ANNEX 6.

LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE DESCRIPTION
Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia) Incision and drainage of pilonidal cyst Incision and removal of foreign body, subcutaneous tissues Incision and drainage of hematoma, seroma, or fluid collection Puncture aspiration of abscess, hematoma, bulla, or cyst Incision and drainage, complex, postoperative wound infection Debridement; skin, partial thickness Debridement; skin, full thickness Debridement; skin, and subcutaneous tissue Debridement; skin, subcutaneous tissue, and muscle Debridement; skin, subcutaneous tissue, muscle, and bone Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o chemical cauterization (such as verrucae or clavi) not extending through the stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; single lesion Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o chemical cauterization (such as verrucae or clavi) not extending through the stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; two to four lesions Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o chemical cauterization (such as verrucae or clavi) not extending through the stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; more than four lesions Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single or multiple lesion Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm

Case Rate

Professional Health Care Fee Institution Fee

10060 10080 10120 10140 10160 10180 11040 11041 11042 11043 11044

2,548 2,548 2,548 2,548 2,548 3,892 2,548 2,548 3,976 5,614 5,614

588 588 588 588 588 882 588 588 1,176 1,764 1,764

1,960 1,960 1,960 1,960 1,960 3,010 1,960 1,960 2,800 3,850 3,850

11050

2,548

588

1,960

11051

3,892

882

3,010

11052

3,976

1,176

2,800

11100

2,548

588

1,960

11300

3,892

882

3,010

11301

2,590

941

1,649

11302

5,614

1,764

3,850

Page 1 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
11305

DESCRIPTION
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose ,lips, mucous membrane; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose ,lips, mucous membrane; lesion diameter 0.6 to 1.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.5 cm or less Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter over 4.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm

Case Rate

Professional Health Care Fee Institution Fee

3,892

882

3,010

11306

2,590

941

1,649

11307

5,614

1,764

3,850

11310

2,590

941

1,649

11311

5,614

1,764

3,850

11400

2,548

588

1,960

11401

2,548

588

1,960

11402

2,548

588

1,960

11403

2,548

588

1,960

11404

2,548

588

1,960

11406

2,548

588

1,960

11420

2,548

588

1,960

11421

2,548

588

1,960

11422

2,548

588

1,960

11423

2,548

588

1,960

11424

2,548

588

1,960

11426

2,548

588

1,960

Page 2 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE DESCRIPTION
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 4.0 cm Excision of skin and subcutaneous tissue for hidradenitis, axillary Excision of skin and subcutaneous tissue for hidradenitis, inguinal Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal or umbilical Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.5 cm or less Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.6 to 1.0 cm Excision, malignant lesion, trunk, arms, or legs; lesion diameter 1.1 to 2.0 cm Excision, malignant lesion, trunk, arms, or legs; lesion diameter 2.1 to 3.0 cm Excision, malignant lesion, trunk, arms, or legs; lesion diameter 3.1 to 4.0 cm Excision, malignant lesion, trunk, arms, or legs; lesion diameter over 4.0 cm Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm

Case Rate

Professional Health Care Fee Institution Fee

11440

2,876

706

2,170

11441

2,876

706

2,170

11442

2,876

706

2,170

11443

2,876

706

2,170

11444

2,876

706

2,170

11446 11450 11462 11470 11600 11601 11602 11603 11604 11606 11620 11621 11622 11623 11624

2,876 5,614 5,614 5,614 3,892 3,892 3,892 3,892 3,892 3,892 3,976 3,976 3,976 3,976 3,976

706 1,764 1,764 1,764 882 882 882 882 882 882 1,176 1,176 1,176 1,176 1,176

2,170 3,850 3,850 3,850 3,010 3,010 3,010 3,010 3,010 3,010 2,800 2,800 2,800 2,800 2,800

Page 3 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
11626 11640 11641 11642 11643 11644 11646 11720 11721 11730 11740 11750

DESCRIPTION
Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.5 cm or less Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.6 to 1.0 cm Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 1.1 to 2.0 cm Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 2.1 to 3.0 cm Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 3.1 to 4.0 cm Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter over 4.0 cm Debridement of nail(s) by any method(s); one to five Debridement of nail(s) by any method(s); six or more Avulsion of nail plate, partial or complete Evacuation of subungual hematoma Excision of nail and nail matrix, partial or complete (e.g., ingrown or deformed nail) for permanent removal Excision of nail and nail matrix, partial or complete (e.g., ingrown or deformed nail) for permanent removal w/ amputation of tuft of distal phalanx Biopsy of nail unit, any method (e.g., plate, bed, matrix, hyponychium, proximal and lateral nail folds) Repair of nail bed Reconstruction of nail bed w/ graft Wedge excision of skin of nail fold (e.g., for ingrown toenail) Excision of pilonidal cyst or sinus Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm

Case Rate
3,976 3,976 3,976 3,976 3,976 3,976 3,976 2,548 3,892 2,548 2,548 2,548

Professional Health Care Fee Institution Fee

1,176 1,176 1,176 1,176 1,176 1,176 1,176 588 882 588 588 588 2,800 2,800 2,800 2,800 2,800 2,800 2,800 1,960 3,010 1,960 1,960 1,960

11752

6,510

1,470

5,040

11755 11760 11762 11765 11770 12001

2,548 3,892 6,510 2,548 3,976 2,548

588 882 1,470 588 1,176 588

1,960 3,010 5,040 1,960 2,800 1,960

12002

3,892

882

3,010

12004

3,976

1,176

2,800

12005

3,976

1,176

2,800

Page 4 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE DESCRIPTION
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 2.5 cm or less Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); over 30.0 cm Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm

