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KENTUCKY PART B 2016 Enrollment Package (Includes Fee Schedule) © 2016 Copyright, CGS Administrators, LLC. MEDICARE PARTICIPATING PROVIDER PROGRAM

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Page 1: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

KENTUCKY PART B

2016 Enrollment Package(Includes Fee Schedule)

© 2016 Copyright, CGS Administrators, LLC.

MEDICARE

PARTICIPATING

PROVIDER PROGRAM

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We wish to emphasize the importance and advantages of being a Medicare participating (PAR) provider, and we are pleased that the favorable trend of participation continued into 2015 with a participation rate of 96.9 percent. As you plan for 2016 and become familiar with the coming changes, we hope that you will continue to be a PAR provider or, if you are non-participating (Non-PAR), will consider becoming a PAR provider.

It is in the interest of patients and providers to build a health care delivery system that’s better, smarter and healthier – a system that delivers better care; a system that spends health care dollars more wisely; and a system that makes our communities healthier. Next year will be the first time since 1999 that physicians will no longer have to worry about the flawed Sustainable Growth Rate (SGR) formula and potentially devastating cuts in physician payment. Bipartisan legislation passed by Congress repealing the SGR provides added momentum to the changes underway in Medicare payment to support physicians in improving care to Medicare beneficiaries. We look forward to working with providers in the coming year to achieve our common goals.

WHY BECOME A PARTICIPATING MEDICARE PROVIDER

All physicians, practitioners and suppliers – regardless of their Medicare participation status – must make their calendar year (CY) 2016 Medicare participation decision by December 31, 2015. Providers who want to maintain their current PAR status or Non-PAR status do not need to take any action during the upcoming annual participation enrollment period. To sign a participation agreement is to agree to accept assignment for all covered services that you provide to Medicare patients in CY 2016. The overwhelming majority of physicians, practitioners and suppliers have chosen to participate in Medicare. During CY 2015, 96.9 percent of all physicians and practitioners are billing under Medicare participation agreements.

If you participate and bill for services paid under the Medicare physician fee schedule (MPFS), your Medicare fee schedule amounts are 5 percent higher than if you do not participate. Your Medicare Administrative Contractor (MAC) publishes an electronic directory of providers that choose to participate.

WHAT TO DO

If you choose to be a PAR physician in CY 2016:

• Do nothing if you are currently participating, or

• If you are not currently a Medicare participant, complete the available blank agreement (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS460.pdf) and mail it (or a copy) to each MAC to which you submit Part B claims. (On the form show the name(s) and identification number(s) under which you bill.)

If you decide not to participate in CY 2016:

• Do nothing if you are currently not participating, or

• If you are currently a participant, write to each MAC to which you submit claims, advising of the termination of your participation in the participating physician program effective January 1, 2016. This written notice must be postmarked prior to January 1, 2016.

We hope you will decide to be a Medicare participant in CY 2016. Please call 1.866.276.9558 if you have any questions or need further information on participation.

ANNOUNCEMENTAbout Medicare Participation for Calendar Year 2016

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2016

The Medicare Learning Network® (MLN) has developed publications in an effort to educate Medicare providers about important Medicare enrollment information. These MLN publications also provide education to Medicare providers on how to use the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) to enroll in the Medicare Program and maintain their enrollment information. A list of publications is available at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/Medicare_Provider-Supplier_Enrollment_National_Education_Products.pdf.

To view updates and the latest information about Medicare, please visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. For CGS Administrators, LLC, you may contact the following toll-free number(s) for assistance: 1.866.276.9558.

New Payment and Care Delivery Model Tests at the CMS Innovation Center:

Physicians can directly participate in health care transformation through the efforts of the CMS Innovation Center which is charged with identifying, testing, and evaluating innovative payment and service delivery models that show promise of providing better access to quality care at lower costs for beneficiaries of Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). The Innovation Center offers opportunities for innovators working in the field to share ideas, contribute to the discussion of improvements in health care, and participate in model tests.

More than 60,000 providers in all 50 states, the District of Columbia, and Puerto Rico are currently participating in over 25 Innovation Center payment and service delivery model tests, serving an estimated 2.5 million beneficiaries of Medicare, Medicaid, and CHIP. Participants include states, organizations, and a broad array of health care professionals, as well as other stakeholders in the health care community. Millions of other Americans are benefiting from Innovation Center quality improvement initiatives and the engagement of other payers in model tests.

The broad engagement of providers across the country in alternative payment and service delivery models is leading to improvement. Medicare per capita spending growth rates have reached historic lows, and hospital readmission rates have declined meaningfully. All alternative payment models and payment reforms that seek to deliver better care at lower cost share a common pathway for success. Providers, payers, and others in the health care system must make fundamental changes in their day-to-day operations that improve quality and reduce the cost of health care.

This work is aligning with the goals the Department of Health and Human Services (HHS) set in January of 2015 of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as physician value-based payment modifier (VM).

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was enacted into law in April 2015 and further facilitates the Department’s goals of paying for value. MACRA replaces the SGR with new payment policies for physicians that support delivery system reform and streamline the programs Medicare uses to reward eligible professionals for improving care. This is a major opportunity to put a broad range of physicians and other practitioners on the pathway to value and to promote the adoption of alternative payment models.

We encourage providers to join the Health Care Payment Learning and Action Network (https://innovation.cms.gov/initiatives/Health-Care-Payment-Learning-and- Action-Network/) that brings together private payers, providers, employers, state partners, consumer groups, individual consumers, and many others to accelerate the transition to alternative payment models. If you would like to join the Network, please complete the online form (http://innovationgov.force.com/hcplan).

We also encourage you to visit the CMS Innovation Center website — at http://innovation.cms.gov—for further information and for announcements of new opportunities including large scale

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2016

transformation of clinical practices to accomplish our aims of better care and better health at lower costs.

Medicare Shared Savings Program:

Currently, over 125,000 physicians participate in ACOs in the Medicare Shared Savings Program (Shared Savings Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers serve, it may share in the savings it achieves for the Medicare program. In performance year 2014, we shared more than $341 million in savings with 86 ACOs.

When a Shared Savings Program ACO successfully reports required quality measures through the Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) Web interface, Eligible professionals (EPs), (i.e. physicians and other practitioners) in the ACO will be deemed eligible to avoid the PQRS payment adjustment, regardless of whether the ACO qualifies to share in savings. In addition, EPs participating in the Shared Savings Program will have their Clinical Quality Measure (CQM) reporting requirements satisfied for the Medicare Electronic Health Record (EHR) Incentive Program if they extract the data necessary for the ACO to satisfy the quality reporting requirements for the Shared Savings Program from certified EHR technology and the EPs meet all other requirements of the Medicare EHR Incentive Program.

We encourage you to consider joining or forming an ACO under the Shared Savings Program. We also encourage physicians and other practitioners to collaborate with ACOs in your area so that together they can achieve the goals of the Shared Savings Program including successful reporting and performance on quality measures.

Please visit the Shared Savings Program Web page for more information about the program including how to apply, join or learn about ACOs in your area - http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/.

Engaging Physicians in Quality:

CMS recognizes the time and resources spent by providers and their practices to meet the requirements of various federal and state mandated quality reporting programs. As the largest payer of healthcare services in the United States, we continuously seek ways to improve healthcare quality while reducing the burden felt by providers. Several efforts have been made to meet this goal, and the needs of providers, including (as a continuation from CY 2015):

• Providers can choose quality measures that best reflect their practice and how they are reported to CMS.

• Many providers may be able to report their 2016 performance on quality measures one time during 2016 in order to avoid the 2018 PQRS negative payment adjustment, satisfy the CQM component of the Medicare EHR Incentive Program, avoid the automatic 2018 downward adjustment under the Value Modifier, and based on performance earn an incentive in 2018. Please note that this option applies to specific reporting options. Please read program requirements for more information; website URLs for each program are listed below;

• Providers and others can contribute new quality measures through open calls for measures and advocate for measures through the Measures Application Partnership (MAP). For More information about the MAP, please visit: http://www.qualityforum.org/Setting_Priorities/Partnership/Measure_Applications_Partnership.aspx.

New for CY 2016:

• For the qualified clinical data registry (QCDR) reporting mechanism, which was introduced in 2014, we increased the minimum number of non-PQRS measures that a QCDR may report for PQRS to 30 measures beginning with CY 2015 reporting. By increasing the minimum number of non-PQRS measure accepted, EPs are provided with more flexibility to meet satisfactory participation requirements and another avenue to submit measures that are meaningful to their specific specialty.

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2016

• Knowledge levels (i.e. Beginner, Intermediate, and Advanced) were established to assist providers with reporting by providing educational resources that range from basic program awareness to reporting via an aligned reporting mechanism to meet the requirements of several quality programs. Prominent icons are used on educational materials displaying these knowledge levels.

• In addition to the traditional channels used, CMS began the use of new forums to receive stakeholder feedback including: hosting virtual office hours, which are smaller virtual sessions in which stakeholders can talk directly with CMS subject matter experts, and hosting in-person vendor summits, in which vendors who support EPs in quality reporting attended and provided insight from their perspective and areas of improvement for CMS.

• The development of the Physician Quality Reporting Programs Strategic Vision, which is a document that describes how CMS will build on its current successes in quality measurement and public reporting to advance the goals and objectives for quality improvement outlined in the CMS Quality Strategy (available here: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/Physician_Quality_Reporting_Programs_Strategic_Vision_Document.pdf)

As noted above, MACRA repeals the SGR formula for Medicare physician payments. It also establishes a new Merit-based Incentive Payment System (MIPS) for MIPS eligible professionals (MIPS EPs) under the MPFS beginning January 1, 2019. Section 101 of the MACRA sunsets payment adjustments under the current PQRS, the VM, and the EHR Incentive Programs on December 31, 2018.

