 Description: INTMD RPR N-HF/GENIT12.6-20 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12046 MEDSV DEF RBRVS 09/01/2019 334.10 Description: INTMD RPR N-HF/GENIT20.1-30 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12047 MEDSV DEF RBRVS 09/01/2019 367.42 Description: INTMD RPR N-HF/GENIT >30.0CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12051 MEDSV DEF RBRVS 09/01/2019 180.43 Description: INTMD RPR FACE/MM 2.5 CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12052 MEDSV DEF RBRVS 09/01/2019 205.59 Description: INTMD RPR FACE/MM 2.6-5.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12053 MEDSV DEF RBRVS 09/01/2019 241.48 Description: INTMD RPR FACE/MM 5.1-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12054 MEDSV DEF RBRVS 09/01/2019 257.86 Description: INTMD RPR FACE/MM 7.6-12.5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12055 MEDSV DEF RBRVS 09/01/2019 334.60 Description: INTMD RPR FACE/MM 12.6-20 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 96 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 12056 MEDSV DEF RBRVS 09/01/2019 387.06 Description: INTMD RPR FACE/MM 20.1-30.0 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 12057 MEDSV DEF RBRVS 09/01/2019 396.70 Description: INTMD RPR FACE/MM >30.0 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1205F NOCOV DEF SYSMAN Description: EPI ETIOL SYND RVWD AND DOCD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 1220F NOCOV DEF SYSMAN Description: PT SCREENED FOR DEPRESSION Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 13100 MEDSV DEF RBRVS 09/01/2019 233.45 Description: CMPLX RPR TRUNK 1.1-2.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13101 MEDSV DEF RBRVS 09/01/2019 276.03 Description: CMPLX RPR TRUNK 2.6-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13102 MEDSV DEF RBRVS 09/01/2019 85.50 Description: CMPLX RPR TRUNK ADDL 5CM/< Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13120 MEDSV DEF RBRVS 09/01/2019 244.33 Description: CMPLX RPR S/A/L 1.1-2.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13121 MEDSV DEF RBRVS 09/01/2019 298.13 Description: CMPLX RPR S/A/L 2.6-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13122 MEDSV DEF RBRVS 09/01/2019 93.85 Description: CMPLX RPR S/A/L ADDL 5 CM/> Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13131 MEDSV DEF RBRVS 09/01/2019 269.57 Description: CMPLX RPR F/C/C/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13132 MEDSV DEF RBRVS 09/01/2019 333.13 Description: CMPLX RPR F/C/C/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13133 MEDSV DEF RBRVS 09/01/2019 125.97 Description: CMPLX RPR F/C/C/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/2000 CMS Term: 13151 MEDSV DEF RBRVS 09/01/2019 296.04 Description: CMPLX RPR E/N/E/L 1.1-2.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13152 MEDSV DEF RBRVS 09/01/2019 355.11 Description: CMPLX RPR E/N/E/L 2.6-7.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 13153 MEDSV DEF RBRVS 09/01/2019 137.27 Description: CMPLX RPR E/N/E/L ADDL 5CM/< Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 97 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 13160 MEDSV DEF RBRVS 09/01/2019 580.63 Description: LATE CLOSURE OF WOUND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 14000 MEDSV DEF RBRVS 09/01/2019 437.45 Description: TIS TRNFR TRUNK 10 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14001 MEDSV DEF RBRVS 09/01/2019 561.90 Description: TIS TRNFR TRUNK 10.1-30SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1400F NOCOV DEF SYSMAN Description: PRKNS DIAG RVIEWED Category: Non Covered Services CMS Add: 10/01/2010 CMS Term: 14020 MEDSV DEF RBRVS 09/01/2019 490.84 Description: TIS TRNFR S/A/L 10 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14021 MEDSV DEF RBRVS 09/01/2019 613.82 Description: TIS TRNFR S/A/L 10.1-30 SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14040 MEDSV DEF RBRVS 09/01/2019 538.73 Description: TIS TRNFR F/C/C/M/N/A/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14041 MEDSV DEF RBRVS 09/01/2019 665.12 Description: TIS TRNFR F/C/C/M/N/A/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14060 MEDSV DEF RBRVS 09/01/2019 550.62 Description: TIS TRNFR E/N/E/L 10 SQ CM/< Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14061 MEDSV DEF RBRVS 09/01/2019 714.78 Description: TIS TRNFR E/N/E/L10.1-30SQCM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 14301 MEDSV DEF RBRVS 02/01/2015 761.66 Description: TIS TRNFR ANY 30.1-60 SQ CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 14302 MEDSV DEF RBRVS 01/01/2019 160.66 Description: TIS TRNFR ADDL 30 SQ CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 14350 MEDSV DEF RBRVS 09/01/2019 513.56 Description: FILLETED FINGER/TOE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 1450F NOCOV DEF SYSMAN Description: SYMPTOMS IMPROVED/CONSIST Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1451F NOCOV DEF SYSMAN Description: SYMPT SHOW CLIN IMPORT DROP Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1460F NOCOV DEF SYSMAN Description: QUAL CARD DIAG PRIOR 12 MONS Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 98 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1461F NOCOV DEF SYSMAN Description: NO QUAL CARD DIAG PRIOR12MON Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1490F NOCOV DEF SYSMAN Description: DEM SEVERITY CLASSIFIED MILD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1491F NOCOV DEF SYSMAN Description: DEM SEVERITY CLASSIFIED MOD Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1493F NOCOV DEF SYSMAN Description: DEM SEVERITY CLASS SEVERE Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 1494F NOCOV DEF SYSMAN Description: COGNIT ASSESSED AND REVIEWED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 15002 MEDSV DEF RBRVS 02/01/2015 245.05 Description: WOUND PREP TRK/ARM/LEG Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15003 MEDSV DEF RBRVS 02/01/2015 53.45 Description: WOUND PREP ADDL 100 CM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15004 MEDSV DEF RBRVS 02/01/2015 285.72 Description: WOUND PREP F/N/HF/G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15005 MEDSV DEF RBRVS 02/01/2015 88.82 Description: WND PREP F/N/HF/G ADDL CM Category: Medical Services CMS Add: 01/01/2007 CMS Term: 1500F NOCOV DEF SYSMAN Description: SYMPTOM&SIGN SYMM POLYNEURO Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 1501F NOCOV DEF SYSMAN Description: NOT INITIAL EVAL FOR COND Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 1502F NOCOV DEF SYSMAN Description: PT QUERIED PAIN FXN W/ INSTR Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 1503F NOCOV DEF SYSMAN Description: PT QUERIED SYMP RESP INSUFF Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 15040 MEDSV DEF RBRVS 02/01/2015 180.40 Description: HARVEST CULTURED SKIN GRAFT Category: Medical Services CMS Add: 01/01/2006 CMS Term: 1504F NOCOV DEF SYSMAN Description: PT HAS RESP INSUFFICIENCY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 15050 MEDSV DEF RBRVS 09/01/2019 400.18 Description: SKIN PINCH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 99 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 1505F NOCOV DEF SYSMAN Description: PT HAS NO RESP INSUFFICIENCY Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 15100 MEDSV DEF RBRVS 09/01/2019 607.60 Description: SKIN SPLT GRFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15101 MEDSV DEF RBRVS 02/01/2015 130.44 Description: SKIN SPLT GRFT T/A/L ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15110 MEDSV DEF RBRVS 02/01/2015 613.39 Description: EPIDRM AUTOGRFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15111 MEDSV DEF RBRVS 02/01/2015 81.17 Description: EPIDRM AUTOGRFT T/A/L ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15115 MEDSV DEF RBRVS 02/01/2015 619.41 Description: EPIDRM A-GRFT FACE/NCK/HF/G Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15116 MEDSV DEF RBRVS 02/01/2015 107.88 Description: EPIDRM A-GRFT F/N/HF/G ADDL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15120 MEDSV DEF RBRVS 09/01/2019 605.89 Description: SKN SPLT A-GRFT FAC/NCK/HF/G Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15121 MEDSV DEF RBRVS 01/01/2019 145.97 Description: SKN SPLT A-GRFT F/N/HF/G ADD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15130 MEDSV DEF RBRVS 02/01/2015 479.93 Description: DERM AUTOGRAFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15131 MEDSV DEF RBRVS 02/01/2015 72.51 Description: DERM AUTOGRAFT T/A/L ADD-ON Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15135 MEDSV DEF RBRVS 02/01/2015 609.47 Description: DERM AUTOGRAFT FACE/NCK/HF/G Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15136 MEDSV DEF RBRVS 02/01/2015 67.47 Description: DERM AUTOGRAFT F/N/HF/G ADD Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15150 MEDSV DEF RBRVS 02/01/2015 488.04 Description: CULT SKIN GRFT T/ARM/LEG Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15151 MEDSV DEF RBRVS 02/01/2015 84.62 Description: CULT SKIN GRFT T/A/L ADDL Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15152 MEDSV DEF RBRVS 02/01/2015 108.13 Description: CULT SKIN GRAFT T/A/L +% Category: Medical Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 100 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15155 MEDSV DEF RBRVS 02/01/2015 508.43 Description: CULT SKIN GRAFT F/N/HF/G Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15156 MEDSV DEF RBRVS 02/01/2015 114.35 Description: CULT SKIN GRFT F/N/HFG ADD Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15157 MEDSV DEF RBRVS 02/01/2015 119.99 Description: CULT EPIDERM GRFT F/N/HFG +% Category: Medical Services CMS Add: 01/01/2006 CMS Term: 15200 MEDSV DEF RBRVS 09/01/2019 587.03 Y Description: SKIN FULL GRAFT TRUNK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15201 MEDSV DEF RBRVS 02/01/2015 104.50 Description: SKIN FULL GRAFT TRUNK ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15220 MEDSV DEF RBRVS 09/01/2019 543.52 Description: SKIN FULL GRAFT SCLP/ARM/LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15221 MEDSV DEF RBRVS 02/01/2015 96.30 Description: SKIN FULL GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15240 MEDSV DEF RBRVS 09/01/2019 659.61 Description: SKIN FULL GRFT FACE/GENIT/HF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15241 MEDSV DEF RBRVS 02/01/2015 130.81 Description: SKIN FULL GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15260 MEDSV DEF RBRVS 09/01/2019 716.69 Description: SKIN FULL GRAFT EEN & LIPS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15261 MEDSV DEF RBRVS 02/01/2015 152.64 Description: SKIN FULL GRAFT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15271 MEDSV DEF RBRVS 02/01/2015 100.25 Description: SKIN SUB GRAFT TRNK/ARM/LEG Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15272 MEDSV DEF RBRVS 02/01/2015 18.94 Description: SKIN SUB GRAFT T/A/L ADD-ON Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15273 MEDSV DEF RBRVS 02/01/2015 209.31 Description: SKIN SUB GRFT T/ARM/LG CHILD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15274 MEDSV DEF RBRVS 02/01/2015 49.16 Description: SKN SUB GRFT T/A/L CHILD ADD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15275 MEDSV DEF RBRVS 02/01/2015 108.37 Description: SKIN SUB GRAFT FACE/NK/HF/G Category: Medical Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 101 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15276 MEDSV DEF RBRVS 02/01/2015 24.58 Description: SKIN SUB GRAFT F/N/HF/G ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15277 MEDSV DEF RBRVS 02/01/2015 224.97 Description: SKN SUB GRFT F/N/HF/G CHILD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15278 MEDSV DEF RBRVS 02/01/2015 58.82 Description: SKN SUB GRFT F/N/HF/G CH ADD Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15570 MEDSV DEF RBRVS 09/01/2019 646.65 Description: SKIN PEDICLE FLAP TRUNK Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15572 MEDSV DEF RBRVS 09/01/2019 627.63 Description: SKIN PEDICLE FLAP ARMS/LEGS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15574 MEDSV DEF RBRVS 09/01/2019 649.65 Description: PEDCLE FH/CH/CH/M/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15576 MEDSV DEF RBRVS 09/01/2019 575.27 Description: PEDICLE E/N/E/L/NTRORAL Category: Medical Services CMS Add: 01/01/1992 CMS Term: 15600 MEDSV DEF RBRVS 09/01/2019 224.19 Description: DELAY FLAP TRUNK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15610 MEDSV DEF RBRVS 09/01/2019 248.21 Description: DELAY FLAP ARMS/LEGS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15620 MEDSV DEF RBRVS 09/01/2019 309.75 Description: DELAY FLAP F/C/C/N/AX/G/H/F Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15630 MEDSV DEF RBRVS 09/01/2019 323.24 Description: DELAY FLAP EYE/NOS/EAR/LIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15650 MEDSV DEF RBRVS 09/01/2019 357.55 Description: TRANSFER SKIN PEDICLE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15730 MEDSV DEF RBRVS 01/01/2018 1109.17 Description: MDFC FLAP W/PRSRV VASC PEDCL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 15731 MEDSV DEF RBRVS 02/01/2015 808.31 Description: FOREHEAD FLAP W/VASC PEDICLE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15733 MEDSV DEF RBRVS 01/01/2018 762.56 Description: MUSC MYOQ/FSCQ FLP H&N PEDCL Category: Medical Services CMS Add: 01/01/2018 CMS Term: 15734 MEDSV DEF RBRVS 09/01/2019 1066.86 Description: MUSCLE-SKIN GRAFT TRUNK Category: Medical Services CMS Add: 01/01/1990 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 102 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15736 MEDSV DEF RBRVS 09/01/2019 939.90 Description: MUSCLE-SKIN GRAFT ARM Category: Medical Services CMS Add: 01/01/1990 CMS Term: 15738 MEDSV DEF RBRVS 09/01/2019 1003.46 Description: MUSCLE-SKIN GRAFT LEG Category: Medical Services CMS Add: 01/01/1990 CMS Term: 15740 MEDSV DEF RBRVS 09/01/2019 720.74 Description: ISLAND PEDICLE FLAP GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15750 MEDSV DEF RBRVS 09/01/2019 657.12 Description: NEUROVASCULAR PEDICLE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15756 MEDSV DEF RBRVS 01/01/2019 1692.40 Description: FREE MYO/SKIN FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15757 MEDSV DEF RBRVS 01/01/2019 1674.26 Description: FREE SKIN FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15758 MEDSV DEF RBRVS 01/01/2019 1674.73 Description: FREE FASCIAL FLAP MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 15760 MEDSV DEF RBRVS 09/01/2019 607.68 Description: COMPOSITE SKIN GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15769 MEDSV DEF RBRVS 01/01/2020 347.93 Y Description: GRFG AUTOL SOFT TISS DIR EXC Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15770 MEDSV DEF RBRVS 09/01/2019 486.72 Description: DERMA-FAT-FASCIA GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15771 MEDSV DEF RBRVS 01/01/2020 414.59 Y Description: GRFG AUTOL FAT LIPO 50 CC/< Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15772 MEDSV DEF RBRVS 01/01/2020 131.00 Y Description: GRFG AUTOL FAT LIPO EA ADDL Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15773 MEDSV DEF RBRVS 01/01/2020 418.51 Y Description: GRFG AUTOL FAT LIPO 25 CC/< Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15774 MEDSV DEF RBRVS 01/01/2020 127.09 Y Description: GFRG AUTOL FAT LIPO EA ADDL Category: Medical Services CMS Add: 01/01/2020 CMS Term: 15775 NOCOV DEF SYSMAN Description: HAIR TRNSPL 1-15 PUNCH GRFTS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15776 NOCOV DEF SYSMAN Description: HAIR TRNSPL >15 PUNCH GRAFTS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 103 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15777 MEDSV DEF RBRVS 01/01/2016 153.15 Description: ACELLULAR DERM MATRIX IMPLT Category: Medical Services CMS Add: 01/01/2012 CMS Term: 15778 MEDSV DEF RBRVS 01/01/2023 285.29 Description: IMPL ABSRB MSH/PRSTH DLY CLS Category: Medical Services CMS Add: 01/01/2023 CMS Term: 15780 MEDSV DEF RBRVS 09/01/2019 592.43 Y Description: DERMABRASION TOTAL FACE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15781 MEDSV DEF RBRVS 09/01/2019 389.45 Y Description: DERMABRASION SEGMENTAL FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15782 MEDSV DEF RBRVS 09/01/2019 445.78 Y Description: DERMABRASION OTHER THAN FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15783 MEDSV DEF RBRVS 09/01/2019 338.46 Y Description: DERMABRASION SUPRFL ANY SITE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 15786 NOCOV DEF SYSMAN Description: ABRASION LESION SINGLE Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15787 NOCOV DEF SYSMAN Description: ABRASION LESIONS ADD-ON Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15788 NOCOV DEF SYSMAN Description: CHEMICAL PEEL FACE EPIDERM Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 15789 NOCOV DEF SYSMAN Description: CHEMICAL PEEL FACE DERMAL Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 15792 NOCOV DEF SYSMAN Description: CHEMICAL PEEL NONFACIAL Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 15793 NOCOV DEF SYSMAN Description: CHEMICAL PEEL NONFACIAL Category: Non Covered Services CMS Add: 01/01/1994 CMS Term: 15819 NOCOV DEF SYSMAN Description: PLASTIC SURGERY NECK Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 15820 MEDSV DEF RBRVS 09/01/2019 416.51 Y Description: REVISION OF LOWER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15821 MEDSV DEF RBRVS 09/01/2019 444.54 Y Description: REVISION OF LOWER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15822 MEDSV DEF RBRVS 09/01/2019 322.30 Y Description: REVISION OF UPPER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 104 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15823 MEDSV DEF RBRVS 09/01/2019 445.47 Y Description: REVISION OF UPPER EYELID Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15824 NOCOV DEF SYSMAN Description: REMOVAL OF FOREHEAD WRINKLES Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15825 NOCOV DEF SYSMAN Description: REMOVAL OF NECK WRINKLES Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 15826 NOCOV DEF SYSMAN Description: REMOVAL OF BROW WRINKLES Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15828 NOCOV DEF SYSMAN Description: REMOVAL OF FACE WRINKLES Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 15829 NOCOV DEF SYSMAN Description: REMOVAL OF SKIN WRINKLES Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 15830 MEDSV DEF RBRVS 02/01/2015 841.70 Y Description: EXC SKIN ABD Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15832 MEDSV DEF RBRVS 09/01/2019 658.87 Y Description: EXCISE EXCESSIVE SKIN THIGH Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15833 MEDSV DEF RBRVS 09/01/2019 628.56 Y Description: EXCISE EXCESSIVE SKIN LEG Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15834 MEDSV DEF RBRVS 09/01/2019 640.93 Y Description: EXCISE EXCESSIVE SKIN HIP Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15835 MEDSV DEF RBRVS 09/01/2019 676.83 Y Description: EXCISE EXCESSIVE SKIN BUTTCK Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15836 MEDSV DEF RBRVS 09/01/2019 547.08 Y Description: EXCISE EXCESSIVE SKIN ARM Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15837 MEDSV DEF RBRVS 09/01/2019 561.29 Y Description: EXCISE EXCESS SKIN ARM/HAND Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15838 MEDSV DEF RBRVS 09/01/2019 413.97 Y Description: EXCISE EXCESS SKIN FAT PAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15839 MEDSV DEF RBRVS 09/01/2019 628.51 Y Description: EXCISE EXCESS SKIN & TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15840 MEDSV DEF RBRVS 09/01/2019 738.49 Description: NERVE PALSY FASCIAL GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 105 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15841 MEDSV DEF RBRVS 09/01/2019 1167.72 Description: NERVE PALSY MUSCLE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15842 MEDSV DEF RBRVS 09/01/2019 1926.67 Description: NERVE PALSY MICROSURG GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15845 MEDSV DEF RBRVS 09/01/2019 740.06 Description: SKIN AND MUSCLE REPAIR FACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15847 MEDSV DEF RBRVS 09/01/2019 596.78 Y Description: EXC SKIN ABD ADD-ON Category: Medical Services CMS Add: 01/01/2007 CMS Term: 15851 MEDSV DEF RBRVS 09/01/2019 69.76 Description: REMOVAL SUTR/STAPLE REQ ANES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15852 MEDSV DEF RBRVS 09/01/2019 33.92 Description: DRESSING CHANGE NOT FOR BURN Category: Medical Services CMS Add: 01/01/1989 CMS Term: 15853 MEDSV DEF RBRVS 01/01/2023 8.34 Description: REMOVAL SUTR/STAPL XREQ ANES Category: Medical Services CMS Add: 01/01/2023 CMS Term: 15854 MEDSV DEF RBRVS 01/01/2023 11.73 Description: REMOVAL SUTR&STAPL XREQ ANES Category: Medical Services CMS Add: 01/01/2023 CMS Term: 15860 MEDSV DEF RBRVS 09/01/2019 80.39 Description: TEST FOR BLOOD FLOW IN GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15876 NOCOV DEF SYSMAN Description: SUCTION LIPECTOMY HEAD&NECK Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 15877 NOCOV DEF SYSMAN Description: SUCTION LIPECTOMY TRUNK Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 15878 NOCOV DEF SYSMAN Description: SUCTION LIPECTOMY UPR EXTREM Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 15879 NOCOV DEF SYSMAN Description: SUCTION LIPECTOMY LWR EXTREM Category: Non Covered Services CMS Add: 01/01/1990 CMS Term: 15920 MEDSV DEF RBRVS 09/01/2019 432.39 Description: REMOVAL OF TAIL BONE ULCER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15922 MEDSV DEF RBRVS 09/01/2019 562.37 Description: REMOVAL OF TAIL BONE ULCER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15931 MEDSV DEF RBRVS 09/01/2019 487.57 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 106 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15933 MEDSV DEF RBRVS 09/01/2019 608.14 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15934 MEDSV DEF RBRVS 09/01/2019 659.46 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15935 MEDSV DEF RBRVS 09/01/2019 781.11 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15936 MEDSV DEF RBRVS 09/01/2019 640.45 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15937 MEDSV DEF RBRVS 09/01/2019 746.25 Description: REMOVE SACRUM PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15940 MEDSV DEF RBRVS 09/01/2019 500.23 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15941 MEDSV DEF RBRVS 09/01/2019 647.05 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15944 MEDSV DEF RBRVS 09/01/2019 637.29 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15945 MEDSV DEF RBRVS 09/01/2019 702.04 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15946 MEDSV DEF RBRVS 09/01/2019 1179.01 Description: REMOVE HIP PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15950 MEDSV DEF RBRVS 09/01/2019 421.94 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15951 MEDSV DEF RBRVS 09/01/2019 632.59 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15952 MEDSV DEF RBRVS 09/01/2019 655.02 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15953 MEDSV DEF RBRVS 09/01/2019 716.86 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 15956 MEDSV DEF RBRVS 09/01/2019 833.10 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 15958 MEDSV DEF RBRVS 09/01/2019 843.92 Description: REMOVE THIGH PRESSURE SORE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 107 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 15999 MEDSV DEF BILL20 Description: UNLISTED PX EXC PRESSURE ULC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16000 MEDSV DEF RBRVS 09/01/2019 49.26 Description: INITIAL TREATMENT OF BURN(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16020 MEDSV DEF RBRVS 09/01/2019 57.64 Description: DRESS/DEBRID P-THICK BURN S Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16025 MEDSV DEF RBRVS 09/01/2019 104.63 Description: DRESS/DEBRID P-THICK BURN M Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16030 MEDSV DEF RBRVS 09/01/2019 132.27 Description: DRESS/DEBRID P-THICK BURN L Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16035 MEDSV DEF RBRVS 09/01/2019 144.09 Description: INCISION OF BURN SCAB INITI Category: Medical Services CMS Add: 01/01/1984 CMS Term: 16036 MEDSV DEF RBRVS 02/01/2015 59.21 Description: ESCHAROTOMY ADDL INCISION Category: Medical Services CMS Add: 01/01/2001 CMS Term: 17000 MEDSV DEF RBRVS 02/01/2015 52.64 0-1 Description: DESTRUCT PREMALG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 17003 MEDSV DEF RBRVS 02/01/2015 6.94 Description: DESTRUCT PREMALG LES 2-14 Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17004 MEDSV DEF RBRVS 02/01/2015 104.60 Description: DESTROY PREMAL LESIONS 15/> Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17106 MEDSV DEF RBRVS 09/01/2019 237.86 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17107 MEDSV DEF RBRVS 09/01/2019 307.47 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17108 MEDSV DEF RBRVS 09/01/2019 446.81 0-1 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 17110 MEDSV DEF RBRVS 09/01/2019 76.36 0-1 Description: DESTRUCT B9 LESION 1-14 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 17111 MEDSV DEF RBRVS 02/01/2015 90.80 Description: DESTRUCT LESION 15 OR MORE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 17250 MEDSV DEF RBRVS 09/01/2019 55.46 Description: CHEM CAUT OF GRANLTJ TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 108 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 17260 MEDSV DEF RBRVS 01/01/2019 65.76 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17261 MEDSV DEF RBRVS 01/01/2019 99.74 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17262 MEDSV DEF RBRVS 01/01/2019 121.74 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17263 MEDSV DEF RBRVS 01/01/2019 133.08 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17264 MEDSV DEF RBRVS 01/01/2019 143.06 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17266 MEDSV DEF RBRVS 01/01/2019 162.56 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17270 MEDSV DEF RBRVS 01/01/2019 104.60 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17271 MEDSV DEF RBRVS 01/01/2019 113.88 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17272 MEDSV DEF RBRVS 01/01/2019 129.82 