Case Rate

Professional Health Care Fee Institution Fee

12006

3,976

1,176

2,800

12007

3,976

1,176

2,800

12011

3,976

1,176

2,800

12013

6,510

1,470

5,040

12014

6,686

1,646

5,040

12015

5,614

1,764

3,850

12016

5,614

1,764

3,850

12017

5,614

1,764

3,850

12018

5,614

1,764

3,850

12031

2,548

588

1,960

12032

3,892

882

3,010

12034

3,976

1,176

2,800

12035

3,976

1,176

2,800

12036

3,976

1,176

2,800

12037 12041 12042

3,976 3,976 6,510

1,176 1,176 1,470

2,800 2,800 5,040

Page 5 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
12044 12051

DESCRIPTION
Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 2.5 cm or less Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 2.6 cm to 5.0 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 5.1 cm to 7.5 cm Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membrances; 7.6 cm to 12.5 cm Destruction by any method, including laser, w/ or w/o surgical curettement, all benign facial lesions or premalignant lesions in any location, or benign lesions other than cutaneous vascular proliferative lesions, including local anesthesia; any number of Destruction by any method, including laser, of benign skin lesions other than cutaneous vascular proliferative lesions on any area other than the face, including local anesthesia; any number of lesions Destruction by any method of flat warts or molluscum contagiosum, milia, all lesions Electosurgical destruction of multiple fibrocutaneous tags; all lesions Chemical cauterization of granulation tissue (proud flesh, sinus or fistula) Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 0.5 cm or less Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter over 4.0 cm Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less

Case Rate
5,614 3,976

Professional Health Care Fee Institution Fee

1,764 1,176 3,850 2,800

12052

3,976

1,176

2,800

12053

5,614

1,764

3,850

12054

5,614

1,764

3,850

17000

5,614

1,764

3,850

17100

5,614

1,764

3,850

17110 17200 17250 17260

3,976 5,614 3,976 3,976

1,176 1,764 1,176 1,176

2,800 3,850 2,800 2,800

17261

3,976

1,176

2,800

17262

3,976

1,176

2,800

17263

3,976

1,176

2,800

17264 17266 17270

3,976 3,976 3,976

1,176 1,176 1,176

2,800 2,800 2,800

Page 6 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
17271

DESCRIPTION
Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 4.0 cm Chemosurgery (Mohs micrographic technique), including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histopathologic preparation; first stage, fresh tissue technique, up to 5 specimens Puncture aspiration of cyst of breast; Biopsy of breast; needle core Biopsy of breast; incisional Excision of cyst, fibroadenoma, or other benign or malignant tumor aberrant breast tissue, duct lesion or nipple lesion (except 19140), male or female, one or more lesions Excision of breast lesion identified by preoperative placement of radiological marker; single lesion Mastectomy for gynecomastia Biopsy, muscle

Case Rate

Professional Health Care Fee Institution Fee

3,976

1,176

2,800

17272

3,976

1,176

2,800

17273

3,976

1,176

2,800

17274

3,976

1,176

2,800

17276

3,976

1,176

2,800

17280

6,510

1,470

5,040

17281

6,510

1,470

5,040

17282

6,510

1,470

5,040

17283

6,510

1,470

5,040

17284

6,510

1,470

5,040

17286

6,510

1,470

5,040

17304

5,614

1,764

3,850

19000 19100 19101 19120

2,548 2,548 3,892 5,614

588 588 882 1,764

1,960 1,960 3,010 3,850

19125 19140 20200

5,614 15,400 2,876

1,764 6,160 706

3,850 9,240 2,170

Page 7 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
20206 20520 20600

DESCRIPTION
Biopsy, muscle, percutaneous needle Removal of foreign body in muscle or tendon sheath Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst (e.g., fingers, toes) Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa) Insertion of wire or pin w/ application of skeletal traction, including removal Replantation, arm (includes surgical neck of humerus through elbow joint), complete amputation Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; w/ partial rib ostectomy Incision, deep, w/ opening of bone cortex (e.g., for osteomyelitis or bone abscess), thorax Biopsy, soft tissue of neck or thorax Excision tumor, soft tissue of neck or thorax; subcutaneous Closed treatment of rib fracture Biopsy, soft tissue of back or flank Excision, tumor, soft tissue of back or flank Biopsy, soft tissue of shoulder area Excision, tumor, shoulder area; subcutaneous Excision, tumor, shoulder area; deep, subfascial, or intramuscular Removal of foreign body, shoulder; subcutaneous Closed treatment of clavicular fracture Closed treatment of acromioclavicular dislocation Closed treatment of scapular fracture Incision and drainage, upper arm or elbow area; deep abscess or hematoma Incision and drainage, upper arm or elbow area; infected bursa Biopsy, soft tissue of upper arm or elbow area Excision, tumor, upper arm or elbow area; subcutaneous Excision, tumor, upper arm or elbow area; deep, subfascial or intramuscular Closed treatment of radial head subluxation in child, "nursemaid elbow"

Case Rate
2,453 5,614 3,892

Professional Health Care Fee Institution Fee

353 1,764 882 2,100 3,850 3,010

20605

6,510

1,470

5,040

20610 20650 20802 21501 21502 21510 21550 21555 21800 21920 21930 23065 23075 23076 23330 23500 23540 23570 23930 23931 24065 24075 24076 24640

6,510 5,614 6,510 3,976 5,614 2,876 3,976 5,614 5,614 2,453 3,976 2,453 3,976 5,614 3,892 5,614 5,614 5,614 2,876 3,892 2,453 3,976 5,614 3,976

1,470 1,764 1,470 1,176 1,764 706 1,176 1,764 1,764 353 1,176 353 1,176 1,764 882 1,764 1,764 1,764 706 882 353 1,176 1,764 1,176