Availability of the 2014 Mid-Year, Annual, and Supplemental Quality and Resource Use Reports (QRURs):

In April 2015, CMS made available the 2014 Mid-Year QRURs to all groups of physicians and physician solo practitioners nationwide, as identified by their Taxpayer Identification Number (TIN). The Mid-Year QRURs provide interim information to TINs about their performance on the three claims-based quality outcome measures and six cost measures. These measures are a subset of the measures that will be used to calculate performance under the Value Modifier and can provide physician groups and physicians insight into their potential performance under the Value Modifier. We encourage you to look at your 2015 Mid-Year QRUR when it is available in April 2016.

In September 2015, CMS made available the 2014 Annual QRURs to all groups and solo practitioners nationwide. These QRURs are also available for groups and solo practitioners that participated in the Shared Savings Program, the Pioneer ACO Model, or the Comprehensive Primary Care initiative in 2014. The 2014 Annual QRURs show how groups and solo practitioners, as identified by their TIN, performed in 2014 on the quality and cost measures used to calculate the 2016 Value Modifier. For TINs with 10 or more EPs who are subject to the 2016 Value Modifier, the QRUR shows how the Value Modifier will apply to physician payments under the MPFS for physicians who bill under the TIN in 2016. For all other TINs, the QRUR is for informational purposes only and will not affect the TINs’ payments under the Medicare MPFS in 2016.

In September 2015, CMS made available the Supplemental QRURs. These QRURs are confidential feedback reports provided to group practices with payment-standardized, risk-adjusted cost information on the management of their Medicare fee-for-service (FFS) patients based on episodes of care. The Supplemental QRURs are currently for informational purposes only and complement the per capita cost and quality information provided in the QRURs.

The Mid-Year, Annual, and Supplemental QRURs are available at https://portal.cms.gov and can be accessed by an authorized representative of the TIN using an Enterprise Identity Management (EIDM) account. Please see the How to Obtain a QRUR (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html) website for instructions on how to set up an EIDM account and access your TIN’s QRURs. Detailed information about the QRURs is available on the 2014 QRUR (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2014-QRUR.html) website.

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2016

Medicare and Medicaid EHR Incentive Programs:

In 2015, EPs will use EHR technology certified to the 2014 Edition to meet the objectives and measures of meaningful use as modified in a recent final rule1, which includes alternate exclusions for EPs scheduled to be in Stage 1. EPs will have a 90-day EHR reporting period within CY 2015 and attest between January 4 through February 29, 2016. For more information about the EHR Incentive Programs, including the 2015 definition of meaningful use, visit http://www.cms.gov/EHRIncentivePrograms.

In order to align programs and reduce the burden on physicians and other eligible professionals, physicians may submit CQM data for both the Medicare EHR Incentive Program and the PQRS program electronically.

Physicians who fail to demonstrate meaningful use for the applicable EHR reporting period may be subject to a payment adjustment to their Medicare claims. In 2016, the result will be payment of 98% of the MPFS amount. Physicians must successfully demonstrate meaningful use every year to avoid the Medicare payment adjustments. Successful demonstration of meaningful use for an EHR reporting period in 2015 will enable physicians to avoid the payment adjustment in 2017. Physicians also have the option of filing a significant hardship exception application by July 1, 2016. Don’t wait until the last minute to meet meaningful use or file a hardship exception!

Payment Adjustments for Quality Reporting:

EPs should note that there is still time to report quality measures for 2015, which will also serve as the reporting period for the 2017 PQRS payment adjustment. The deadline is December 31, 2015. The payment adjustment for 2017, based on 2015 reporting, is negative 2.0%. The reporting requirements to avoid the 2017 PQRS payment adjustment can be found at 42 C.F.R. § 414.90, and guidance materials are available on the PQRS Web page of the CMS website.

Likewise, 2016 will also serve as the reporting period for the 2018 PQRS payment adjustment, which remains at negative 2%.

The reporting requirements to avoid the 2018 PQRS payment adjustment are detailed in the CY 2016 MPFS Final Rule. More information will be available on the PQRS Web page soon.

Please use the links below for more detailed information about CMS quality reporting programs.

PQRS Web page: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

Medicare EHR Incentive Program: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/

VM: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html

Information Related to Medicare Prescription Drug (Part D) Coverage:

Prescriber Enrollment in Medicare

Beginning June 1, 2016 physicians and EPs who write prescriptions for Part D drugs are required to be enrolled in Medicare in an approved status or have a valid record of opting out of Medicare for their prescriptions to be covered under Part D. Any physicians and EPs not in compliance with these requirements should submit their paper Medicare enrollment applications or opt-out affidavits to their Part A/B MACs or complete their Internet-based PECOS applications by January 1, 2016, or earlier, to ensure sufficient processing time. Medicare prescription drug benefit plans will validate whether the prescriber is enrolled or has opted out of Medicare as part of determining whether the drug is coverable under Part D when the beneficiary’s prescription is filled at the pharmacy. Providers may enroll by completing their Internet-based PECOS application or may enroll or opt out of Medicare by submitting to their MAC one of the following documents:

1 Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 3 and Modifications to Meaningful Use in 2015 Through 2017; Final Rule, 80 Fed. Reg. 62,762 (Oct. 16, 2015).

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2016

• A CMS-855O application (allows the physician to enroll in Medicare to order and certify services and items, and to prescribe Part D drugs; however, this option does not confer billing privileges): or

• An opt out affidavit.

If you are unsure if you are compliant with this requirement, please review the prescriber enrollment file located at https://data.cms.gov/dataset/Medicare-Individual-Provider-List/u8u9-2upx. The file identifies those providers who are currently in compliance with the prescriber enrollment requirements.

As part of the enrollment process, provider credentials and eligibility are verified. Requiring Medicare prescription drug benefit plans to validate a provider’s Medicare enrollment status improves CMS’s ability to protect the Part D program from fraud and abuse. To avoid the denial of coverage of Part D prescriptions due to your failure to enroll or opt-out, please note the following information:

• Be sure to maintain an active enrollment or opt out status with Medicare;

• If you haven’t enrolled, please do so and encourage your colleagues who are not enrolled in Medicare to enroll by January 1, 2016. The options available for enrolling or opting out are identified above. Please visit the prescriber enrollment website to obtain additional information at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Prescriber-Enrollment-Information.html.

• Interns, residents, and fellows who are prescribers of Part D drugs may enroll in Medicare to prescribe if the state licenses these prescribers. Licensure can include a provisional license or similarly- regulated credential. Otherwise, un-licensed interns, residents, and fellows must specify the teaching physician as the authorized prescriber on the prescription. Licensed residents have the option to either enroll or use the teaching physician on claims.

• Pharmacists need not enroll or opt out for their prescriptions to be covered under Part D. More information is available by visiting https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Prescriber-Enrollment-Information.html.

NPPES Taxonomy

Please check your data in the National Plan and Provider Enumeration System (NPPES) and confirm that it still correctly reflects you as a health care provider. There is increased focus on the National Provider Identifier (NPI) as a health care provider identifier for program integrity purposes. Incorrect taxonomy data in NPPES may lead to unnecessary inquiries about your credentials as it may appear to Medicare oversight authorities that you may not be lawfully prescribing Part D drugs. Comprehensive information about how the NPI rule pertains to prescribers may be obtained at: http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/Downloads/NPI-Requirements-for-Prescribers.pdf.

Prescription Drug Abuse

Prescription drug abuse is the nation’s fastest growing drug problem. Additional prescriber awareness and engagement are crucial to addressing this problem. CMS has implemented an approach to help Medicare prescription drug plans identify and manage the most egregious cases of opioid overutilization, which often involves multiple prescribers and pharmacies who are not aware of each other. If you are contacted by a prescription drug plan about the opioid use of one of your patients, please take the time to provide your feedback and expertise to help assure the safe use of these products.

Prescriber Identifiers in Research

You should be aware that CMS now allows researchers to request the release of unencrypted prescriber identifiers contained in Medicare Part D data. This change in policy now gives researchers the ability to conduct important research that involves identified prescribers, which will increase the positive contributions researchers make to the evaluation and function of the

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2016

Part D program. This access supports CMS’s growing role as a value-based purchaser of health care, and is only granted pursuant to CMS’s policies and procedures for release of such data to researchers.

Serving Qualified Medicare Beneficiaries (QMBs):

Many Medicare beneficiaries with limited incomes and resources are also covered by their state’s Qualified Medicare Beneficiary (QMB) program. This means that the state Medicaid agency is responsible for these beneficiaries’ Medicare cost sharing. We encourage all Medicare physicians and other practitioners to serve individuals eligible for the QMB program.

We also remind all Medicare physicians and other practitioners that they may not balance bill their QMB patients for Medicare cost sharing, including deductibles, coinsurance, and copayments. Under federal law, Medicare payment plus any Medicaid payment are considered payment in full for services rendered to a beneficiary participating in the QMB program. Physicians and other practitioners may want to refresh their understanding of how their state handles QMB cost sharing claims. In most states, claims submitted to Medicare are crossed over automatically to the state Medicaid agency. States may require providers to register with their State payment system in order to receive cost sharing payments. Providers can also query their state’s Medicaid eligibility verification system to identify QMBs. More information on billing procedures for QMBs is available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1128.pdf.

We understand that the intersection between Medicare and Medicaid is complex. If you have any questions about serving QMBs, please contact [email protected].

Revalidation:

CMS has met the requirements established in section 6401(a) of the Affordable Care Act (ACA) and has mailed revalidation letters to all 1.6 million providers and suppliers by the March 23, 2015 deadline. CMS is resuming regular revalidation cycles every 3 years for Durable Medical Equipment (DME) suppliers and every 5 years for all other providers and suppliers.

When undergoing a revalidation, providers will receive requests from their respective MACs to revalidate their Medicare enrollment information. Providers can revalidate their enrollment information using the Internet-based PECOS found at https://pecos.cms.hhs.gov/pecos/login.do or the CMS-855 paper application found at http://www.cms.gov/CMSForms/CMSForms/list.asp. CMS encourages all practitioners to respond timely to revalidation requests received by their MAC. Failure to submit a complete revalidation application, including all supporting documents, may result in deactivation of your Medicare billing privileges.

