Medica Health Plans. Minnesota Fee Schedule Revised 5/1/2016 NEW PATIENT EXAMS: MN Medicaid. Medicare

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1 Medica Health Plans Minnesota Fee Schedule Revised 5/1/2016 NEW PATIENT EXAMS: Problem focused history and examination --straightforward $ % of CMS $ Problem focused history and examination --straightforward $ % of CMS $ Expanded history and examination straightforward $ % of CMS $ Expanded history and examination straightforward $ % of CMS $ Detailed history and examination low complexity $ % of CMS $ Detailed history and examination low complexity $ % of CMS $ Comprehensive history and examination moderate complexity $ % of CMS Not covered Comprehensive history and examination moderate complexity $ % of CMS Not covered Comprehensive history and examination high complexity $ % of CMS Not covered Comprehensive history and examination high complexity $ % of CMS Not covered ESTABLISHED PATIENT EXAMS: Problem focused history and examination $ % of CMS $ Problem focused history and examination $ % of CMS $ Problem focused history and examination - straightforward $ % of CMS $ Problem focused history and examination - straightforward $ % of CMS $ Expanded history and examination low complexity $ % of CMS $ Expanded history and examination low complexity $ % of CMS $ Detailed history and examination moderate complexity $ % of CMS Not covered Detailed history and examination moderate complexity $ % of CMS Not covered Comprehensive history and examination high complexity $ % of CMS Not covered Comprehensive history and examination high complexity $ % of CMS Not covered CHIROPRACTIC MANIPULATIVE TREATMENT: Chiropractic manipulative treatment; spinal, one to two regions $ % of CMS $ Spinal, three to four regions $ % of CMS $ Spinal, five regions $ % of CMS $ Extraspinal one or more regions $ % of CMS Not covered Extraspinal in addition to spinal $ % of CMS Not covered 1

2 MODALITIES: Traction, mechanical $ % of CMS Not covered Whirlpool therapy $ % of CMS Not covered Diathermy treatment $ % of CMS Not covered Infrared therapy $ % of CMS Not covered Electronic stimulation-manual $ % of CMS Not covered Iontophoresis $ % of CMS Not covered Ultrasound $ % of CMS Not covered G0283 Physical Medicine Trmt to One Area, Electrical Stimulation $ % of CMS Not covered PROCEDURES: Therapeutic exercise $ % of CMS Not covered Massage $ % of CMS Not covered Manual therapy $ % of CMS Not covered Manual therapy $ % of CMS Not covered Functional performance improvement activities $ % of CMS Not covered Acupuncture without electrical stimulation 15 minutes $ % of CMS $ Acupuncture without electrical stimulation Additional 15 $ % of CMS $18.20 minutes Acupuncture with electrical stimulation 15 minutes $ % of CMS $ Acupuncture with electrical stimulation Additional 15 minutes $ % of CMS $20.59 RADIOLOGY: Chest, frontal $ % of CMS Not covered Chest, frontal and lateral $ % of CMS Not covered Ribs, unilateral, two views $ % of CMS Not covered Ribs, unilateral, three views $ % of CMS Not covered Ribs, bilateral, three views $ % of CMS Not covered Ribs, bilateral, four views $ % of CMS Not covered Sternum, two views $ % of CMS Not covered Sternum, three views $ % of CMS Not covered Spine, single view $ % of CMS $ Spine, cervical, a/p and lateral (includes APOM) $ % of CMS $ Spine, cervical, comprehensive, a/p and lateral, four views $ % of CMS $ Spine, cervical, complete, a/p and lateral, seven views $ % of CMS $ Spine, thoracic, a/p and lateral $ % of CMS $ Spine, thoracic, a/p and lateral plus swimmer s view $ % of CMS Not covered

