Sage Program Reimbursement Rates Code Description of Service Allowable Rates New Patient 99201 History, exam, straight forward decision-making; 10 $44.47 99202 Expanded history; exam, straightforward decision-making; 20 $74.85 99203 Detailed history, exam, straightforward decision-making; 30 $106.84 Established Patient 99211 Evaluation and management; 5 $21.88 99212 Evaluation and management, problem focused history, problem focused examination straightforward medical decision-making; 10 $43.97. 99213 Expanded history and exam straight forward decision-making; 15 $72.89 99214 Established Patient, detailed exam (25 ) $107.20 G0101 Pelvic exam with breast exam $37.93 G0463 Hospital outpatient clinic visit for assessment and management of a $113.69 patient 99385-99387 Will be reimbursed at or below the 99203 rate 99395-99397 Will be reimbursed at or below the 99213 rate Cervical Screening 88150, 88164, P3000 Conventional Screening Pap $14.65 88142, G0123 Liquid-based, thin layer prep Screening Pap $25.01 88143 Liquid-based, thin layer prep Screening Pap, manual screening and rescreening under physician supervision. $25.01 88174, G0144 Liquid-based, thin layer prep Screening Pap, screening by automated system. $26.38 88175, G0145 Liquid-based, thin layer prep Screening Pap, screening by automated system and manual rescreening. $32.71 Pap Smear/Pathology with Additional Interpretation 88141, G0124 Cytopathology, cervical / vaginal; requiring physician interpretation $32.82 P3001 Screening Pap Smear, requiring interpretation by physician $32.82 HPV Test 87624 Human Papillomavirus (HPV) Test high-risk types $43.33 87625 Human Papillomavirus (HPV) Test types 16 & 18 only $43.33 Colposcopy 57420 57421 Colposcopy of entire vagina, with cervix if present-without Biopsy (this CPT code is for vaginoscopy for patients with an ABNORMAL PAP and who have had a hysterectomy) Colposcopy of entire vagina, with cervix if present-with Biopsy(s) (this CPT code is for vaginoscopy for patients with an ABNORMAL PAP and who have had a hysterectomy) $115.47 $154.31 57452 Colposcopy - Without Cervical Biopsy $107.09
Sage Program Reimbursement Rates Code Description of Service Allowable Rates 57454 Colposcopy - With Cervical Biopsy(s) and Endocervical Curettage $149.47 57455 Colposcopy - With Cervical Biopsy(s) $140.27 57456 Colposcopy - With Endocervical Curettage $132.43 Endometrial Biopsy 58100 Endometrial Biopsy $106.94 58110 Endometrial Biopsy performed in conjunction with Colposcopy $47.17 Pathology Global TC 26 88305 Surgical Cervical Pathology, Global $69.92 $30.34 $39.58 Mammography Global TC 26 77067 Screening Mammogram w/cad Bilateral $139.69 $102.40 $37.29 77066 Diagnostic Mammogram w/cad Bilateral $172.60 $123.88 $48.72 77065 Diagnostics Mammogram w/cad Unilateral $136.16 $96.94 $39.22 Tomosynthesis/ 3d Mammogram Global TC 26 77063 Screening digital breast Tomosynthesis $55.80 $25.84 $29.95 G0279 Diagnostic digital breast, Tomosynthesis $55.80 $25.84 $29.95 Breast Ultrasound Global TC 26 76641 Ultrasound breast complete, Unilateral $109.86 $73.29 $36.58 76642 Ultrasound breast limited, Unilateral $89.87 $55.82 $34.05 Fine Needle Aspiration Allowable Rates 10021 Fine Needle Aspiration (without imaging guidance) $121.73 10022 Fine Needle Aspiration (with imaging guidance) $141.95 19000 Aspiration of Cyst $113.50 Cytology Global TC 26 88172 Evaluation of Fine Needle Aspirate $58.66 $20.88 $37.79 88173 Interpretation and Report $157.35 $74.34 $73.61 Outpatient Breast Diagnostic Procedures (special arrangements must be made with SAGE prior to offering these services) Itemized charges for each procedure code Patient Breast Diagnostic Procedures (must receive prior authorization for each procedure). Please call for instructions. * Sage rates are based on CMS rates and subject to adjustment whenever CMS does the same. TC: Technical Component 26: Professional Component Varies