Please refer to the MLN Matters Special Edition Article on this subject at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1126.pdf.

The Medicare Learning Network:

Medicare Learning Network® (MLN) educational resources provide health care professionals comprehensive, easy-to-understand information on CMS program and policy changes, regulations, and initiatives.

Publications & Multimedia

• MLN Publications come in a variety of formats on topics such as provider enrollment, preventive services, claims processing, compliance, and payment policies.

- http://go.cms.gov/MLNProducts

• MLN Matters® Articles are prepared in consultation with clinicians, billing experts, and CMS subject matter experts; they are tailored to specific provider types affected by complex program changes.

- http://go.cms.gov/MLNMattersArticles

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2016

• Videos & Podcasts offer additional educational options in multimedia formats.

- http://go.cms.gov/mlnmultimedia

- http://go.cms.gov/MLNplaylist

Training & Events

• MLN Connects® National Provider Calls & Events cover new policies and changes to the Medicare program, and typically include Question & Answer sessions for participants.

- http://www.cms.gov/npc

• Web-Based Trainings are self-paced online courses on a broad range of Medicare and other health care-related topics.

- http://go.cms.gov/MLNTraining

Newsletter & Mailing Lists

• MLN Connects Provider eNews is a weekly newsletter for health care professionals containing CMS program and policy news, announcements, upcoming events, claim, pricer, and code information, and MLN updates.

- http://go.cms.gov/enews

• Educational Products Mailing List subscribers are e-mailed when new and revised MLN Publications are released.

- http://go.cms.gov/mlnproductslist

• MLN Matters Mailing List subscribers are e-mailed when new and revised MLN Matters Articles are released.

- http://go.cms.gov/mlnmatterslist

Continuing Education (CE) Credit

CMS is an accredited provider of IACET continuing education units (CEUs) and ACCME continuing medical education (CME) offering AMA PRA Category 1 Credits™. In addition, many professional associations offer continuing education credit for the completion of training activities designed for health care professionals including physicians, nurses, billers, coders, and other clinicians. You can find a broad range of courses that focus on staying abreast of Medicare updates, meeting professional development goals, and state license renewal requirements.

Please visit https://www.cms.gov/Outreach-and-Education/Learn/Earn-Credit/Earn-credit-page.html for more information about earning CE credit for CMS training.

For more information about MLN products and services, visit http://go.cms.gov/MLNGenInfo.

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 10Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

ANES 21.28 20.22 23.25 22.79 22.79 22.33 G0101 35.64 33.86 38.94 38.16 38.16 37.40 # G0101 26.59 25.26 29.05 28.46 28.46 27.90 G0102 17.92 17.02 19.57 19.18 19.18 18.80 # G0102 8.56 8.13 9.35 9.17 9.17 8.98 G0104 151.51 143.93 165.52 162.21 162.21 158.96 # G0104 54.41 51.69 59.44 58.26 58.26 57.10 G0105 350.04 332.54 382.42 374.77 374.77 367.28 # G0105 188.01 178.61 205.40 201.30 201.30 197.27 G0105 53 174.41 165.69 190.54 186.74 186.74 183.00 # G0105 53 94.49 89.77 103.24 101.17 101.17 99.14 G0106 190.76 181.22 208.40 204.24 204.24 200.16 G0106 TC 142.34 135.22 155.50 152.40 152.40 149.35 G0106 26 48.42 46.00 52.90 51.84 51.84 50.81 G0108 50.51 47.98 55.18 54.07 54.07 52.99 G0109 13.61 12.93 14.87 14.57 14.57 14.28 G0117 49.78 47.29 54.38 53.29 53.29 52.22 G0118 39.78 37.79 43.46 42.58 42.58 41.73 G0120 192.19 182.58 209.97 205.77 205.77 201.65 G0120 TC 142.34 135.22 155.50 152.40 152.40 149.35 G0120 26 49.84 47.35 54.45 53.36 53.36 52.29 G0121 350.33 332.81 382.73 375.07 375.07 367.57 # G0121 188.29 178.88 205.71 201.60 201.60 197.56 G0121 53 174.72 165.98 190.88 187.06 187.06 183.32 # G0121 53 94.17 89.46 102.88 100.82 100.82 98.81 G0124 30.59 29.06 33.42 32.75 32.75 32.10 G0127 21.05 20.00 23.00 22.54 22.54 22.09 # G0127 7.62 7.24 8.33 8.17 8.17 8.00 G0128 6.84 6.50 7.48 7.33 7.33 7.18 G0130 30.93 29.38 33.79 33.11 33.11 32.44 G0130 TC 19.95 18.95 21.79 21.36 21.36 20.93 G0130 26 10.97 10.42 11.98 11.74 11.74 11.51 G0141 30.59 29.06 33.42 32.75 32.75 32.10 G0166 121.66 115.58 132.92 130.26 130.26 127.65 G0168 92.44 87.82 100.99 98.97 98.97 96.99 # G0168 26.87 25.53 29.36 28.77 28.77 28.20 G0179 38.20 36.29 41.73 40.89 40.89 40.08 G0180 50.08 47.58 54.72 53.62 53.62 52.56 G0181 102.51 97.38 111.99 109.74 109.74 107.55 G0182 102.85 97.71 112.37 110.12 110.12 107.92 G0202 120.77 114.73 131.94 129.31 129.31 126.72 G0202 TC 86.77 82.43 94.79 92.90 92.90 91.03 G0202 26 34.01 32.31 37.16 36.41 36.41 35.68 G0204 147.75 140.36 161.41 158.18 158.18 155.02 G0204 TC 105.19 99.93 114.92 112.62 112.62 110.37 G0204 26 42.56 40.43 46.49 45.56 45.56 44.65 G0206 116.09 110.29 126.83 124.29 124.29 121.81 G0206 TC 82.08 77.98 89.68 87.88 87.88 86.12 G0206 26 34.01 32.31 37.16 36.41 36.41 35.68

Page 11: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 11Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

G0237 8.71 8.27 9.51 9.32 9.32 9.13 G0238 9.34 8.87 10.20 9.99 9.99 9.80 G0239 11.52 10.94 12.58 12.33 12.33 12.09 G0245 61.94 58.84 67.67 66.31 66.31 64.99 # G0245 41.96 39.86 45.84 44.92 44.92 44.02 G0246 35.70 33.92 39.01 38.23 38.23 37.47 # G0246 21.02 19.97 22.97 22.51 22.51 22.06 G0247 66.21 62.90 72.34 70.89 70.89 69.47 # G0247 22.81 21.67 24.92 24.43 24.43 23.94 G0248 97.98 93.08 107.04 104.90 104.90 102.81 G0249 98.01 93.11 107.08 104.94 104.94 102.84 G0250 8.91 8.46 9.73 9.53 9.53 9.34 G0268 50.00 47.50 54.63 53.53 53.53 52.46 # G0268 32.83 31.19 35.87 35.16 35.16 34.45 G0270 28.55 27.12 31.19 30.57 30.57 29.96 # G0270 26.36 25.04 28.80 28.22 28.22 27.66 G0271 15.17 14.41 16.57 16.24 16.24 15.92 # G0271 14.54 13.81 15.88 15.56 15.56 15.25 G0276 385.76 366.47 421.44 413.01 413.01 404.75 G0277 39.31 37.34 42.94 42.08 42.08 41.24 G0278 13.47 12.80 14.72 14.42 14.42 14.13 G0279 51.37 48.80 56.12 54.99 54.99 53.89 G0279 TC 22.17 21.06 24.22 23.74 23.74 23.26 G0279 26 29.21 27.75 31.91 31.28 31.28 30.66 G0281 12.97 12.32 14.17 13.88 13.88 13.60 G0283 12.97 12.32 14.17 13.88 13.88 13.60 G0288 31.91 30.31 34.86 34.16 34.16 33.48 G0289 84.63 80.40 92.46 90.61 90.61 88.79 G0296 27.28 25.92 29.81 29.21 29.21 28.62 # G0296 25.72 24.43 28.09 27.53 27.53 26.98 G0297 226.86 215.52 247.85 242.89 242.89 238.04 G0297 TC 177.31 168.44 193.71 189.83 189.83 186.04 G0297 26 49.55 47.07 54.13 53.05 53.05 51.99 G0329 8.68 8.25 9.49 9.30 9.30 9.12 G0339 3,240.51 3,078.48 3,540.25 3,469.45 3,469.45 3,400.06 G0340 2,381.11 2,262.05 2,601.36 2,549.33 2,549.33 2,498.34 G0341 2,070.96 1,967.41 2,262.52 2,217.27 2,217.27 2,172.93 # G0341 369.09 350.64 403.24 395.17 395.17 387.27 G0342 679.87 645.88 742.76 727.90 727.90 713.35 G0343 1,195.66 1,135.88 1,306.26 1,280.13 1,280.13 1,254.54 G0364 11.63 11.05 12.71 12.45 12.45 12.20 # G0364 8.51 8.08 9.29 9.11 9.11 8.92 C G0365 145.56 138.28 159.02 155.84 155.84 152.72 C G0365 TC 133.57 126.89 145.92 143.00 143.00 140.14 G0365 26 11.99 11.39 13.10 12.83 12.83 12.58 G0372 8.56 8.13 9.35 9.17 9.17 8.98 G0389 104.61 99.38 114.29 112.00 112.00 109.76 G0389 TC 76.15 72.34 83.19 81.52 81.52 79.89 G0389 26 28.46 27.04 31.10 30.48 30.48 29.87

Page 12: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 12Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

