Medica Health Plans Minnesota Fee Schedule Revised 5/1/2016 NEW PATIENT EXAMS: 99201 Problem focused history and examination --straightforward $23.48 100% of CMS $29.53 99201.25 Problem focused history and examination --straightforward $23.48 100% of CMS $29.53 99202 Expanded history and examination straightforward $41.63 100% of CMS $50.55 99202.25 Expanded history and examination straightforward $41.63 100% of CMS $50.55 99203 Detailed history and examination low complexity $61.96 100% of CMS $72.84 99203.25 Detailed history and examination low complexity $61.96 100% of CMS $72.84 99204 Comprehensive history and examination moderate complexity $87.62 100% of CMS Not covered 99204.25 Comprehensive history and examination moderate complexity $87.62 100% of CMS Not covered 99205 Comprehensive history and examination high complexity $110.20 100% of CMS Not covered 99205.25 Comprehensive history and examination high complexity $110.20 100% of CMS Not covered ESTABLISHED PATIENT EXAMS: 99211 Problem focused history and examination $19.23 100% of CMS $14.19 99211.25 Problem focused history and examination $19.23 100% of CMS $14.19 99212 Problem focused history and examination - straightforward $30.73 100% of CMS $29.53 99212.25 Problem focused history and examination - straightforward $30.73 100% of CMS $29.53 99213 Expanded history and examination low complexity $41.88 100% of CMS $49.08 99213.25 Expanded history and examination low complexity $41.88 100% of CMS $49.08 99214 Detailed history and examination moderate complexity $52.77 100% of CMS Not covered 99214.25 Detailed history and examination moderate complexity $52.77 100% of CMS Not covered 99215 Comprehensive history and examination high complexity $56.00 100% of CMS Not covered 99215.25 Comprehensive history and examination high complexity $56.00 100% of CMS Not covered CHIROPRACTIC MANIPULATIVE TREATMENT: 98940 Chiropractic manipulative treatment; spinal, one to two regions $22.92 100% of CMS $15.84 98941 Spinal, three to four regions $32.38 100% of CMS $21.90 98942 Spinal, five regions $37.66 100% of CMS $28.10 98943 Extraspinal one or more regions $19.58 100% of CMS Not covered 98943.51 Extraspinal in addition to spinal $9.79 100% of CMS Not covered 1
MODALITIES: 2 97012 Traction, mechanical $13.16 100% of CMS Not covered 97022 Whirlpool therapy $11.75 100% of CMS Not covered 97024 Diathermy treatment $4.72 100% of CMS Not covered 97026 Infrared therapy $4.39 100% of CMS Not covered 97032 Electronic stimulation-manual $12.65 100% of CMS Not covered 97033 Iontophoresis $13.07 100% of CMS Not covered 97035 Ultrasound $10.79 100% of CMS Not covered G0283 Physical Medicine Trmt to One Area, Electrical Stimulation $12.64 100% of CMS Not covered PROCEDURES: 97110 Therapeutic exercise $24.96 100% of CMS Not covered 97124 Massage $19.90 100% of CMS Not covered 97140 Manual therapy $16.70 100% of CMS Not covered 97140.59 Manual therapy $16.70 100% of CMS Not covered 97530 Functional performance improvement activities $23.20 100% of CMS Not covered 97810 Acupuncture without electrical stimulation 15 minutes $24.45 100% of CMS $24.09 97811 Acupuncture without electrical stimulation Additional 15 $23.50 100% of CMS $18.20 minutes 97813 Acupuncture with electrical stimulation 15 minutes $26.14 100% of CMS $25.74 97814 Acupuncture with electrical stimulation Additional 15 minutes $26.51 100% of CMS $20.59 RADIOLOGY: 71010 Chest, frontal $31.00 