5,040 3,850 5,040 2,800 3,850 2,170 2,800 3,850 3,850 2,100 2,800 2,100 2,800 3,850 3,010 3,850 3,850 3,850 2,170 3,010 2,100 2,800 3,850 2,800

Page 8 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
25065 25075 25076 25110 25210 26010 26011 26020 26440 26445 26531 27040 27047 27323 27327 27328 27600 27601 27603 27604 27613 27618 27619 27630 27656 28001 28043 28045 28080 29055

DESCRIPTION
Biopsy, soft tissue of forearm and/or wrist Excision, tumor, forearm and/or wrist area; subcutaneous Excision, tumor, forearm and/or wrist area; deep, subfascial or intramuscular Excision, lesion of tendon sheath, forearm and/or wrist Carpectomy; one bone Drainage of finger abscess; simple Drainage of finger abscess; complicated (e.g., felon) Drainage of tendon sheath, one digit and/or palm Tenolysis, simple, flexor tendon; palm or finger, single, each tendon Tenolysis, extensor tendon, dorsum of hand or finger; each tendon Arthroplasty, metacarpophalangeal joint; w/ prosthetic implant, single, each Biopsy, soft tissue of pelvis and hip area Excision, tumor, pelvis and hip area; subcutaneous Biopsy, soft tissue of thigh or knee area Excision, tumor, thigh or knee area; subcutaneous Excision, tumor, thigh or knee area; deep, subfascial, or intramuscular Decompression fasciotomy, leg; anterior and/or lateral compartments only Decompression fasciotomy, leg; posterior compartments(s) only Incision and drainage, leg or ankle; deep abscess or hematoma Incision and drainage, leg or ankle; infected bursa Biopsy, soft tissue of leg or ankle area Excision, tumor, leg or ankle area; subcutaneous Excision, tumor, leg or ankle area; deep, subfascial or intramuscular Excision of lesion of tendon sheath or capsule (e.g., cyst or ganglion), leg and/or ankle Repair, fascial defect of leg Incision and drainage, infected bursa, foot Excision, tumor, foot; subcutaneous Excision, tumor, foot; deep, subfascial, intramuscular Excision of interdigital (Morton) neuroma, single, each Application of body cast, shoulder to hips; shoulder spica

Case Rate
2,453 3,976 5,614 5,614 4,152 2,453 2,876 5,614 5,614 5,614 5,614 2,453 3,976 2,453 3,976 5,614 5,614 5,614 2,876 3,976 2,453 3,976 5,614 3,976 3,976 3,976 3,976 5,614 3,976 6,510

Professional Health Care Fee Institution Fee

353 1,176 1,764 1,764 1,352 353 706 1,764 1,764 1,764 1,764 353 1,176 353 1,176 1,764 1,764 1,764 706 1,176 353 1,176 1,764 1,176 1,176 1,176 1,176 1,764 1,176 1,470 2,100 2,800 3,850 3,850 2,800 2,100 2,170 3,850 3,850 3,850 3,850 2,100 2,800 2,100 2,800 3,850 3,850 3,850 2,170 2,800 2,100 2,800 3,850 2,800 2,800 2,800 2,800 3,850 2,800 5,040

Page 9 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
29058 29065 29075 29085 29305 29345 29365 29405 29425 29435 29445 29450 30000 30020 30100 30110 30310 30320 30905 31000 31002 31500 31515 31525 31527 31528 31529 31710 32000 32400

DESCRIPTION
Application of body cast, shoulder to hips; plaster Velpeau Application of body cast, shoulder to hips; shoulder to hand (long arm) Application of body cast, shoulder to hips; elbow to finger (short arm) Application of body cast, shoulder to hips; hand and lower forearm (gauntlet) Application of hip spica cast; one leg Application of long leg cast (thigh to toes); Application of cylinder cast (thigh to ankle) Application of short leg cast (below knee to toes); Application of short leg cast (below knee to toes); walking or ambulatory type Application of patellar tendon bearing (PTB) cast Application of rigid total contact leg cast Application of clubfoot cast w/ molding or manipulation, long or short leg Drainage abscess or hematoma, nasal, internal approach Drainage abscess or hematoma, nasal septum Biopsy, intranasal Excision, nasal polyp(s), simple Removal foreign body, intranasal; requiring general anesthesia Removal foreign body, intranasal; by lateral rhinotomy Control nasal hemorrhage, posterior, w/ posterior nasal packs and/or cauterization, any method; initial Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium) Lavage by cannulation; sphenoid sinus Intubation, endotracheal, emergency emergency procedure Laryngoscopy direct, w/ or w/o tracheoscopy; for aspiration Laryngoscopy direct, w/ or w/o tracheoscopy; diagnostic, except newborn Laryngoscopy direct, w/ or w/o tracheoscopy; w/ insertion of obturator Laryngoscopy direct, w/ or w/o tracheoscopy; w/ dilatation, initial Laryngoscopy direct, w/ or w/o tracheoscopy; w/ dilatation, subsequent Catheterization for bronchography, w/ or w/o instillation of contrast material Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent Biopsy, pleura; percutaneous needle

Case Rate
3,892 3,976 3,892 3,892 5,614 5,614 5,614 5,614 5,614 5,614 3,976 3,976 3,892 3,892 3,976 5,614 5,614 5,614 5,614 6,510 5,614 0 5,614 5,614 5,614 5,614 5,614 3,892 1,260 3,892