G0396 34.40 32.68 37.58 36.83 36.83 36.10 # G0396 32.53 30.90 35.54 34.82 34.82 34.12 G0397 68.49 65.07 74.83 73.34 73.34 71.86 # G0397 66.31 62.99 72.44 70.99 70.99 69.58 G0398 173.39 164.72 189.43 185.64 185.64 181.93 G0398 TC 115.60 109.82 126.29 123.76 123.76 121.29 G0398 26 57.80 54.91 63.15 61.88 61.88 60.64 G0399 167.75 159.36 183.26 179.60 179.60 176.01 G0399 TC 111.83 106.24 122.18 119.74 119.74 117.35 G0399 26 55.92 53.12 61.09 59.87 59.87 58.67 G0400 162.10 154.00 177.10 173.56 173.56 170.09 G0400 TC 108.08 102.68 118.08 115.72 115.72 113.41 G0400 26 54.03 51.33 59.03 57.85 57.85 56.68 G0402 156.84 149.00 171.35 167.92 167.92 164.57 # G0402 122.50 116.38 133.84 131.16 131.16 128.54 G0403 15.71 14.92 17.16 16.81 16.81 16.48 G0404 7.47 7.10 8.17 8.00 8.00 7.84 G0405 8.24 7.83 9.00 8.82 8.82 8.65 G0406 37.69 35.81 41.18 40.35 40.35 39.55 G0407 68.93 65.48 75.30 73.80 73.80 72.32 G0408 99.12 94.16 108.28 106.12 106.12 103.99 G0409 10.59 10.06 11.57 11.34 11.34 11.11 G0412 686.59 652.26 750.10 735.09 735.09 720.39 G0413 1,024.57 973.34 1,119.34 1,096.95 1,096.95 1,075.01 G0414 932.83 886.19 1,019.12 998.74 998.74 978.77 G0415 1,318.49 1,252.57 1,440.46 1,411.65 1,411.65 1,383.42 G0416 479.74 455.75 524.11 513.64 513.64 503.37 G0416 TC 328.05 311.65 358.40 351.23 351.23 344.21 G0416 26 151.68 144.10 165.72 162.40 162.40 159.16 G0420 105.49 100.22 115.25 112.95 112.95 110.70 G0421 24.38 23.16 26.63 26.11 26.11 25.59 G0422 97.13 92.27 106.11 103.98 103.98 101.90 G0423 97.13 92.27 106.11 103.98 103.98 101.90 G0424 27.45 26.08 29.99 29.39 29.39 28.81 # G0424 13.40 12.73 14.64 14.35 14.35 14.06 G0425 95.86 91.07 104.73 102.64 102.64 100.59 G0426 130.47 123.95 142.54 139.69 139.69 136.90 G0427 194.03 184.33 211.98 207.74 207.74 203.58 G0429 92.12 87.51 100.64 98.62 98.62 96.65 # G0429 68.39 64.97 74.72 73.22 73.22 71.76 G0436 13.85 13.16 15.13 14.84 14.84 14.54 # G0436 11.97 11.37 13.08 12.81 12.81 12.56 G0437 26.56 25.23 29.01 28.44 28.44 27.88 # G0437 25.00 23.75 27.31 26.77 26.77 26.23 G0438 161.21 153.15 176.12 172.60 172.60 169.15 G0439 108.69 103.26 118.75 116.37 116.37 114.05 G0442 16.72 15.88 18.26 17.89 17.89 17.54 # G0442 9.23 8.77 10.09 9.88 9.88 9.68 G0443 24.77 23.53 27.06 26.52 26.52 25.99

Page 13: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 13Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# G0443 22.90 21.76 25.02 24.52 24.52 24.02 G0444 16.72 15.88 18.26 17.89 17.89 17.54 # G0444 8.91 8.46 9.73 9.53 9.53 9.34 G0445 25.71 24.42 28.08 27.52 27.52 26.97 # G0445 22.90 21.76 25.02 24.52 24.52 24.02 G0446 24.77 23.53 27.06 26.52 26.52 25.99 # G0446 22.90 21.76 25.02 24.52 24.52 24.02 G0447 24.77 23.53 27.06 26.52 26.52 25.99 # G0447 22.90 21.76 25.02 24.52 24.52 24.02 G0451 7.78 7.39 8.50 8.33 8.33 8.17 G0452 26 17.90 17.01 19.56 19.17 19.17 18.79 G0453 31.65 30.07 34.58 33.89 33.89 33.21 G0454 8.91 8.46 9.73 9.53 9.53 9.34 G0455 119.32 113.35 130.35 127.74 127.74 125.19 # G0455 71.24 67.68 77.83 76.28 76.28 74.75 G0459 40.46 38.44 44.21 43.32 43.32 42.46 G0460 165.28 157.02 180.57 176.96 176.96 173.42 G0473 11.95 11.35 13.05 12.79 12.79 12.54 # G0473 11.33 10.76 12.37 12.12 12.12 11.88 G6001 48.16 45.75 52.61 51.57 51.57 50.53 G6001 TC 19.33 18.36 21.11 20.69 20.69 20.27 G6001 26 28.83 27.39 31.50 30.87 30.87 30.25 G6002 67.89 64.50 74.18 72.69 72.69 71.24 G6002 TC 48.37 45.95 52.84 51.78 51.78 50.75 G6002 26 19.53 18.55 21.33 20.91 20.91 20.49 G6003 164.20 155.99 179.39 175.80 175.80 172.28 G6004 127.04 120.69 138.79 136.02 136.02 133.30 G6005 126.73 120.39 138.45 135.68 135.68 132.96 G6006 126.42 120.10 138.12 135.36 135.36 132.65 G6007 264.11 250.90 288.54 282.76 282.76 277.10 G6008 175.75 166.96 192.00 188.16 188.16 184.40 G6009 173.88 165.19 189.97 186.17 186.17 182.45 G6010 173.56 164.88 189.61 185.82 185.82 182.10 G6011 282.21 268.10 308.32 302.15 302.15 296.11 G6012 231.63 220.05 253.06 248.00 248.00 243.04 G6013 231.95 220.35 253.40 248.33 248.33 243.36 G6014 231.95 220.35 253.40 248.33 248.33 243.36 G6015 302.74 287.60 330.74 324.13 324.13 317.64 G6016 301.88 286.79 329.81 323.21 323.21 316.74 G9157 95.47 90.70 104.31 102.22 102.22 100.18 G9187 40.08 38.08 43.79 42.92 42.92 42.06 G9481 18.61 17.68 20.33 19.93 19.93 19.53 G9482 35.58 33.80 38.87 38.09 38.09 37.33 G9483 55.11 52.35 60.20 59.00 59.00 57.81 G9484 93.27 88.61 101.90 99.87 99.87 97.87 G9485 121.75 115.66 133.01 130.35 130.35 127.74 G9486 18.32 17.40 20.01 19.61 19.61 19.22 G9487 36.72 34.88 40.11 39.31 39.31 38.53 G9488 56.55 53.72 61.78 60.55 60.55 59.34

Page 14: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 14Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

G9489 79.82 75.83 87.20 85.46 85.46 83.74 G9490 40.08 38.08 43.79 42.92 42.92 42.06 G9685 194.85 185.11 212.88 208.62 208.62 204.45 G9686 75.60 71.82 82.59 80.94 80.94 79.32 P3001 30.59 29.06 33.42 32.75 32.75 32.10 Q0035 19.14 18.18 20.91 20.49 20.49 20.08 Q0035 TC 10.59 10.06 11.57 11.34 11.34 11.11 Q0035 26 8.56 8.13 9.35 9.17 9.17 8.98 Q0091 41.24 39.18 45.06 44.16 44.16 43.27 # Q0091 19.07 18.12 20.84 20.42 20.42 20.01 Q0092 22.14 21.03 24.18 23.70 23.70 23.23 R0070 116.38 110.56 127.14 124.60 124.60 122.11 R0075 116.38 110.56 127.14 124.60 124.60 122.11 0100T 2,782.02 2,642.92 3,039.36 2,978.57 2,978.57 2,919.00 0171T 731.90 695.31 799.61 783.61 783.61 767.94 0172T 134.81 128.07 147.28 144.34 144.34 141.45 0191T 865.16 821.90 945.19 926.28 926.28 907.75 0249T 377.90 359.01 412.86 404.60 404.60 396.51 0281T 1,357.78 1,289.89 1,483.37 1,453.70 1,453.70 1,424.63 0295T 85.98 81.68 93.93 92.06 92.06 90.22 0296T 24.51 23.28 26.77 26.23 26.23 25.70 0297T 34.52 32.79 37.71 36.95 36.95 36.21 0298T 26.93 25.58 29.42 28.83 28.83 28.26 0308T 803.27 763.11 877.58 860.03 860.03 842.82 0387T 722.17 686.06 788.97 773.19 773.19 757.72 0389T 47.79 45.40 52.21 51.16 51.16 50.14 0395T 1,776.38 1,687.56 1,940.69 1,901.88 1,901.88 1,863.84 10021 114.31 108.59 124.88 122.38 122.38 119.93 # 10021 67.79 64.40 74.06 72.58 72.58 71.13 10022 130.35 123.83 142.40 139.55 139.55 136.76 # 10022 64.16 60.95 70.09 68.69 68.69 67.32 10030 703.06 667.91 768.10 752.73 752.73 737.68 # 10030 163.87 155.68 179.03 175.46 175.46 171.95 10035 481.26 457.20 525.78 515.27 515.27 504.97 # 10035 85.38 81.11 93.28 91.41 91.41 89.59 10036 415.77 394.98 454.23 445.14 445.14 436.24 # 10036 42.99 40.84 46.97 46.02 46.02 45.10 10040 94.99 90.24 103.78 101.71 101.71 99.67 # 10040 83.44 79.27 91.16 89.33 89.33 87.55 10060 108.89 103.45 118.97 116.59 116.59 114.25 # 10060 91.40 86.83 99.85 97.85 97.85 95.90 10061 193.05 183.40 210.91 206.69 206.69 202.56 # 10061 170.25 161.74 186.00 182.29 182.29 178.64 10080 163.70 155.52 178.85 175.27 175.27 171.76 # 10080 96.57 91.74 105.50 103.40 103.40 101.33 10081 248.09 235.69 271.04 265.63 265.63 260.31 # 10081 161.92 153.82 176.89 173.35 173.35 169.89 10120 139.46 132.49 152.36 149.32 149.32 146.33 # 10120 97.31 92.44 106.31 104.18 104.18 102.10