100% of CMS Not covered 71020 Chest, frontal and lateral $54.53 100% of CMS Not covered 71100 Ribs, unilateral, two views $30.70 100% of CMS Not covered 71101 Ribs, unilateral, three views $36.43 100% of CMS Not covered 71110 Ribs, bilateral, three views $40.48 100% of CMS Not covered 71111 Ribs, bilateral, four views $97.01 100% of CMS Not covered 71120 Sternum, two views $54.53 100% of CMS Not covered 71130 Sternum, three views $64.28 100% of CMS Not covered 72020 Spine, single view $21.93 100% of CMS $14.81 72040 Spine, cervical, a/p and lateral (includes APOM) $31.71 100% of CMS $24.09 72050 Spine, cervical, comprehensive, a/p and lateral, four views $46.21 100% of CMS $33.06 72052 Spine, cervical, complete, a/p and lateral, seven views $57.01 100% of CMS $42.20 72070 Spine, thoracic, a/p and lateral $33.40 100% of CMS $21.22 72072 Spine, thoracic, a/p and lateral plus swimmer s view $36.43 100% of CMS Not covered
RADIOLOGY (CONT): 72074 Spine, thoracic, complete with obliques, four views $42.84 100% of CMS $28.04 72080 Spine, thoracic, thoracolumbar, a/p and lateral $34.07 100% of CMS $22.59 72081 Spine, thoracic and lumbar, including skull, cervical and sacral, $31.00 100% of CMS $31.00 one view 72082 Spine, thoracic and lumbar, including skull, cervical and sacral, $50.00 100% of CMS $38.62 two or three views 72083 Spine, thoracic and lumbar, including skull, cervical and sacral, $54.00 100% of CMS $41.93 four or five views 72084 Spine, thoracic and lumbar, including skull, cervical and sacral, $65.00 100% of CMS $50.09 minimum of six views 72100 Spine, lumbosacral, a/p and lateral $34.07 100% of CMS $25.37 72110 Spine lumbosacral, complete, oblique view $46.89 100% of CMS $34.53 72114 Spine, lumbosacral, complete, bending view $59.03 100% of CMS $46.51 72120 Spine, lumbosacral, bending only, four views $42.17 100% of CMS $32.19 72170 Pelvis, a/p only $26.31 100% of CMS $16.64 72190 Pelvis, three views $33.73 100% of CMS $25.99 72200 Sacroiliac limited $26.31 100% of CMS $18.43 72202 Sacroiliac joints, three views $31.03 100% of CMS $21.84 72220 Sacrum and coccyx $28.67 100% of CMS $18.22 73000 Clavicle, complete $25.64 100% of CMS Not covered 73010 Scapula, complete $26.31 100% of CMS Not covered 73020 Shoulder, one view $23.61 100% of CMS Not covered 73030 Shoulder, complete, two views $29.01 100% of CMS Not covered 73050 Acromioclavicular joints, bilateral $33.40 100% of CMS Not covered 73060 Humerus, two views $28.67 100% of CMS Not covered 73070 Elbow, a/p and lateral $25.30 100% of CMS Not covered 73080 Elbow, complete, three views $28.67 100% of CMS Not covered 73090 Forearm, a/p and lateral $25.64 100% of CMS Not covered 73100 Wrist, a/p and lateral $24.62 100% of CMS Not covered 73110 Wrist, complete, three views $26.65 100% of CMS Not covered 73120 Hand, two views $24.62 100% of CMS Not covered 73130 Hand, complete, three views $26.65 100% of CMS Not covered 73140 Fingers, two views $20.91 100% of CMS Not covered 73501 Hip, unilateral, with pelvis when performed, one view $23.77 100% of CMS Not covered 73502 Hip, unilateral, with pelvis when performed, two or three views $33.22 100% of CMS Not covered 73503 Hip, unilateral, with pelvis when performed, minimum of four $41.54 100% of CMS Not covered views 73521 Hips, bilateral, with pelvis when performed, two views $31.80 100% of CMS Not covered 73522 Hips, bilateral, with pelvis with performed, three or four views $39.60 100% of CMS Not covered 73523 Hips, bilateral, with pelvis when performed, minimum of five $45.54 100% of CMS Not covered views 73551 Femur, one view $22.34 100% of CMS Not Covered 73552 Femur, minimum two views $26.00 100% of CMS Not Covered 73560 Knee, two views $26.31 100% of CMS Not covered 73562 Knee, three views $29.01 100% of CMS Not covered 73564 Knee, complete, including obliques $32.38 100% of CMS Not covered 73565 Knee, both, standing, anteroposterior $25.30 100% of CMS Not covered 3