Professional Health Care Fee Institution Fee

882 1,176 882 882 1,764 1,764 1,764 1,764 1,764 1,764 1,176 1,176 882 882 1,176 1,764 1,764 1,764 1,764 1,470 1,764 0 1,764 1,764 1,764 1,764 1,764 882 840 882 3,010 2,800 3,010 3,010 3,850 3,850 3,850 3,850 3,850 3,850 2,800 2,800 3,010 3,010 2,800 3,850 3,850 3,850 3,850 5,040 3,850 0 3,850 3,850 3,850 3,850 3,850 3,010 420 3,010

Page 10 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
32420 32960 33010 36010 36011 36012 36013 36014 36120 36140 36200 36215

DESCRIPTION
Pneumonocentesis, puncture of lung for aspiration Pneumothorax, therapeutic, intrapleural injection of air Pericardiocentesis Introduction of catheter, superior or inferior vena cava Selective catheter placement, venous system; first order branch (e.g., renal vein, jugular vein) Selective catheter placement, venous system; second order, or more selective, branch (e.g., left adrenal vein, petrosal sinus) Introduction of catheter, right heart or main pulmonary artery Selective catheter placement, left or right pulmonary artery Introduction of needle or intracatheter; retrograde brachial artery Introduction of needle or intracatheter; extremity artery Introduction of catheter, aorta Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, w/in a vascular family Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, w/in a vascular family Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, w/in a vascular family Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, w/in a vascular family Selective catheter placement, arterial system; initial second order abdominal, pelvic or lower extremity artery branch, w/in a vascular family Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic or lower extremity artery branch, w/in a vascular family Outpatient Transfusion of Blood or Blood Products; one or more units Exchange transfusion, blood Percutaneous portal vein catheterization by any method Catheterization of umbilical vein for diagnosis or therapy, newborn Therapeutic apheresis Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown Catheterization, umbilical artery, newborn, for diagnosis or therapy

Case Rate
3,892 3,892 5,614 2,548 6,510 5,614 5,614 5,614 6,510 6,510 6,510 6,510

Professional Health Care Fee Institution Fee

882 882 1,764 588 1,470 1,764 1,764 1,764 1,470 1,470 1,470 1,470 3,010 3,010 3,850 1,960 5,040 3,850 3,850 3,850 5,040 5,040 5,040 5,040

36216

6,510

1,470

5,040

36217

5,614

1,764

3,850

36245

6,510

1,470

5,040

36246

6,510

1,470

5,040

36247

5,614

1,764

3,850

36430 36450 36481 36510 36511 36640 36660

2,548 3,976 6,510 2,548 2,548 2,548 3,976

588 1,176 1,470 588 588 588 1,176

1,960 2,800 5,040 1,960 1,960 1,960 2,800

Page 11 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
36781 36800 36835 37201 37202 37565 37600 37607 37609 37650 37700 38500 38505 38520 38525 38530 40490 40500 40510 40520 40800 40808 40810 40819 40830 40831 41000

DESCRIPTION
Percutaneousportal vein catheterization by any method Insertion of cannula for hemodialysis, other purpose ; vein to vein Insertion of Thomas shunt Transcatheter therapy, infusion for thrombolysis other than coronary Transchatheter therapy, infusion other than for thrombolysis, any type (e.g., spasmolytic, vasoconstrictive) Ligation, internal jugular vein Ligation; external carotid artery Ligation or banding of angioaccess arteriovenous fistula Ligation or biopsy, temporal artery Ligation of femoral vein Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions Biopsy or excision or lymph node(s); superficial Biopsy or excision or lymph node(s); by needle, superficial (e.g., cervical, inguinal, axillary) Biopsy or excision or lymph node(s); deep cervical node(s) w/ excision scalene fat pad Biopsy or excision or lymph node(s); deep axillary node(s) Biopsy or excision or lymph node(s); internal mammary node(s) Biopsy of lip Vermilionectomy (lip shave), w/ mucosal advancement Excision of lip; transverse wedge excision w/ primary closure V-excision w/ primary defect linear closure; Drainage of abscess, cyst, hematoma, vestibule of mouth Biopsy, vestibule of mouth Excision of lesion of mucosa and submucosa, vestibule of mouth Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) Closure of laceration, vestibule of mouth; 2.5 cm or less Closure of laceration, vestibule of mouth; over 2.5 cm or complex Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, superficial

Case Rate
6,510 6,510 6,510 5,614 5,614 3,976 3,976 6,510 6,510 6,510 6,510 3,976 3,976 6,510 6,510 6,510 3,892 5,614 5,614 5,614 3,976 3,976 3,976 6,510 3,976 3,976 3,976

Professional Health Care Fee Institution Fee

1,470 1,470 1,470 1,764 1,764 1,176 1,176 1,470 1,470 1,470 1,470 1,176 1,176 1,470 1,470 1,470 882 1,764 1,764 1,764 1,176 1,176 1,176 1,470 1,176 1,176 1,176 5,040 5,040 5,040 3,850 3,850 2,800 2,800 5,040 5,040 5,040 5,040 2,800 2,800 5,040 5,040 5,040 3,010 3,850 3,850 3,850 2,800 2,800 2,800 5,040 2,800 2,800 2,800