Page 15: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 15Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

10121 254.04 241.34 277.54 271.99 271.99 266.55 # 10121 177.24 168.38 193.64 189.76 189.76 185.97 10140 150.93 143.38 164.89 161.59 161.59 158.36 # 10140 112.22 106.61 122.60 120.15 120.15 117.75 10160 120.49 114.47 131.64 129.01 129.01 126.43 # 10160 90.83 86.29 99.23 97.24 97.24 95.30 10180 228.02 216.62 249.11 244.13 244.13 239.25 # 10180 169.33 160.86 184.99 181.29 181.29 177.66 11000 50.69 48.16 55.38 54.28 54.28 53.20 # 11000 28.21 26.80 30.82 30.20 30.20 29.59 11001 20.34 19.32 22.22 21.77 21.77 21.33 # 11001 14.09 13.39 15.40 15.09 15.09 14.79 11004 567.17 538.81 619.63 607.23 607.23 595.09 11005 764.80 726.56 835.54 818.83 818.83 802.46 11006 688.13 653.72 751.78 736.75 736.75 722.02 11008 268.89 255.45 293.77 287.89 287.89 282.13 11010 453.89 431.20 495.88 485.97 485.97 476.25 # 11010 268.13 254.72 292.93 287.07 287.07 281.34 11011 494.81 470.07 540.58 529.77 529.77 519.18 # 11011 289.07 274.62 315.81 309.50 309.50 303.31 11012 662.02 628.92 723.26 708.79 708.79 694.61 # 11012 411.93 391.33 450.03 441.03 441.03 432.20 11042 107.33 101.96 117.25 114.91 114.91 112.61 # 11042 59.56 56.58 65.07 63.77 63.77 62.49 11043 213.90 203.21 233.69 229.02 229.02 224.45 # 11043 150.83 143.29 164.78 161.48 161.48 158.25 11044 296.71 281.87 324.15 317.66 317.66 311.32 # 11044 224.90 213.66 245.71 240.80 240.80 235.98 11045 38.32 36.40 41.86 41.02 41.02 40.20 # 11045 25.51 24.23 27.86 27.31 27.31 26.77 11046 69.48 66.01 75.91 74.39 74.39 72.91 # 11046 54.49 51.77 59.54 58.34 58.34 57.18 11047 117.84 111.95 128.74 126.17 126.17 123.65 # 11047 96.92 92.07 105.88 103.76 103.76 101.69 11055 43.39 41.22 47.40 46.46 46.46 45.53 # 11055 15.91 15.11 17.38 17.03 17.03 16.69 11056 53.41 50.74 58.35 57.19 57.19 56.05 # 11056 22.50 21.38 24.59 24.09 24.09 23.61 11057 60.63 57.60 66.24 64.92 64.92 63.62 # 11057 29.41 27.94 32.13 31.49 31.49 30.85 11100 94.58 89.85 103.33 101.26 101.26 99.23 # 11100 47.12 44.76 51.47 50.44 50.44 49.43 11101 30.75 29.21 33.59 32.92 32.92 32.27 # 11101 24.19 22.98 26.43 25.90 25.90 25.38 11200 81.20 77.14 88.71 86.94 86.94 85.20 # 11200 68.71 65.27 75.06 73.55 73.55 72.08 11201 18.08 17.18 19.76 19.37 19.37 18.98 # 11201 16.21 15.40 17.71 17.35 17.35 17.01 11300 88.08 83.68 96.23 94.31 94.31 92.43

Page 16: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 16Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 11300 34.06 32.36 37.21 36.47 36.47 35.74 11301 109.32 103.85 119.43 117.04 117.04 114.69 # 11301 51.87 49.28 56.67 55.53 55.53 54.42 11302 128.66 122.23 140.56 137.76 137.76 135.00 # 11302 60.91 57.86 66.54 65.21 65.21 63.91 11303 142.61 135.48 155.80 152.69 152.69 149.63 # 11303 72.05 68.45 78.72 77.14 77.14 75.60 11305 90.89 86.35 99.30 97.31 97.31 95.37 # 11305 38.75 36.81 42.33 41.48 41.48 40.65 11306 111.50 105.93 121.82 119.38 119.38 116.99 # 11306 50.62 48.09 55.30 54.20 54.20 53.12 11307 131.84 125.25 144.04 141.16 141.16 138.35 # 11307 65.03 61.78 71.05 69.62 69.62 68.23 11308 139.31 132.34 152.19 149.14 149.14 146.17 # 11308 72.49 68.87 79.20 77.61 77.61 76.06 11310 103.27 98.11 112.83 110.57 110.57 108.36 # 11310 45.82 43.53 50.06 49.06 49.06 48.08 11311 102.95 97.80 112.47 110.22 110.22 108.01 # 11311 63.61 60.43 69.49 68.10 68.10 66.75 11312 146.87 139.53 160.46 157.25 157.25 154.11 # 11312 75.68 71.90 82.69 81.03 81.03 79.41 11313 170.92 162.37 186.73 182.99 182.99 179.33 # 11313 97.24 92.38 106.24 104.11 104.11 102.03 11400 113.04 107.39 123.50 121.03 121.03 118.61 # 11400 75.26 71.50 82.23 80.58 80.58 78.97 11401 136.78 129.94 149.43 146.44 146.44 143.51 # 11401 97.76 92.87 106.80 104.66 104.66 102.57 11402 152.13 144.52 166.20 162.87 162.87 159.62 # 11402 107.79 102.40 117.76 115.40 115.40 113.09 11403 177.08 168.23 193.46 189.60 189.60 185.81 # 11403 139.30 132.34 152.19 149.14 149.14 146.17 11404 201.23 191.17 219.85 215.45 215.45 211.14 # 11404 153.77 146.08 167.99 164.63 164.63 161.35 11406 292.04 277.44 319.06 312.67 312.67 306.42 # 11406 235.22 223.46 256.98 251.84 251.84 246.80 11420 112.42 106.80 122.82 120.36 120.36 117.96 # 11420 77.14 73.28 84.27 82.58 82.58 80.93 11421 144.50 137.28 157.87 154.71 154.71 151.62 # 11421 104.22 99.01 113.86 111.58 111.58 109.35 11422 161.87 153.78 176.85 173.31 173.31 169.84 # 11422 127.84 121.45 139.67 136.87 136.87 134.14 11423 187.12 177.76 204.42 200.33 200.33 196.33 # 11423 149.03 141.58 162.82 159.56 159.56 156.38 11424 216.89 206.05 236.96 232.22 232.22 227.57 # 11424 171.00 162.45 186.82 183.08 183.08 179.42 11426 312.34 296.72 341.23 334.41 334.41 327.72 # 11426 263.01 249.86 287.34 281.59 281.59 275.95 11440 123.41 117.24 134.83 132.14 132.14 129.49 # 11440 96.24 91.43 105.14 103.04 103.04 100.98

Page 17: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 17Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

11441 154.68 146.95 168.99 165.61 165.61 162.30 # 11441 123.77 117.58 135.22 132.51 132.51 129.87 11442 173.44 164.77 189.49 185.69 185.69 181.98 # 11442 137.22 130.36 149.91 146.91 146.91 143.98 11443 207.93 197.53 227.16 222.62 222.62 218.17 # 11443 169.22 160.76 184.87 181.17 181.17 177.55 11444 262.33 249.21 286.59 280.86 280.86 275.25 # 11444 216.44 205.62 236.46 231.74 231.74 227.10 11446 366.09 347.79 399.96 391.95 391.95 384.11 # 11446 311.46 295.89 340.27 333.47 333.47 326.80 11450 350.33 332.81 382.73 375.07 375.07 367.57 # 11450 238.56 226.63 260.62 255.42 255.42 250.31 11451 447.94 425.54 489.37 479.58 479.58 469.99 # 11451 308.69 293.26 337.25 330.50 330.50 323.89 11462 341.40 324.33 372.98 365.52 365.52 358.20 # 11462 227.44 216.07 248.48 243.51 243.51 238.65 11463 453.02 430.37 494.93 485.02 485.02 475.32 # 11463 309.71 294.22 338.35 331.59 331.59 324.96 11470 381.27 362.21 416.54 408.22 408.22 400.05 # 11470 267.00 253.65 291.70 285.87 285.87 280.15 11471 472.01 448.41 515.67 505.36 505.36 495.25 # 11471 332.77 316.13 363.55 356.28 356.28 349.15 11600 176.68 167.85 193.03 189.16 189.16 185.38 # 11600 113.30 107.64 123.79 121.31 121.31 118.89 11601 210.63 200.10 230.12 225.52 225.52 221.01 # 11601 141.95 134.85 155.08 151.97 151.97 148.94 11602 228.64 217.21 249.79 244.80 244.80 239.90 # 11602 155.89 148.10 170.32 166.91 166.91 163.58 11603 262.42 249.30 286.70 280.96 280.96 275.33 # 11603 187.17 177.81 204.48 200.39 200.39 196.39 11604 291.90 277.31 318.91 312.52 312.52 306.27 # 11604 206.35 196.03 225.43 220.93 220.93 216.51 11606 420.13 399.12 458.99 449.81 449.81 440.82 # 11606 308.36 292.94 336.88 330.14 330.14 323.54 11620 178.54 169.61 195.05 191.15 191.15 187.34 # 11620 114.85 109.11 125.48 122.97 122.97 120.51 11621 211.90 201.31 231.51 226.87 226.87 222.33 # 11621 143.21 136.05 156.46 153.33 153.33 150.26 11622 236.69 224.86 258.59 253.41 253.41 248.34 # 11622 163.95 155.75 179.11 175.54 175.54 172.03 11623 279.19 265.23 305.01 298.92 298.92 292.94 # 11623 203.64 193.46 222.48 218.03 218.03 213.67 11624 315.29 299.53 344.46 337.57 337.57 330.82 # 11624 230.99 219.44 252.36 247.31 247.31 242.36 11626 381.03 361.98 416.28 407.95 407.95 399.80 # 11626 283.94 269.74 310.20 304.00 304.00 297.92 11640 183.99 174.79 201.01 196.98 196.98 193.04 # 11640 118.74 112.80 129.72 127.12 127.12 124.58 11641 219.47 208.50 239.78 234.98 234.98 230.28