RADIOLOGY (CONT): 4 73590 Tibia and Fibula, A/P and lateral $26.31 100% of CMS Not covered 73592 Tibia and Fibula, lower extremity, infant $41.32 100% of CMS Not covered 73600 Ankle, a/p and lateral $24.62 100% of CMS Not covered 73610 Ankle, complete, three views $26.65 100% of CMS Not covered 73620 Foot, a/p and lateral $24.62 100% of CMS Not covered 73630 Foot, complete, three views $26.65 100% of CMS Not covered 73650 Calcaneus, two views $23.95 100% of CMS Not covered 73660 Toes, two views $20.91 100% of CMS Not covered 76140 Consultation on x-rays made elsewhere, written report $15.52 100% of CMS Not covered LABORATORY 80048 Basic Metabolic Panel $29.04 100% of CMS Not covered 80050 General Health Panel $33.09 100% of CMS Not covered 80053 Comprehensive Metabolic Panel $37.15 100% of CMS Not covered 80061 Lips Panel: Cholesterol, Serum, Total Lipoprotein, HD $17.22 100% of CMS Not covered 80074 Acute Hepatic Function Panel $129.68 100% of CMS Not covered 80076 Hepatic Function Panel $22.63 100% of CMS Not covered 81000 Urinalysis, Dip Stix or Tablet, Bilirubin, Glucose, HE $4.39 100% of CMS Not covered 81002 Urinalysis, by Dipstick or Tablet Reagent; w/o Micros $2.70 100% of CMS Not covered 81003 Urinalysis, By Dipstick/Tablet Reagent Bilirubin; WO $2.03 100% of CMS Not covered 81015 Microscope Exam of Urine $3.38 100% of CMS Not covered 81025 Urine Pregnancy Test, By Visual Color Comparison ME $2.70 100% of CMS Not covered 85651 Sedimentation Rate, Erythrocyte; Non-Automated $5.07 100% of CMS Not covered DME E0860 Home Traction Unit - cervical $26.16 100% of CMS Not covered E0890 Home Traction Unit - lumbar $23.76 100% of CMS Not covered L0120 Cervical collar $21.92 100% of CMS Not covered L0450 Lumbar brace $48.70 100% of CMS Not covered L0625 Lumbar support $45.67 100% of CMS Not covered L0628 Thorcolumbar lumbar support, prefab $69.56 100% of CMS Not covered L0637 Thoroocolumbar lumbar support, prefab, sagittal-coronal $572.27 100% of CMS Not covered anterior/posterior L1800 Knee brace with slats or hinges $52.12 100% of CMS Not covered L1810 Knee brace, elastic with joints $64.93 100% of CMS Not covered L1902 Ankle brace $61.89 100% of CMS Not covered L1906 Ankle support $37.87 100% of CMS Not covered L3030 Orthotics $63.26 100% of CMS Not covered L3030LT Orthotics $63.26 100% of CMS Not covered
DME L3030RT Orthotics $63.26 100% of CMS Not covered L3650 Figure 8 shoulder Orthosis $54.37 100% of CMS Not covered L3660 Figure 8 shoulder Orthosis with canvas and webbing $77.98 100% of CMS Not covered A4466 Elbow orthosis, elastic with stays, prefabricated, including $57.25 100% of CMS Not covered fitting and adjustment L3808 Wrist, hand, finger orthosis, short opponens, not attachments, $125.23 100% of CMS Not covered custom fabrication L3908 Wrist, hand orthosis, wrist extension cock-up, prefabricated, includes fitting and adjustment $29.92 100% 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