41005

3,976

1,176

2,800

Page 12 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
41006

DESCRIPTION
Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, deep, supramylohyoid Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submental space Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular space Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; masticator space Extraoral incision and drainage of abscess,cyst,or hematoma of floor of mouth; sublingual Extraoral incision and drainage of abscess,cyst,or hematoma of floor of mouth; submental Extraoral incision and drainage of abscess,cyst,or hematoma of floor of mouth; submandibular Extraoral incision and drainage of abscess,cyst,or hematoma of floor of mouth; masticator space Biopsy of tongue; anterior two-thirds Biopsy of tongue; posterior one-third Biopsy of floor of mouth Excision of lesion of tongue w/o closure Excision of lesion of tongue w/ closure; anterior twothirds Excision of lesion of tongue w/ closure; posterior one-third Excision of lesion of tongue w/ closure; w/ local tongue flap Excision of lingual frenum (frenectomy) Excision, lesion of floor of mouth Drainage of abscess, cyst, hematoma from dentoalveolar structures Removal of embedded foreign body from dentoalveolar structures; soft tissues Removal of embedded foreign body from dentoalveolar structures; bone Gingivectomy, excision gingiva Operculectomy, excision pericoronal tissues Excision of fibrous tuberosities, dentoalveolar structures Excision of osseous tuberosities, dentoalveolar structures Excision of lesion or or tumor (except listed above), dentoalveolar structures Excision of hyperplastic alveolar mucosa Drainage of abscess of palate, uvula

Case Rate

Professional Health Care Fee Institution Fee

3,976

1,176

2,800

41007

3,976

1,176

2,800

41008

3,976

1,176

2,800

41009

3,976

1,176

2,800

41015

3,976

1,176

2,800

41016

3,976

1,176

2,800

41017

3,976

1,176

2,800

41018 41100 41105 41108 41110 41112 41113 41114 41115 41116 41800 41805 41806 41820 41821 41822 41823 41825 41828 42000

3,976 3,892 3,892 3,892 6,510 6,510 6,510 6,510 6,510 6,510 3,976 2,548 2,548 5,614 5,614 5,614 5,614 5,614 5,614 5,614

1,176 882 882 882 1,470 1,470 1,470 1,470 1,470 1,470 1,176 588 588 1,764 1,764 1,764 1,764 1,764 1,764 1,764

2,800 3,010 3,010 3,010 5,040 5,040 5,040 5,040 5,040 5,040 2,800 1,960 1,960 3,850 3,850 3,850 3,850 3,850 3,850 3,850

Page 13 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
42100 42104 42106 42107 42300 42310 42320 42325 42326 42330 42400 42405 42408 42409 42800 42802 42804 42806 42808 42809 42860 42870 42955 43750 43760 44500 45300 45305 46083 46600 46604 46606 46608 46610

DESCRIPTION
Biopsy of palate, uvula Excision, lesion of palate , uvula; w/o closure Excision, lesion of palate , uvula; w/ simple primary closure Excision, lesion of palate , uvula; w/ local flap closure Drainage of abscess; parotid Drainage of abscess; submaxillary or sublingual, intraoral Drainage of abscess; submaxillary, external Fistulization of sublingual salivary cyst (ranula); Fistulization of sublingual salivary cyst (ranula); w/ prosthesis Sialolithotomy; submandibular (submaxillary), sublingual or parotid, intraoral Biopsy of salivary gland; needle Biopsy of salivary gland; incisional Excision of sublingual salivary cyst (ranula) Marsupialization of sublingual salivary cyst (ranula) Biopsy; oropharynx Biopsy; hypopharynx Biopsy; nasopharynx, visible lesion, simple Biopsy; nasopharynx, survey for unknown primary lesion Excision or destruction of lesion of pharynx, any method Removal of foreign body from pharynx Excision of tonsil tags Excision or destruction lingual tonsil, any method Pharyngostomy (fistulization of pharynx, external for feeding) Percutaneous placement of gastrostomy tube Change of gastrostomy tube Introduction of long gastrointestinal tube (e.g., Miller-Abbott) Proctosigmoidoscopy, rigid; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Proctosigmoidoscopy, rigid; w/ biopsy, single or multiple Incision of thrombosed hemorrhoid, external Anoscopy; diagnostic, w/ or w/o collection of specimen(s) by brushing or washing Anoscopy; w/ dilation, any method Anoscopy; w/ biopsy, single or multiple Anoscopy; w/ removal of foreign body Anoscopy; w/ removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery

Case Rate
3,892 3,976 6,510 6,510 3,976 3,976 3,976 3,976 6,510 6,510 3,892 3,892 6,510 6,510 5,614 5,614 5,614 5,614 5,614 5,614 5,614 5,614 5,614 5,614 3,892 5,614 5,614 5,614 5,614 3,976 3,976 3,976 3,976 5,614

Professional Health Care Fee Institution Fee

882 1,176 1,470 1,470 1,176 1,176 1,176 1,176 1,470 1,470 882 882 1,470 1,470 1,764 1,764 1,764 1,764 1,764 1,764 1,764 1,764 1,764 1,764 882 1,764 1,764 1,764 1,764 1,176 1,176 1,176 1,176 1,764 3,010 2,800 5,040 5,040 2,800 2,800 2,800 2,800 5,040 5,040 3,010 3,010 5,040 5,040 3,850 3,850 3,850 3,850 3,850 3,850 3,850 3,850 3,850 3,850 3,010 3,850 3,850 3,850 3,850 2,800 2,800 2,800 2,800 3,850

Page 14 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
46614 47000 47525 49080

DESCRIPTION
Anoscopy; w/ control of bleeding, any method Biopsy of liver, needle; percutaneous Change of percutaneous biliary drainage catheter Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic) Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing Renal biopsy; percutaneous, by trocar or needle Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous Aspiration of bladder; by trocar or intracatheter w/ insertion of suprapubic catheter Injection procedure for cystography or voiding urethrocystography Bladder instillation of anticarcinogenic agent local anesthesia Cystourethroscopy, w/ calibration and/or dilation of urethral stricture or stenosis, w/ or w/o meatotomy and injection procedure for cystography, male or female Cystourethroscopy, w/ steroid injection into stricture Urethrotomy or urethrostomy, external ; pendulous urethra Meatotomy, cutting of meatus ; except infant Drainage of deep periurethral abscess Drainage of Skenes gland abscess or cyst Drainage of perineal urinary extravasation Biopsy of urethra Marsupialization of urethral diverticulum, male or female Excision or fulguration; urethral polyp(s), distal urethra Excision or fulguration; urethral caruncle Skenes glands Skenes glands urethral prolapse Closure of urethrostomy or urethrocutaneous fistula, male Dilation of urethral stricture by passage of sound or urethral dilator, male Dilation of urethral stricture or vesical neck, male, general or conduction (spinal) anesthesia Dilation of female urethra, general or conduction (spinal) anesthesia Incision and drainage of penis