Page 18: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 18Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 11641 149.22 141.76 163.02 159.76 159.76 156.56 11642 251.28 238.72 274.53 269.04 269.04 263.66 # 11642 176.35 167.53 192.66 188.81 188.81 185.04 11643 297.67 282.79 325.21 318.70 318.70 312.33 # 11643 221.18 210.12 241.64 236.81 236.81 232.07 11644 367.64 349.26 401.65 393.61 393.61 385.73 # 11644 274.29 260.58 299.67 293.68 293.68 287.80 11646 483.21 459.05 527.91 517.35 517.35 507.00 # 11646 382.06 362.96 417.40 409.06 409.06 400.88 11719 12.93 12.28 14.12 13.83 13.83 13.56 # 11719 7.62 7.24 8.33 8.17 8.17 8.00 11720 29.82 28.33 32.58 31.92 31.92 31.28 # 11720 14.52 13.79 15.86 15.54 15.54 15.23 11721 42.02 39.92 45.91 44.99 44.99 44.09 # 11721 24.53 23.30 26.80 26.25 26.25 25.73 11730 92.24 87.63 100.77 98.76 98.76 96.78 # 11730 50.40 47.88 55.06 53.96 53.96 52.88 11732 33.47 31.80 36.57 35.83 35.83 35.12 # 11732 20.04 19.04 21.90 21.46 21.46 21.03 11740 45.32 43.05 49.51 48.52 48.52 47.55 # 11740 30.65 29.12 33.49 32.82 32.82 32.17 11750 166.45 158.13 181.85 178.22 178.22 174.65 # 11750 132.11 125.50 144.33 141.44 141.44 138.61 11752 302.74 287.60 330.74 324.13 324.13 317.64 # 11752 249.98 237.48 273.10 267.64 267.64 262.29 11755 123.74 117.55 135.18 132.48 132.48 129.84 # 11755 75.35 71.58 82.32 80.67 80.67 79.06 11760 178.64 169.71 195.17 191.27 191.27 187.44 # 11760 111.20 105.64 121.49 119.06 119.06 116.68 11762 260.63 247.60 284.74 279.05 279.05 273.47 # 11762 176.95 168.10 193.32 189.45 189.45 185.67 11765 153.02 145.37 167.18 163.83 163.83 160.55 # 11765 89.02 84.57 97.26 95.31 95.31 93.40 11770 256.96 244.11 280.73 275.11 275.11 269.62 # 11770 176.72 167.88 193.06 189.20 189.20 185.41 11771 533.35 506.68 582.68 571.03 571.03 559.61 # 11771 413.46 392.79 451.71 442.67 442.67 433.81 11772 646.72 614.38 706.54 692.40 692.40 678.56 # 11772 545.56 518.28 596.02 584.10 584.10 572.41 11900 51.21 48.65 55.95 54.83 54.83 53.74 # 11900 30.29 28.78 33.10 32.43 32.43 31.79 11901 65.18 61.92 71.21 69.78 69.78 68.39 # 11901 46.76 44.42 51.08 50.06 50.06 49.06 11920 156.84 149.00 171.35 167.92 167.92 164.57 # 11920 108.44 103.02 118.47 116.10 116.10 113.78 11921 183.11 173.95 200.04 196.04 196.04 192.12 # 11921 128.48 122.06 140.37 137.56 137.56 134.81 11922 56.35 53.53 61.56 60.33 60.33 59.12 # 11922 28.56 27.13 31.20 30.58 30.58 29.97

Page 19: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 19Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

11950 68.60 65.17 74.95 73.45 73.45 71.98 # 11950 49.24 46.78 53.80 52.72 52.72 51.66 11951 91.05 86.50 99.48 97.49 97.49 95.53 # 11951 69.19 65.73 75.59 74.08 74.08 72.60 11952 122.89 116.75 134.26 131.58 131.58 128.95 # 11952 93.85 89.16 102.53 100.49 100.49 98.47 11954 147.18 139.82 160.79 157.57 157.57 154.42 # 11954 110.34 104.82 120.54 118.13 118.13 115.77 11960 891.85 847.26 974.35 954.86 954.86 935.76 11970 577.41 548.54 630.82 618.21 618.21 605.84 11971 429.30 407.84 469.02 459.63 459.63 450.44 # 11971 298.48 283.56 326.09 319.57 319.57 313.18 11976 133.71 127.02 146.07 143.15 143.15 140.29 # 11976 91.56 86.98 100.03 98.03 98.03 96.07 11980 87.76 83.37 95.88 93.96 93.96 92.08 # 11980 54.98 52.23 60.06 58.87 58.87 57.70 11981 130.33 123.81 142.38 139.53 139.53 136.74 # 11981 80.06 76.06 87.47 85.72 85.72 84.01 11982 148.42 141.00 162.15 158.91 158.91 155.73 # 11982 97.22 92.36 106.21 104.09 104.09 102.01 11983 210.92 200.37 230.43 225.81 225.81 221.29 # 11983 169.71 161.22 185.40 181.70 181.70 178.07 12001 82.22 78.11 89.83 88.03 88.03 86.27 # 12001 43.20 41.04 47.20 46.25 46.25 45.33 12002 100.66 95.63 109.97 107.78 107.78 105.63 # 12002 56.95 54.10 62.22 60.97 60.97 59.75 12004 119.07 113.12 130.09 127.49 127.49 124.94 # 12004 71.30 67.74 77.90 76.35 76.35 74.82 12005 150.94 143.39 164.90 161.60 161.60 158.37 # 12005 93.18 88.52 101.80 99.76 99.76 97.77 12006 179.21 170.25 195.79 191.88 191.88 188.04 # 12006 114.27 108.56 124.84 122.35 122.35 119.90 12007 209.63 199.15 229.02 224.45 224.45 219.96 # 12007 143.75 136.56 157.04 153.90 153.90 150.82 12011 100.96 95.91 110.30 108.09 108.09 105.93 # 12011 53.82 51.13 58.80 57.63 57.63 56.48 12013 105.97 100.67 115.77 113.46 113.46 111.19 # 12013 56.95 54.10 62.22 60.97 60.97 59.75 12014 124.61 118.38 136.14 133.41 133.41 130.74 # 12014 73.40 69.73 80.19 78.59 78.59 77.02 12015 151.30 143.74 165.30 162.00 162.00 158.76 # 12015 92.29 87.68 100.83 98.82 98.82 96.84 12016 192.92 183.27 210.76 206.54 206.54 202.41 # 12016 126.10 119.80 137.77 135.01 135.01 132.31 12017 150.85 143.31 164.81 161.51 161.51 158.27 12018 171.08 162.53 186.91 183.17 183.17 179.50 12020 267.67 254.29 292.43 286.58 286.58 280.85 # 12020 185.25 175.99 202.39 198.34 198.34 194.37 12021 156.03 148.23 170.46 167.06 167.06 163.71

Page 20: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 20Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 12021 134.17 127.46 146.58 143.65 143.65 140.77 12031 217.49 206.62 237.61 232.86 232.86 228.21 # 12031 145.37 138.10 158.82 155.64 155.64 152.52 12032 278.38 264.46 304.13 298.05 298.05 292.09 # 12032 185.34 176.07 202.48 198.43 198.43 194.47 12034 287.66 273.28 314.27 307.98 307.98 301.82 # 12034 197.74 187.85 216.03 211.70 211.70 207.47 12035 352.83 335.19 385.47 377.76 377.76 370.21 # 12035 230.13 218.62 251.41 246.39 246.39 241.47 12036 390.30 370.79 426.41 417.88 417.88 409.52 # 12036 267.92 254.52 292.70 286.84 286.84 281.11 12037 443.40 421.23 484.41 474.73 474.73 465.23 # 12037 313.83 298.14 342.86 336.01 336.01 329.29 12041 217.95 207.05 238.11 233.35 233.35 228.68 # 12041 143.65 136.47 156.94 153.80 153.80 150.73 12042 267.02 253.67 291.72 285.89 285.89 280.17 # 12042 191.46 181.89 209.17 204.99 204.99 200.89 12044 330.51 313.98 361.08 353.86 353.86 346.78 # 12044 205.93 195.63 224.97 220.48 220.48 216.07 12045 372.08 353.48 406.50 398.37 398.37 390.40 # 12045 258.12 245.21 281.99 276.36 276.36 270.83 12046 440.60 418.57 481.36 471.73 471.73 462.30 # 12046 295.73 280.94 323.08 316.62 316.62 310.28 12047 479.42 455.45 523.77 513.29 513.29 503.02 # 12047 329.87 313.38 360.39 353.18 353.18 346.12 12051 237.91 226.01 259.91 254.71 254.71 249.62 # 12051 163.61 155.43 178.74 175.17 175.17 171.66 12052 272.04 258.44 297.21 291.26 291.26 285.43 # 12052 194.92 185.17 212.95 208.69 208.69 204.52 12053 318.24 302.33 347.68 340.72 340.72 333.90 # 12053 208.65 198.22 227.95 223.40 223.40 218.93 12054 333.35 316.68 364.18 356.90 356.90 349.76 # 12054 214.40 203.68 234.23 229.55 229.55 224.96 12055 432.66 411.03 472.68 463.23 463.23 453.96 # 12055 293.73 279.04 320.90 314.48 314.48 308.19 12056 505.48 480.21 552.24 541.20 541.20 530.38 # 12056 361.24 343.18 394.66 386.77 386.77 379.03 12057 523.24 497.08 571.64 560.21 560.21 549.01 # 12057 389.93 370.43 425.99 417.47 417.47 409.12 13100 308.15 292.74 336.65 329.92 329.92 323.32 # 13100 197.62 187.74 215.90 211.59 211.59 207.36 13101 364.54 346.31 398.26 390.29 390.29 382.48 # 13101 242.47 230.35 264.90 259.60 259.60 254.41 13102 112.79 107.15 123.22 120.76 120.76 118.35 # 13102 72.20 68.59 78.88 77.30 77.30 75.76 13120 322.83 306.69 352.69 345.64 345.64 338.73 # 13120 225.73 214.44 246.61 241.67 241.67 236.84 13121 394.43 374.71 430.92 422.30 422.30 413.86 # 13121 257.37 244.50 281.18 275.55 275.55 270.04