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17273 MEDSV DEF RBRVS 01/01/2019 145.19 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17274 MEDSV DEF RBRVS 01/01/2019 171.83 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17276 MEDSV DEF RBRVS 01/01/2019 199.70 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17280 MEDSV DEF RBRVS 01/01/2019 98.01 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17281 MEDSV DEF RBRVS 01/01/2019 124.02 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17282 MEDSV DEF RBRVS 01/01/2019 142.69 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17283 MEDSV DEF RBRVS 01/01/2019 171.36 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 109 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 17284 MEDSV DEF RBRVS 01/01/2019 196.21 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17286 MEDSV DEF RBRVS 01/01/2019 253.06 Description: DESTRUCTION OF SKIN LESIONS Category: Medical Services CMS Add: 01/01/1992 CMS Term: 17311 MEDSV DEF RBRVS 02/01/2015 459.96 Description: MOHS 1 STAGE H/N/HF/G Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17312 MEDSV DEF RBRVS 02/01/2015 269.41 Description: MOHS ADDL STAGE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17313 MEDSV DEF RBRVS 02/01/2015 429.80 Description: MOHS 1 STAGE T/A/L Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17314 MEDSV DEF RBRVS 02/01/2015 258.26 Description: MOHS ADDL STAGE T/A/L Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17315 MEDSV DEF RBRVS 02/01/2015 55.66 Description: MOHS SURG ADDL BLOCK Category: Medical Services CMS Add: 01/01/2007 CMS Term: 17340 NOCOV DEF SYSMAN Description: CRYOTHERAPY OF SKIN Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: 17360 NOCOV DEF SYSMAN Description: SKIN PEEL THERAPY Category: Non Covered Services CMS Add: 01/01/1985 CMS Term: 17380 NOCOV DEF SYSMAN Description: HAIR REMOVAL BY ELECTROLYSIS Category: Non Covered Services CMS Add: 01/01/1982 CMS Term: 17999 MEDSV DEF BILL20 Y Description: UNLISTD PX SKN MUC MEMB SUBQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19000 MEDSV DEF RBRVS 09/01/2019 79.13 Description: DRAINAGE OF BREAST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19001 MEDSV DEF RBRVS 01/01/2016 19.29 Description: DRAIN BREAST LESION ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19020 MEDSV DEF RBRVS 09/01/2019 328.82 Description: INCISION OF BREAST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19030 MEDSV DEF RBRVS 09/01/2019 116.08 Description: INJECTION FOR BREAST X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19081 MEDSV DEF RBRVS 02/01/2015 472.52 Description: BX BREAST 1ST LESION STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 110 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19082 MEDSV DEF RBRVS 02/01/2015 382.46 Description: BX BREAST ADD LESION STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19083 MEDSV DEF RBRVS 02/01/2015 469.48 Description: BX BREAST 1ST LESION US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19084 MEDSV DEF RBRVS 02/01/2015 377.22 Description: BX BREAST ADD LESION US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19085 MEDSV DEF RBRVS 02/01/2015 710.40 Description: BX BREAST 1ST LESION MR IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19086 MEDSV DEF RBRVS 02/01/2015 568.36 Description: BX BREAST ADD LESION MR IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19100 MEDSV DEF RBRVS 09/01/2019 105.13 Description: BX BREAST PERCUT W/O IMAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19101 MEDSV DEF RBRVS 09/01/2019 237.56 Description: BIOPSY OF BREAST OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19105 NOCOV DEF SYSMAN Description: CRYOSURG ABLATE FA EACH Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 19110 MEDSV DEF RBRVS 09/01/2019 338.61 Description: NIPPLE EXPLORATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 19112 MEDSV DEF RBRVS 09/01/2019 320.69 Description: EXCISE BREAST DUCT FISTULA Category: Medical Services CMS Add: 01/01/1987 CMS Term: 19120 MEDSV DEF RBRVS 09/01/2019 346.09 Description: REMOVAL OF BREAST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19125 MEDSV DEF RBRVS 09/01/2019 383.79 0-2 Description: EXCISION BREAST LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 19126 MEDSV DEF RBRVS 01/01/2019 115.14 Description: EXCISION ADDL BREAST LESION Category: Medical Services CMS Add: 01/01/1994 CMS Term: 19281 MEDSV DEF RBRVS 02/01/2015 172.56 Description: PERQ DEVICE BREAST 1ST IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19282 MEDSV DEF RBRVS 02/01/2015 119.76 Description: PERQ DEVICE BREAST EA IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19283 MEDSV DEF RBRVS 02/01/2015 195.59 Description: PERQ DEV BREAST 1ST STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 111 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19284 MEDSV DEF RBRVS 02/01/2015 143.29 Description: PERQ DEV BREAST ADD STRTCTC Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19285 MEDSV DEF RBRVS 02/01/2015 328.73 Description: PERQ DEV BREAST 1ST US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19286 MEDSV DEF RBRVS 02/01/2015 275.26 Description: PERQ DEV BREAST ADD US IMAG Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19287 MEDSV DEF RBRVS 02/01/2015 605.73 Description: PERQ DEV BREAST 1ST MR GUIDE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19288 MEDSV DEF RBRVS 02/01/2015 483.91 Description: PERQ DEV BREAST ADD MR GUIDE Category: Medical Services CMS Add: 01/01/2014 CMS Term: 19294 MEDSV DEF RBRVS 01/01/2018 118.59 Description: PREPJ TUM CAV IORT PRTL MAST Category: Medical Services CMS Add: 01/01/2018 CMS Term: 19296 MEDSV DEF RBRVS 02/01/2015 2752.21 Description: PLACE PO BREAST CATH FOR RAD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19297 MEDSV DEF RBRVS 01/01/2016 67.27 Description: PLACE BREAST CATH FOR RAD Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19298 MEDSV DEF RBRVS 09/15/2017 694.59 Description: PLACE BREAST RAD TUBE/CATHS Category: Medical Services CMS Add: 01/01/2005 CMS Term: 19300 MEDSV DEF RBRVS 02/01/2015 365.86 Y Description: REMOVAL OF BREAST TISSUE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19301 MEDSV DEF RBRVS 02/01/2015 461.52 Y Description: PARTIAL MASTECTOMY Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19302 MEDSV DEF RBRVS 02/01/2015 635.50 Description: P-MASTECTOMY W/LN REMOVAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19303 MEDSV DEF RBRVS 02/01/2015 714.79 Y 0-2 Description: MAST SIMPLE COMPLETE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19305 MEDSV DEF RBRVS 02/01/2015 800.08 0-2 Description: MAST RADICAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19306 MEDSV DEF RBRVS 02/01/2015 847.72 0-2 Description: MAST RAD URBAN TYPE Category: Medical Services CMS Add: 01/01/2007 CMS Term: 19307 MEDSV DEF RBRVS 02/01/2015 845.95 0-2 Description: MAST MOD RAD Category: Medical Services CMS Add: 01/01/2007 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 112 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19316 MEDSV DEF RBRVS 09/01/2019 553.95 Y Description: SUSPENSION OF BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19318 MEDSV DEF RBRVS 09/01/2019 798.15 Y Description: BREAST REDUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19325 MEDSV DEF RBRVS 09/01/2019 464.25 Y Description: BREAST AUGMENTATION W/IMPLT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19328 MEDSV DEF RBRVS 09/01/2019 356.01 Description: RMVL INTACT BREAST IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19330 MEDSV DEF RBRVS 09/01/2019 455.62 Description: RMVL RUPTURED BREAST IMPLANT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 19340 MEDSV DEF RBRVS 09/01/2019 724.76 Y Description: INSJ BREAST IMPLT SM D MAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19342 MEDSV DEF RBRVS 09/01/2019 665.92 Y Description: INSJ/RPLCMT BRST IMPLT SEP D Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19350 MEDSV DEF RBRVS 09/01/2019 586.21 Y Description: BREAST RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 19355 NOCOV DEF SYSMAN Description: CORRECT INVERTED NIPPLE(S) Category: Non Covered Services CMS Add: 01/01/1988 CMS Term: 19357 MEDSV DEF RBRVS 09/01/2019 1081.84 Description: TISS XPNDR PLMT BRST RCNSTJ Category: Medical Services CMS Add: 01/01/1992 CMS Term: 19361 MEDSV DEF RBRVS 09/01/2019 1141.99 Description: BRST RCNSTJ LATSMS DRSI FLAP Category: Medical Services CMS Add: 01/01/1992 CMS Term: 19364 MEDSV DEF RBRVS 09/01/2019 2003.15 Description: BRST RCNSTJ FREE FLAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19367 MEDSV DEF RBRVS 01/01/2019 1299.98 Description: BRST RCNSTJ 1 PDCL TRAM FLAP Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19368 MEDSV DEF RBRVS 01/01/2019 1600.32 Description: BRST RCNSTJ 1PDCL TRAM ANAST Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19369 MEDSV DEF RBRVS 01/01/2019 1484.82 Description: BRST RCNSTJ 2 PDCL TRAM FLAP Category: Medical Services CMS Add: 01/01/1995 CMS Term: 19370 MEDSV DEF RBRVS 09/01/2019 493.77 Description: REVJ PERI-IMPLT CAPSULE BRST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 113 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 19371 MEDSV DEF RBRVS 09/01/2019 565.51 Description: PERI-IMPLT CAPSLC BRST COMPL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19380 MEDSV DEF RBRVS 09/01/2019 556.98 Description: REVJ RECONSTRUCTED BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 19396 NOCOV DEF SYSMAN Description: DESIGN CUSTOM BREAST IMPLANT Category: Non Covered Services CMS Add: 01/01/1984 CMS Term: 19499 MEDSV DEF BILL20 Y Description: UNLISTED PROCEDURE BREAST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2000F NOCOV DEF SYSMAN Description: BLOOD PRESSURE MEASURE Category: Non Covered Services CMS Add: 01/01/2005 CMS Term: 2001F NOCOV DEF SYSMAN Description: WEIGHT RECORD Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 2002F NOCOV DEF SYSMAN Description: CLIN SIGN VOL OVRLD ASSESS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 2004F NOCOV DEF SYSMAN Description: INITIAL EXAM INVOLVED JOINTS Category: Non Covered Services CMS Add: 01/01/2006 CMS Term: 20100 MEDSV DEF RBRVS 02/01/2015 435.12 Description: EXPLORE WOUND NECK Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20101 MEDSV DEF RBRVS 01/01/2019 315.18 Description: EXPLORE WOUND CHEST Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20102 MEDSV DEF RBRVS 01/01/2019 344.58 Description: EXPLORE WOUND ABDOMEN Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20103 MEDSV DEF RBRVS 02/01/2015 410.35 Description: EXPLORE WOUND EXTREMITY Category: Medical Services CMS Add: 01/01/1996 CMS Term: 2010F NOCOV DEF SYSMAN Description: VITAL SIGNS RECORDED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2014F NOCOV DEF SYSMAN Description: MENTAL STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 20150 MEDSV DEF RBRVS 01/01/2019 654.35 Description: EXCISE EPIPHYSEAL BAR Category: Medical Services CMS Add: 01/01/1997 CMS Term: 2015F NOCOV DEF SYSMAN Description: ASTHMA IMPAIRMENT ASSESSED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 114 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 2016F NOCOV DEF SYSMAN Description: ASTHMA RISK ASSESSED Category: Non Covered Services CMS Add: 01/01/2012 CMS Term: 2018F NOCOV DEF SYSMAN Description: HYDRATION STATUS ASSESS Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2019F NOCOV DEF SYSMAN Description: DILATED MACUL EXAM DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 20200 MEDSV DEF RBRVS 09/01/2019 144.59 Description: MUSCLE BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20205 MEDSV DEF RBRVS 09/01/2019 201.12 Description: DEEP MUSCLE BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20206 MEDSV DEF RBRVS 09/01/2019 164.99 Description: NEEDLE BIOPSY MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2020F NOCOV DEF SYSMAN Description: DILATED FUNDUS EVAL DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2021F NOCOV DEF SYSMAN Description: DILAT MACULAR EXAM DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 20220 MEDSV DEF RBRVS 09/01/2019 119.17 Description: BONE BIOPSY TROCAR/NEEDLE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20225 MEDSV DEF RBRVS 09/01/2019 369.22 Description: BONE BIOPSY TROCAR/NEEDLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2022F NOCOV DEF SYSMAN Description: DILAT RTA XM EVC RTNOPTHY Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2023F NOCOV DEF SYSMAN Description: DILAT RTA XM W/O RTNOPTHY Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 20240 MEDSV DEF RBRVS 09/01/2019 158.31 Description: BONE BIOPSY OPEN SUPERFICIAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20245 MEDSV DEF RBRVS 09/01/2019 445.42 Description: BONE BIOPSY OPEN DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2024F NOCOV DEF SYSMAN Description: 7 FLD RTA PHOTO EVC RTNOPTHY Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 20250 MEDSV DEF RBRVS 09/01/2019 275.20 Description: OPEN BONE BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 115 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20251 MEDSV DEF RBRVS 09/01/2019 299.84 Description: OPEN BONE BIOPSY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 2025F NOCOV DEF SYSMAN Description: 7 FLD RTA PHOTO W/O RTNOPTHY Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 2026F NOCOV DEF SYSMAN Description: EYE IMG VALID EVC RTNOPTHY Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2027F NOCOV DEF SYSMAN Description: OPTIC NERVE HEAD EVAL DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2028F NOCOV DEF SYSMAN Description: FOOT EXAM PERFORMED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2029F NOCOV DEF SYSMAN Description: COMPLETE PHYS SKIN EXAM DONE Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2030F NOCOV DEF SYSMAN Description: H2O STAT DOCD NORMAL Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2031F NOCOV DEF SYSMAN Description: H2O STAT DOCD DEHYDRATED Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 2033F NOCOV DEF SYSMAN Description: EYE IMG VALID W/O RTNOPTHY Category: Non Covered Services CMS Add: 10/01/2019 CMS Term: 2035F NOCOV DEF SYSMAN Description: TYMP MEMB MOTION EXAMD Category: Non Covered Services CMS Add: 10/01/2007 CMS Term: 2040F NOCOV DEF SYSMAN Description: BK PN XM ON INIT VISIT DATE Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 2044F NOCOV DEF SYSMAN Description: DOC MNTL TST B/4 BK TRXMNT Category: Non Covered Services CMS Add: 04/01/2008 CMS Term: 20500 MEDSV DEF RBRVS 09/01/2019 75.10 Description: INJECTION OF SINUS TRACT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20501 MEDSV DEF RBRVS 09/01/2019 83.01 Description: INJECT SINUS TRACT FOR X-RAY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 2050F NOCOV DEF SYSMAN Description: WOUND CHAR SIZE ETC DOCD Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 20520 MEDSV DEF RBRVS 09/01/2019 144.03 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 116 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20525 MEDSV DEF RBRVS 09/01/2019 337.05 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20526 ANEST DEF RBRVS 01/01/2016 54.16 Description: THER INJECTION CARP TUNNEL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20527 MEDSV DEF RBRVS 02/01/2015 58.91 Description: INJ DUPUYTREN CORD W/ENZYME Category: Medical Services CMS Add: 01/01/2012 CMS Term: 20550 ANEST DEF RBRVS 09/01/2019 41.78 Description: INJ TENDON SHEATH/LIGAMENT Category: Anesthesia CMS Add: 01/01/1984 CMS Term: 20551 MEDSV DEF RBRVS 02/01/2015 43.27 Description: INJ TENDON ORIGIN/INSERTION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 20552 ANEST DEF RBRVS 02/01/2015 39.45 Description: INJ TRIGGER POINT 1/2 MUSCL Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20553 ANEST DEF RBRVS 02/01/2015 45.58 Description: INJECT TRIGGER POINTS 3/> Category: Anesthesia CMS Add: 01/01/2002 CMS Term: 20555 MEDSV DEF RBRVS 02/01/2015 241.88 Description: PLACE NDL MUSC/TIS FOR RT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 20560 NOCOV DEF SYSMAN Description: NDL INSJ W/O NJX 1 OR 2 MUSC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 20561 NOCOV DEF SYSMAN Description: NDL INSJ W/O NJX 3+ MUSC Category: Non Covered Services CMS Add: 01/01/2020 CMS Term: 20600 MEDSV DEF RBRVS 09/01/2019 34.25 Description: DRAIN/INJ JOINT/BURSA W/O US Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20604 MEDSV DEF RBRVS 02/01/2015 51.82 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20605 MEDSV DEF RBRVS 09/01/2019 35.69 Description: DRAIN/INJ JOINT/BURSA W/O US Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20606 MEDSV DEF RBRVS 02/01/2015 57.34 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 2060F NOCOV DEF SYSMAN Description: PT TALK EVAL HLTHWKR RE MDD Category: Non Covered Services CMS Add: 01/01/2010 CMS Term: 20610 MEDSV DEF RBRVS 09/01/2019 42.86 Description: DRAIN/INJ JOINT/BURSA W/O US Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 117 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20611 MEDSV DEF RBRVS 02/01/2015 65.80 Description: DRAIN/INJ JOINT/BURSA W/US Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20612 MEDSV DEF RBRVS 02/01/2015 42.92 Description: ASPIRATE/INJ GANGLION CYST Category: Medical Services CMS Add: 01/01/2003 CMS Term: 20615 MEDSV DEF RBRVS 09/01/2019 173.00 Description: TREATMENT OF BONE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20650 MEDSV DEF RBRVS 09/01/2019 145.65 Description: INSERT AND REMOVE BONE PIN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20660 MEDSV DEF RBRVS 09/01/2019 171.39 Description: APPLY REM FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20661 MEDSV DEF RBRVS 09/01/2019 352.97 Description: APPLICATION OF HEAD BRACE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20662 MEDSV DEF RBRVS 09/01/2019 317.98 Description: APPLICATION OF PELVIS BRACE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 20663 MEDSV DEF RBRVS 09/01/2019 320.86 Description: APPLICATION OF THIGH BRACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20664 MEDSV DEF RBRVS 02/01/2015 603.99 Description: APPLICATION OF HALO Category: Medical Services CMS Add: 01/01/1998 CMS Term: 20665 MEDSV DEF RBRVS 09/01/2019 75.51 Description: REMOVAL OF FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20670 MEDSV DEF RBRVS 09/01/2019 265.67 Description: REMOVAL OF SUPPORT IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20680 MEDSV DEF RBRVS 09/01/2019 438.90 Description: REMOVAL OF SUPPORT IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20690 MEDSV DEF RBRVS 09/01/2019 424.75 Description: APPLY BONE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20692 MEDSV DEF RBRVS 09/01/2019 803.69 Description: APPLY BONE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20693 MEDSV DEF RBRVS 09/01/2019 322.02 Description: ADJUST BONE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 20694 MEDSV DEF RBRVS 09/01/2019 300.70 Description: REMOVE BONE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 118 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20696 MEDSV DEF RBRVS 02/01/2015 826.52 Description: COMP MULTIPLANE EXT FIXATION Category: Medical Services CMS Add: 01/01/2009 CMS Term: 20697 MEDSV DEF RBRVS 09/01/2019 1286.30 Description: COMP EXT FIXATE STRUT CHANGE Category: Medical Services CMS Add: 01/01/2009 CMS Term: 20700 MEDSV DEF RBRVS 01/01/2020 61.36 Description: MNL PREP&INSJ DP RX DLVR DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20701 MEDSV DEF RBRVS 01/01/2020 45.88 Description: RMVL DEEP RX DELIVERY DEVICE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20702 MEDSV DEF RBRVS 01/01/2020 102.02 Description: MNL PREP&INSJ IMED RX DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20703 MEDSV DEF RBRVS 01/01/2020 73.30 Description: RMVL IMED RX DELIVERY DEVICE Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20704 MEDSV DEF RBRVS 01/01/2020 106.27 Description: MNL PREP&INSJ I-ARTIC RX DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20705 MEDSV DEF RBRVS 01/01/2020 87.58 Description: RMVL I-ARTIC RX DELIVERY DEV Category: Medical Services CMS Add: 01/01/2020 CMS Term: 20802 MEDSV DEF RBRVS 01/01/2019 1708.82 Description: REPLANTATION ARM COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20805 MEDSV DEF RBRVS 01/01/2019 2197.07 Description: REPLANT FOREARM COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20808 MEDSV DEF RBRVS 01/01/2019 2848.43 Description: REPLANTATION HAND COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20816 MEDSV DEF RBRVS 01/01/2019 1444.45 Description: REPLANTATION DIGIT COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20822 MEDSV DEF RBRVS 01/01/2019 1307.37 Description: REPLANTATION DIGIT COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20824 MEDSV DEF RBRVS 01/01/2019 1532.82 Description: REPLANTATION THUMB COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20827 MEDSV DEF RBRVS 01/01/2019 1305.21 Description: REPLANTATION THUMB COMPLETE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 20838 MEDSV DEF RBRVS 01/01/2019 1913.40 Description: REPLANTATION FOOT COMPLETE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 119 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20900 MEDSV DEF RBRVS 09/01/2019 296.12 Description: REMOVAL OF BONE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20902 MEDSV DEF RBRVS 09/01/2019 206.37 Description: REMOVAL OF BONE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20910 MEDSV DEF RBRVS 09/01/2019 296.80 Description: REMOVE CARTILAGE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20912 MEDSV DEF RBRVS 09/01/2019 347.96 Description: REMOVE CARTILAGE FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20920 MEDSV DEF RBRVS 09/01/2019 286.27 Description: REMOVAL OF FASCIA FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20922 MEDSV DEF RBRVS 09/01/2019 436.23 Description: REMOVAL OF FASCIA FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20924 MEDSV DEF RBRVS 09/01/2019 360.97 Description: REMOVAL OF TENDON FOR GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20930 NOCOV DEF SYSMAN Description: SP BONE ALGRFT MORSEL ADD-ON Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 20931 MEDSV DEF RBRVS 01/01/2019 79.35 Description: SP BONE ALGRFT STRUCT ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20932 MEDSV DEF RBRVS 01/01/2019 519.16 Description: OSTEOART ALGRFT W/SURF & B1 Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20933 MEDSV DEF RBRVS 01/01/2019 476.29 Description: HEMICRT INTRCLRY ALGRFT PRTL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20934 MEDSV DEF RBRVS 01/01/2019 518.89 Description: INTERCALARY ALGRFT COMPL Category: Medical Services CMS Add: 01/01/2019 CMS Term: 20936 NOCOV DEF SYSMAN Description: SP BONE AGRFT LOCAL ADD-ON Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 20937 MEDSV DEF RBRVS 01/01/2016 119.88 Description: SP BONE AGRFT MORSEL ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20938 MEDSV DEF RBRVS 01/01/2016 130.61 Description: SP BONE AGRFT STRUCT ADD-ON Category: Medical Services CMS Add: 01/01/1996 CMS Term: 20939 MEDSV DEF RBRVS 01/01/2018 48.92 Description: BONE MARROW ASPIR BONE GRFG Category: Medical Services CMS Add: 01/01/2018 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 120 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 20950 MEDSV DEF RBRVS 09/01/2019 175.71 Description: FLUID PRESSURE MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20955 MEDSV DEF RBRVS 01/01/2019 1821.73 Description: FIBULA BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20956 MEDSV DEF RBRVS 01/01/2019 1900.38 Description: ILIAC BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 20957 MEDSV DEF RBRVS 01/01/2019 1648.73 Description: MT BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1997 CMS Term: 20962 MEDSV DEF RBRVS 01/01/2019 1579.34 Description: OTHER BONE GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20969 MEDSV DEF RBRVS 01/01/2019 2026.78 Description: BONE/SKIN GRAFT MICROVASC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20970 MEDSV DEF RBRVS 01/01/2019 2056.14 Description: BONE/SKIN GRAFT ILIAC CREST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20972 MEDSV DEF RBRVS 01/01/2019 1629.55 Description: BONE/SKIN GRAFT METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20973 MEDSV DEF RBRVS 01/01/2019 2073.21 Description: BONE/SKIN GRAFT GREAT TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 20974 MEDSV DEF RBRVS 02/01/2015 53.16 Description: ELECTRICAL BONE STIMULATION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 20975 MEDSV DEF RBRVS 02/01/2015 125.93 Description: ELECTRICAL BONE STIMULATION Category: Medical Services CMS Add: 01/01/1982 CMS Term: 20979 NOCOV DEF SYSMAN Description: US BONE STIMULATION Category: Non Covered Services CMS Add: 01/01/2000 CMS Term: 20982 MEDSV DEF RBRVS 09/15/2017 1206.80 Description: ABLATE BONE TUMOR(S) PERQ Category: Medical Services CMS Add: 01/01/2004 CMS Term: 20983 MEDSV DEF BILL20 Description: ABLATE BONE TUMOR(S) PERQ Category: Medical Services CMS Add: 01/01/2015 CMS Term: 20985 MEDSV DEF RBRVS 02/01/2015 106.15 Description: CPTR-ASST DIR MS PX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 20999 MEDSV DEF BILL20 Description: UNLISTED PX MUSCSKEL GENERAL Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 121 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21010 MEDSV DEF RBRVS 09/01/2019 542.28 Y Description: INCISION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21011 MEDSV DEF RBRVS 02/01/2015 243.99 Description: EXC FACE LES SC <2 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21012 MEDSV DEF RBRVS 02/01/2015 239.71 Description: EXC FACE LES SBQ 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21013 MEDSV DEF RBRVS 02/01/2015 365.35 Description: EXC FACE TUM DEEP < 2 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21014 MEDSV DEF RBRVS 02/01/2015 370.92 Description: EXC FACE TUM DEEP 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21015 MEDSV DEF RBRVS 09/01/2019 510.14 Description: RESECT FACE/SCALP TUM < 2 CM Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21016 MEDSV DEF RBRVS 02/01/2015 744.02 Description: RESECT FACE/SCALP TUM 2 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21025 MEDSV DEF RBRVS 09/01/2019 641.80 Description: EXCISION OF BONE LOWER JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21026 MEDSV DEF RBRVS 09/01/2019 442.89 Description: EXCISION OF FACIAL BONE(S) Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21029 MEDSV DEF RBRVS 09/01/2019 556.71 Description: CONTOUR OF FACE BONE LESION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21030 MEDSV DEF RBRVS 09/01/2019 373.36 Description: EXCISE MAX/ZYGOMA B9 TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21031 MEDSV DEF RBRVS 09/01/2019 281.63 Description: REMOVE EXOSTOSIS MANDIBLE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21032 MEDSV DEF RBRVS 09/01/2019 286.59 Description: REMOVE EXOSTOSIS MAXILLA Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21034 MEDSV DEF RBRVS 09/01/2019 952.57 Description: EXCISE MAX/ZYGOMA MAL TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21040 MEDSV DEF RBRVS 09/01/2019 376.17 Description: EXCISE MANDIBLE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21044 MEDSV DEF RBRVS 09/01/2019 640.26 Description: REMOVAL OF JAW BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 122 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21045 MEDSV DEF RBRVS 09/01/2019 891.07 Description: EXTENSIVE JAW SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21046 MEDSV DEF RBRVS 01/01/2019 805.64 Description: REMOVE MANDIBLE CYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21047 MEDSV DEF RBRVS 02/01/2015 950.78 Description: EXCISE LWR JAW CYST W/REPAIR Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21048 MEDSV DEF RBRVS 01/01/2019 827.66 Description: REMOVE MAXILLA CYST COMPLEX Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21049 MEDSV DEF RBRVS 02/01/2015 887.36 Description: EXCIS UPPR JAW CYST W/REPAIR Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21050 MEDSV DEF RBRVS 09/01/2019 621.08 Description: REMOVAL OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21060 MEDSV DEF RBRVS 09/01/2019 594.28 Description: REMOVE JAW JOINT CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21070 MEDSV DEF RBRVS 09/01/2019 445.88 Description: REMOVE CORONOID PROCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21073 MEDSV DEF RBRVS 02/01/2015 278.81 Description: MNPJ OF TMJ W/ANESTH Category: Medical Services CMS Add: 01/01/2008 CMS Term: 21076 MEDSV DEF RBRVS 02/01/2015 722.36 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21077 MEDSV DEF RBRVS 02/01/2015 1814.32 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21079 MEDSV DEF RBRVS 01/01/2019 1217.64 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21080 MEDSV DEF RBRVS 01/01/2019 1368.65 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21081 MEDSV DEF RBRVS 01/01/2019 1264.19 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21082 MEDSV DEF RBRVS 01/01/2019 1198.79 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21083 MEDSV DEF RBRVS 01/01/2019 1124.48 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 123 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21084 MEDSV DEF RBRVS 01/01/2019 1301.73 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21085 MEDSV DEF RBRVS 01/01/2019 583.49 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21086 MEDSV DEF RBRVS 01/01/2019 1351.18 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21087 MEDSV DEF RBRVS 01/01/2019 1351.18 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21088 MEDSV DEF BILL20 Description: PREPARE FACE/ORAL PROSTHESIS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21089 MEDSV DEF BILL20 Description: UNLISTED MAXLFCL PROSTH PX Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21100 MEDSV DEF RBRVS 09/01/2019 505.26 Description: MAXILLOFACIAL FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21110 MEDSV DEF RBRVS 09/01/2019 575.28 Y Description: INTERDENTAL FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21116 MEDSV DEF RBRVS 09/01/2019 101.61 Description: INJECTION JAW JOINT X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21120 MEDSV DEF RBRVS 09/01/2019 473.10 Y Description: RECONSTRUCTION OF CHIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21121 MEDSV DEF RBRVS 09/01/2019 552.10 Y Description: RECONSTRUCTION OF CHIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21122 MEDSV DEF RBRVS 09/01/2019 504.44 Y Description: RECONSTRUCTION OF CHIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21123 MEDSV DEF RBRVS 09/01/2019 638.43 Y Description: RECONSTRUCTION OF CHIN Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21125 MEDSV DEF RBRVS 09/01/2019 2165.30 Y Description: AUGMENTATION LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21127 MEDSV DEF RBRVS 09/01/2019 3007.91 Y Description: AUGMENTATION LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21137 MEDSV DEF RBRVS 01/01/2019 543.74 Y Description: REDUCTION OF FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 124 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21138 MEDSV DEF RBRVS 01/01/2019 661.38 Y Description: REDUCTION OF FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21139 MEDSV DEF RBRVS 01/01/2019 784.62 Y Description: REDUCTION OF FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21141 MEDSV DEF RBRVS 02/01/2015 985.66 Description: LEFORT I-1 PIECE W/O GRAFT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21142 MEDSV DEF RBRVS 02/01/2015 1013.91 Description: LEFORT I-2 PIECE W/O GRAFT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21143 MEDSV DEF RBRVS 02/01/2015 1025.35 Description: LEFORT I-3/> PIECE W/O GRAFT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 21145 MEDSV DEF RBRVS 09/01/2019 1111.39 Description: LEFORT I-1 PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21146 MEDSV DEF RBRVS 09/01/2019 1253.74 Description: LEFORT I-2 PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21147 MEDSV DEF RBRVS 09/01/2019 1117.44 Description: LEFORT I-3/> PIECE W/ GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21150 MEDSV DEF RBRVS 01/01/2019 1321.07 Description: LEFORT II ANTERIOR INTRUSION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21151 MEDSV DEF RBRVS 01/01/2019 1480.91 Description: LEFORT II W/BONE GRAFTS Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21154 MEDSV DEF RBRVS 01/01/2019 1612.42 Description: LEFORT III W/O LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21155 MEDSV DEF RBRVS 01/01/2019 1650.12 Description: LEFORT III W/ LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21159 MEDSV DEF RBRVS 01/01/2019 1822.64 Description: LEFORT III W/FHDW/O LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21160 MEDSV DEF RBRVS 01/01/2019 1935.73 Description: LEFORT III W/FHD W/ LEFORT I Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21172 MEDSV DEF RBRVS 01/01/2019 1362.77 Description: RECONSTRUCT ORBIT/FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21175 MEDSV DEF RBRVS 01/01/2019 1497.68 Description: RECONSTRUCT ORBIT/FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 125 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21179 MEDSV DEF RBRVS 01/01/2019 1120.52 Description: RECONSTRUCT ENTIRE FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21180 MEDSV DEF RBRVS 01/01/2019 1119.55 Description: RECONSTRUCT ENTIRE FOREHEAD Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21181 MEDSV DEF RBRVS 01/01/2019 524.50 Description: CONTOUR CRANIAL BONE LESION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21182 MEDSV DEF RBRVS 01/01/2019 1401.43 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21183 MEDSV DEF RBRVS 01/01/2019 1717.06 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21184 MEDSV DEF RBRVS 01/01/2019 1598.75 Description: RECONSTRUCT CRANIAL BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21188 MEDSV DEF RBRVS 01/01/2019 1142.70 Description: RECONSTRUCTION OF MIDFACE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21193 MEDSV DEF RBRVS 09/01/2019 931.50 Description: RECONST LWR JAW W/O GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21194 MEDSV DEF RBRVS 09/01/2019 995.90 Description: RECONST LWR JAW W/GRAFT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21195 MEDSV DEF RBRVS 09/01/2019 970.09 Description: RECONST LWR JAW W/O FIXATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21196 MEDSV DEF RBRVS 09/01/2019 1075.16 Y Description: RECONST LWR JAW W/FIXATION Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21198 MEDSV DEF RBRVS 09/01/2019 843.13 Description: RECONSTR LWR JAW SEGMENT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21199 MEDSV DEF RBRVS 02/01/2015 766.17 Y Y Description: RECONSTR LWR JAW W/ADVANCE Category: Medical Services CMS Add: 01/01/2001 CMS Term: 21206 MEDSV DEF RBRVS 09/01/2019 864.85 Y Description: RECONSTRUCT UPPER JAW BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21208 MEDSV DEF RBRVS 09/01/2019 1355.00 Y Description: AUGMENTATION OF FACIAL BONES Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21209 MEDSV DEF RBRVS 09/01/2019 594.07 Y Description: REDUCTION OF FACIAL BONES Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 126 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21210 MEDSV DEF RBRVS 09/01/2019 1636.39 Y Description: FACE BONE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21215 MEDSV DEF RBRVS 09/01/2019 2928.70 Y Description: LOWER JAW BONE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21230 MEDSV DEF RBRVS 09/01/2019 530.58 Y Description: RIB CARTILAGE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21235 MEDSV DEF RBRVS 09/01/2019 520.07 Y Description: EAR CARTILAGE GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21240 MEDSV DEF RBRVS 09/01/2019 802.60 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21242 MEDSV DEF RBRVS 09/01/2019 735.59 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21243 MEDSV DEF RBRVS 09/01/2019 1218.99 Description: RECONSTRUCTION OF JAW JOINT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21244 MEDSV DEF RBRVS 09/01/2019 774.51 Y Description: RECONSTRUCTION OF LOWER JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21245 MEDSV DEF RBRVS 09/01/2019 803.52 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21246 MEDSV DEF RBRVS 09/01/2019 598.90 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21247 MEDSV DEF RBRVS 09/01/2019 1141.88 Y Description: RECONSTRUCT LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21248 MEDSV DEF RBRVS 09/01/2019 799.33 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21249 MEDSV DEF RBRVS 09/01/2019 1098.42 Y Description: RECONSTRUCTION OF JAW Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21255 MEDSV DEF RBRVS 09/01/2019 1005.78 Y Description: RECONSTRUCT LOWER JAW BONE Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21256 MEDSV DEF RBRVS 09/01/2019 893.87 Description: RECONSTRUCTION OF ORBIT Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21260 MEDSV DEF RBRVS 09/01/2019 979.25 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 127 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21261 MEDSV DEF RBRVS 09/01/2019 1565.59 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21263 MEDSV DEF RBRVS 09/01/2019 1382.60 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21267 MEDSV DEF RBRVS 09/01/2019 1191.55 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21268 MEDSV DEF RBRVS 09/01/2019 1288.82 Description: REVISE EYE SOCKETS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21270 MEDSV DEF RBRVS 09/01/2019 692.11 Y Description: AUGMENTATION CHEEK BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21275 MEDSV DEF RBRVS 09/01/2019 606.22 Description: REVISION ORBITOFACIAL BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21280 MEDSV DEF RBRVS 09/01/2019 421.78 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21282 MEDSV DEF RBRVS 09/01/2019 277.48 Description: REVISION OF EYELID Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21295 MEDSV DEF RBRVS 09/01/2019 146.01 Y Description: REVISION OF JAW MUSCLE/BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21296 MEDSV DEF RBRVS 09/01/2019 333.21 Y Description: REVISION OF JAW MUSCLE/BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21299 MEDSV DEF BILL20 Y Y Description: UNLISTED CRANFCL&MAXLFCL PX Category: Medical Services CMS Add: 01/01/1991 CMS Term: 21315 MEDSV DEF RBRVS 09/01/2019 197.72 Description: CLSD TX NSL FX MNPJ WO STBLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21320 MEDSV DEF RBRVS 09/01/2019 183.37 Description: CLSD TX NSL FX W/MNPJ&STABLJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21325 MEDSV DEF RBRVS 09/01/2019 336.66 Description: OPEN TX NOSE FX UNCOMPLICATD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21330 MEDSV DEF RBRVS 09/01/2019 404.44 Description: OPEN TX NOSE FX W/SKELE FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21335 MEDSV DEF RBRVS 09/01/2019 526.98 Description: OPEN TX NOSE & SEPTAL FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 128 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21336 MEDSV DEF RBRVS 09/01/2019 464.54 Description: OPEN TX SEPTAL FX W/WO STABJ Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21337 MEDSV DEF RBRVS 09/01/2019 289.34 Description: CLOSED TX SEPTAL&NOSE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21338 MEDSV DEF RBRVS 09/01/2019 512.73 Description: OPEN NASOETHMOID FX W/O FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21339 MEDSV DEF RBRVS 09/01/2019 554.13 Description: OPEN NASOETHMOID FX W/ FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21340 MEDSV DEF RBRVS 09/01/2019 545.94 Description: PERQ TX NASOETHMOID FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21343 MEDSV DEF RBRVS 09/01/2019 873.42 Description: OPEN TX DPRSD FRONT SINUS FX Category: Medical Services CMS Add: 01/01/1990 CMS Term: 21344 MEDSV DEF RBRVS 09/01/2019 1090.96 Description: OPEN TX COMPL FRONT SINUS FX Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21345 MEDSV DEF RBRVS 09/01/2019 558.44 Description: CLOSED TX NOSE/JAW FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21346 MEDSV DEF RBRVS 09/01/2019 658.07 Description: OPN TX NASOMAX FX W/FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21347 MEDSV DEF RBRVS 09/01/2019 799.09 Description: OPN TX NASOMAX FX MULTPLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21348 MEDSV DEF RBRVS 09/01/2019 858.24 Description: OPN TX NASOMAX FX W/GRAFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21355 MEDSV DEF RBRVS 09/01/2019 309.81 Description: PERQ TX MALAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21356 MEDSV DEF RBRVS 09/01/2019 357.75 Description: OPN TX DPRSD ZYGOMATIC ARCH Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21360 MEDSV DEF RBRVS 09/01/2019 387.89 Description: OPN TX DPRSD MALAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21365 MEDSV DEF RBRVS 09/01/2019 809.69 Description: OPN TX COMPLX MALAR FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21366 MEDSV DEF RBRVS 09/01/2019 857.21 Description: OPN TX COMPLX MALAR W/GRFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 129 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21385 MEDSV DEF RBRVS 09/01/2019 496.42 Description: OPN TX ORBIT FX TRANSANTRAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21386 MEDSV DEF RBRVS 09/01/2019 503.86 Description: OPN TX ORBIT FX PERIORBITAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21387 MEDSV DEF RBRVS 09/01/2019 528.61 Description: OPN TX ORBIT FX COMBINED Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21390 MEDSV DEF RBRVS 09/01/2019 583.55 Description: OPN TX ORBIT PERIORBTL IMPLT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21395 MEDSV DEF RBRVS 09/01/2019 716.00 Description: OPN TX ORBIT PERIORBT W/GRFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21400 MEDSV DEF RBRVS 09/01/2019 136.99 Description: CLOSED TX ORBIT W/O MANIPULJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21401 MEDSV DEF RBRVS 09/01/2019 350.56 Description: CLOSED TX ORBIT W/MANIPULJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21406 MEDSV DEF RBRVS 09/01/2019 373.18 Description: OPN TX ORBIT FX W/O IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21407 MEDSV DEF RBRVS 09/01/2019 473.31 Description: OPN TX ORBIT FX W/IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21408 MEDSV DEF RBRVS 09/01/2019 652.70 Description: OPN TX ORBIT FX W/BONE GRFT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21421 MEDSV DEF RBRVS 09/01/2019 546.53 Description: TREAT MOUTH ROOF FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21422 MEDSV DEF RBRVS 09/01/2019 483.76 Description: TREAT MOUTH ROOF FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21423 MEDSV DEF RBRVS 09/01/2019 595.89 Description: TREAT MOUTH ROOF FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21431 MEDSV DEF RBRVS 09/01/2019 518.11 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21432 MEDSV DEF RBRVS 09/01/2019 473.14 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21433 MEDSV DEF RBRVS 09/01/2019 1266.13 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 130 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21435 MEDSV DEF RBRVS 09/01/2019 922.11 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21436 MEDSV DEF RBRVS 09/01/2019 1484.85 Description: TREAT CRANIOFACIAL FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 21440 MEDSV DEF RBRVS 09/01/2019 415.86 Description: TREAT DENTAL RIDGE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21445 MEDSV DEF RBRVS 09/01/2019 553.72 Description: TREAT DENTAL RIDGE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21450 MEDSV DEF RBRVS 09/01/2019 436.16 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21451 MEDSV DEF RBRVS 09/01/2019 548.15 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21452 MEDSV DEF RBRVS 09/01/2019 444.89 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21453 MEDSV DEF RBRVS 09/01/2019 655.42 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21454 MEDSV DEF RBRVS 09/01/2019 425.73 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21461 MEDSV DEF RBRVS 09/01/2019 1535.37 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21462 MEDSV DEF RBRVS 09/01/2019 1619.52 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21465 MEDSV DEF RBRVS 09/01/2019 707.33 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21470 MEDSV DEF RBRVS 09/01/2019 881.41 Description: TREAT LOWER JAW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21480 MEDSV DEF RBRVS 09/01/2019 71.05 Description: RESET DISLOCATED JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21485 MEDSV DEF RBRVS 09/01/2019 503.86 Description: RESET DISLOCATED JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21490 MEDSV DEF RBRVS 09/01/2019 673.04 Description: REPAIR DISLOCATED JAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 131 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21497 MEDSV DEF RBRVS 09/01/2019 526.55 Description: INTERDENTAL WIRING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21499 MEDSV DEF BILL20 Y Description: UNLISTED MUSCSKEL PX HEAD Category: Medical Services CMS Add: 01/01/1982 CMS Term: 21501 MEDSV DEF RBRVS 09/01/2019 321.95 Description: DRAIN NECK/CHEST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21502 MEDSV DEF RBRVS 09/01/2019 379.15 Description: DRAIN CHEST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21510 MEDSV DEF RBRVS 09/01/2019 316.54 Description: DRAINAGE OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21550 MEDSV DEF RBRVS 09/01/2019 186.33 Description: BIOPSY OF NECK/CHEST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21552 MEDSV DEF RBRVS 02/01/2015 316.65 Description: EXC NECK LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21554 MEDSV DEF RBRVS 02/01/2015 521.17 Description: EXC NECK TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21555 MEDSV DEF RBRVS 09/01/2019 293.18 Description: EXC NECK LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21556 MEDSV DEF RBRVS 09/01/2019 381.69 Description: EXC NECK TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21557 MEDSV DEF RBRVS 09/01/2019 689.86 Description: RESECT NECK THORAX TUMOR<5CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21558 MEDSV DEF RBRVS 02/01/2015 967.00 Description: RESECT NECK TUMOR 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21600 MEDSV DEF RBRVS 09/01/2019 400.67 Description: PARTIAL REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21601 MEDSV DEF RBRVS 01/01/2020 849.47 Description: EXC CHEST WALL TUMOR W/RIBS Category: Medical Services CMS Add: 01/01/2020 CMS Term: 21602 MEDSV DEF RBRVS 01/01/2020 1140.21 Description: EXC CH WAL TUM W/O LYMPHADEC Category: Medical Services CMS Add: 01/01/2020 CMS Term: 21603 MEDSV DEF RBRVS 01/01/2020 1260.99 Description: EXC CH WAL TUM W/LYMPHADEC Category: Medical Services CMS Add: 01/01/2020 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 132 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21610 MEDSV DEF RBRVS 09/01/2019 834.42 Description: PARTIAL REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21615 MEDSV DEF RBRVS 09/01/2019 452.37 Description: REMOVAL OF RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21616 MEDSV DEF RBRVS 09/01/2019 607.51 Description: REMOVAL OF RIB AND NERVES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21620 MEDSV DEF RBRVS 09/01/2019 363.39 Description: PARTIAL REMOVAL OF STERNUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21627 MEDSV DEF RBRVS 09/01/2019 387.21 Description: STERNAL DEBRIDEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 21630 MEDSV DEF RBRVS 09/01/2019 873.38 Description: EXTENSIVE STERNUM SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21632 MEDSV DEF RBRVS 09/01/2019 867.33 Description: EXTENSIVE STERNUM SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21685 MEDSV DEF RBRVS 02/01/2015 729.97 Description: HYOID MYOTOMY & SUSPENSION Category: Medical Services CMS Add: 01/01/2004 CMS Term: 21700 MEDSV DEF RBRVS 09/01/2019 265.74 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21705 MEDSV DEF RBRVS 09/01/2019 397.42 Description: REVISION OF NECK MUSCLE/RIB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21720 MEDSV DEF RBRVS 09/01/2019 338.66 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21725 MEDSV DEF RBRVS 09/01/2019 337.03 Description: REVISION OF NECK MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21740 MEDSV DEF RBRVS 09/01/2019 734.00 Description: RECONSTRUCTION OF STERNUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21742 MEDSV DEF BILL20 Description: REPAIR STERN/NUSS W/O SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21743 MEDSV DEF BILL20 Description: REPAIR STERNUM/NUSS W/SCOPE Category: Medical Services CMS Add: 01/01/2003 CMS Term: 21750 MEDSV DEF RBRVS 09/01/2019 493.25 Description: REPAIR OF STERNUM SEPARATION Category: Medical Services CMS Add: 01/01/1992 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 133 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 21811 MEDSV DEF RBRVS 02/01/2015 436.65 Description: OPTX OF RIB FX W/FIXJ SCOPE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 21812 MEDSV DEF RBRVS 02/01/2015 523.52 Description: TREATMENT OF RIB FRACTURE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 21813 MEDSV DEF RBRVS 02/01/2015 712.54 Description: TREATMENT OF RIB FRACTURE Category: Medical Services CMS Add: 01/01/2015 CMS Term: 21820 MEDSV DEF RBRVS 09/01/2019 101.11 Description: TREAT STERNUM FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21825 MEDSV DEF RBRVS 09/01/2019 390.82 Description: TREAT STERNUM FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 21899 MEDSV DEF BILL20 Description: UNLISTED PX NECK/THORAX Category: Medical Services CMS Add: 01/01/1982 CMS Term: 21920 MEDSV DEF RBRVS 09/01/2019 182.78 Description: BIOPSY SOFT TISSUE OF BACK Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21925 MEDSV DEF RBRVS 09/01/2019 313.99 Description: BIOPSY SOFT TISSUE OF BACK Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21930 MEDSV DEF RBRVS 09/01/2019 332.72 Description: EXC BACK LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21931 MEDSV DEF RBRVS 02/01/2015 333.65 Description: EXC BACK LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21932 MEDSV DEF RBRVS 02/01/2015 469.13 Description: EXC BACK TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21933 MEDSV DEF RBRVS 02/01/2015 522.74 Description: EXC BACK TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 21935 MEDSV DEF RBRVS 09/01/2019 733.43 Description: RESECT BACK TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 21936 MEDSV DEF RBRVS 02/01/2015 1008.26 Description: RESECT BACK TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22010 MEDSV DEF RBRVS 02/01/2015 672.04 Description: I&D P-SPINE C/T/CERV-THOR Category: Medical Services CMS Add: 01/01/2006 CMS Term: 22015 MEDSV DEF RBRVS 02/01/2015 637.54 Description: I&D ABSCESS P-SPINE L/S/LS Category: Medical Services CMS Add: 01/01/2006 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 134 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22100 MEDSV DEF RBRVS 09/01/2019 610.58 Description: REMOVE PART OF NECK VERTEBRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 22101 MEDSV DEF RBRVS 09/01/2019 621.07 Description: REMOVE PART THORAX VERTEBRA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 22102 MEDSV DEF RBRVS 09/01/2019 580.35 Description: REMOVE PART LUMBAR VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22103 MEDSV DEF RBRVS 09/01/2019 101.19 Description: REMOVE EXTRA SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22110 MEDSV DEF RBRVS 09/01/2019 756.75 Description: REMOVE PART OF NECK VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22112 MEDSV DEF RBRVS 09/01/2019 747.16 Description: REMOVE PART THORAX VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22114 MEDSV DEF RBRVS 09/01/2019 711.30 Description: REMOVE PART LUMBAR VERTEBRA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22116 MEDSV DEF RBRVS 09/01/2019 99.74 Description: REMOVE EXTRA SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22206 MEDSV DEF RBRVS 02/01/2015 1693.74 Description: INCIS SPINE 3 COLUMN THORAC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 22207 MEDSV DEF RBRVS 02/01/2015 1702.12 Description: INCIS SPINE 3 COLUMN LUMBAR Category: Medical Services CMS Add: 01/01/2008 CMS Term: 22208 MEDSV DEF RBRVS 02/01/2015 418.43 Description: INCIS SPINE 3 COLUMN ADL SEG Category: Medical Services