Case Rate
5,614 5,614 5,614 5,614

Professional Health Care Fee Institution Fee

1,764 1,764 1,764 1,764 3,850 3,850 3,850 3,850

49320 50200 50390 51010 51600 51720 52265 52281

3,976 5,614 3,976 3,976 5,614 5,614 5,614 5,614

1,176 1,764 1,176 1,176 1,764 1,764 1,764 1,764

2,800 3,850 2,800 2,800 3,850 3,850 3,850 3,850

52283 53000 53020 53040 53060 53080 53200 53240 53260 53265 53270 53275 53520 53600 53605 53665 54015

5,614 3,976 3,892 6,510 3,892 5,614 3,892 6,510 3,892 3,892 3,892 6,510 5,614 3,976 3,976 3,976 2,548

1,764 1,176 882 1,470 882 1,764 882 1,470 882 882 882 1,470 1,764 1,176 1,176 1,176 588

3,850 2,800 3,010 5,040 3,010 3,850 3,010 5,040 3,010 3,010 3,010 5,040 3,850 2,800 2,800 2,800 1,960

Page 15 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
54050 54100 54110 54150 54152 54160 54161 54200 54205 54220 54500 54505 54510 54620 54700 54800 54820 54830 54840 54860 55000 55100 55101 55110 55120 55150 55175 55200 55250 55700 55720 56405 56420 56441 56501

DESCRIPTION
Destruction of lesion(s), penis (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), any method Biopsy of penis Excision of penile plaque (Peyronie disease); Circumcision, using clamp or other device; newborn Circumcision, using clamp or other device; except newborn Circumcision, surgical excision other than clamp, device or dorsal slit; newborn Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn Injection procedure for Peyronie disease; Injection procedure for Peyronie disease;w/ surgical exposure of plaque Irrigation of corpora cavernosa for priapism Biopsy of testis, needle Biopsy of testis, incisional Excision of local lesion of testis Fixation of contralateral testis Incision and drainage of epididymis, testis and/or scrotal space (e.g., abscess or hematoma) Biopsy of epididymis, needle Exploration of epididymis, w/ or w/o biopsy Excision of local lesion of epidydimis Excision of spermatocele, w/ or w/o epididymectomy Epididymectomy; unilateral Puncture aspiration of hydrocele, tunica vaginalis, w/ or w/o injection of medication Drainage of scrotal wall abscess Drainage and debridement of Fourniers gangrene of the scrotum Scrotal exploration Removal of foreign body in scrotum Resection of scrotum Scrotoplasty Vasotomy, cannulization w/ or w/o incision of vas, unilateral or bilateral Vasectomy, unilateral or bilateral Biopsy, prostate; needle or punch, single or multiple, any approach Prostatotomy, external drainage of prostatic abscess, any approach Incision and drainage of vulva or perineal abscess Incision and drainage of Bartholins gland abscess Lysis of labial adhesions Destruction of lesion(s), vulva; any method

Case Rate

Professional Health Care Fee Institution Fee

2,548 2,453 6,510 1,260 1,260 1,260 1,260 3,892 3,976 5,614 2,453 3,976 3,976 6,510 2,876 2,453 6,510 3,976 5,614 6,510 2,453 2,453 6,510 6,510 2,876 3,892 3,976 3,976 4,000 6,510 3,976 3,892 6,510 6,510 6,510

588 353 1,470 840 840 840 840 882 1,176 1,764 353 1,176 1,176 1,470 706 353 1,470 1,176 1,764 1,470 353 353 1,470 1,470 706 882 1,176 1,176 1,000 1,470 1,176 882 1,470 1,470 1,470

1,960 2,100 5,040 420 420 420 420 3,010 2,800 3,850 2,100 2,800 2,800 5,040 2,170 2,100 5,040 2,800 3,850 5,040 2,100 2,100 5,040 5,040 2,170 3,010 2,800 2,800 3,000 5,040 2,800 3,010 5,040 5,040 5,040

Page 16 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
56605 56720 57020 57061 57100 57130 57200 57452 57500 57510 58300 58565

DESCRIPTION
Biopsy of vulva or perineum ; one lesion Hymenotomy, simple incision Colpocentesis Destruction of vaginal lesion(s) Biopsy of vaginal mucosa Excision of vaginal septum Colporrhaphy, suture of injury of vagina (nonobsterical) Colposcopy (Vaginoscopy) Biopsy, single or multiple, or local excision of lesion, w/ or w/o fulguration Cauterization of cervix; any method Insertion of intrauterine device (IUD) Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants Routine Obstetric care including prenatal, delivery and newborn services of non-hospital facilities (Maternity Care Package), 1st claim Undelivered cases (baby delivered in referral facility) in non-hospital facilities Incision and drainage of thyroglossal cyst, infected Subdural tap through fontanelle, or suture, infant, unilateral or bilateral Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir Spinal puncture, lumbar, diagnostic Spinal puncture , therapeutic, for drainage of spinal fluid (by needle or catheter) Percutaneous implantation of neurostimulator electrodes; epidural Excision of neuroma; cutaneous nerve, surgically identifiable Excision of neuroma; digital nerve, one or both, same digit Excision of neuroma; hand or foot, except digital nerve Excision of neuroma; major peripheral nerve, except sciatic Excision of neurofibroma or neurolemmoma; cutaneous nerve Excision of neurofibroma or neurolemmoma; major peripheral nerve Biopsy of nerve Suture of digital nerve, hand or foot; each additional digital nerve Suture of each additional nerve, hand or foot Suture of each additional major peripheral nerve