Page 21: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 21Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

13122 123.95 117.75 135.41 132.71 132.71 130.05 # 13122 83.05 78.90 90.74 88.92 88.92 87.14 13131 356.18 338.37 389.13 381.34 381.34 373.72 # 13131 240.34 228.32 262.57 257.31 257.31 252.17 13132 441.41 419.34 482.24 472.59 472.59 463.14 # 13132 303.41 288.24 331.48 324.85 324.85 318.35 13133 167.70 159.32 183.22 179.55 179.55 175.96 # 13133 127.43 121.06 139.22 136.44 136.44 133.71 13151 391.48 371.91 427.70 419.14 419.14 410.76 # 13151 276.58 262.75 302.16 296.13 296.13 290.20 13152 471.18 447.62 514.76 504.47 504.47 494.39 # 13152 335.99 319.19 367.07 359.73 359.73 352.53 13153 181.89 172.80 198.72 194.74 194.74 190.84 # 13153 137.56 130.68 150.28 147.28 147.28 144.34 13160 772.77 734.13 844.25 827.37 827.37 810.82 14000 577.50 548.63 630.92 618.31 618.31 605.95 # 14000 476.66 452.83 520.75 510.34 510.34 500.12 14001 745.54 708.26 814.50 798.20 798.20 782.24 # 14001 622.84 591.70 680.46 666.85 666.85 653.51 14020 647.11 614.75 706.96 692.83 692.83 678.97 # 14020 539.40 512.43 589.29 577.51 577.51 565.96 14021 813.00 772.35 888.20 870.44 870.44 853.02 # 14021 685.31 651.04 748.70 733.72 733.72 719.05 14040 711.77 676.18 777.61 762.06 762.06 746.82 # 14040 603.43 573.26 659.25 646.06 646.06 633.13 14041 882.13 838.02 963.72 944.45 944.45 925.55 # 14041 743.82 706.63 812.62 796.38 796.38 780.45 14060 728.18 691.77 795.54 779.62 779.62 764.03 # 14060 642.94 610.79 702.41 688.36 688.36 674.59 14061 948.21 900.80 1,035.92 1,015.20 1,015.20 994.89 # 14061 795.54 755.76 869.12 851.74 851.74 834.70 14301 1,009.46 958.99 1,102.84 1,080.78 1,080.78 1,059.16 # 14301 845.23 802.97 923.42 904.95 904.95 886.85 14302 215.12 204.36 235.01 230.31 230.31 225.70 14350 670.12 636.61 732.10 717.46 717.46 703.11 15002 323.12 306.96 353.00 345.94 345.94 339.02 # 15002 219.15 208.19 239.42 234.63 234.63 229.94 15003 70.38 66.86 76.89 75.35 75.35 73.84 # 15003 44.47 42.25 48.59 47.62 47.62 46.67 15004 375.18 356.42 409.88 401.68 401.68 393.65 # 15004 262.47 249.35 286.75 281.01 281.01 275.39 15005 117.37 111.50 128.23 125.66 125.66 123.14 # 15005 88.65 84.22 96.85 94.92 94.92 93.02 15040 235.38 223.61 257.15 252.01 252.01 246.97 # 15040 123.30 117.14 134.71 132.02 132.02 129.38 15050 522.95 496.80 571.32 559.89 559.89 548.69 # 15050 421.49 400.42 460.48 451.27 451.27 442.24 15100 803.16 763.00 877.45 859.90 859.90 842.71 # 15100 682.33 648.21 745.44 730.54 730.54 715.93

Page 22: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 22Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

15101 172.05 163.45 187.97 184.21 184.21 180.53 # 15101 107.11 101.75 117.01 114.68 114.68 112.39 15110 759.79 721.80 830.07 813.46 813.46 797.19 # 15110 669.88 636.39 731.85 717.21 717.21 702.87 15111 111.00 105.45 121.27 118.84 118.84 116.46 # 15111 101.32 96.25 110.69 108.48 108.48 106.31 15115 780.22 741.21 852.39 835.35 835.35 818.64 # 15115 689.68 655.20 753.48 738.42 738.42 723.65 15116 147.20 139.84 160.82 157.60 157.60 154.45 # 15116 134.09 127.39 146.50 143.57 143.57 140.69 15120 798.89 758.95 872.79 855.34 855.34 838.22 # 15120 669.01 635.56 730.89 716.28 716.28 701.95 15121 193.23 183.57 211.11 206.89 206.89 202.75 # 15121 127.67 121.29 139.48 136.69 136.69 133.95 15130 628.77 597.33 686.93 673.19 673.19 659.72 # 15130 536.67 509.84 586.32 574.59 574.59 563.10 15131 95.14 90.38 103.94 101.86 101.86 99.82 # 15131 87.96 83.56 96.09 94.17 94.17 92.29 15135 797.41 757.54 871.17 853.75 853.75 836.67 # 15135 707.18 671.82 772.59 757.14 757.14 741.99 15136 90.82 86.28 99.22 97.23 97.23 95.29 # 15136 85.51 81.23 93.41 91.55 91.55 89.72 15150 659.75 626.76 720.77 706.35 706.35 692.23 # 15150 607.92 577.52 664.15 650.87 650.87 637.85 15151 117.48 111.61 128.35 125.79 125.79 123.27 # 15151 109.37 103.90 119.49 117.09 117.09 114.75 15152 144.42 137.20 157.78 154.63 154.63 151.54 # 15152 135.99 129.19 148.57 145.60 145.60 142.69 15155 686.37 652.05 749.86 734.86 734.86 720.16 # 15155 639.22 607.26 698.35 684.38 684.38 670.69 15156 152.78 145.14 166.91 163.58 163.58 160.31 # 15156 145.60 138.32 159.07 155.88 155.88 152.77 15157 168.39 159.97 183.97 180.29 180.29 176.67 # 15157 158.39 150.47 173.04 169.58 169.58 166.19 15200 774.94 736.19 846.62 829.69 829.69 813.10 # 15200 640.38 608.36 699.61 685.62 685.62 671.91 15201 136.52 129.69 149.14 146.17 146.17 143.24 # 15201 76.26 72.45 83.32 81.65 81.65 80.02 15220 716.84 681.00 783.15 767.49 767.49 752.13 # 15220 585.09 555.84 639.22 626.43 626.43 613.90 15221 126.01 119.71 137.67 134.92 134.92 132.22 # 15221 69.19 65.73 75.59 74.08 74.08 72.60 15240 872.03 828.43 952.69 933.64 933.64 914.96 # 15240 762.13 724.02 832.62 815.97 815.97 799.65 15241 171.58 163.00 187.45 183.70 183.70 180.03 # 15241 108.20 102.79 118.21 115.84 115.84 113.53 15260 947.81 900.42 1,035.48 1,014.77 1,014.77 994.47 # 15260 820.11 779.10 895.97 878.05 878.05 860.49 15261 200.95 190.90 219.54 215.14 215.14 210.84

Page 23: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 23Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 15261 135.70 128.92 148.26 145.29 145.29 142.38 15271 130.87 124.33 142.98 140.12 140.12 137.31 # 15271 82.48 78.36 90.11 88.31 88.31 86.54 15272 25.41 24.14 27.76 27.21 27.21 26.67 # 15272 16.99 16.14 18.56 18.19 18.19 17.83 15273 278.41 264.49 304.16 298.08 298.08 292.12 # 15273 196.61 186.78 214.80 210.50 210.50 206.29 15274 66.58 63.25 72.74 71.29 71.29 69.86 # 15274 44.72 42.48 48.85 47.87 47.87 46.92 15275 139.96 132.96 152.90 149.85 149.85 146.84 # 15275 93.75 89.06 102.42 100.37 100.37 98.36 15276 32.72 31.08 35.74 35.03 35.03 34.33 # 15276 24.61 23.38 26.89 26.35 26.35 25.82 15277 302.84 287.70 330.86 324.24 324.24 317.76 # 15277 219.17 208.21 239.44 234.66 234.66 229.97 15278 79.59 75.61 86.95 85.22 85.22 83.51 # 15278 55.55 52.77 60.69 59.47 59.47 58.28 15570 853.11 810.45 932.02 913.38 913.38 895.11 # 15570 701.68 666.60 766.59 751.26 751.26 736.23 15572 829.32 787.85 906.03 887.90 887.90 870.15 # 15572 710.37 674.85 776.08 760.55 760.55 745.34 15574 856.34 813.52 935.55 916.84 916.84 898.51 # 15574 732.70 696.07 800.48 784.47 784.47 768.79 15576 755.33 717.56 825.19 808.69 808.69 792.52 # 15576 641.06 609.01 700.36 686.35 686.35 672.62 15600 293.33 278.66 320.46 314.05 314.05 307.77 # 15600 193.10 183.45 210.97 206.75 206.75 202.61 15610 324.45 308.23 354.46 347.38 347.38 340.43 # 15610 225.79 214.50 246.68 241.74 241.74 236.91 15620 404.86 384.62 442.31 433.47 433.47 424.80 # 15620 307.45 292.08 335.89 329.18 329.18 322.60 15630 423.75 402.56 462.94 453.69 453.69 444.61 # 15630 327.27 310.91 357.55 350.39 350.39 343.39 15650 465.92 442.62 509.01 498.84 498.84 488.85 # 15650 361.95 343.85 395.43 387.52 387.52 379.76 15731 1,063.75 1,010.56 1,162.14 1,138.90 1,138.90 1,116.12 # 15731 964.78 916.54 1,054.02 1,032.94 1,032.94 1,012.29 15732 1,213.47 1,152.80 1,325.72 1,299.20 1,299.20 1,273.22 # 15732 1,070.47 1,016.95 1,169.49 1,146.10 1,146.10 1,123.18 15734 1,421.99 1,350.89 1,553.52 1,522.45 1,522.45 1,492.00 # 15734 1,265.57 1,202.29 1,382.63 1,354.98 1,354.98 1,327.88 15736 1,246.56 1,184.23 1,361.86 1,334.63 1,334.63 1,307.94 # 15736 1,092.64 1,038.01 1,193.71 1,169.84 1,169.84 1,146.45 15738 1,328.96 1,262.51 1,451.89 1,422.85 1,422.85 1,394.39 # 15738 1,184.41 1,125.19 1,293.97 1,268.09 1,268.09 1,242.74 15740 954.43 906.71 1,042.72 1,021.87 1,021.87 1,001.43 # 15740 815.49 774.72 890.93 873.11 873.11 855.66 15750 876.78 832.94 957.88 938.72 938.72 919.94 15756 2,245.30 2,133.04 2,453.00 2,403.94 2,403.94 2,355.86