Sage Program Breast Diagnostic Reimbursement Rates Code Description of Service Visit Allowable Rates 99201 History, exam, straight forward decision-making; 10 $44.47 99202 Expanded history; exam, straightforward decision-making; 20 $74.85 99203 Detailed history, exam, straightforward decision-making; 30 $106.84 99204 Comprehensive history, exam, moderate complexity decision-making; 45 $162.96 99205 Comprehensive history, exam, high complexity decision-making; 60 $204.66 99211 Evaluation and management; 5 $21.88 99212 Evaluation and management, problem focused history, problem focused examination straightforward medical decision-making; 10. $43.97 99213 Expanded history and exam straight forward decision-making; 15 $72.89 99214 Established Patient, detailed exam (25 ) $107.20 G0463 Hospital outpatient clinic visit for assessment and management of a $113.69 patient 99386-99387 Will be reimbursed at or below the 99203 rate 99396-99397 Will be reimbursed at or below the 99213 rate Diagnostic Mammography Global Tech Prof 77066 Diagnostic Mammogram w/cad Bilateral. $172.60 $123.88 $48.72 77065 Diagnostics Mammogram w/cad Unilateral. $136.16 $96.94 $39.22 Breast Ultrasound Global Tech Prof 76641 Ultrasound breast complete, Unilateral $109.86 $73.29 $36.58 76642 Ultrasound breast limited, Unilateral $89.87 $55.82 $34.05 76942 Ultrasonic guidance for needle placement, imaging supervision and interpretation $60.62 $28.15 $32.47 Breast Diagnostic Procedures PFS (11) PFS (22) OPPS(13) 10021 Fine needle aspiration without imaging guidance $121.73 $67.86 $310.80 10022 Fine needle aspiration with imaging guidance $141.95 $64.79 $572.85 19000 Puncture aspiration of cyst of breast $113.50 $42.90 $572.85 19001 Puncture aspiration of cyst of breast, each additional cyst, used with 19000 $26.66 $21.20 Bundled 19081 Breast biopsy, with placement of localization devise and imaging biopsy specimen, percutaneous; stereotactic guidance; first lesion $704.49 $166.57 $1348.03 19082 Code 19081 plus each additional lesion $584.76 $83.96 Bundled 19083 Breast biopsy, with placement of localization devise and imaging of biopsy specimen, percutaneous; ultrasound guidance; first lesion $685.63 $156.80 $1348.03 19084 Code 19083 plus each additional lesion $561.85 $78.52 Bundled 19085 Breast biopsy, with placement of localization devise and imaging of biopsy specimen, percutaneous, magnetic resonance guidance; first lesion $1029.06 $183.59 $1348.03 19086 Code 19085 plus each additional lesion $836.51 $92.22 Bundled 19100 Breast biopsy, percutaneous, needle core, not using imaging guidance $148.77 $66.15 $1348.03 19101 Breast biopsy, open, incisional $335.93 $213.27 $2727.84 19120 Breast biopsy, open, incisional $480.12 $397.86 $2727.84 19125 Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion $530.40 $440.14 $2727.84 19126 Code 19125 plus each additional lesion separately identified by a preoperative radiological marker $152.24 $152.24 Bundled
Sage Program Breast Diagnostic Reimbursement Rates Code Description of Service 19281 Placement of breast localization device, percutaneous; mammographic guidance; first lesion $243.44 $100.77 $572.85 19282 Code 19281 plus each additional lesion $169.94 $50.57 Bundled 19283 Placement of breast localization device, percutaneous; stereotactic $275.13 $100.80 guidance; first lesion $572.85 19284 Code 19283 plus each additional lesion $207.95 $50.72 Bundled 19285 Placement of breast localization device, percutaneous; ultrasound $531.34 $86.22 guidance; first lesion $572.85 19286 Code 19285 plus each additional lesion $466.64 $42.99 Bundled 19287 Placement of breast localization device, percutaneous; magnetic $882.58 $128.46 resonance guidance; first lesion $572.85 19288 Code 19287 plus each additional lesion $715.28 $64.89 Bundled Anesthesia Formula 00400 Anesthesia for procedures on the integumentary system, anterior trunk, not otherwise