Case Rate
6,510 6,510 3,976 3,976 3,976 6,510 5,614 5,614 3,976 3,976 2,000 3,976

Professional Health Care Fee Institution Fee

1,470 1,470 1,176 1,176 1,176 1,470 1,764 1,764 1,176 1,176 800 1,176 5,040 5,040 2,800 2,800 2,800 5,040 3,850 3,850 2,800 2,800 1,200 2,800

59401 59403 60000 61000 61020 62270 62272 63650 64774 64776 64782 64784 64788 64790 64795 64832 64837 64859

8,000 650 2,453 3,976 3,976 3,976 3,892 5,614 5,614 5,614 5,614 5,614 5,614 5,614 5,614 5,614 5,614 5,614

2,600 0 353 1,176 1,176 1,176 882 1,764 1,764 1,764 1,764 1,764 1,764 1,764 1,764 1,764 1,764 1,764

3,900 650 2,100 2,800 2,800 2,800 3,010 3,850 3,850 3,850 3,850 3,850 3,850 3,850 3,850 3,850 3,850 3,850

Page 17 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
64901 64902 65205 65210 65222 65270 65273 65410 65450 65805 65930 67700 67710 67715 67800 67810 67825 67830 67835 67840 67875 67880 67882 67914 67915 67921 67922 68100 68110 68115 68130 68400 68420 68440

DESCRIPTION
Nerve graft, each additional nerve; single strand Nerve graft, each additional nerve; multiple strands (cable) Removal of foreign body, external eye; conjunctival, superficial Removal of foreign body, external eye; subconjunctival or scleral, with slit lamp Removal of foreign body, external eye; cornea, with slit lamp Repair of laceration; conjunctiva, w/ or w/o nonperforating laceration sclera, direct closure Repair of laceration; conjunctiva, by mobilization and rearrangement Biopsy of cornea Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization Paracentesis of anterior chamber of eye; w/ therapeutic release of aqueous Removal of blood clot, anterior segment eye Blepharotomy, drainage of abscess, eyelid Severing of tarsorrhaphy Canthotomy Excision of chalazion Biopsy of eyelid Repair of trichiasis; by electroepilation, electrosurgery, cryotherapy or laser surgery Repair of trichiasis; incision of lid margin Repair of trichiasis; incision of lid margin, with free mucous membrane graft Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure Temporary closure of eyelids suture (e.g., frost suture) Construction of intermargin adhesions, median tarsorrhaphy, or canthorrhaphy; Construction of intermargin adhesions, median tarsorrhaphy, or canthorrhaphy; with transportation of tarsal plate Repair of ectropion; suture Repair of ectropion; thermocauterization Repair of entropion; suture Repair of entropion; thermocauterization Biopsy of conjunctiva Excision of lesion, conjunctiva; up to 1 cm Excision of lesion, conjunctiva; over 1 cm Excision of lesion, conjunctiva; with adjacent sclera Incision, drainage of lacrimal gland Incision, drainage of lacrimal sac (dacryocystostomy) Snip incision of lacrimal punctum

Case Rate
5,614 5,614 2,548 5,614 5,614 5,614 5,614 5,614 5,614 5,614 5,614 3,976 3,976 3,976 3,976 3,976 3,976 2,548 6,510 3,892 3,976 3,976 5,614 5,614 5,614 3,976 3,976 3,976 5,614 5,614 5,614 3,976 3,976 3,976

Professional Health Care Fee Institution Fee

1,764 1,764 588 1,764 1,764 1,764 1,764 1,764 1,764 1,764 1,764 1,176 1,176 1,176 1,176 1,176 1,176 588 1,470 882 1,176 1,176 1,764 1,764 1,764 1,176 1,176 1,176 1,764 1,764 1,764 1,176 1,176 1,176 3,850 3,850 1,960 3,850 3,850 3,850 3,850 3,850 3,850 3,850 3,850 2,800 2,800 2,800 2,800 2,800 2,800 1,960 5,040 3,010 2,800 2,800 3,850 3,850 3,850 2,800 2,800 2,800 3,850 3,850 3,850 2,800 2,800 2,800

Page 18 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
68510 68525 68530 68705 68760 68811 69000 69020 69100 69105 69200 69220 69400 69405 69420 69421 69540 70010 70390 71090

DESCRIPTION
Biopsy of lacrimal gland Biopsy of lacrimal sac Removal of foreign body or dacryolith, lacrimal passages Correction of everted punctum, cautery Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery Probing of nasolacrimal duct; requiring general anesthesia Drainage external ear, abscess or hematoma Drainage external auditory canal, abscess Biopsy external ear Biopsy external auditory canal Removal foreign body from external auditory canal; w/ general anesthesia Debridement, mastoidectomy cavity, simple (e.g., routine cleaning) Eustachian tube inflation, transnasal; w/ catheterization Eustachian tube catheterization, transtympanic Myringotomy including aspiration and/or eustachian tube inflation Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia Excision aural polyp Myelography, brain, including spinal puncture and radiological supervision and interpretation Sialography; including duct catheterization and radiological supervision and interpretation Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation Myelography, spine, including spinal puncture and radiological supervision and interpretation Cholangiography and/or pancreatography, intraoperative, radiological supervision and interpretation Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation Combined endoscopic catheterization of the biliary and pancreatic ductal system, radiological supervision and interpretation Transcervical catheterization of fallopian tube, radiological supervision and interpretation