3 RADIOLOGY (CONT): Spine, thoracic, complete with obliques, four views $ % of CMS $ Spine, thoracic, thoracolumbar, a/p and lateral $ % of CMS $ Spine, thoracic and lumbar, including skull, cervical and sacral, $ % of CMS $31.00 one view Spine, thoracic and lumbar, including skull, cervical and sacral, $ % of CMS $38.62 two or three views Spine, thoracic and lumbar, including skull, cervical and sacral, $ % of CMS $41.93 four or five views Spine, thoracic and lumbar, including skull, cervical and sacral, $ % of CMS $50.09 minimum of six views Spine, lumbosacral, a/p and lateral $ % of CMS $ Spine lumbosacral, complete, oblique view $ % of CMS $ Spine, lumbosacral, complete, bending view $ % of CMS $ Spine, lumbosacral, bending only, four views $ % of CMS $ Pelvis, a/p only $ % of CMS $ Pelvis, three views $ % of CMS $ Sacroiliac limited $ % of CMS $ Sacroiliac joints, three views $ % of CMS $ Sacrum and coccyx $ % of CMS $ Clavicle, complete $ % of CMS Not covered Scapula, complete $ % of CMS Not covered Shoulder, one view $ % of CMS Not covered Shoulder, complete, two views $ % of CMS Not covered Acromioclavicular joints, bilateral $ % of CMS Not covered Humerus, two views $ % of CMS Not covered Elbow, a/p and lateral $ % of CMS Not covered Elbow, complete, three views $ % of CMS Not covered Forearm, a/p and lateral $ % of CMS Not covered Wrist, a/p and lateral $ % of CMS Not covered Wrist, complete, three views $ % of CMS Not covered Hand, two views $ % of CMS Not covered Hand, complete, three views $ % of CMS Not covered Fingers, two views $ % of CMS Not covered Hip, unilateral, with pelvis when performed, one view $ % of CMS Not covered Hip, unilateral, with pelvis when performed, two or three views $ % of CMS Not covered Hip, unilateral, with pelvis when performed, minimum of four $ % of CMS Not covered views Hips, bilateral, with pelvis when performed, two views $ % of CMS Not covered Hips, bilateral, with pelvis with performed, three or four views $ % of CMS Not covered Hips, bilateral, with pelvis when performed, minimum of five $ % of CMS Not covered views Femur, one view $ % of CMS Not Covered Femur, minimum two views $ % of CMS Not Covered Knee, two views $ % of CMS Not covered Knee, three views $ % of CMS Not covered Knee, complete, including obliques $ % of CMS Not covered Knee, both, standing, anteroposterior $ % of CMS Not covered 3

4 RADIOLOGY (CONT): Tibia and Fibula, A/P and lateral $ % of CMS Not covered Tibia and Fibula, lower extremity, infant $ % of CMS Not covered Ankle, a/p and lateral $ % of CMS Not covered Ankle, complete, three views $ % of CMS Not covered Foot, a/p and lateral $ % of CMS Not covered Foot, complete, three views $ % of CMS Not covered Calcaneus, two views $ % of CMS Not covered Toes, two views $ % of CMS Not covered Consultation on x-rays made elsewhere, written report $ % of CMS Not covered LABORATORY Basic Metabolic Panel $ % of CMS Not covered General Health Panel $ % of CMS Not covered Comprehensive Metabolic Panel $ % of CMS Not covered Lips Panel: Cholesterol, Serum, Total Lipoprotein, HD $ % of CMS Not covered Acute Hepatic Function Panel $ % of CMS Not covered Hepatic Function Panel $ % of CMS Not covered Urinalysis, Dip Stix or Tablet, Bilirubin, Glucose, HE $ % of CMS Not covered Urinalysis, by Dipstick or Tablet Reagent; w/o Micros $ % of CMS Not covered Urinalysis, By Dipstick/Tablet Reagent Bilirubin; WO $ % of CMS Not covered Microscope Exam of Urine $ % of CMS Not covered Urine Pregnancy Test, By Visual Color Comparison ME $ % of CMS Not covered Sedimentation Rate, Erythrocyte; Non-Automated $ % of CMS Not covered DME E0860 Home Traction Unit - cervical $ % of CMS Not covered E0890 Home Traction Unit - lumbar $ % of CMS Not covered L0120 Cervical collar $ % of CMS Not covered L0450 Lumbar brace $ % of CMS Not covered L0625 Lumbar support $ % of CMS Not covered L0628 Thorcolumbar lumbar support, prefab $ % of CMS Not covered L0637 Thoroocolumbar lumbar support, prefab, sagittal-coronal $ % of CMS Not covered anterior/posterior L1800 Knee brace with slats or hinges $ % of CMS Not covered L1810 Knee brace, elastic with joints $ % of CMS Not covered L1902 Ankle brace $ % of CMS Not covered L1906 Ankle support $ % of CMS Not covered L3030 Orthotics $ % of CMS Not covered L3030LT Orthotics $ % of CMS Not covered

5 DME L3030RT Orthotics $ % of CMS Not covered L3650 Figure 8 shoulder Orthosis $ % of CMS Not covered L3660 Figure 8 shoulder Orthosis with canvas and webbing $ % of CMS Not covered A4466 Elbow orthosis, elastic with stays, prefabricated, including $ % of CMS Not covered fitting and adjustment L3808 Wrist, hand, finger orthosis, short opponens, not attachments, $ % of CMS Not covered custom fabrication L3908 Wrist, hand orthosis, wrist extension cock-up, prefabricated, includes fitting and adjustment $ % of CMS Not covered * : In accordance with state regulation, codes listed as not covered are deemed non-covered by the State program for chiropractic services. Medica rates in the fee schedule reflect rates. For all DME items not listed above, please refer the member to a Medica approved DME vendor. A listing of approved DME vendors can be obtained by calling Medica at the phone number on the back of the member s ID card. This fee schedule is not all-inclusive as certain labs may also be covered. This fee schedule is not a guarantee of coverage, final coverage will be determined by each members benefit contract. 5