specified. Base (B): 3 units [B+(Times/15min)] *$21.33* X% Cytology & Pathology Global Tech Prof 88172 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s) $58.66 $20.88 $37.79 88173 Cytopathology, evaluation of fine needle aspirate; interpretation and report $157.35 $73.61 $74.34 88305 Surgical pathology, gross and microscopic examination $69.92 $30.34 $39.58 88307 Surgical pathology, gross and microscopic examination; requiring microscopic evaluation of surgical margins $270.82 $183.69 $87.13 88360 Morphometric analysis, tumor immunohistochemistry, per specimen; manual $136.84 $90.39 $46.45 88361 Morphometric analysis, tumor immunohistochemistry, per specimen; using computer-assisted technology $148.80 $99.49 $49.31 Supplies Rate Various Pre-operative testing; complete blood count, urinalysis, pregnancy test, or other procedures medically necessary for the planned surgical procedure. Please call for instructions and or prior authorization for each procedures. Anesthesia (x) percentages by Modifier: AA Anesthesia personally provided by a physician 100% QZ Anesthesia personally provided by CRNA 100% AD Anesthesia supervised by a physician 100% QY Medical direction of Anesthesia services by a physician 50% QK Medical direction of multiple Anesthesia services by a physician 50% QX Anesthesia services provided by a CRNA under medical direction by a physician 50% * Sage rates are based on CMS rates and subject to adjustment whenever CMS does the same Tech (TC): Technical Component Prof (26): Professional Component
Sage Scopes Program Reimbursement Rates Code Description of Service Rates Visits PFS (11) PFS (22) OPPS (13) ASC 99201 History, exam, straight forward decision-making; 10 $44.47 $26.27 Bundled $26.27 99202 Expanded history; exam, straightforward decision-making; 20 $74.85 $49.74 Bundled $49.74 99203 Detailed history, exam, straightforward decision-making; 30 $106.84 $74.81 Bundled $74.81 99211 Evaluation and management; 5 $21.88 $9.14 Bundled $9.14 99212 Evaluation and management, problem-focused history; 10. $43.97 $25.05 Bundled $25.05 99213 Expanded history and exam straight forward decision-making; 15 $72.89 $50.68 Bundled $50.68 G0463 Hospital outpatient clinic visit for assessment and management of a patient $113.69 99386-99387 Will be reimbursed at or below the 99203 rate 99396-99397 Will be reimbursed at or below the 99213 rate Moderate Sedation Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that G0500 sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient s level of consciousness and $59.90 $5.31 Bundled Bundled physiological status; initial 15 of intra-service time; patient age 5 years or older 99152 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic services $52.32 $12.28 Bundled Bundled that the sedation supports; initial 15 + 99153 each additional 15 listed separately, in addition to the primary code $11.05 $11.05 Bundled Bundled 99156 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the $73.97 $73.97 Bundled Bundled sedation supports; initial 15 of intraservice time, patient age 5 years or older. + 99157 each additional 15 listed separately, in addition to the primary code $56.53 $56.53 Bundled Bundled Prep Kit PFS OPPS ASC 99070 Supplies and materials provided by the physician $28.99 $28.99 $28.99 Colorectal Cancer Screening and Diagnostics Procedures G0121 Screening colonoscopy on average risk individual $315.78 $709.98 $463.42 45378 Colonoscopy, flexible; diagnostic including collection of specimens(s) by brushing or washing, when performed. $315.78 $709.98 $463.42 45380 Colonoscopy, flexible; with biopsy, single or multiple. $407.49 $936.39 $463.42 45381 Colonoscopy, flexible; with directed submucosal injection(s) any substance. $389.29 $936.39 $463.42 45382 Colonoscopy, flexible; with control of bleeding, any method. $732.46 $936.39 $463.42 45384 Colonoscopy, flexible; with removal of tumors, polyps(s) or