CMS Add: 01/01/2008 CMS Term: 22210 MEDSV DEF RBRVS 09/01/2019 1254.08 Description: INCIS 1 VERTEBRAL SEG CERV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22212 MEDSV DEF RBRVS 09/01/2019 1047.44 Description: INCIS 1 VERTEBRAL SEG THORAC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22214 MEDSV DEF RBRVS 09/01/2019 1053.94 Description: INCIS 1 VERTEBRAL SEG LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22216 MEDSV DEF RBRVS 01/01/2016 259.62 Description: INCIS ADDL SPINE SEGMENT Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22220 MEDSV DEF RBRVS 09/01/2019 1142.61 Description: OSTEOT DSC ANT 1 VRT SGM CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 135 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22222 MEDSV DEF RBRVS 09/01/2019 1119.79 Description: OSTEOT DSC ANT 1VRT SGM THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22224 MEDSV DEF RBRVS 09/01/2019 1131.28 Description: OSTEOT DSC ANT 1VRT SGM LMBR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22226 MEDSV DEF RBRVS 01/01/2016 260.03 Description: OSTEOT DSC ANT 1VRT SGM EA Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22310 MEDSV DEF RBRVS 09/01/2019 218.22 Description: CLOSED TX VERT FX W/O MANJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22315 MEDSV DEF RBRVS 09/01/2019 623.32 Description: CLOSED TX VERT FX W/MANJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22318 MEDSV DEF RBRVS 02/01/2015 1142.41 Description: TREAT ODONTOID FX W/O GRAFT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 22319 MEDSV DEF RBRVS 02/01/2015 1270.84 0-1 Description: TREAT ODONTOID FX W/GRAFT Category: Medical Services CMS Add: 01/01/2000 CMS Term: 22325 MEDSV DEF RBRVS 09/01/2019 1016.86 Description: TREAT SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22326 MEDSV DEF RBRVS 09/01/2019 1046.81 Description: TREAT NECK SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22327 MEDSV DEF RBRVS 09/01/2019 1051.77 Description: TREAT THORAX SPINE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22328 MEDSV DEF RBRVS 02/01/2015 200.06 Description: TREAT EACH ADD SPINE FX Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22505 MEDSV DEF RBRVS 09/01/2019 88.31 Description: MANIPULATION OF SPINE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22510 MEDSV DEF RBRVS 09/15/2017 1192.22 Description: PERQ CERVICOTHORACIC INJECT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22511 MEDSV DEF RBRVS 09/15/2017 1180.45 Description: PERQ LUMBOSACRAL INJECTION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22512 MEDSV DEF RBRVS 09/15/2017 676.89 Description: VERTEBROPLASTY ADDL INJECT Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22513 MEDSV DEF RBRVS 09/15/2017 5050.05 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 136 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22514 MEDSV DEF RBRVS 09/15/2017 5020.59 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22515 MEDSV DEF BILL20 Description: PERQ VERTEBRAL AUGMENTATION Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22526 MEDSV DEF RBRVS 09/15/2017 1630.75 Description: IDET SINGLE LEVEL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22527 MEDSV DEF RBRVS 09/15/2017 1375.06 Description: IDET 1 OR MORE LEVELS Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22532 MEDSV DEF RBRVS 02/01/2015 1264.04 Description: ARTHRD LAT XTRCVTRY TQ THRC Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22533 MEDSV DEF RBRVS 02/01/2015 1190.42 Description: ARTHRD LAT XTRCVTRY TQ LMBR Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22534 MEDSV DEF RBRVS 02/01/2015 258.13 Description: ARTHRD LAT XTRCVTRY TQ EA AD Category: Medical Services CMS Add: 01/01/2004 CMS Term: 22548 MEDSV DEF RBRVS 09/01/2019 1365.47 Description: ARTHRD ANT TORAL/XORAL C1-C2 Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22551 MEDSV DEF RBRVS 02/01/2015 1208.71 Description: ARTHRD ANT NTRBDY CERVICAL Category: Medical Services CMS Add: 01/01/2011 CMS Term: 22552 MEDSV DEF RBRVS 02/01/2015 280.26 Description: ARTHRD ANT NTRBD CERVICAL EA Category: Medical Services CMS Add: 01/01/2011 CMS Term: 22554 MEDSV DEF RBRVS 09/01/2019 894.38 Description: ARTHRD ANT NTRBD MIN DSC CRV Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22556 MEDSV DEF RBRVS 09/01/2019 1182.55 Description: ARTHRD ANT NTRBD MIN DSC THC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22558 MEDSV DEF RBRVS 09/01/2019 1097.85 Description: ARTHRD ANT NTRBD MIN DSC LUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22585 MEDSV DEF RBRVS 02/01/2015 237.58 Description: ARTHRD ANT NTRBD MIN DSC EA Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22586 NOCOV DEF SYSMAN Description: ARTHRD PRE-SAC NTRBDY L5-S1 Category: Non Covered Services CMS Add: 01/01/2013 CMS Term: 22590 MEDSV DEF RBRVS 09/01/2019 1107.94 Description: ARTHRD PST TQ CRANIOCERVICAL Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 137 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22595 MEDSV DEF RBRVS 09/01/2019 1055.89 Description: ARTHRD PST TQ ATLAS-AXIS Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22600 MEDSV DEF RBRVS 09/01/2019 907.06 Description: ARTHRD PST TQ 1NTRSPC CRV Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22610 MEDSV DEF RBRVS 09/01/2019 891.12 Description: ARTHRD PST TQ 1NTRSPC THRC Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22612 MEDSV DEF RBRVS 09/01/2019 1131.71 Description: ARTHRD PST TQ 1NTRSPC LUMBAR Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22614 MEDSV DEF RBRVS 02/01/2015 278.21 Description: ARTHRD PST TQ 1NTRSPC EA ADD Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22630 MEDSV DEF RBRVS 09/01/2019 1095.91 Description: ARTHRD PST TQ 1NTRSPC LUM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22632 MEDSV DEF RBRVS 02/01/2015 226.30 Description: ARTHRD PST TQ 1NTRSPC LM EA Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22633 MEDSV DEF RBRVS 02/01/2015 1309.59 Description: ARTHRD CMBN 1NTRSPC LUMBAR Category: Medical Services CMS Add: 01/01/2012 CMS Term: 22634 MEDSV DEF RBRVS 02/01/2015 352.86 Description: ARTHRD CMBN 1NTRSPC EA ADDL Category: Medical Services CMS Add: 01/01/2012 CMS Term: 22800 MEDSV DEF RBRVS 09/01/2019 965.54 Description: ARTHRD PST DFRM<6 VRT SGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22802 MEDSV DEF RBRVS 09/01/2019 1497.58 Description: ARTHRD PST DFRM 7-12 VRT SGM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22804 MEDSV DEF RBRVS 02/01/2015 1725.47 Description: ARTHRD PST DFRM 13+ VRT SGM Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22808 MEDSV DEF RBRVS 02/01/2015 1295.38 Description: ARTHRD ANT DFRM 2-3 VRT SGM Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22810 MEDSV DEF RBRVS 09/01/2019 1454.11 Description: ARTHRD ANT DFRM 4-7 VRT SGM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22812 MEDSV DEF RBRVS 09/01/2019 1612.29 Description: ARTHRD ANT DFRM 8+ VRT SGM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22818 MEDSV DEF RBRVS 02/01/2015 1561.92 Description: KYPHECTOMY 1-2 SEGMENTS Category: Medical Services CMS Add: 01/01/1998 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 138 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22819 MEDSV DEF RBRVS 02/01/2015 1910.78 Description: KYPHECTOMY 3 OR MORE Category: Medical Services CMS Add: 01/01/1998 CMS Term: 22830 MEDSV DEF RBRVS 09/01/2019 576.11 Description: EXPLORATION OF SPINAL FUSION Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22840 MEDSV DEF RBRVS 02/01/2015 542.26 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22841 NOCOV DEF SYSMAN Description: INSERT SPINE FIXATION DEVICE Category: Non Covered Services CMS Add: 01/01/1996 CMS Term: 22842 MEDSV DEF RBRVS 02/01/2015 543.17 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22843 MEDSV DEF RBRVS 02/01/2015 579.20 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22844 MEDSV DEF RBRVS 02/01/2015 701.87 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22845 MEDSV DEF RBRVS 01/01/2019 520.81 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22846 MEDSV DEF RBRVS 02/01/2015 540.69 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22847 MEDSV DEF RBRVS 02/01/2015 615.84 Description: INSERT SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22848 MEDSV DEF RBRVS 02/01/2015 256.48 Description: INSERT PELV FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1996 CMS Term: 22849 MEDSV DEF RBRVS 09/01/2019 923.57 Description: REINSERT SPINAL FIXATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 22850 MEDSV DEF RBRVS 09/01/2019 512.48 Description: REMOVE SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22852 MEDSV DEF RBRVS 09/01/2019 490.64 Description: REMOVE SPINE FIXATION DEVICE Category: Medical Services CMS Add: 01/01/1988 CMS Term: 22853 MEDSV DEF RBRVS 01/01/2017 186.94 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22854 MEDSV DEF RBRVS 01/01/2017 242.00 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 139 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22855 MEDSV DEF RBRVS 09/01/2019 788.97 Description: REMOVAL ANTERIOR INSTRMJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 22856 MEDSV DEF RBRVS 03/29/2019 1168.73 Y Description: TOT DISC ARTHRP 1NTRSPC CRV Category: Medical Services CMS Add: 01/01/2009 CMS Term: 22857 MEDSV DEF RBRVS 07/19/2018 1218.70 Y Description: TOT DISC ARTHRP 1NTRSPC LMBR Category: Medical Services CMS Add: 01/01/2007 CMS Term: 22858 MEDSV DEF RBRVS 12/03/2019 366.33 Description: TOT DISC ARTHRP 2ND LVL CRV Category: Medical Services CMS Add: 01/01/2015 CMS Term: 22859 MEDSV DEF RBRVS 01/01/2017 242.00 Description: INSJ BIOMECHANICAL DEVICE Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22860 MEDSV DEF BILL20 Y Description: TOT DISC ARTHRP 2NTRSPC LMBR Category: Medical Services CMS Add: 01/01/2023 CMS Term: 22861 NOCOV DEF SYSMAN Description: REV RPLCM ARTHRP 1NTRSPC CRV Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 22862 NOCOV DEF SYSMAN Description: REV RPLCM RTHRP 1NTRSPC LMBR Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 22864 NOCOV DEF SYSMAN Description: RMVL TOT ARTHRP 1NTRSPC CRV Category: Non Covered Services CMS Add: 01/01/2009 CMS Term: 22865 NOCOV DEF SYSMAN Description: RMVL TOT ARTHRP 1NTRSPC LMBR Category: Non Covered Services CMS Add: 01/01/2007 CMS Term: 22867 MEDSV DEF RBRVS 01/01/2019 700.30 Y Description: INSJ STABLJ DEV W/DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22868 MEDSV DEF RBRVS 01/01/2017 175.19 Y Description: INSJ STABLJ DEV W/DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22869 MEDSV DEF RBRVS 01/01/2019 387.48 Y Description: INSJ STABLJ DEV W/O DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22870 MEDSV DEF RBRVS 01/01/2017 102.26 Y Description: INSJ STABLJ DEV W/O DCMPRN Category: Medical Services CMS Add: 01/01/2017 CMS Term: 22899 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE SPINE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 22900 MEDSV DEF RBRVS 09/01/2019 400.00 Description: EXC ABDL TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 140 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 22901 MEDSV DEF RBRVS 02/01/2015 470.31 Description: EXC ABDL TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22902 MEDSV DEF RBRVS 02/01/2015 305.12 Description: EXC ABD LES SC < 3 CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22903 MEDSV DEF RBRVS 02/01/2015 308.26 Description: EXC ABD LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22904 MEDSV DEF RBRVS 02/01/2015 746.44 Description: RADICAL RESECT ABD TUMOR<5CM Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22905 MEDSV DEF RBRVS 02/01/2015 950.99 Description: RAD RESECT ABD TUMOR 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 22999 MEDSV DEF BILL20 Description: UNLISTED PX ABDOMEN MUSCSKEL Category: Medical Services CMS Add: 01/01/1982 CMS Term: 23000 MEDSV DEF RBRVS 09/01/2019 409.62 Description: REMOVAL OF CALCIUM DEPOSITS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23020 MEDSV DEF RBRVS 09/01/2019 491.94 Description: RELEASE SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23030 MEDSV DEF RBRVS 09/01/2019 309.82 Description: DRAIN SHOULDER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23031 MEDSV DEF RBRVS 09/01/2019 297.91 Description: DRAIN SHOULDER BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23035 MEDSV DEF RBRVS 09/01/2019 487.56 Description: DRAIN SHOULDER BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23040 MEDSV DEF RBRVS 09/01/2019 512.66 Description: EXPLORATORY SHOULDER SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23044 MEDSV DEF RBRVS 09/01/2019 404.17 Description: EXPLORATORY SHOULDER SURGERY Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23065 MEDSV DEF RBRVS 09/01/2019 153.20 Description: BIOPSY SHOULDER TISSUES Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23066 MEDSV DEF RBRVS 09/01/2019 389.84 Description: BIOPSY SHOULDER TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23071 MEDSV DEF RBRVS 02/01/2015 297.35 Description: EXC SHOULDER LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 141 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23073 MEDSV DEF RBRVS 02/01/2015 492.40 Description: EXC SHOULDER TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 23075 MEDSV DEF RBRVS 09/01/2019 328.79 Description: EXC SHOULDER LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23076 MEDSV DEF RBRVS 09/01/2019 383.15 Description: EXC SHOULDER TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23077 MEDSV DEF RBRVS 09/01/2019 817.26 Description: RESECT SHOULDER TUMOR < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 23078 MEDSV DEF RBRVS 02/01/2015 1030.06 Description: RESECT SHOULDER TUMOR 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 23100 MEDSV DEF RBRVS 09/01/2019 355.35 Description: BIOPSY OF SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23101 MEDSV DEF RBRVS 09/01/2019 323.87 Description: SHOULDER JOINT SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23105 MEDSV DEF RBRVS 09/01/2019 454.75 Description: REMOVE SHOULDER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23106 MEDSV DEF RBRVS 09/01/2019 352.31 Description: INCISION OF COLLARBONE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23107 MEDSV DEF RBRVS 09/01/2019 471.76 Description: EXPLORE TREAT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1989 CMS Term: 23120 MEDSV DEF RBRVS 09/01/2019 416.63 Description: PARTIAL REMOVAL COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23125 MEDSV DEF RBRVS 09/01/2019 504.67 Description: REMOVAL OF COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23130 MEDSV DEF RBRVS 09/01/2019 433.12 Description: REMOVE SHOULDER BONE PART Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23140 MEDSV DEF RBRVS 09/01/2019 376.76 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23145 MEDSV DEF RBRVS 09/01/2019 494.83 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23146 MEDSV DEF RBRVS 09/01/2019 441.36 Description: REMOVAL OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 142 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23150 MEDSV DEF RBRVS 09/01/2019 470.35 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23155 MEDSV DEF RBRVS 09/01/2019 564.94 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23156 MEDSV DEF RBRVS 09/01/2019 482.50 Description: REMOVAL OF HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23170 MEDSV DEF RBRVS 09/01/2019 398.25 Description: REMOVE COLLAR BONE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23172 MEDSV DEF RBRVS 09/01/2019 402.84 Description: REMOVE SHOULDER BLADE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23174 MEDSV DEF RBRVS 09/01/2019 539.38 Description: REMOVE HUMERUS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23180 MEDSV DEF RBRVS 09/01/2019 474.24 Description: REMOVE COLLAR BONE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23182 MEDSV DEF RBRVS 09/01/2019 470.63 Description: REMOVE SHOULDER BLADE LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23184 MEDSV DEF RBRVS 09/01/2019 523.62 Description: REMOVE HUMERUS LESION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 23190 MEDSV DEF RBRVS 09/01/2019 405.74 Description: PARTIAL REMOVAL OF SCAPULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23195 MEDSV DEF RBRVS 09/01/2019 538.05 Description: REMOVAL OF HEAD OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23200 MEDSV DEF RBRVS 09/01/2019 1085.64 Description: RESECT CLAVICLE TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23210 MEDSV DEF RBRVS 09/01/2019 1277.06 Description: RESECT SCAPULA TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23220 MEDSV DEF RBRVS 09/01/2019 1401.02 Description: RESECT PROX HUMERUS TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23330 MEDSV DEF RBRVS 09/01/2019 169.71 Description: REMOVE SHOULDER FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23333 MEDSV DEF RBRVS 02/01/2015 325.61 Description: REMOVE SHOULDER FB DEEP Category: Medical Services CMS Add: 01/01/2014 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 143 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23334 MEDSV DEF RBRVS 02/01/2015 769.29 Description: SHOULDER PROSTHESIS REMOVAL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23335 MEDSV DEF RBRVS 02/01/2015 917.67 Description: SHOULDER PROSTHESIS REMOVAL Category: Medical Services CMS Add: 01/01/2014 CMS Term: 23350 MEDSV DEF RBRVS 09/01/2019 91.93 Description: INJECTION FOR SHOULDER X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23395 MEDSV DEF RBRVS 09/01/2019 920.67 Description: MUSCLE TRANSFER SHOULDER/ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23397 MEDSV DEF RBRVS 09/01/2019 815.78 Description: MUSCLE TRANSFERS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23400 MEDSV DEF RBRVS 09/01/2019 693.13 Description: FIXATION OF SHOULDER BLADE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23405 MEDSV DEF RBRVS 09/01/2019 448.93 Description: INCISION OF TENDON & MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23406 MEDSV DEF RBRVS 09/01/2019 551.22 Description: INCISE TENDON(S) & MUSCLE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23410 MEDSV DEF RBRVS 09/01/2019 586.78 Description: REPAIR ROTATOR CUFF ACUTE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23412 MEDSV DEF RBRVS 09/01/2019 609.46 Description: REPAIR ROTATOR CUFF CHRONIC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23415 MEDSV DEF RBRVS 09/01/2019 496.04 Description: RELEASE OF SHOULDER LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23420 MEDSV DEF RBRVS 09/01/2019 692.44 Description: REPAIR OF SHOULDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23430 MEDSV DEF RBRVS 09/01/2019 534.18 Description: REPAIR BICEPS TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23440 MEDSV DEF RBRVS 09/01/2019 540.29 Description: REMOVE/TRANSPLANT TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23450 MEDSV DEF RBRVS 09/01/2019 677.17 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23455 MEDSV DEF RBRVS 09/01/2019 717.35 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 144 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23460 MEDSV DEF RBRVS 09/01/2019 778.64 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23462 MEDSV DEF RBRVS 09/01/2019 766.62 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23465 MEDSV DEF RBRVS 09/01/2019 798.80 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23466 MEDSV DEF RBRVS 09/01/2019 801.71 Description: REPAIR SHOULDER CAPSULE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 23470 MEDSV DEF RBRVS 09/01/2019 864.39 Description: RECONSTRUCT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23472 MEDSV DEF RBRVS 09/01/2019 1049.00 Description: RECONSTRUCT SHOULDER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23473 MEDSV DEF RBRVS 02/01/2015 1169.96 0-1 Description: REVIS RECONST SHOULDER JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 23474 MEDSV DEF RBRVS 02/01/2015 1264.43 0-1 Description: REVIS RECONST SHOULDER JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 23480 MEDSV DEF RBRVS 09/01/2019 585.28 Description: REVISION OF COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23485 MEDSV DEF RBRVS 09/01/2019 683.22 Description: REVISION OF COLLAR BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23490 MEDSV DEF RBRVS 09/01/2019 615.15 Description: REINFORCE CLAVICLE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 23491 MEDSV DEF RBRVS 09/01/2019 724.26 Description: REINFORCE SHOULDER BONES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 23500 MEDSV DEF RBRVS 09/01/2019 154.75 Description: CLTX CLAVICULAR FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23505 MEDSV DEF RBRVS 09/01/2019 249.55 Description: CLTX CLAVICULAR FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23515 MEDSV DEF RBRVS 09/01/2019 514.68 Description: OPTX CLAVICULAR FX W/INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23520 MEDSV DEF RBRVS 09/01/2019 162.60 Description: CLTX STRNCLAV DISLC W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 145 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23525 MEDSV DEF RBRVS 09/01/2019 270.44 Description: CLTX STRNCLAV DISLC W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23530 MEDSV DEF RBRVS 09/01/2019 406.99 Description: OPTX STRNCLAV DISLC AQT/CHRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23532 MEDSV DEF RBRVS 09/01/2019 443.68 Description: OPTX STRCLV DSLC AQ/CHRN GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23540 MEDSV DEF RBRVS 09/01/2019 158.70 Description: CLTX ACROMCLAV DISLC WO MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23545 MEDSV DEF RBRVS 09/01/2019 241.04 Description: CLTX ACROMCLAV DISLC W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23550 MEDSV DEF RBRVS 09/01/2019 408.05 Description: OPTX ACROMCLV DISLC AQT/CHRN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23552 MEDSV DEF RBRVS 09/01/2019 467.27 Description: OPTX ACRCLV DSLC AQ/CHRN GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23570 MEDSV DEF RBRVS 09/01/2019 163.49 Description: CLTX SCAPULAR FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23575 MEDSV DEF RBRVS 09/01/2019 282.27 Description: CLTX SCAP FX W/MNPJ +-TRACTJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23585 MEDSV DEF RBRVS 09/01/2019 701.89 Description: OPTX SCAPULAR FX W/INT FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23600 MEDSV DEF RBRVS 09/01/2019 230.14 Description: CLTX PROX HUMRL FX W/O MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23605 MEDSV DEF RBRVS 09/01/2019 328.60 Description: CLTX PRX HMRL FX MNPJ+-TRACT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23615 MEDSV DEF RBRVS 09/01/2019 632.53 Description: OPTX PROX HUMRL FX W/INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23616 MEDSV DEF RBRVS 09/01/2019 889.92 Description: OPTX PRX HMRL FX FIX RPR RPL Category: Medical Services CMS Add: 01/01/1993 CMS Term: 23620 MEDSV DEF RBRVS 09/01/2019 189.98 Description: CLTX GR HMRL TBRS FX WO MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23625 MEDSV DEF RBRVS 09/01/2019 268.70 Description: CLTX GR HMRL TBRS FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 146 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23630 MEDSV DEF RBRVS 09/01/2019 558.72 Description: OPTX GR HMRL TBRS FX INT FIX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23650 MEDSV DEF RBRVS 09/01/2019 222.34 Description: CLTX SHO DSLC W/MNPJ WO ANES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23655 MEDSV DEF RBRVS 09/01/2019 283.46 Description: CLTX SHO DSLC W/MNPJ W/ANES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23660 MEDSV DEF RBRVS 09/01/2019 415.71 Description: OPTX ACUTE SHOULDER DISLC Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23665 MEDSV DEF RBRVS 09/01/2019 301.33 Description: CLTX SHO DSLC FX GR HMRL TBR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23670 MEDSV DEF RBRVS 09/01/2019 627.29 Description: OPTX SHO DISLC FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23675 MEDSV DEF RBRVS 09/01/2019 389.10 Description: CLTX SHO DISLC NECK FX MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23680 MEDSV DEF RBRVS 09/01/2019 663.96 Description: OPTX SHO DISLC NECK FX FIXJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23700 MEDSV DEF RBRVS 09/01/2019 139.24 Description: MNPJ ANES SHO JT FIXJ APRATS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23800 MEDSV DEF RBRVS 09/01/2019 732.83 Description: ARTHRODESIS GLENOHUMERAL JT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23802 MEDSV DEF RBRVS 09/01/2019 917.19 Description: ARTHRD GLENOHUMERAL JT W/GRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23900 MEDSV DEF RBRVS 09/01/2019 993.52 Description: INTERTHORACOSCPLR AMPUTATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23920 MEDSV DEF RBRVS 09/01/2019 805.18 Description: DISARTICULATION SHOULDER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23921 MEDSV DEF RBRVS 09/01/2019 335.68 Description: DISARTICULATION SHO SEC CLSR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23929 MEDSV DEF BILL20 Description: UNLISTED PROCEDURE SHOULDER Category: Medical Services CMS Add: 01/01/1982 CMS Term: 23930 MEDSV DEF RBRVS 09/01/2019 247.46 Description: I&D UPR A/E DP ABSC/HMTMA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 147 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 23931 MEDSV DEF RBRVS 09/01/2019 202.53 Description: I&D UPR A/E BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 23935 MEDSV DEF RBRVS 09/01/2019 362.00 Description: INC DP OPN B1 CRTX HUM/ELBW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24000 MEDSV DEF RBRVS 09/01/2019 339.40 Description: ARTHRT ELBW EXPL DRG/RMVL FB Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24006 MEDSV DEF RBRVS 09/01/2019 507.93 Description: ARTHRT ELBW CAPSL EXC RLS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24065 MEDSV DEF RBRVS 09/01/2019 180.34 Description: BIOPSY ARM/ELBOW SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24066 MEDSV DEF RBRVS 09/01/2019 433.49 Description: BIOPSY ARM/ELBOW SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24071 MEDSV DEF RBRVS 02/01/2015 288.40 Description: EXC ARM/ELBOW LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 24073 MEDSV DEF RBRVS 02/01/2015 492.15 Description: EX ARM/ELBOW TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 24075 MEDSV DEF RBRVS 09/01/2019 343.89 Description: EXC ARM/ELBOW LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24076 MEDSV DEF RBRVS 09/01/2019 386.29 Description: EX ARM/ELBOW TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24077 MEDSV DEF RBRVS 09/01/2019 740.36 Description: RAD RESCJ TUM TISS A/E <5CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 24079 MEDSV DEF RBRVS 02/01/2015 946.73 Description: RAD RESCJ TUM TISS A/E 5 CM+ Category: Medical Services CMS Add: 01/01/2010 CMS Term: 24100 MEDSV DEF RBRVS 09/01/2019 296.41 Description: ARTHRT ELBW SYNOVIAL BX ONLY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24101 MEDSV DEF RBRVS 09/01/2019 355.14 Description: ARTHRT ELBW JT EXPL BX RMVL Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24102 MEDSV DEF RBRVS 09/01/2019 439.10 Description: ARTHRT ELBOW W/SYNOVECTOMY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24105 MEDSV DEF RBRVS 09/01/2019 247.47 Description: EXCISION OLECRANON BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 148 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24110 MEDSV DEF RBRVS 09/01/2019 417.77 Description: EXC/CURTG B1 CST/B9 TUM HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24115 MEDSV DEF RBRVS 09/01/2019 525.24 Description: EXC/CRTG B1 CST/TUM HUM AGRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24116 MEDSV DEF RBRVS 09/01/2019 614.80 Description: EXC/CRTG B1 CST/TUM HUM ALGR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24120 MEDSV DEF RBRVS 09/01/2019 376.21 Description: EXC/CRTG B1 CST/B9 TUM RDS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24125 MEDSV DEF RBRVS 09/01/2019 440.99 Description: EXC/CRTG B1 CST/TUM RDS AGRF Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24126 MEDSV DEF RBRVS 09/01/2019 461.74 Description: EXC/CRTG B1 CST/TUM RDS ALGR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24130 MEDSV DEF RBRVS 09/01/2019 360.93 Description: EXCISION RADIAL HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24134 MEDSV DEF RBRVS 09/01/2019 532.06 Description: SEQUESTRECTOMY SHFT/DSTL HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24136 MEDSV DEF RBRVS 09/01/2019 453.18 Description: SEQUESTRECTOMY RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24138 MEDSV DEF RBRVS 09/01/2019 479.07 Description: SEQUESTRECTOMY OLECRN PROCES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24140 MEDSV DEF RBRVS 09/01/2019 498.70 Description: PARTIAL EXC BONE HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24145 MEDSV DEF RBRVS 09/01/2019 420.90 Description: PRTL EXC BONE RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24147 MEDSV DEF RBRVS 09/01/2019 442.26 Description: PRTL EXC BONE OLECRN PROCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24149 MEDSV DEF RBRVS 01/01/2019 838.59 Description: RADICAL RESECTION OF ELBOW Category: Medical Services CMS Add: 01/01/1997 CMS Term: 24150 MEDSV DEF RBRVS 09/01/2019 1114.95 Description: RAD RESCJ TUM DSTL/SHFT HUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24152 MEDSV DEF RBRVS 09/01/2019 984.89 Description: RAD RESECTION TUM RADIAL H/N Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 149 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24155 MEDSV DEF RBRVS 09/01/2019 608.97 Description: RESECTION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24160 MEDSV DEF RBRVS 09/01/2019 903.27 Description: RMVL PROSTHHUMRL&ULNAR CMPNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24164 MEDSV DEF RBRVS 09/01/2019 519.87 Description: REMOVAL PROSTH RADIAL HEAD Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24200 MEDSV DEF RBRVS 09/01/2019 144.99 Description: RMVL FB UPPER ARM/ELBW SUBQ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24201 MEDSV DEF RBRVS 09/01/2019 394.15 Description: RMVL FB UPPER ARM/ELBW DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24220 MEDSV DEF RBRVS 09/01/2019 113.31 Description: INJECTION PX FOR ELBOW ARTHG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24300 MEDSV DEF RBRVS 01/01/2016 291.86 Description: MNPJ ELBOW UNDER ANES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24301 MEDSV DEF RBRVS 09/01/2019 536.85 Description: MUSC/TDN TRANSFER UPR A/E 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24305 MEDSV DEF RBRVS 09/01/2019 411.00 Description: TENDON LNGTH UPR A/E EA TDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24310 MEDSV DEF RBRVS 09/01/2019 338.42 Description: TNOT OPN ELBW TO SHO EA TDN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24320 MEDSV DEF RBRVS 09/01/2019 556.52 Description: TENOPLASTY ELBOW TO SHO 1 Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24330 MEDSV DEF RBRVS 09/01/2019 510.93 Description: FLEXOR-PLASTY ELBOW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24331 MEDSV DEF RBRVS 09/01/2019 560.51 Description: FLEXOR-PLASTY ELBW W/ADVMNT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24332 MEDSV DEF RBRVS 01/01/2016 435.39 0-2 Description: TENOLYSIS TRICEPS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24340 MEDSV DEF RBRVS 09/01/2019 437.98 Description: TENODESIS BICEPS TDN AT ELBW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24341 MEDSV DEF RBRVS 01/01/2019 532.18 Description: RPR TDN/MUSC UPR A/E EACH Category: Medical Services CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 150 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24342 MEDSV DEF RBRVS 09/01/2019 554.87 Description: REPAIR OF RUPTURED TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24343 MEDSV DEF RBRVS 02/01/2015 502.91 0-2 Description: REPR ELBOW LAT LIGMNT W/TISS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24344 MEDSV DEF RBRVS 02/01/2015 783.47 0-2 Description: RECONSTRUCT ELBOW LAT LIGMNT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24345 MEDSV DEF RBRVS 02/01/2015 500.19 0-2 Description: REPR ELBW MED LIGMNT W/TISSU Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24346 MEDSV DEF RBRVS 02/01/2015 783.47 0-2 Description: RECONSTRUCT ELBOW MED LIGMNT Category: Medical Services CMS Add: 01/01/2002 CMS Term: 24357 MEDSV DEF RBRVS 02/01/2015 313.13 Description: REPAIR ELBOW PERC Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24358 MEDSV DEF RBRVS 02/01/2015 372.16 Description: REPAIR ELBOW W/DEB OPEN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24359 MEDSV DEF RBRVS 02/01/2015 470.83 Description: REPAIR ELBOW DEB/ATTCH OPEN Category: Medical Services CMS Add: 01/01/2008 CMS Term: 24360 MEDSV DEF RBRVS 09/01/2019 641.15 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24361 MEDSV DEF RBRVS 09/01/2019 718.46 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24362 MEDSV DEF RBRVS 09/01/2019 757.44 Description: RECONSTRUCT ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24363 MEDSV DEF RBRVS 09/01/2019 1046.58 Description: REPLACE ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24365 MEDSV DEF RBRVS 09/01/2019 454.80 Description: RECONSTRUCT HEAD OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24366 MEDSV DEF RBRVS 09/01/2019 485.99 Description: RECONSTRUCT HEAD OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24370 MEDSV DEF RBRVS 02/01/2015 1107.96 0-1 Description: REVISE RECONST ELBOW JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: 24371 MEDSV DEF RBRVS 02/01/2015 1279.90 0-1 Description: REVISE RECONST ELBOW JOINT Category: Medical Services CMS Add: 01/01/2013 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 151 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24400 MEDSV DEF RBRVS 09/01/2019 583.93 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24410 MEDSV DEF RBRVS 09/01/2019 754.69 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24420 MEDSV DEF RBRVS 09/01/2019 708.44 Description: REVISION OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24430 MEDSV DEF RBRVS 09/01/2019 757.29 Description: REPAIR OF HUMERUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24435 MEDSV DEF RBRVS 09/01/2019 770.54 Description: REPAIR HUMERUS WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24470 MEDSV DEF RBRVS 09/01/2019 418.21 Description: REVISION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24495 MEDSV DEF RBRVS 09/01/2019 461.21 Description: DECOMPRESSION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24498 MEDSV DEF RBRVS 09/01/2019 619.61 Description: REINFORCE HUMERUS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 24500 MEDSV DEF RBRVS 09/01/2019 252.06 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24505 MEDSV DEF RBRVS 09/01/2019 352.82 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24515 MEDSV DEF RBRVS 09/01/2019 625.96 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24516 MEDSV DEF RBRVS 09/01/2019 614.88 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24530 MEDSV DEF RBRVS 09/01/2019 267.84 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24535 MEDSV DEF RBRVS 09/01/2019 436.11 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24538 MEDSV DEF RBRVS 09/01/2019 528.47 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24545 MEDSV DEF RBRVS 09/01/2019 664.78 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 152 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24546 MEDSV DEF RBRVS 09/01/2019 744.36 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 24560 MEDSV DEF RBRVS 09/01/2019 226.72 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24565 MEDSV DEF RBRVS 09/01/2019 376.18 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24566 MEDSV DEF RBRVS 09/01/2019 509.64 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 24575 MEDSV DEF RBRVS 09/01/2019 523.47 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24576 MEDSV DEF RBRVS 09/01/2019 238.86 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24577 MEDSV DEF RBRVS 09/01/2019 387.48 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 24579 MEDSV DEF RBRVS 09/01/2019 596.21 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24582 MEDSV DEF RBRVS 09/01/2019 574.33 Description: TREAT HUMERUS FRACTURE Category: Medical Services CMS Add: 01/01/1994 CMS Term: 24586 MEDSV DEF RBRVS 09/01/2019 776.40 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24587 MEDSV DEF RBRVS 09/01/2019 775.43 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24600 MEDSV DEF RBRVS 09/01/2019 259.27 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24605 MEDSV DEF RBRVS 09/01/2019 332.95 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24615 MEDSV DEF RBRVS 09/01/2019 507.71 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24620 MEDSV DEF RBRVS 09/01/2019 394.06 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24635 MEDSV DEF RBRVS 09/01/2019 479.87 Description: TREAT ELBOW FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 153 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24640 MEDSV DEF RBRVS 09/01/2019 98.40 Description: TREAT ELBOW DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24650 MEDSV DEF RBRVS 09/01/2019 184.36 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24655 MEDSV DEF RBRVS 09/01/2019 310.08 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24665 MEDSV DEF RBRVS 09/01/2019 464.00 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24666 MEDSV DEF RBRVS 09/01/2019 522.71 Description: TREAT RADIUS FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24670 MEDSV DEF RBRVS 09/01/2019 205.05 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24675 MEDSV DEF RBRVS 09/01/2019 321.51 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24685 MEDSV DEF RBRVS 09/01/2019 466.00 Description: TREAT ULNAR FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24800 MEDSV DEF RBRVS 09/01/2019 591.03 Description: FUSION OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24802 MEDSV DEF RBRVS 09/01/2019 714.88 Description: FUSION/GRAFT OF ELBOW JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24900 MEDSV DEF RBRVS 09/01/2019 523.96 Description: AMPUTATION OF UPPER ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24920 MEDSV DEF RBRVS 09/01/2019 521.79 Description: AMPUTATION OF UPPER ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24925 MEDSV DEF RBRVS 09/01/2019 401.99 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24930 MEDSV DEF RBRVS 09/01/2019 551.75 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24931 MEDSV DEF RBRVS 09/01/2019 567.61 Description: AMPUTATE UPPER ARM & IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24935 MEDSV DEF RBRVS 09/01/2019 747.34 Description: REVISION OF AMPUTATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 154 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 24940 MEDSV DEF MAXFEE 02/01/2015 822.18 0.0 Description: REVISION OF UPPER ARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 24999 MEDSV DEF BILL20 Description: UNLISTED PX HUMERUS/ELBOW Category: Medical Services CMS Add: 01/01/1982 CMS Term: 25000 MEDSV DEF RBRVS 09/01/2019 237.24 Description: INCISION OF TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25001 MEDSV DEF RBRVS 02/01/2015 242.70 0-2 Description: INCISE FLEXOR CARPI RADIALIS Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25020 MEDSV DEF RBRVS 09/01/2019 405.91 Description: DECOMPRESS FOREARM 1 SPACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25023 MEDSV DEF RBRVS 09/01/2019 783.96 Description: DECOMPRESS FOREARM 1 SPACE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25024 MEDSV DEF RBRVS 02/01/2015 553.32 0-2 Description: DECOMPRESS FOREARM 2 SPACES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25025 MEDSV DEF RBRVS 02/01/2015 867.22 0-2 Description: DECOMPRESS FOREARM 2 SPACES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25028 MEDSV DEF RBRVS 09/01/2019 369.00 Description: DRAINAGE OF FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25031 MEDSV DEF RBRVS 09/01/2019 257.81 Description: DRAINAGE OF FOREARM BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25035 MEDSV DEF RBRVS 09/01/2019 412.80 Description: TREAT FOREARM BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25040 MEDSV DEF RBRVS 09/01/2019 400.10 Description: EXPLORE/TREAT WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25065 MEDSV DEF RBRVS 09/01/2019 178.01 Description: BIOPSY FOREARM SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25066 MEDSV DEF RBRVS 09/01/2019 253.04 Description: BIOPSY FOREARM SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25071 MEDSV DEF RBRVS 02/01/2015 302.14 Description: EXC FOREARM LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 25073 MEDSV DEF RBRVS 02/01/2015 377.53 Description: EXC FOREARM TUM DEEP 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 155 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25075 MEDSV DEF RBRVS 09/01/2019 335.95 Description: EXC FOREARM LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25076 MEDSV DEF RBRVS 09/01/2019 367.71 Description: EXC FOREARM TUM DEEP < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25077 MEDSV DEF RBRVS 09/01/2019 630.72 Description: RESECT FOREARM/WRIST TUM<3CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 25078 MEDSV DEF RBRVS 02/01/2015 833.92 Description: RESECT FORARM/WRIST TUM 3CM> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 25085 MEDSV DEF RBRVS 09/01/2019 319.49 Description: INCISION OF WRIST CAPSULE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25100 MEDSV DEF RBRVS 09/01/2019 245.00 Description: BIOPSY OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25101 MEDSV DEF RBRVS 09/01/2019 286.41 Description: EXPLORE/TREAT WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25105 MEDSV DEF RBRVS 09/01/2019 343.08 Description: REMOVE WRIST JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25107 MEDSV DEF RBRVS 09/01/2019 437.92 Description: REMOVE WRIST JOINT CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25109 MEDSV DEF RBRVS 02/01/2015 382.99 Description: EXCISE TENDON FOREARM/WRIST Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25110 MEDSV DEF RBRVS 09/01/2019 241.08 Description: REMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25111 MEDSV DEF RBRVS 09/01/2019 226.30 Description: REMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25112 MEDSV DEF RBRVS 09/01/2019 274.19 Description: REREMOVE WRIST TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25115 MEDSV DEF RBRVS 09/01/2019 540.29 Description: REMOVE WRIST/FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25116 MEDSV DEF RBRVS 09/01/2019 426.48 Description: REMOVE WRIST/FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25118 MEDSV DEF RBRVS 09/01/2019 269.89 Description: EXCISE WRIST TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 156 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25119 MEDSV DEF RBRVS 09/01/2019 352.89 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25120 MEDSV DEF RBRVS 09/01/2019 353.43 Description: REMOVAL OF FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25125 MEDSV DEF RBRVS 09/01/2019 421.10 Description: REMOVE/GRAFT FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25126 MEDSV DEF RBRVS 09/01/2019 424.14 Description: REMOVE/GRAFT FOREARM LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25130 MEDSV DEF RBRVS 09/01/2019 317.65 Description: REMOVAL OF WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25135 MEDSV DEF RBRVS 09/01/2019 396.00 Description: REMOVE & GRAFT WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25136 MEDSV DEF RBRVS 09/01/2019 349.85 Description: REMOVE & GRAFT WRIST LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25145 MEDSV DEF RBRVS 09/01/2019 366.79 Description: REMOVE FOREARM BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25150 MEDSV DEF RBRVS 09/01/2019 401.58 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25151 MEDSV DEF RBRVS 09/01/2019 415.18 Description: PARTIAL REMOVAL OF RADIUS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25170 MEDSV DEF RBRVS 09/01/2019 1058.66 Description: RESECT RADIUS/ULNAR TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25210 MEDSV DEF RBRVS 09/01/2019 346.67 Description: REMOVAL OF WRIST BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25215 MEDSV DEF RBRVS 09/01/2019 438.76 Description: REMOVAL OF WRIST BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25230 MEDSV DEF RBRVS 09/01/2019 305.38 Description: PARTIAL REMOVAL OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25240 MEDSV DEF RBRVS 09/01/2019 303.93 Description: PARTIAL REMOVAL OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25246 MEDSV DEF RBRVS 09/01/2019 115.17 Description: INJECTION FOR WRIST X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 157 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25248 MEDSV DEF RBRVS 09/01/2019 294.19 Description: REMOVE FOREARM FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25250 MEDSV DEF RBRVS 09/01/2019 378.59 Description: REMOVAL OF WRIST PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25251 MEDSV DEF RBRVS 09/01/2019 512.14 Description: REMOVAL OF WRIST PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25259 MEDSV DEF RBRVS 01/01/2016 293.59 Description: MANIPULATE WRIST W/ANESTHES Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25260 MEDSV DEF RBRVS 09/01/2019 448.79 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25263 MEDSV DEF RBRVS 09/01/2019 444.09 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25265 MEDSV DEF RBRVS 09/01/2019 532.30 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25270 MEDSV DEF RBRVS 09/01/2019 349.34 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25272 MEDSV DEF RBRVS 09/01/2019 393.63 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25274 MEDSV DEF RBRVS 09/01/2019 476.69 Description: REPAIR FOREARM TENDON/MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25275 MEDSV DEF RBRVS 01/01/2016 478.22 Description: REPAIR FOREARM TENDON SHEATH Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25280 MEDSV DEF RBRVS 09/01/2019 400.53 Description: REVISE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25290 MEDSV DEF RBRVS 09/01/2019 309.80 Description: INCISE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25295 MEDSV DEF RBRVS 09/01/2019 371.63 Description: RELEASE WRIST/FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25300 MEDSV DEF RBRVS 09/01/2019 487.68 Description: FUSION OF TENDONS AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25301 MEDSV DEF RBRVS 09/01/2019 457.46 Description: FUSION OF TENDONS AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 158 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25310 MEDSV DEF RBRVS 09/01/2019 440.21 Y Description: TRANSPLANT FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25312 MEDSV DEF RBRVS 09/01/2019 510.66 Y Description: TRANSPLANT FOREARM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25315 MEDSV DEF RBRVS 09/01/2019 548.79 Description: REVISE PALSY HAND TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25316 MEDSV DEF RBRVS 09/01/2019 636.84 Description: REVISE PALSY HAND TENDON(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25320 MEDSV DEF RBRVS 09/01/2019 701.51 Description: REPAIR/REVISE WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25332 MEDSV DEF RBRVS 09/01/2019 601.96 Description: REVISE WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25335 MEDSV DEF RBRVS 09/01/2019 645.79 Description: REALIGNMENT OF HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25337 MEDSV DEF RBRVS 01/01/2019 631.50 Description: RECONSTRUCT ULNA/RADIOULNAR Category: Medical Services CMS Add: 01/01/1995 CMS Term: 25350 MEDSV DEF RBRVS 09/01/2019 480.23 Description: REVISION OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25355 MEDSV DEF RBRVS 09/01/2019 545.51 Description: REVISION OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25360 MEDSV DEF RBRVS 09/01/2019 466.53 Description: REVISION OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25365 MEDSV DEF RBRVS 09/01/2019 652.23 Description: REVISE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25370 MEDSV DEF RBRVS 09/01/2019 717.56 Description: REVISE RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25375 MEDSV DEF RBRVS 09/01/2019 652.31 Description: REVISE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25390 MEDSV DEF RBRVS 09/01/2019 548.09 Description: SHORTEN RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25391 MEDSV DEF RBRVS 09/01/2019 710.83 Description: LENGTHEN RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 159 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25392 MEDSV DEF RBRVS 09/01/2019 723.60 Description: SHORTEN RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25393 MEDSV DEF RBRVS 09/01/2019 807.44 Description: LENGTHEN RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25394 MEDSV DEF RBRVS 02/01/2015 558.48 0-2 Description: REPAIR CARPAL BONE SHORTEN Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25400 MEDSV DEF RBRVS 09/01/2019 572.59 Description: REPAIR RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25405 MEDSV DEF RBRVS 09/01/2019 740.60 Description: REPAIR/GRAFT RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25415 MEDSV DEF RBRVS 09/01/2019 689.93 Description: REPAIR RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25420 MEDSV DEF RBRVS 09/01/2019 834.21 Description: REPAIR/GRAFT RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25425 MEDSV DEF RBRVS 09/01/2019 686.62 Description: REPAIR/GRAFT RADIUS OR ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25426 MEDSV DEF RBRVS 09/01/2019 802.58 Description: REPAIR/GRAFT RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25430 MEDSV DEF RBRVS 01/01/2016 508.93 Description: VASC GRAFT INTO CARPAL BONE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25431 MEDSV DEF RBRVS 02/01/2015 561.95 0-2 Description: REPAIR NONUNION CARPAL BONE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25440 MEDSV DEF RBRVS 09/01/2019 547.97 Description: REPAIR/GRAFT WRIST BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25441 MEDSV DEF RBRVS 09/01/2019 662.59 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25442 MEDSV DEF RBRVS 09/01/2019 566.22 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25443 MEDSV DEF RBRVS 09/01/2019 555.93 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25444 MEDSV DEF RBRVS 09/01/2019 565.53 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 160 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25445 MEDSV DEF RBRVS 09/01/2019 513.09 Description: RECONSTRUCT WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25446 MEDSV DEF RBRVS 09/01/2019 838.38 Description: WRIST REPLACEMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25447 MEDSV DEF RBRVS 09/01/2019 589.56 Description: REPAIR WRIST JOINTS Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25449 MEDSV DEF RBRVS 09/01/2019 741.78 Description: REMOVE WRIST JOINT IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25450 MEDSV DEF RBRVS 09/01/2019 437.44 Description: REVISION OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25455 MEDSV DEF RBRVS 09/01/2019 496.30 Description: REVISION OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25490 MEDSV DEF RBRVS 09/01/2019 500.97 Description: REINFORCE RADIUS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25491 MEDSV DEF RBRVS 09/01/2019 526.30 Description: REINFORCE ULNA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25492 MEDSV DEF RBRVS 09/01/2019 644.10 Description: REINFORCE RADIUS AND ULNA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 25500 MEDSV DEF RBRVS 09/01/2019 192.15 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25505 MEDSV DEF RBRVS 09/01/2019 355.01 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25515 MEDSV DEF RBRVS 09/01/2019 476.65 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25520 MEDSV DEF RBRVS 09/01/2019 400.89 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25525 MEDSV DEF RBRVS 09/01/2019 559.91 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25526 MEDSV DEF RBRVS 09/01/2019 680.31 Description: TREAT FRACTURE OF RADIUS Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25530 MEDSV DEF RBRVS 09/01/2019 184.29 Description: TREAT FRACTURE OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 161 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25535 MEDSV DEF RBRVS 09/01/2019 345.49 Description: TREAT FRACTURE OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25545 MEDSV DEF RBRVS 09/01/2019 443.22 Description: TREAT FRACTURE OF ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25560 MEDSV DEF RBRVS 09/01/2019 196.58 Description: TREAT FRACTURE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25565 MEDSV DEF RBRVS 09/01/2019 367.74 Description: TREAT FRACTURE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25574 MEDSV DEF RBRVS 09/01/2019 479.12 Description: TREAT FRACTURE RADIUS & ULNA Category: Medical Services CMS Add: 01/01/1993 CMS Term: 25575 MEDSV DEF RBRVS 09/01/2019 642.42 Description: TREAT FRACTURE RADIUS/ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25600 MEDSV DEF RBRVS 09/01/2019 230.84 Description: TREAT FRACTURE RADIUS/ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25605 MEDSV DEF RBRVS 09/01/2019 388.31 Description: TREAT FRACTURE RADIUS/ULNA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25606 MEDSV DEF RBRVS 02/01/2015 470.42 Description: TREAT FX DISTAL RADIAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25607 MEDSV DEF RBRVS 02/01/2015 523.16 Description: TREAT FX RAD EXTRA-ARTICUL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25608 MEDSV DEF RBRVS 02/01/2015 587.26 Description: TREAT FX RAD INTRA-ARTICUL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25609 MEDSV DEF RBRVS 02/01/2015 747.13 Description: TREAT FX RADIAL 3+ FRAG Category: Medical Services CMS Add: 01/01/2007 CMS Term: 25622 MEDSV DEF RBRVS 09/01/2019 214.26 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25624 MEDSV DEF RBRVS 09/01/2019 335.75 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25628 MEDSV DEF RBRVS 09/01/2019 513.40 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25630 MEDSV DEF RBRVS 09/01/2019 215.43 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 162 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25635 MEDSV DEF RBRVS 09/01/2019 313.70 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25645 MEDSV DEF RBRVS 09/01/2019 404.23 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25650 MEDSV DEF RBRVS 09/01/2019 226.74 Description: TREAT WRIST BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25651 MEDSV DEF RBRVS 01/01/2016 344.14 Description: PIN ULNAR STYLOID FRACTURE Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25652 MEDSV DEF RBRVS 01/01/2016 442.97 Description: TREAT FRACTURE ULNAR STYLOID Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25660 MEDSV DEF RBRVS 09/01/2019 287.47 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25670 MEDSV DEF RBRVS 09/01/2019 431.48 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25671 MEDSV DEF RBRVS 01/01/2016 375.62 Description: PIN RADIOULNAR DISLOCATION Category: Medical Services CMS Add: 01/01/2002 CMS Term: 25675 MEDSV DEF RBRVS 09/01/2019 309.33 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25676 MEDSV DEF RBRVS 09/01/2019 447.42 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 25680 MEDSV DEF RBRVS 09/01/2019 336.75 Description: TREAT WRIST FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25685 MEDSV DEF RBRVS 09/01/2019 523.36 Description: TREAT WRIST FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25690 MEDSV DEF RBRVS 09/01/2019 340.38 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25695 MEDSV DEF RBRVS 09/01/2019 450.36 Description: TREAT WRIST DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25800 MEDSV DEF RBRVS 09/01/2019 521.83 Description: FUSION OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25805 MEDSV DEF RBRVS 09/01/2019 601.69 Description: FUSION/GRAFT OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 163 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 25810 MEDSV DEF RBRVS 09/01/2019 619.16 Description: FUSION/GRAFT OF WRIST JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25820 MEDSV DEF RBRVS 09/01/2019 436.72 Description: FUSION OF HAND BONES Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25825 MEDSV DEF RBRVS 09/01/2019 539.04 Description: FUSE HAND BONES WITH GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 25830 MEDSV DEF RBRVS 01/01/2019 673.40 Description: FUSION RADIOULNAR JNT/ULNA Category: Medical Services CMS Add: 01/01/1995 CMS Term: 25900 MEDSV DEF RBRVS 09/01/2019 504.44 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25905 MEDSV DEF RBRVS 09/01/2019 453.04 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25907 MEDSV DEF RBRVS 09/01/2019 435.44 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25909 MEDSV DEF RBRVS 09/01/2019 487.54 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25915 MEDSV DEF RBRVS 01/01/2019 748.51 Description: AMPUTATION OF FOREARM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25920 MEDSV DEF RBRVS 09/01/2019 494.88 Description: AMPUTATE HAND AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25922 MEDSV DEF RBRVS 09/01/2019 359.37 Description: AMPUTATE HAND AT WRIST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25924 MEDSV DEF RBRVS 09/01/2019 436.95 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25927 MEDSV DEF RBRVS 09/01/2019 574.11 Description: AMPUTATION OF HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25929 MEDSV DEF RBRVS 09/01/2019 423.89 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25931 MEDSV DEF RBRVS 09/01/2019 475.55 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 25999 MEDSV DEF BILL20 Description: UNLISTED PX FOREARM/WRIST Category: Medical Services CMS Add: 01/01/1982 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 164 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26010 MEDSV DEF RBRVS 09/01/2019 184.74 Description: DRAINAGE OF FINGER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26011 MEDSV DEF RBRVS 09/01/2019 272.15 Description: DRAINAGE OF FINGER ABSCESS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26020 MEDSV DEF RBRVS 09/01/2019 307.00 Description: DRAIN HAND TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26025 MEDSV DEF RBRVS 09/01/2019 298.50 Description: DRAINAGE OF PALM BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26030 MEDSV DEF RBRVS 09/01/2019 350.25 Description: DRAINAGE OF PALM BURSAS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26034 MEDSV DEF RBRVS 09/01/2019 380.03 Description: TREAT HAND BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26035 MEDSV DEF RBRVS 09/01/2019 616.13 Description: DECOMPRESS FINGERS/HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26037 MEDSV DEF RBRVS 09/01/2019 403.80 Description: DECOMPRESS FINGERS/HAND Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26040 MEDSV DEF RBRVS 09/01/2019 219.79 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26045 MEDSV DEF RBRVS 09/01/2019 332.15 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26055 MEDSV DEF RBRVS 09/01/2019 389.24 Description: INCISE FINGER TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26060 MEDSV DEF RBRVS 09/01/2019 187.35 Description: INCISION OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26070 MEDSV DEF RBRVS 09/01/2019 223.09 Description: EXPLORE/TREAT HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26075 MEDSV DEF RBRVS 09/01/2019 233.79 Description: EXPLORE/TREAT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26080 MEDSV DEF RBRVS 09/01/2019 276.41 Description: EXPLORE/TREAT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26100 MEDSV DEF RBRVS 09/01/2019 236.75 Description: BIOPSY HAND JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 165 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26105 MEDSV DEF RBRVS 09/01/2019 236.18 Description: BIOPSY FINGER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26110 MEDSV DEF RBRVS 09/01/2019 227.29 Description: BIOPSY FINGER JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26111 MEDSV DEF RBRVS 02/01/2015 296.32 Description: EXC HAND LES SC 1.5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 26113 MEDSV DEF RBRVS 02/01/2015 390.24 Description: EXC HAND TUM DEEP 1.5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 26115 MEDSV DEF RBRVS 09/01/2019 352.96 Description: EXC HAND LES SC < 1.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26116 MEDSV DEF RBRVS 09/01/2019 374.23 Description: EXC HAND TUM DEEP < 1.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26117 MEDSV DEF RBRVS 09/01/2019 532.03 Description: RAD RESECT HAND TUMOR < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26118 MEDSV DEF RBRVS 02/01/2015 751.75 Description: RAD RESECT HAND TUMOR 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 26121 MEDSV DEF RBRVS 09/01/2019 424.28 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26123 MEDSV DEF RBRVS 09/01/2019 592.73 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26125 MEDSV DEF RBRVS 02/01/2015 197.41 Description: RELEASE PALM CONTRACTURE Category: Medical Services CMS Add: 01/01/1990 CMS Term: 26130 MEDSV DEF RBRVS 09/01/2019 326.90 Description: REMOVE WRIST JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26135 MEDSV DEF RBRVS 09/01/2019 391.40 Description: REVISE FINGER JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26140 MEDSV DEF RBRVS 09/01/2019 357.78 Description: REVISE FINGER JOINT EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26145 MEDSV DEF RBRVS 09/01/2019 362.97 Description: TENDON EXCISION PALM/FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26160 MEDSV DEF RBRVS 09/01/2019 400.44 Description: REMOVE TENDON SHEATH LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 166 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26170 MEDSV DEF RBRVS 09/01/2019 288.15 Description: REMOVAL OF PALM TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26180 MEDSV DEF RBRVS 09/01/2019 314.26 Description: REMOVAL OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26185 MEDSV DEF RBRVS 01/01/2019 390.53 Description: REMOVE FINGER BONE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26200 MEDSV DEF RBRVS 09/01/2019 319.51 Description: REMOVE HAND BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26205 MEDSV DEF RBRVS 09/01/2019 427.84 Description: REMOVE/GRAFT BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26210 MEDSV DEF RBRVS 09/01/2019 313.04 Description: REMOVAL OF FINGER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26215 MEDSV DEF RBRVS 09/01/2019 399.95 Description: REMOVE/GRAFT FINGER LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26230 MEDSV DEF RBRVS 09/01/2019 354.92 Description: PARTIAL REMOVAL OF HAND BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26235 MEDSV DEF RBRVS 09/01/2019 350.41 Description: PARTIAL REMOVAL FINGER BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26236 MEDSV DEF RBRVS 09/01/2019 312.84 Description: PARTIAL REMOVAL FINGER BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26250 MEDSV DEF RBRVS 09/01/2019 779.75 Description: EXTENSIVE HAND SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26260 MEDSV DEF RBRVS 09/01/2019 582.33 Description: RESECT PROX FINGER TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26262 MEDSV DEF RBRVS 09/01/2019 454.44 Description: RESECT DISTAL FINGER TUMOR Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26320 MEDSV DEF RBRVS 09/01/2019 245.25 Description: REMOVAL OF IMPLANT FROM HAND Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26340 MEDSV DEF RBRVS 01/01/2016 234.60 Description: MANIPULATE FINGER W/ANESTH Category: Medical Services CMS Add: 01/01/2002 CMS Term: 26341 MEDSV DEF RBRVS 02/01/2015 68.96 Description: MANIPULAT PALM CORD POST INJ Category: Medical Services CMS Add: 01/01/2012 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 167 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26350 MEDSV DEF RBRVS 09/01/2019 494.09 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26352 MEDSV DEF RBRVS 09/01/2019 569.57 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26356 MEDSV DEF RBRVS 09/01/2019 764.09 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26357 MEDSV DEF RBRVS 09/01/2019 607.79 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26358 MEDSV DEF RBRVS 09/01/2019 641.39 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26370 MEDSV DEF RBRVS 09/01/2019 528.45 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26372 MEDSV DEF RBRVS 09/01/2019 618.20 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26373 MEDSV DEF RBRVS 09/01/2019 592.67 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26390 MEDSV DEF RBRVS 09/01/2019 585.72 Description: REVISE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26392 MEDSV DEF RBRVS 09/01/2019 681.44 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26410 MEDSV DEF RBRVS 09/01/2019 392.06 Description: REPAIR HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26412 MEDSV DEF RBRVS 09/01/2019 473.60 Description: REPAIR/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26415 MEDSV DEF RBRVS 09/01/2019 560.50 Description: EXCISION HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1989 CMS Term: 26416 MEDSV DEF RBRVS 09/01/2019 532.82 Description: GRAFT HAND OR FINGER TENDON Category: Medical Services CMS Add: 01/01/1989 CMS Term: 26418 MEDSV DEF RBRVS 09/01/2019 400.52 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26420 MEDSV DEF RBRVS 09/01/2019 494.96 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 168 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26426 MEDSV DEF RBRVS 09/01/2019 355.76 Description: REPAIR FINGER/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26428 MEDSV DEF RBRVS 09/01/2019 528.04 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26432 MEDSV DEF RBRVS 09/01/2019 345.78 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26433 MEDSV DEF RBRVS 09/01/2019 368.71 Description: REPAIR FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26434 MEDSV DEF RBRVS 09/01/2019 451.17 Description: REPAIR/GRAFT FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26437 MEDSV DEF RBRVS 09/01/2019 432.69 Description: REALIGNMENT OF TENDONS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26440 MEDSV DEF RBRVS 09/01/2019 428.80 Description: RELEASE PALM/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26442 MEDSV DEF RBRVS 09/01/2019 673.34 Description: RELEASE PALM & FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26445 MEDSV DEF RBRVS 09/01/2019 398.99 Description: RELEASE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26449 MEDSV DEF RBRVS 09/01/2019 492.39 Description: RELEASE FOREARM/HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26450 MEDSV DEF RBRVS 09/01/2019 283.24 Description: INCISION OF PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26455 MEDSV DEF RBRVS 09/01/2019 280.87 Description: INCISION OF FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26460 MEDSV DEF RBRVS 09/01/2019 274.30 Description: INCISE HAND/FINGER TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26471 MEDSV DEF RBRVS 09/01/2019 428.29 Description: FUSION OF FINGER TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26474 MEDSV DEF RBRVS 09/01/2019 418.18 Description: FUSION OF FINGER TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26476 MEDSV DEF RBRVS 09/01/2019 405.91 Description: TENDON LENGTHENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 169 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26477 MEDSV DEF RBRVS 09/01/2019 404.86 Description: TENDON SHORTENING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26478 MEDSV DEF RBRVS 09/01/2019 432.73 Description: LENGTHENING OF HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26479 MEDSV DEF RBRVS 09/01/2019 430.46 Description: SHORTENING OF HAND TENDON Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26480 MEDSV DEF RBRVS 09/01/2019 523.85 Y Description: TRANSPLANT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26483 MEDSV DEF RBRVS 09/01/2019 588.27 Y Description: TRANSPLANT/GRAFT HAND TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26485 MEDSV DEF RBRVS 09/01/2019 561.11 Y Description: TRANSPLANT PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26489 MEDSV DEF RBRVS 09/01/2019 649.96 Y Description: TRANSPLANT/GRAFT PALM TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26490 MEDSV DEF RBRVS 09/01/2019 553.84 Description: REVISE THUMB TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26492 MEDSV DEF RBRVS 09/01/2019 615.98 Description: TENDON TRANSFER WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26494 MEDSV DEF RBRVS 09/01/2019 558.92 Description: HAND TENDON/MUSCLE TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26496 MEDSV DEF RBRVS 09/01/2019 589.10 Description: REVISE THUMB TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26497 MEDSV DEF RBRVS 09/01/2019 605.98 Description: FINGER TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26498 MEDSV DEF RBRVS 09/01/2019 803.58 Description: FINGER TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26499 MEDSV DEF RBRVS 09/01/2019 580.88 Y Description: REVISION OF FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26500 MEDSV DEF RBRVS 09/01/2019 434.14 Description: HAND TENDON RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26502 MEDSV DEF RBRVS 09/01/2019 492.26 Description: HAND TENDON RECONSTRUCTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 170 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26508 MEDSV DEF RBRVS 09/01/2019 445.72 Description: RELEASE THUMB CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26510 MEDSV DEF RBRVS 09/01/2019 416.18 Description: THUMB TENDON TRANSFER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26516 MEDSV DEF RBRVS 09/01/2019 488.49 Description: FUSION OF KNUCKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26517 MEDSV DEF RBRVS 09/01/2019 577.31 Description: FUSION OF KNUCKLE JOINTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26518 MEDSV DEF RBRVS 09/01/2019 583.24 Description: FUSION OF KNUCKLE JOINTS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26520 MEDSV DEF RBRVS 09/01/2019 451.25 Description: RELEASE KNUCKLE CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26525 MEDSV DEF RBRVS 09/01/2019 451.15 Description: RELEASE FINGER CONTRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26530 MEDSV DEF RBRVS 09/01/2019 381.29 Description: REVISE KNUCKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26531 MEDSV DEF RBRVS 09/01/2019 443.28 Description: REVISE KNUCKLE WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26535 MEDSV DEF RBRVS 09/01/2019 298.36 Description: REVISE FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26536 MEDSV DEF RBRVS 09/01/2019 496.06 Description: REVISE/IMPLANT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26540 MEDSV DEF RBRVS 09/01/2019 458.57 Description: REPAIR HAND JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26541 MEDSV DEF RBRVS 09/01/2019 559.15 Description: REPAIR HAND JOINT WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26542 MEDSV DEF RBRVS 09/01/2019 475.08 Description: REPAIR HAND JOINT WITH GRAFT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26545 MEDSV DEF RBRVS 09/01/2019 483.01 Description: RECONSTRUCT FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26546 MEDSV DEF RBRVS 01/01/2019 694.27 Description: REPAIR NONUNION HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 171 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26548 MEDSV DEF RBRVS 09/01/2019 533.06 Description: RECONSTRUCT FINGER JOINT Category: Medical Services CMS Add: 01/01/1988 CMS Term: 26550 MEDSV DEF RBRVS 02/01/2015 1160.52 Description: CONSTRUCT THUMB REPLACEMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26551 MEDSV DEF RBRVS 01/01/2019 2106.10 Description: GREAT TOE-HAND TRANSFER Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26553 MEDSV DEF RBRVS 01/01/2019 2235.45 Description: SINGLE TRANSFER TOE-HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26554 MEDSV DEF RBRVS 01/01/2019 2337.71 Description: DOUBLE TRANSFER TOE-HAND Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26555 MEDSV DEF RBRVS 01/01/2019 968.06 Description: POSITIONAL CHANGE OF FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26556 MEDSV DEF RBRVS 01/01/2019 2002.94 Description: TOE JOINT TRANSFER Category: Medical Services CMS Add: 01/01/1997 CMS Term: 26560 MEDSV DEF RBRVS 09/01/2019 398.09 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26561 MEDSV DEF RBRVS 09/01/2019 662.14 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26562 MEDSV DEF RBRVS 09/01/2019 916.66 Description: REPAIR OF WEB FINGER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26565 MEDSV DEF RBRVS 09/01/2019 474.66 Description: CORRECT METACARPAL FLAW Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26567 MEDSV DEF RBRVS 09/01/2019 475.00 Description: CORRECT FINGER DEFORMITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26568 MEDSV DEF RBRVS 09/01/2019 629.07 Description: LENGTHEN METACARPAL/FINGER Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26580 MEDSV DEF RBRVS 02/01/2015 1076.37 Description: REPAIR HAND DEFORMITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26587 MEDSV DEF RBRVS 02/01/2015 669.10 Description: RECONSTRUCT EXTRA FINGER Category: Medical Services CMS Add: 01/01/1989 CMS Term: 26590 MEDSV DEF RBRVS 01/01/2019 993.85 Description: REPAIR FINGER DEFORMITY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 172 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26591 MEDSV DEF RBRVS 09/01/2019 302.28 Description: REPAIR MUSCLES OF HAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26593 MEDSV DEF RBRVS 09/01/2019 415.64 Description: RELEASE MUSCLES OF HAND Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26596 MEDSV DEF RBRVS 09/01/2019 537.22 Description: EXCISION CONSTRICTING TISSUE Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26600 MEDSV DEF RBRVS 09/01/2019 207.26 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26605 MEDSV DEF RBRVS 09/01/2019 226.57 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26607 MEDSV DEF RBRVS 09/01/2019 322.95 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26608 MEDSV DEF RBRVS 09/01/2019 337.88 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 26615 MEDSV DEF RBRVS 09/01/2019 408.45 Description: TREAT METACARPAL FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26641 MEDSV DEF RBRVS 09/01/2019 262.82 Description: TREAT THUMB DISLOCATION Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26645 MEDSV DEF RBRVS 09/01/2019 300.92 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26650 MEDSV DEF RBRVS 09/01/2019 337.79 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26665 MEDSV DEF RBRVS 09/01/2019 446.93 Description: TREAT THUMB FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26670 MEDSV DEF RBRVS 09/01/2019 240.06 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26675 MEDSV DEF RBRVS 09/01/2019 320.19 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26676 MEDSV DEF RBRVS 09/01/2019 354.46 Description: PIN HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26685 MEDSV DEF RBRVS 09/01/2019 411.34 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 173 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26686 MEDSV DEF RBRVS 09/01/2019 443.12 Description: TREAT HAND DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26700 MEDSV DEF RBRVS 09/01/2019 231.31 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26705 MEDSV DEF RBRVS 09/01/2019 292.08 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26706 MEDSV DEF RBRVS 09/01/2019 312.03 Description: PIN KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26715 MEDSV DEF RBRVS 09/01/2019 407.21 Description: TREAT KNUCKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26720 MEDSV DEF RBRVS 09/01/2019 140.02 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26725 MEDSV DEF RBRVS 09/01/2019 237.84 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26727 MEDSV DEF RBRVS 09/01/2019 331.99 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26735 MEDSV DEF RBRVS 09/01/2019 423.63 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26740 MEDSV DEF RBRVS 09/01/2019 161.39 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26742 MEDSV DEF RBRVS 09/01/2019 260.29 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26746 MEDSV DEF RBRVS 09/01/2019 527.46 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26750 MEDSV DEF RBRVS 09/01/2019 130.44 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26755 MEDSV DEF RBRVS 09/01/2019 222.37 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26756 MEDSV DEF RBRVS 09/01/2019 295.14 Description: PIN FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26765 MEDSV DEF RBRVS 09/01/2019 355.70 Description: TREAT FINGER FRACTURE EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 174 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26770 MEDSV DEF RBRVS 09/01/2019 196.03 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26775 MEDSV DEF RBRVS 09/01/2019 269.27 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26776 MEDSV DEF RBRVS 09/01/2019 312.92 Description: PIN FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1987 CMS Term: 26785 MEDSV DEF RBRVS 09/01/2019 387.97 Description: TREAT FINGER DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26820 MEDSV DEF RBRVS 09/01/2019 550.56 Description: THUMB FUSION WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26841 MEDSV DEF RBRVS 09/01/2019 508.04 Description: FUSION OF THUMB Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26842 MEDSV DEF RBRVS 09/01/2019 550.39 Description: THUMB FUSION WITH GRAFT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26843 MEDSV DEF RBRVS 09/01/2019 515.71 Description: FUSION OF HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26844 MEDSV DEF RBRVS 09/01/2019 570.82 Description: FUSION/GRAFT OF HAND JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 26850 MEDSV DEF RBRVS 09/01/2019 482.74 Description: FUSION OF KNUCKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26852 MEDSV DEF RBRVS 09/01/2019 555.31 Description: FUSION OF KNUCKLE WITH GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26860 MEDSV DEF RBRVS 09/01/2019 390.81 Description: FUSION OF FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26861 MEDSV DEF RBRVS 02/01/2015 74.74 Description: FUSION OF FINGER JNT ADD-ON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26862 MEDSV DEF RBRVS 09/01/2019 505.17 Description: FUSION/GRAFT OF FINGER JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26863 MEDSV DEF RBRVS 02/01/2015 164.96 Description: FUSE/GRAFT ADDED JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26910 MEDSV DEF RBRVS 09/01/2019 501.45 Description: AMPUTATE METACARPAL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 175 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 26951 MEDSV DEF RBRVS 09/01/2019 455.00 Description: AMPUTATION OF FINGER/THUMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26952 MEDSV DEF RBRVS 09/01/2019 450.64 Description: AMPUTATION OF FINGER/THUMB Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26989 MEDSV DEF BILL20 Description: UNLISTED PX HANDS/FINGERS Category: Medical Services CMS Add: 01/01/1982 CMS Term: 26990 MEDSV DEF RBRVS 09/01/2019 442.66 Description: DRAINAGE OF PELVIS LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26991 MEDSV DEF RBRVS 09/01/2019 497.27 Description: DRAINAGE OF PELVIS BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 26992 MEDSV DEF RBRVS 09/01/2019 687.44 Description: DRAINAGE OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27000 MEDSV DEF RBRVS 09/01/2019 300.05 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27001 MEDSV DEF RBRVS 09/01/2019 385.64 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27003 MEDSV DEF RBRVS 09/01/2019 423.62 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27005 MEDSV DEF RBRVS 09/01/2019 518.61 Description: INCISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27006 MEDSV DEF RBRVS 09/01/2019 524.97 Description: INCISION OF HIP TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27025 MEDSV DEF RBRVS 09/01/2019 654.74 Description: INCISION OF HIP/THIGH FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27027 MEDSV DEF RBRVS 02/01/2015 619.13 Description: BUTTOCK FASCIOTOMY Category: Medical Services CMS Add: 01/01/2009 CMS Term: 27030 MEDSV DEF RBRVS 09/01/2019 656.09 Description: DRAINAGE OF HIP JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27033 MEDSV DEF RBRVS 09/01/2019 696.52 Description: EXPLORATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27035 MEDSV DEF RBRVS 09/01/2019 841.67 Description: DENERVATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 176 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27036 MEDSV DEF RBRVS 01/01/2019 723.26 Description: EXCISION OF HIP JOINT/MUSCLE Category: Medical Services CMS Add: 01/01/1997 CMS Term: 27040 MEDSV DEF RBRVS 09/01/2019 243.85 Description: BIOPSY OF SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27041 MEDSV DEF RBRVS 09/01/2019 493.33 Description: BIOPSY OF SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27043 MEDSV DEF RBRVS 02/01/2015 332.66 Description: EXC HIP PELVIS LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27045 MEDSV DEF RBRVS 02/01/2015 533.64 Description: EXC HIP/PELV TUM DEEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27047 MEDSV DEF RBRVS 09/01/2019 329.50 Description: EXC HIP/PELVIS LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27048 MEDSV DEF RBRVS 09/01/2019 434.06 Description: EXC HIP/PELV TUM DEEP < 5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27049 MEDSV DEF RBRVS 09/01/2019 976.85 Description: RESECT HIP/PELV TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27050 MEDSV DEF RBRVS 09/01/2019 284.74 Description: BIOPSY OF SACROILIAC JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27052 MEDSV DEF RBRVS 09/01/2019 410.91 Description: BIOPSY OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27054 MEDSV DEF RBRVS 09/01/2019 488.82 Description: REMOVAL OF HIP JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27057 MEDSV DEF RBRVS 02/01/2015 695.21 Description: BUTTOCK FASCIOTOMY W/DBRDMT Category: Medical Services CMS Add: 01/01/2009 CMS Term: 27059 MEDSV DEF RBRVS 02/01/2015 1294.60 Description: RESECT HIP/PELV TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27060 MEDSV DEF RBRVS 09/01/2019 330.29 Description: REMOVAL OF ISCHIAL BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27062 MEDSV DEF RBRVS 09/01/2019 323.93 Description: REMOVE FEMUR LESION/BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27065 MEDSV DEF RBRVS 09/01/2019 365.08 Description: REMOVE HIP BONE LES SUPER Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 177 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27066 MEDSV DEF RBRVS 09/01/2019 580.10 Description: REMOVE HIP BONE LES DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27067 MEDSV DEF RBRVS 09/01/2019 738.43 Description: REMOVE/GRAFT HIP BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27070 MEDSV DEF RBRVS 09/01/2019 607.28 Description: PART REMOVE HIP BONE SUPER Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27071 MEDSV DEF RBRVS 09/01/2019 654.52 Description: PART REMOVAL HIP BONE DEEP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27075 MEDSV DEF RBRVS 09/01/2019 1507.74 Description: RESECT HIP TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27076 MEDSV DEF RBRVS 09/01/2019 1813.46 Description: RESECT HIP TUM INCL ACETABUL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27077 MEDSV DEF RBRVS 09/01/2019 2038.88 Description: RESECT HIP TUM W/INNOM BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27078 MEDSV DEF RBRVS 09/01/2019 1486.46 Description: RSECT HIP TUM INCL FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27080 MEDSV DEF RBRVS 09/01/2019 363.89 Description: REMOVAL OF TAIL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27086 MEDSV DEF RBRVS 09/01/2019 205.42 Description: REMOVE HIP FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27087 MEDSV DEF RBRVS 09/01/2019 448.22 Description: REMOVE HIP FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27090 MEDSV DEF RBRVS 09/01/2019 591.78 Description: REMOVAL OF HIP PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27091 MEDSV DEF RBRVS 09/01/2019 1148.45 Description: REMOVAL OF HIP PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27093 MEDSV DEF RBRVS 09/01/2019 131.95 Description: INJECTION FOR HIP X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27095 MEDSV DEF RBRVS 09/01/2019 168.21 Description: INJECTION FOR HIP X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27096 MEDSV DEF RBRVS 02/01/2015 116.31 Description: INJECT SACROILIAC JOINT Category: Medical Services CMS Add: 01/01/2000 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 178 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27097 MEDSV DEF RBRVS 09/01/2019 485.64 Description: REVISION OF HIP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27098 MEDSV DEF RBRVS 09/01/2019 494.00 Description: TRANSFER TENDON TO PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27100 MEDSV DEF RBRVS 09/01/2019 583.89 Description: TRANSFER OF ABDOMINAL MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27105 MEDSV DEF RBRVS 09/01/2019 617.54 Description: TRANSFER OF SPINAL MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27110 MEDSV DEF RBRVS 09/01/2019 691.35 Description: TRANSFER OF ILIOPSOAS MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27111 MEDSV DEF RBRVS 09/01/2019 641.17 Description: TRANSFER OF ILIOPSOAS MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27120 MEDSV DEF RBRVS 09/01/2019 930.16 Description: RECONSTRUCTION OF HIP SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27122 MEDSV DEF RBRVS 09/01/2019 787.13 Description: RECONSTRUCTION OF HIP SOCKET Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27125 MEDSV DEF RBRVS 09/01/2019 812.31 Description: PARTIAL HIP REPLACEMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27130 MEDSV DEF RBRVS 09/01/2019 975.85 Description: TOTAL HIP ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27132 MEDSV DEF RBRVS 09/01/2019 1205.67 Description: TOTAL HIP ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27134 MEDSV DEF RBRVS 09/01/2019 1380.85 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27137 MEDSV DEF RBRVS 09/01/2019 1059.69 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27138 MEDSV DEF RBRVS 09/01/2019 1101.75 Description: REVISE HIP JOINT REPLACEMENT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27140 MEDSV DEF RBRVS 09/01/2019 638.58 Y Description: TRANSPLANT FEMUR RIDGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27146 MEDSV DEF RBRVS 09/01/2019 919.73 Description: INCISION OF HIP BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 179 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27147 MEDSV DEF RBRVS 09/01/2019 1052.92 Description: REVISION OF HIP BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27151 MEDSV DEF RBRVS 09/01/2019 1140.37 Description: INCISION OF HIP BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27156 MEDSV DEF RBRVS 09/01/2019 1229.84 Description: REVISION OF HIP BONES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27158 MEDSV DEF RBRVS 09/01/2019 1003.94 Description: REVISION OF PELVIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27161 MEDSV DEF RBRVS 09/01/2019 871.58 Description: INCISION OF NECK OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27165 MEDSV DEF RBRVS 09/01/2019 987.75 Description: INCISION/FIXATION OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27170 MEDSV DEF RBRVS 09/01/2019 843.58 Description: REPAIR/GRAFT FEMUR HEAD/NECK Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27175 MEDSV DEF RBRVS 09/01/2019 421.96 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27176 MEDSV DEF RBRVS 09/01/2019 655.38 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27177 MEDSV DEF RBRVS 09/01/2019 795.96 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27178 MEDSV DEF RBRVS 09/01/2019 655.38 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27179 MEDSV DEF RBRVS 09/01/2019 696.97 Description: REVISE HEAD/NECK OF FEMUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27181 MEDSV DEF RBRVS 09/01/2019 730.26 Description: TREAT SLIPPED EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27185 MEDSV DEF RBRVS 09/01/2019 430.74 Description: REVISION OF FEMUR EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27187 MEDSV DEF RBRVS 09/01/2019 709.99 Description: REINFORCE HIP BONES Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27197 MEDSV DEF RBRVS 01/01/2017 84.46 Description: CLSD TX PELVIC RING FX Category: Medical Services CMS Add: 01/01/2017 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 180 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27198 MEDSV DEF RBRVS 01/01/2017 215.40 Description: CLSD TX PELVIC RING FX Category: Medical Services CMS Add: 01/01/2017 CMS Term: 27200 MEDSV DEF RBRVS 09/01/2019 127.64 Description: TREAT TAIL BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27202 MEDSV DEF RBRVS 09/01/2019 379.80 Description: TREAT TAIL BONE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27215 MEDSV DEF RBRVS 09/01/2019 441.95 Description: TREAT PELVIC FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27216 MEDSV DEF RBRVS 09/01/2019 655.98 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27217 MEDSV DEF RBRVS 09/01/2019 615.48 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27218 MEDSV DEF RBRVS 09/01/2019 851.01 Description: TREAT PELVIC RING FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27220 MEDSV DEF RBRVS 09/01/2019 377.64 Description: TREAT HIP SOCKET FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27222 MEDSV DEF RBRVS 09/01/2019 697.18 Description: TREAT HIP SOCKET FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27226 MEDSV DEF RBRVS 09/01/2019 758.62 Description: TREAT HIP WALL FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27227 MEDSV DEF RBRVS 09/01/2019 1192.86 Description: TREAT HIP FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27228 MEDSV DEF RBRVS 09/01/2019 1359.21 Description: TREAT HIP FRACTURE(S) Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27230 MEDSV DEF RBRVS 09/01/2019 337.35 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27232 MEDSV DEF RBRVS 09/01/2019 545.36 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27235 MEDSV DEF RBRVS 09/01/2019 650.10 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27236 MEDSV DEF RBRVS 09/01/2019 858.19 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 181 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27238 MEDSV DEF RBRVS 09/01/2019 326.90 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27240 MEDSV DEF RBRVS 09/01/2019 684.00 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27244 MEDSV DEF RBRVS 09/01/2019 882.42 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27245 MEDSV DEF RBRVS 09/01/2019 882.67 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27246 MEDSV DEF RBRVS 09/01/2019 273.29 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27248 MEDSV DEF RBRVS 09/01/2019 532.24 Description: TREAT THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27250 MEDSV DEF RBRVS 09/01/2019 133.02 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27252 MEDSV DEF RBRVS 09/01/2019 543.00 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27253 MEDSV DEF RBRVS 09/01/2019 674.27 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27254 MEDSV DEF RBRVS 09/01/2019 907.96 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27256 MEDSV DEF RBRVS 09/01/2019 214.58 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27257 MEDSV DEF RBRVS 09/01/2019 258.67 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27258 MEDSV DEF RBRVS 09/01/2019 793.68 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27259 MEDSV DEF RBRVS 09/01/2019 1111.81 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27265 MEDSV DEF RBRVS 09/01/2019 285.54 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: 27266 MEDSV DEF RBRVS 09/01/2019 414.06 Description: TREAT HIP DISLOCATION Category: Medical Services CMS Add: 01/01/1989 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 182 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27267 MEDSV DEF RBRVS 02/01/2015 311.10 Description: CLTX THIGH FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27268 MEDSV DEF RBRVS 02/01/2015 382.87 Description: CLTX THIGH FX W/MNPJ Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27269 MEDSV DEF RBRVS 02/01/2015 892.75 Description: OPTX THIGH FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27275 MEDSV DEF RBRVS 09/01/2019 129.63 Description: MANIPULATION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27279 MEDSV DEF RBRVS 02/01/2015 407.10 Description: ARTHRD SI JT PERQ/MIN NVAS Category: Medical Services CMS Add: 01/01/2015 CMS Term: 27280 MEDSV DEF RBRVS 09/01/2019 743.38 Description: ARTHR SI JT OPN B1GRF INSTRM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27282 MEDSV DEF RBRVS 09/01/2019 609.29 Description: ARTHRODESIS SYMPHYSIS PUBIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27284 MEDSV DEF RBRVS 09/01/2019 1161.41 Description: FUSION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27286 MEDSV DEF RBRVS 09/01/2019 1185.01 Description: FUSION OF HIP JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27290 MEDSV DEF RBRVS 09/01/2019 1164.06 Description: AMPUTATION OF LEG AT HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27295 MEDSV DEF RBRVS 09/01/2019 906.58 Description: AMPUTATION OF LEG AT HIP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27299 MEDSV DEF BILL20 Description: UNLISTED PX PELVIS/HIP JOINT Category: Medical Services CMS Add: 01/01/1982 CMS Term: 27301 MEDSV DEF RBRVS 09/01/2019 464.90 Description: DRAIN THIGH/KNEE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27303 MEDSV DEF RBRVS 09/01/2019 455.32 Description: DRAINAGE OF BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27305 MEDSV DEF RBRVS 09/01/2019 344.40 Description: INCISE THIGH TENDON & FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27306 MEDSV DEF RBRVS 09/01/2019 263.19 Description: INCISION OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 183 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27307 MEDSV DEF RBRVS 09/01/2019 340.85 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27310 MEDSV DEF RBRVS 09/01/2019 521.77 Description: EXPLORATION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27323 MEDSV DEF RBRVS 09/01/2019 191.17 Description: BIOPSY THIGH SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27324 MEDSV DEF RBRVS 09/01/2019 280.50 Description: BIOPSY THIGH SOFT TISSUES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27325 MEDSV DEF RBRVS 02/01/2015 396.00 Description: NEURECTOMY HAMSTRING Category: Medical Services CMS Add: 01/01/2007 CMS Term: 27326 MEDSV DEF RBRVS 02/01/2015 364.75 Description: NEURECTOMY POPLITEAL Category: Medical Services CMS Add: 01/01/2007 CMS Term: 27327 MEDSV DEF RBRVS 09/01/2019 322.99 Description: EXC THIGH/KNEE LES SC < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27328 MEDSV DEF RBRVS 09/01/2019 440.75 Description: EXC THIGH/KNEE TUM DEEP <5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27329 MEDSV DEF RBRVS 09/01/2019 742.34 Description: RESECT THIGH/KNEE TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 27330 MEDSV DEF RBRVS 09/01/2019 296.99 Description: BIOPSY KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27331 MEDSV DEF RBRVS 09/01/2019 338.45 Description: EXPLORE/TREAT KNEE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27332 MEDSV DEF RBRVS 09/01/2019 456.03 Description: REMOVAL OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27333 MEDSV DEF RBRVS 09/01/2019 416.22 Description: REMOVAL OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27334 MEDSV DEF RBRVS 09/01/2019 487.79 Description: REMOVE KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27335 MEDSV DEF RBRVS 09/01/2019 545.55 Description: REMOVE KNEE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27337 MEDSV DEF RBRVS 02/01/2015 296.85 Description: EXC THIGH/KNEE LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 184 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27339 MEDSV DEF RBRVS 02/01/2015 534.38 Description: EXC THIGH/KNEE TUM DEP 5CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27340 MEDSV DEF RBRVS 09/01/2019 263.55 Description: REMOVAL OF KNEECAP BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27345 MEDSV DEF RBRVS 09/01/2019 341.90 Description: REMOVAL OF KNEE CYST Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27347 MEDSV DEF RBRVS 02/01/2015 376.27 Description: REMOVE KNEE CYST Category: Medical Services CMS Add: 01/01/1999 CMS Term: 27350 MEDSV DEF RBRVS 09/01/2019 465.78 Description: REMOVAL OF KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27355 MEDSV DEF RBRVS 09/01/2019 429.64 Description: REMOVE FEMUR LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27356 MEDSV DEF RBRVS 09/01/2019 526.33 Description: REMOVE FEMUR LESION/GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27357 MEDSV DEF RBRVS 09/01/2019 580.52 Description: REMOVE FEMUR LESION/GRAFT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27358 MEDSV DEF RBRVS 09/01/2019 200.66 Description: REMOVE FEMUR LESION/FIXATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27360 MEDSV DEF RBRVS 09/01/2019 607.90 Description: PARTIAL REMOVAL LEG BONE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27364 MEDSV DEF RBRVS 02/01/2015 1119.43 Description: RESECT THIGH/KNEE TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27365 MEDSV DEF RBRVS 09/01/2019 1486.55 Description: RESECT FEMUR/KNEE TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27369 MEDSV DEF RBRVS 01/01/2020 101.44 Description: NJX CNTRST KNE ARTHG/CT/MRI Category: Medical Services CMS Add: 01/01/2019 CMS Term: 27372 MEDSV DEF RBRVS 09/01/2019 428.82 Description: REMOVAL OF FOREIGN BODY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27380 MEDSV DEF RBRVS 09/01/2019 423.12 Description: REPAIR OF KNEECAP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27381 MEDSV DEF RBRVS 09/01/2019 570.35 Description: REPAIR/GRAFT KNEECAP TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 185 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27385 MEDSV DEF RBRVS 09/01/2019 409.06 Description: REPAIR OF THIGH MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27386 MEDSV DEF RBRVS 09/01/2019 592.43 Description: REPAIR/GRAFT OF THIGH MUSCLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27390 MEDSV DEF RBRVS 09/01/2019 318.10 Description: INCISION OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27391 MEDSV DEF RBRVS 09/01/2019 409.99 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27392 MEDSV DEF RBRVS 09/01/2019 506.87 Description: INCISION OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27393 MEDSV DEF RBRVS 09/01/2019 362.36 Description: LENGTHENING OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27394 MEDSV DEF RBRVS 09/01/2019 464.73 Description: LENGTHENING OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27395 MEDSV DEF RBRVS 09/01/2019 626.21 Description: LENGTHENING OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27396 MEDSV DEF RBRVS 09/01/2019 438.13 Y Description: TRANSPLANT OF THIGH TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27397 MEDSV DEF RBRVS 09/01/2019 653.27 Y Description: TRANSPLANTS OF THIGH TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27400 MEDSV DEF RBRVS 09/01/2019 494.27 Description: REVISE THIGH MUSCLES/TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27403 MEDSV DEF RBRVS 09/01/2019 456.70 Description: REPAIR OF KNEE CARTILAGE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27405 MEDSV DEF RBRVS 09/01/2019 482.44 Description: REPAIR OF KNEE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27407 MEDSV DEF RBRVS 09/01/2019 564.43 Description: REPAIR OF KNEE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27409 MEDSV DEF RBRVS 09/01/2019 688.83 Description: REPAIR OF KNEE LIGAMENTS Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27412 MEDSV DEF RBRVS 02/01/2015 1185.18 Description: AUTOCHONDROCYTE IMPLANT KNEE Category: Medical Services CMS Add: 01/01/2005 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 186 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27415 MEDSV DEF RBRVS 02/01/2015 983.43 Description: OSTEOCHONDRAL KNEE ALLOGRAFT Category: Medical Services CMS Add: 01/01/2005 CMS Term: 27416 MEDSV DEF RBRVS 02/01/2015 700.51 Description: OSTEOCHONDRAL KNEE AUTOGRAFT Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27418 MEDSV DEF RBRVS 09/01/2019 593.58 Description: REPAIR DEGENERATED KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27420 MEDSV DEF RBRVS 09/01/2019 524.71 Description: REVISION OF UNSTABLE KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27422 MEDSV DEF RBRVS 09/01/2019 530.88 Description: REVISION OF UNSTABLE KNEECAP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27424 MEDSV DEF RBRVS 09/01/2019 532.59 Description: REVISION/REMOVAL OF KNEECAP Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27425 MEDSV DEF RBRVS 09/01/2019 317.56 Description: LAT RETINACULAR RELEASE OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27427 MEDSV DEF RBRVS 09/01/2019 510.18 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27428 MEDSV DEF RBRVS 09/01/2019 795.22 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27429 MEDSV DEF RBRVS 09/01/2019 894.46 Description: RECONSTRUCTION KNEE Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27430 MEDSV DEF RBRVS 09/01/2019 528.79 Description: REVISION OF THIGH MUSCLES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27435 MEDSV DEF RBRVS 09/01/2019 577.78 Description: INCISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27437 MEDSV DEF RBRVS 09/01/2019 470.23 Description: REVISE KNEECAP Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27438 MEDSV DEF RBRVS 09/01/2019 602.28 Description: REVISE KNEECAP WITH IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27440 MEDSV DEF RBRVS 09/01/2019 568.64 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27441 MEDSV DEF RBRVS 09/01/2019 587.75 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 187 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27442 MEDSV DEF RBRVS 09/01/2019 622.44 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27443 MEDSV DEF RBRVS 09/01/2019 582.36 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27445 MEDSV DEF RBRVS 09/01/2019 898.21 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27446 MEDSV DEF RBRVS 09/01/2019 833.81 Description: REVISION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27447 MEDSV DEF RBRVS 09/01/2019 975.44 Description: TOTAL KNEE ARTHROPLASTY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27448 MEDSV DEF RBRVS 09/01/2019 577.23 Description: INCISION OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27450 MEDSV DEF RBRVS 09/01/2019 724.66 Description: INCISION OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27454 MEDSV DEF RBRVS 09/01/2019 929.91 Description: REALIGNMENT OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27455 MEDSV DEF RBRVS 09/01/2019 672.57 Description: REALIGNMENT OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27457 MEDSV DEF RBRVS 09/01/2019 684.63 Description: REALIGNMENT OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27465 MEDSV DEF RBRVS 09/01/2019 897.18 Description: SHORTENING OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27466 MEDSV DEF RBRVS 09/01/2019 843.54 Description: LENGTHENING OF THIGH BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27468 MEDSV DEF RBRVS 09/01/2019 863.72 Description: SHORTEN/LENGTHEN THIGHS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27470 MEDSV DEF RBRVS 09/01/2019 843.00 Description: REPAIR OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27472 MEDSV DEF RBRVS 09/01/2019 906.26 Description: REPAIR/GRAFT OF THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27475 MEDSV DEF RBRVS 09/01/2019 471.22 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 188 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27477 MEDSV DEF RBRVS 09/01/2019 522.06 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27479 MEDSV DEF RBRVS 09/01/2019 630.85 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27485 MEDSV DEF RBRVS 09/01/2019 477.75 Description: SURGERY TO STOP LEG GROWTH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27486 MEDSV DEF RBRVS 09/01/2019 1011.54 Description: REVISE/REPLACE KNEE JOINT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27487 MEDSV DEF RBRVS 09/01/2019 1266.12 Description: REVISE/REPLACE KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27488 MEDSV DEF RBRVS 09/01/2019 861.89 Description: REMOVAL OF KNEE PROSTHESIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27495 MEDSV DEF RBRVS 09/01/2019 808.14 Description: REINFORCE THIGH Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27496 MEDSV DEF RBRVS 09/01/2019 385.96 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27497 MEDSV DEF RBRVS 09/01/2019 414.42 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27498 MEDSV DEF RBRVS 09/01/2019 465.78 Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27499 MEDSV DEF RBRVS 09/01/2019 498.53 Y Description: DECOMPRESSION OF THIGH/KNEE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27500 MEDSV DEF RBRVS 09/01/2019 367.44 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27501 MEDSV DEF RBRVS 09/01/2019 357.52 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27502 MEDSV DEF RBRVS 09/01/2019 551.79 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27503 MEDSV DEF RBRVS 09/01/2019 573.32 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27506 MEDSV DEF RBRVS 09/01/2019 959.41 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 189 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27507 MEDSV DEF RBRVS 09/01/2019 697.88 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27508 MEDSV DEF RBRVS 09/01/2019 373.59 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27509 MEDSV DEF RBRVS 09/01/2019 458.58 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27510 MEDSV DEF RBRVS 09/01/2019 489.97 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27511 MEDSV DEF RBRVS 09/01/2019 715.88 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27513 MEDSV DEF RBRVS 09/01/2019 891.52 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27514 MEDSV DEF RBRVS 09/01/2019 693.67 Description: TREATMENT OF THIGH FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27516 MEDSV DEF RBRVS 09/01/2019 359.27 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27517 MEDSV DEF RBRVS 09/01/2019 487.72 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27519 MEDSV DEF RBRVS 09/01/2019 637.58 Description: TREAT THIGH FX GROWTH PLATE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27520 MEDSV DEF RBRVS 09/01/2019 228.16 Description: TREAT KNEECAP FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27524 MEDSV DEF RBRVS 09/01/2019 537.33 Description: TREAT KNEECAP FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27530 MEDSV DEF RBRVS 09/01/2019 212.81 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27532 MEDSV DEF RBRVS 09/01/2019 436.87 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27535 MEDSV DEF RBRVS 09/01/2019 643.45 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27536 MEDSV DEF RBRVS 09/01/2019 853.60 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 190 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27538 MEDSV DEF RBRVS 09/01/2019 335.26 Description: TREAT KNEE FRACTURE(S) Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27540 MEDSV DEF RBRVS 09/01/2019 580.89 Description: TREAT KNEE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27550 MEDSV DEF RBRVS 09/01/2019 359.84 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27552 MEDSV DEF RBRVS 09/01/2019 445.62 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27556 MEDSV DEF RBRVS 09/01/2019 625.00 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27557 MEDSV DEF RBRVS 09/01/2019 750.48 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27558 MEDSV DEF RBRVS 09/01/2019 855.95 Description: TREAT KNEE DISLOCATION Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27560 MEDSV DEF RBRVS 09/01/2019 255.75 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27562 MEDSV DEF RBRVS 09/01/2019 343.08 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27566 MEDSV DEF RBRVS 09/01/2019 637.36 Description: TREAT KNEECAP DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27570 MEDSV DEF RBRVS 09/01/2019 107.05 Description: FIXATION OF KNEE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27580 MEDSV DEF RBRVS 09/01/2019 1029.33 Description: FUSION OF KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27590 MEDSV DEF RBRVS 09/01/2019 582.64 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27591 MEDSV DEF RBRVS 09/01/2019 692.95 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27592 MEDSV DEF RBRVS 09/01/2019 493.03 Description: AMPUTATE LEG AT THIGH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27594 MEDSV DEF RBRVS 09/01/2019 366.47 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 191 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27596 MEDSV DEF RBRVS 09/01/2019 523.65 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27598 MEDSV DEF RBRVS 09/01/2019 525.32 Description: AMPUTATE LOWER LEG AT KNEE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27599 MEDSV DEF BILL20 Description: UNLISTED PX FEMUR/KNEE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 27600 MEDSV DEF RBRVS 09/01/2019 296.94 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27601 MEDSV DEF RBRVS 09/01/2019 315.81 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27602 MEDSV DEF RBRVS 09/01/2019 358.66 Description: DECOMPRESSION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27603 MEDSV DEF RBRVS 09/01/2019 373.79 Description: DRAIN LOWER LEG LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27604 MEDSV DEF RBRVS 09/01/2019 329.43 Description: DRAIN LOWER LEG BURSA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27605 MEDSV DEF RBRVS 09/01/2019 243.19 Description: INCISION OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27606 MEDSV DEF RBRVS 09/01/2019 205.45 Description: INCISION OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27607 MEDSV DEF RBRVS 09/01/2019 437.87 Description: TREAT LOWER LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27610 MEDSV DEF RBRVS 09/01/2019 469.24 Description: EXPLORE/TREAT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27612 MEDSV DEF RBRVS 09/01/2019 407.74 Description: EXPLORATION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27613 MEDSV DEF RBRVS 09/01/2019 179.05 Description: BIOPSY LOWER LEG SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27614 MEDSV DEF RBRVS 09/01/2019 411.48 Description: BIOPSY LOWER LEG SOFT TISSUE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27615 MEDSV DEF RBRVS 09/01/2019 733.01 Description: RESECT LEG/ANKLE TUM < 5 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 192 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27616 MEDSV DEF RBRVS 02/01/2015 907.02 Description: RESECT LEG/ANKLE TUM 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27618 MEDSV DEF RBRVS 09/01/2019 315.64 Description: EXC LEG/ANKLE TUM < 3 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27619 MEDSV DEF RBRVS 09/01/2019 338.75 Description: EXC LEG/ANKLE TUM DEEP <5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27620 MEDSV DEF RBRVS 09/01/2019 326.42 Description: EXPLORE/TREAT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27625 MEDSV DEF RBRVS 09/01/2019 418.27 Description: REMOVE ANKLE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27626 MEDSV DEF RBRVS 09/01/2019 450.52 Description: REMOVE ANKLE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27630 MEDSV DEF RBRVS 09/01/2019 400.26 Description: REMOVAL OF TENDON LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27632 MEDSV DEF RBRVS 02/01/2015 295.04 Description: EXC LEG/ANKLE LES SC 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27634 MEDSV DEF RBRVS 02/01/2015 489.34 Description: EXC LEG/ANKLE TUM DEP 5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 27635 MEDSV DEF RBRVS 09/01/2019 422.18 Description: REMOVE LOWER LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27637 MEDSV DEF RBRVS 09/01/2019 537.86 Description: REMOVE/GRAFT LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27638 MEDSV DEF RBRVS 09/01/2019 551.18 Description: REMOVE/GRAFT LEG BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27640 MEDSV DEF RBRVS 09/01/2019 598.63 Description: PARTIAL REMOVAL OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27641 MEDSV DEF RBRVS 09/01/2019 481.55 Description: PARTIAL REMOVAL OF FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27645 MEDSV DEF RBRVS 09/01/2019 1277.06 Description: RESECT TIBIA TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27646 MEDSV DEF RBRVS 09/01/2019 1106.75 Description: RESECT FIBULA TUMOR Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 193 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27647 MEDSV DEF RBRVS 09/01/2019 768.36 Description: RESECT TALUS/CALCANEUS TUM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27648 MEDSV DEF RBRVS 09/01/2019 115.05 Description: INJECTION FOR ANKLE X-RAY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27650 MEDSV DEF RBRVS 09/01/2019 477.34 Description: REPAIR ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27652 MEDSV DEF RBRVS 09/01/2019 499.45 Description: REPAIR/GRAFT ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27654 MEDSV DEF RBRVS 09/01/2019 512.31 Description: REPAIR OF ACHILLES TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27656 MEDSV DEF RBRVS 09/01/2019 446.60 Description: REPAIR LEG FASCIA DEFECT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27658 MEDSV DEF RBRVS 09/01/2019 269.35 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27659 MEDSV DEF RBRVS 09/01/2019 352.11 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27664 MEDSV DEF RBRVS 09/01/2019 259.62 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27665 MEDSV DEF RBRVS 09/01/2019 298.04 Description: REPAIR OF LEG TENDON EACH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27675 MEDSV DEF RBRVS 09/01/2019 351.64 Description: REPAIR LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27676 MEDSV DEF RBRVS 09/01/2019 440.33 Description: REPAIR LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27680 MEDSV DEF RBRVS 09/01/2019 308.02 Description: RELEASE OF LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27681 MEDSV DEF RBRVS 09/01/2019 388.50 Description: RELEASE OF LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27685 MEDSV DEF RBRVS 09/01/2019 477.01 Description: REVISION OF LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27686 MEDSV DEF RBRVS 09/01/2019 397.24 Description: REVISE LOWER LEG TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 194 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27687 MEDSV DEF RBRVS 09/01/2019 327.87 Description: REVISION OF CALF TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27690 MEDSV DEF RBRVS 09/01/2019 456.69 Description: REVISE LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27691 MEDSV DEF RBRVS 09/01/2019 541.21 Description: REVISE LOWER LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27692 MEDSV DEF RBRVS 01/01/2016 76.75 Description: REVISE ADDITIONAL LEG TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27695 MEDSV DEF RBRVS 09/01/2019 345.16 Description: REPAIR OF ANKLE LIGAMENT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27696 MEDSV DEF RBRVS 09/01/2019 406.65 Description: REPAIR OF ANKLE LIGAMENTS Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27698 MEDSV DEF RBRVS 09/01/2019 463.31 Description: REPAIR OF ANKLE LIGAMENT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 27700 MEDSV DEF RBRVS 09/01/2019 431.38 Description: REVISION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27702 MEDSV DEF RBRVS 09/01/2019 698.49 Description: RECONSTRUCT ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27703 MEDSV DEF RBRVS 09/01/2019 805.84 Description: RECONSTRUCTION ANKLE JOINT Category: Medical Services CMS Add: 01/01/1987 CMS Term: 27704 MEDSV DEF RBRVS 09/01/2019 413.38 Description: REMOVAL OF ANKLE IMPLANT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27705 MEDSV DEF RBRVS 09/01/2019 544.22 Description: INCISION OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27707 MEDSV DEF RBRVS 09/01/2019 288.04 Description: INCISION OF FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27709 MEDSV DEF RBRVS 09/01/2019 838.60 Description: INCISION OF TIBIA & FIBULA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27712 MEDSV DEF RBRVS 09/01/2019 790.05 Description: REALIGNMENT OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27715 MEDSV DEF RBRVS 09/01/2019 765.41 Description: REVISION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 195 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27720 MEDSV DEF RBRVS 09/01/2019 626.96 Description: REPAIR OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27722 MEDSV DEF RBRVS 09/01/2019 635.08 Description: REPAIR/GRAFT OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27724 MEDSV DEF RBRVS 09/01/2019 910.97 Description: REPAIR/GRAFT OF TIBIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27725 MEDSV DEF RBRVS 09/01/2019 872.14 Description: REPAIR OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27726 MEDSV DEF RBRVS 02/01/2015 695.52 Description: REPAIR FIBULA NONUNION Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27727 MEDSV DEF RBRVS 09/01/2019 659.66 Description: REPAIR OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27730 MEDSV DEF RBRVS 09/01/2019 416.87 Description: REPAIR OF TIBIA EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27732 MEDSV DEF RBRVS 09/01/2019 272.96 Description: REPAIR OF FIBULA EPIPHYSIS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27734 MEDSV DEF RBRVS 09/01/2019 449.53 Description: REPAIR LOWER LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27740 MEDSV DEF RBRVS 09/01/2019 443.66 Description: REPAIR OF LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27742 MEDSV DEF RBRVS 09/01/2019 488.41 Description: REPAIR OF LEG EPIPHYSES Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27745 MEDSV DEF RBRVS 09/01/2019 541.21 Description: REINFORCE TIBIA Category: Medical Services CMS Add: 01/01/1986 CMS Term: 27750 MEDSV DEF RBRVS 09/01/2019 244.79 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27752 MEDSV DEF RBRVS 09/01/2019 381.34 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27756 MEDSV DEF RBRVS 09/01/2019 409.57 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27758 MEDSV DEF RBRVS 09/01/2019 637.41 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 196 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27759 MEDSV DEF RBRVS 09/01/2019 715.32 Description: TREATMENT OF TIBIA FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27760 MEDSV DEF RBRVS 09/01/2019 236.69 Description: CLTX MEDIAL ANKLE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27762 MEDSV DEF RBRVS 09/01/2019 339.61 Description: CLTX MED ANKLE FX W/MNPJ Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27766 MEDSV DEF RBRVS 09/01/2019 435.19 Description: OPTX MEDIAL ANKLE FX Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27767 MEDSV DEF RBRVS 02/01/2015 199.99 Description: CLTX POST ANKLE FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27768 MEDSV DEF RBRVS 02/01/2015 312.08 Description: CLTX POST ANKLE FX W/MNPJ Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27769 MEDSV DEF RBRVS 02/01/2015 521.57 Description: OPTX POST ANKLE FX Category: Medical Services CMS Add: 01/01/2008 CMS Term: 27780 MEDSV DEF RBRVS 09/01/2019 216.49 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27781 MEDSV DEF RBRVS 09/01/2019 296.56 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27784 MEDSV DEF RBRVS 09/01/2019 512.74 Description: TREATMENT OF FIBULA FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27786 MEDSV DEF RBRVS 09/01/2019 224.24 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27788 MEDSV DEF RBRVS 09/01/2019 298.90 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27792 MEDSV DEF RBRVS 09/01/2019 467.46 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27808 MEDSV DEF RBRVS 09/01/2019 236.73 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27810 MEDSV DEF RBRVS 09/01/2019 332.86 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27814 MEDSV DEF RBRVS 09/01/2019 553.13 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 197 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27816 MEDSV DEF RBRVS 09/01/2019 225.83 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27818 MEDSV DEF RBRVS 09/01/2019 345.03 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27822 MEDSV DEF RBRVS 09/01/2019 602.42 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27823 MEDSV DEF RBRVS 09/01/2019 684.21 Description: TREATMENT OF ANKLE FRACTURE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27824 MEDSV DEF RBRVS 09/01/2019 222.62 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27825 MEDSV DEF RBRVS 09/01/2019 387.67 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27826 MEDSV DEF RBRVS 09/01/2019 599.63 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27827 MEDSV DEF RBRVS 09/01/2019 775.57 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27828 MEDSV DEF RBRVS 09/01/2019 929.10 Description: TREAT LOWER LEG FRACTURE Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27829 MEDSV DEF RBRVS 09/01/2019 489.86 Description: TREAT LOWER LEG JOINT Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27830 MEDSV DEF RBRVS 09/01/2019 268.57 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27831 MEDSV DEF RBRVS 09/01/2019 283.15 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27832 MEDSV DEF RBRVS 09/01/2019 538.72 Description: TREAT LOWER LEG DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27840 MEDSV DEF RBRVS 09/01/2019 264.82 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27842 MEDSV DEF RBRVS 09/01/2019 352.75 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27846 MEDSV DEF RBRVS 09/01/2019 524.42 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 198 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 27848 MEDSV DEF RBRVS 09/01/2019 584.91 Description: TREAT ANKLE DISLOCATION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27860 MEDSV DEF RBRVS 09/01/2019 127.55 Description: FIXATION OF ANKLE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27870 MEDSV DEF RBRVS 09/01/2019 744.91 Description: FUSION OF ANKLE JOINT OPEN Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27871 MEDSV DEF RBRVS 09/01/2019 492.65 Description: FUSION OF TIBIOFIBULAR JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27880 MEDSV DEF RBRVS 09/01/2019 664.98 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27881 MEDSV DEF RBRVS 09/01/2019 634.08 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27882 MEDSV DEF RBRVS 09/01/2019 436.78 Description: AMPUTATION OF LOWER LEG Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27884 MEDSV DEF RBRVS 09/01/2019 415.63 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27886 MEDSV DEF RBRVS 09/01/2019 475.49 Description: AMPUTATION FOLLOW-UP SURGERY Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27888 MEDSV DEF RBRVS 09/01/2019 486.54 Description: AMPUTATION OF FOOT AT ANKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27889 MEDSV DEF RBRVS 09/01/2019 478.16 Description: AMPUTATION OF FOOT AT ANKLE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 27892 MEDSV DEF RBRVS 09/01/2019 397.39 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27893 MEDSV DEF RBRVS 09/01/2019 435.62 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27894 MEDSV DEF RBRVS 09/01/2019 614.15 Description: DECOMPRESSION OF LEG Category: Medical Services CMS Add: 01/01/1993 CMS Term: 27899 MEDSV DEF BILL20 Description: UNLISTED PX LEG/ANKLE Category: Medical Services CMS Add: 01/01/1982 CMS Term: 28001 MEDSV DEF RBRVS 09/01/2019 199.46 Description: DRAINAGE OF BURSA OF FOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 199 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28002 MEDSV DEF RBRVS 09/01/2019 322.82 Description: TREATMENT OF FOOT INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28003 MEDSV DEF RBRVS 09/01/2019 516.49 Description: TREATMENT OF FOOT INFECTION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28005 MEDSV DEF RBRVS 09/01/2019 424.89 Description: TREAT FOOT BONE LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28008 MEDSV DEF RBRVS 09/01/2019 312.58 Description: INCISION OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28010 MEDSV DEF RBRVS 09/01/2019 169.06 Description: INCISION OF TOE TENDON Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28011 MEDSV DEF RBRVS 09/01/2019 235.22 Description: INCISION OF TOE TENDONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28020 MEDSV DEF RBRVS 09/01/2019 388.73 Description: EXPLORATION OF FOOT JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28022 MEDSV DEF RBRVS 09/01/2019 352.76 Description: EXPLORATION OF FOOT JOINT Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28024 MEDSV DEF RBRVS 09/01/2019 332.17 Description: EXPLORATION OF TOE JOINT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28035 MEDSV DEF RBRVS 09/01/2019 382.37 Description: DECOMPRESSION OF TIBIA NERVE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28039 MEDSV DEF RBRVS 02/01/2015 370.22 Description: EXC FOOT/TOE TUM SC 1.5 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 28041 MEDSV DEF RBRVS 02/01/2015 335.90 Description: EXC FOOT/TOE TUM DEP 1.5CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: 28043 MEDSV DEF RBRVS 09/01/2019 288.14 Description: EXC FOOT/TOE TUM SC < 1.5 CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28045 MEDSV DEF RBRVS 09/01/2019 359.47 Description: EXC FOOT/TOE TUM DEEP <1.5CM Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28046 MEDSV DEF RBRVS 09/01/2019 536.25 Description: RESECT FOOT/TOE TUMOR < 3 CM Category: Medical Services CMS Add: 01/01/1988 CMS Term: 28047 MEDSV DEF RBRVS 02/01/2015 756.36 Description: RESECT FOOT/TOE TUMOR 3 CM/> Category: Medical Services CMS Add: 01/01/2010 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 200 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28050 MEDSV DEF RBRVS 09/01/2019 308.61 Description: BIOPSY OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28052 MEDSV DEF RBRVS 09/01/2019 316.26 Description: BIOPSY OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1985 CMS Term: 28054 MEDSV DEF RBRVS 09/01/2019 271.38 Description: BIOPSY OF TOE JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28055 MEDSV DEF RBRVS 01/01/2016 277.00 Description: NEURECTOMY FOOT Category: Medical Services CMS Add: 01/01/2007 CMS Term: 28060 MEDSV DEF RBRVS 09/01/2019 373.89 Description: PARTIAL REMOVAL FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28062 MEDSV DEF RBRVS 09/01/2019 425.23 Description: REMOVAL OF FOOT FASCIA Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28070 MEDSV DEF RBRVS 09/01/2019 383.80 Description: REMOVAL OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28072 MEDSV DEF RBRVS 09/01/2019 365.78 Description: REMOVAL OF FOOT JOINT LINING Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28080 MEDSV DEF RBRVS 09/01/2019 376.97 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28086 MEDSV DEF RBRVS 09/01/2019 391.80 Description: EXCISE FOOT TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28088 MEDSV DEF RBRVS 09/01/2019 334.75 Description: EXCISE FOOT TENDON SHEATH Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28090 MEDSV DEF RBRVS 09/01/2019 339.41 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28092 MEDSV DEF RBRVS 09/01/2019 304.60 Description: REMOVAL OF TOE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28100 MEDSV DEF RBRVS 09/01/2019 435.49 Description: REMOVAL OF ANKLE/HEEL LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28102 MEDSV DEF RBRVS 09/01/2019 416.58 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28103 MEDSV DEF RBRVS 09/01/2019 288.45 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 201 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max Age Units ------ --- --- --- --- -------- ---- ------- ---------- ---------- ------------ ------ -- --- ----------------- --------- 28104 MEDSV DEF RBRVS 09/01/2019 378.31 Description: REMOVAL OF FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28106 MEDSV DEF RBRVS 09/01/2019 327.78 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28107 MEDSV DEF RBRVS 09/01/2019 397.87 Description: REMOVE/GRAFT FOOT LESION Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28108 MEDSV DEF RBRVS 09/01/2019 319.15 Description: REMOVAL OF TOE LESIONS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28110 MEDSV DEF RBRVS 09/01/2019 333.60 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28111 MEDSV DEF RBRVS 09/01/2019 358.84 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28112 MEDSV DEF RBRVS 09/01/2019 353.12 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28113 MEDSV DEF RBRVS 09/01/2019 428.47 Description: PART REMOVAL OF METATARSAL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28114 MEDSV DEF RBRVS 09/01/2019 774.09 Description: REMOVAL OF METATARSAL HEADS Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28116 MEDSV DEF RBRVS 09/01/2019 540.02 Description: REVISION OF FOOT Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28118 MEDSV DEF RBRVS 09/01/2019 424.55 Description: REMOVAL OF HEEL BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28119 MEDSV DEF RBRVS 09/01/2019 380.50 Description: REMOVAL OF HEEL SPUR Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28120 MEDSV DEF RBRVS 09/01/2019 489.37 Description: PART REMOVAL OF ANKLE/HEEL Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28122 MEDSV DEF RBRVS 09/01/2019 433.55 Description: PARTIAL REMOVAL OF FOOT BONE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28124 MEDSV DEF RBRVS 09/01/2019 345.31 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: 28126 MEDSV DEF RBRVS 09/01/2019 286.56 Description: PARTIAL REMOVAL OF TOE Category: Medical Services CMS Add: 01/01/1984 CMS Term: *Note: Please refer to the Additional Notes link on the fee schedule main information page for additional fee schedule information. Report : REF-0401-W INDIANA CORE MMIS Run Date: 11/25/2023 Process : REFJW013 Run Time: 12:27:51 Location: REFPW006 Indiana Health Coverage Programs Fee Schedule Page: 202 Proc Mod Mod Mod Mod Service Rate Pricing Pricing Pricing Fee Schedule Base Min/Max Code 1 2 3 4 Category Type Method Start Date End Date Amount Units PA Att Min/Max A