Case Rate
3,976 3,976 3,976 2,548 5,614 5,614 2,570 2,430 3,976 3,976 6,510 5,614 4,068 3,976 3,976 5,614 5,614 5,614 5,614 5,614

Professional Health Care Fee Institution Fee

1,176 1,176 1,176 588 1,764 1,764 470 176 1,176 1,176 1,470 1,764 1,058 1,176 1,176 1,764 1,764 1,764 1,764 1,764 2,800 2,800 2,800 1,960 3,850 3,850 2,100 2,254 2,800 2,800 5,040 3,850 3,010 2,800 2,800 3,850 3,850 3,850 3,850 3,850

72240

5,614

1,764

3,850

74300

5,614

1,764

3,850

74328

5,614

1,764

3,850

74329

5,614

1,764

3,850

74330 74742

5,614 5,614

1,764 1,764

3,850 3,850

Page 19 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE DESCRIPTION
Change of percutaneous tube or drainage catheter with contrast monitoring (e.g., gastrointestinal system, genitourinary system, abscess), radiologic supervision and interpretation Radiological guidance for percutaneous drainage (abscess, cyst, fluid collection), with placement of catheter and radiological supervision and interpretation Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) Radiologic examination, abscess, fistula or sinus tract study, including catheterization of lesion and radiological supervision and interpretation Mammary ductogram or galactogram, 1 or multiple duct, injection and radiological supervision and interpretation Stereotactic localization guidance for breast biopsy or needle placement (e.g., for wire localization or for injection), one or more lesion, radiological supervision and interpretation Mammographic guidance for needle placement, breast (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation Computed tomography guidance for stereotactic localization Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation Computed tomography guidance for visceral tissue ablation Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation Magnetic resonance guidance for visceral tissue ablation Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation Ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous fistulae (includes diagnostic ultrasound evaluation, compression of lesion and imaging) Ultrasonic guidance for visceral tissue ablation

Case Rate

Professional Health Care Fee Institution Fee

75984

5,614

1,764

3,850

75989

5,614

1,764

3,850

76003

5,614

1,764

3,850

76080

5,614

1,764

3,850

76086

5,614

1,764

3,850

76095

5,614

1,764

3,850

76096

5,614

1,764

3,850

76355

5,614

1,764

3,850

76360

5,614

1,764

3,850

76362

5,614

1,764

3,850

76393

5,614

1,764

3,850

76394 76930 76932

5,614 5,614 5,614

1,764 1,764 1,764

3,850 3,850 3,850

76936

5,614

1,764

3,850

76940

5,614

1,764

3,850

Page 20 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
76942 76965 76986 77401 77401 77418

DESCRIPTION
Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation Ultrasonic guidance for interstitial radioelement application Ultrasonic guidance, intraoperative Radiation treatment delivery (Linear Accelerator) Radiation treatment delivery (Cobalt) Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC per session Infusion or instillation of radioelement solution Remote after loading high intensity brachytherapy (RAHIB); 1 or more source position or catheters per session Radiopharmaceutical (radioactive iodine) therapy Radiopharmaceutical ablation of gland for thyroid carcinoma or metastases of thyroid carcinoma Radiopharmaceutical therapy, by radiolabeled monoclonal antibody by intravenous infusion Radiopharmaceutical therapy, by intra-articular administration Radiopharmaceutical therapy, by intra-arterial particulate administration Outpatient Malaria Package Evaluation of aspirate (CT-guided biopsy) with or without preparation of smears; immediate cytologic study to determine adequacy of specimen(s), interpretation and report Pathology consultation during surgery; with frozen section(s), single block Directly Observed Treatment Short-course; intensive phase Directly Observed Treatment Short-course; maintenance phase Animal bite Hemodialysis procedure Dialysis procedure other than hemodialysis (e.g. peritoneal, hemofiltration) Chemotherapy administration Chemotherapy administration into pleural cavity, requiring and including thoracentesis Chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis Chemotherapy administration into CNS, requiring and including spinal puncture

Case Rate

Professional Health Care Fee Institution Fee

5,614 5,614 5,614 3,000 2,000 3,976

1,764 1,764 1,764 800 800 1,176

3,850 3,850 3,850 2,200 1,200 2,800

77750 77781 79000 79005 79403 79440 79445 87207 88174

3,976 3,976 2,548 5,614 5,614 5,614 5,614 600 3,976

1,176 1,176 588 1,764 1,764 1,764 1,764 0 1,176

2,800 2,800 1,960 3,850 3,850 3,850 3,850 600 2,800

88331 89221 89222 90375 90935 90945 96408 96440 96445 96450

3,976 2,500 1,500 3,000 4,000 4,000 7,280 3,892 5,614 3,892

1,176 0 0 500 500 1,680 882 1,764 882

2,800 2,500 1,500 3,000 3,500 3,500 5,600 3,010 3,850 3,010

Page 21 of 22

ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/ DISPENSARIES RVS CODE
96542

DESCRIPTION
Chemotherapy injection, subarachnoid or interventricular via subcutaneous reservoir Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (e.g., lip) by activation of photosensitive drug(s), 1 or more phototherapy exposure session Normal newborn care package Referral package

Case Rate
2,548

Professional Health Care Fee Institution Fee

588 1,960

96567

5,614

1,764

3,850

99432 P00001

1,750 0 0

500 0

1,250

Page 22 of 22