other lesions(s) by hot biopsy forceps. $450.57 $936.39 $463.42 45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique $425.09 $936.39 $463.42 45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (included preand post-dilation and guide wire passage when performed) $271.30 $936.39 $463.42 45390 Colonoscopy, flexible, with endoscopic mucosal resection. $335.50 $936.39 $463.42 G0105 Will be reimbursed at or below the G0121 rate. Fecal test 82270 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening $4.38 $4.38 $4.38 82274 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations (Fecal Immunochemical Test) $19.64 $19.64 $19.64 Pathology Global Tech. Prof. 88300 Surgical Pathology, gross examination only (surgical specimen) $17.47 $12.14 $4.46 88302 Surgical Pathology, gross and microscopic examination (review level II) $31.50 $24.15 $7.35
Sage Scopes Program Reimbursement Rates 88304 Surgical pathology, gross and microscopic examination (review level III) $41.65 $29.61 $12.04 88305 Surgical pathology, gross and microscopic examination, colon, colorectal polyp biopsy (review level IV) $69.92 $30.24 $39.58 88307 Surgical Pathology, gross and microscopic examination (review level III) $270.82 $183.69 $87.13 88309 Surgical pathology, gross and microscopic examination, colon, segmental resection for tumor or total resection (review level VI) $540.96 $256.25 $154.65 88342 Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure $111.80 $74.74 $37.06 88341 Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) $95.22 $65.51 $29.71 Anesthesiology Formula 00811 Anesthesia for lower intestinal endoscopy procedures, endoscope introduced distal to duodenum; not otherwise specified. Base (B): 4 units 00812 Anesthesia for lower intestinal endoscopy procedures, endoscope introduced distal to duodenum; screening colonoscopy. Base (B): 3 units [B+(Times/15min)] *$21.33* X% 00840 Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified. Base (B): 6 units Electrocardiogram Rate 93000 Routine ECG with at least 12 leads; with interpretation and report $16.92 93005 Routine ECG with at least 12 leads; tracing only, without interpretation and report $8.50 93010 Routine ECG with at least 12 leads; tracing only interpretation and report $8.42 93040 Rhythm ECG, one to three leads; with interpretation and report $12.56 93041 Rhythm ECG, one to three leads; tracing only without interpretation and report $55.96 93042 Rhythm ECG, one to leads; interpretation and report only $6.98 Lab Work 80048 Basic metabolic panel (calcium, total). This panel must include the following: calcium, total (82310), carbon dioxide (82374), creatinine (82565), glucose (82947), potassium (84132) $10.44 and sodium (84295) 80053 Comprehensive metabolic panel. This panel must include the following: albumin (82040), bilirubin total (82247), calcium (82310), carbon dioxide bicarbonate (82374), chloride (82435), creatinine (82565), glucose (82947), phosphatase alkaline (84075), potassium $13.04 (84132), total protein (84155), sodium (84295), transferase alanine amino (84460), transferase aspartate amino (84450), and urea nitrogen (84520) 85025 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count $9.59 85027 Blood count, complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) $7.98 85610 Prothrombin time $4.85 85730 Thromboplastin time, partial (PTT); plasma, or whole blood $7.42 Anesthesia (x) percentages by Modifier: AA Anesthesia personally provided by a physician 100% QZ Anesthesia personally provided by CRNA 100% AD Anesthesia supervised by a physician 100% QY Medical direction of Anesthesia services by a physician 50% QK Medical direction of multiple Anesthesia services by a physician 50% QX Anesthesia services provided by a CRNA under medical direction by a physician 50% * Sage Scopes rates are based on CMS rates and subject to adjustment whenever CMS does the same