Page 24: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 24Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

15757 2,221.63 2,110.55 2,427.13 2,378.59 2,378.59 2,331.02 15758 2,223.36 2,112.19 2,429.02 2,380.44 2,380.44 2,332.83 15760 799.84 759.85 873.83 856.35 856.35 839.22 # 15760 677.45 643.58 740.12 725.32 725.32 710.82 15770 638.93 606.98 698.03 684.07 684.07 670.38 15775 283.87 269.68 310.13 303.93 303.93 297.85 # 15775 217.05 206.20 237.13 232.39 232.39 227.75 15776 463.03 439.88 505.86 495.74 495.74 485.83 # 15776 343.14 325.98 374.88 367.38 367.38 360.03 15777 207.15 196.79 226.31 221.78 221.78 217.34 15780 783.60 744.42 856.08 838.96 838.96 822.18 # 15780 603.45 573.28 659.27 646.08 646.08 633.16 15781 513.05 487.40 560.51 549.30 549.30 538.32 # 15781 409.08 388.63 446.92 437.99 437.99 429.23 15782 581.71 552.62 635.51 622.81 622.81 610.35 # 15782 417.48 396.61 456.10 446.98 446.98 438.05 15783 431.73 410.14 471.66 462.23 462.23 452.99 # 15783 341.19 324.13 372.75 365.30 365.30 358.00 15786 225.23 213.97 246.07 241.14 241.14 236.33 # 15786 130.32 123.80 142.37 139.52 139.52 136.72 15787 44.83 42.59 48.98 48.00 48.00 47.05 # 15787 17.04 16.19 18.62 18.25 18.25 17.88 15788 416.50 395.68 455.03 445.94 445.94 437.01 # 15788 229.49 218.02 250.72 245.71 245.71 240.80 15789 507.07 481.72 553.98 542.90 542.90 532.05 # 15789 390.61 371.08 426.74 418.21 418.21 409.85 15792 400.09 380.09 437.10 428.36 428.36 419.80 # 15792 242.74 230.60 265.19 259.89 259.89 254.69 15793 453.28 430.62 495.21 485.31 485.31 475.61 # 15793 344.94 327.69 376.84 369.31 369.31 361.93 15819 703.40 668.23 768.46 753.10 753.10 738.04 15820 525.28 499.02 573.87 562.40 562.40 551.15 # 15820 477.20 453.34 521.34 510.91 510.91 500.69 15821 566.28 537.97 618.67 606.29 606.29 594.17 # 15821 512.58 486.95 559.99 548.79 548.79 537.82 15822 413.86 393.17 452.15 443.11 443.11 434.24 # 15822 366.41 348.09 400.30 392.30 392.30 384.46 15823 566.36 538.04 618.75 606.37 606.37 594.24 # 15823 511.72 486.13 559.05 547.87 547.87 536.91 15830 1,120.87 1,064.83 1,224.55 1,200.06 1,200.06 1,176.06 15832 874.72 830.98 955.63 936.51 936.51 917.78 15833 819.69 778.71 895.52 877.61 877.61 860.06 15834 844.31 802.09 922.40 903.96 903.96 885.88 15835 884.59 840.36 966.41 947.08 947.08 928.14 15836 725.27 689.01 792.36 776.51 776.51 760.99 15837 755.94 718.14 825.86 809.35 809.35 793.16 # 15837 640.11 608.10 699.32 685.33 685.33 671.62 15838 547.70 520.32 598.37 586.40 586.40 574.67 15839 829.54 788.06 906.27 888.15 888.15 870.38

Page 25: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 25Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 15839 704.34 669.12 769.49 754.10 754.10 739.02 15840 968.05 919.65 1,057.60 1,036.45 1,036.45 1,015.71 15841 1,560.20 1,482.19 1,704.52 1,670.43 1,670.43 1,637.03 15842 2,533.01 2,406.36 2,767.31 2,711.96 2,711.96 2,657.73 15845 959.78 911.79 1,048.56 1,027.58 1,027.58 1,007.03 15847 669.04 635.59 730.93 716.31 716.31 701.98 15851 91.11 86.55 99.53 97.54 97.54 95.59 # 15851 44.59 42.36 48.71 47.74 47.74 46.78 15852 45.70 43.42 49.93 48.93 48.93 47.96 15860 107.57 102.19 117.52 115.17 115.17 112.87 15920 574.46 545.74 627.60 615.05 615.05 602.75 15922 740.80 703.76 809.32 793.13 793.13 777.27 15931 655.94 623.14 716.61 702.28 702.28 688.24 15933 807.20 766.84 881.87 864.23 864.23 846.94 15934 886.52 842.19 968.52 949.15 949.15 930.17 15935 1,043.62 991.44 1,140.16 1,117.35 1,117.35 1,095.01 15936 852.02 809.42 930.83 912.21 912.21 893.98 15937 987.65 938.27 1,079.01 1,057.43 1,057.43 1,036.28 15940 669.07 635.62 730.96 716.35 716.35 702.02 15941 855.17 812.41 934.27 915.58 915.58 897.28 15944 843.50 801.33 921.53 903.10 903.10 885.03 15945 929.76 883.27 1,015.76 995.44 995.44 975.53 15946 1,564.37 1,486.15 1,709.07 1,674.89 1,674.89 1,641.40 15950 561.94 533.84 613.92 601.63 601.63 589.61 15951 832.83 791.19 909.87 891.68 891.68 873.84 15952 852.42 809.80 931.27 912.64 912.64 894.39 15953 944.98 897.73 1,032.39 1,011.75 1,011.75 991.51 15956 1,101.18 1,046.12 1,203.04 1,178.98 1,178.98 1,155.41 15958 1,118.39 1,062.47 1,221.84 1,197.40 1,197.40 1,173.46 16000 64.66 61.43 70.64 69.23 69.23 67.85 # 16000 44.99 42.74 49.15 48.17 48.17 47.21 16020 75.13 71.37 82.08 80.43 80.43 78.82 # 16020 51.40 48.83 56.15 55.03 55.03 53.92 16025 137.79 130.90 150.54 147.52 147.52 144.57 # 16025 106.88 101.54 116.77 114.44 114.44 112.15 16030 173.13 164.47 189.14 185.36 185.36 181.65 # 16030 128.49 122.07 140.38 137.57 137.57 134.83 16035 190.89 181.35 208.55 204.38 204.38 200.30 16036 78.90 74.96 86.20 84.48 84.48 82.79 17000 61.56 58.48 67.25 65.91 65.91 64.58 # 17000 50.00 47.50 54.63 53.53 53.53 52.46 17003 5.15 4.89 5.62 5.51 5.51 5.39 # 17003 2.34 2.22 2.55 2.51 2.51 2.46 17004 138.42 131.50 151.23 148.20 148.20 145.23 # 17004 95.02 90.27 103.81 101.73 101.73 99.69 17106 317.70 301.82 347.09 340.15 340.15 333.34 # 17106 262.13 249.02 286.37 280.65 280.65 275.03 17107 404.41 384.19 441.82 432.99 432.99 424.33 # 17107 330.42 313.90 360.99 353.76 353.76 346.69

Page 26: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 26Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

17108 597.82 567.93 653.12 640.06 640.06 627.26 # 17108 501.97 476.87 548.40 537.43 537.43 526.68 17110 100.68 95.65 110.00 107.80 107.80 105.65 # 17110 65.09 61.84 71.12 69.69 69.69 68.30 17111 119.92 113.92 131.01 128.39 128.39 125.82 # 17111 80.58 76.55 88.03 86.27 86.27 84.55 17250 72.03 68.43 78.69 77.12 77.12 75.58 # 17250 35.19 33.43 38.44 37.67 37.67 36.92 17260 87.69 83.31 95.81 93.89 93.89 92.01 # 17260 66.77 63.43 72.94 71.48 71.48 70.06 17261 131.85 125.26 144.05 141.16 141.16 138.35 # 17261 86.89 82.55 94.93 93.04 93.04 91.17 17262 161.35 153.28 176.27 172.74 172.74 169.29 # 17262 111.09 105.54 121.37 118.94 118.94 116.56 17263 176.60 167.77 192.94 189.07 189.07 185.29 # 17263 123.52 117.34 134.94 132.24 132.24 129.59 17264 189.40 179.93 206.92 202.78 202.78 198.72 # 17264 131.96 125.36 144.16 141.28 141.28 138.45 17266 215.45 204.68 235.38 230.68 230.68 226.07 # 17266 154.57 146.84 168.87 165.49 165.49 162.17 17270 138.73 131.79 151.56 148.52 148.52 145.56 # 17270 95.02 90.27 103.81 101.73 101.73 99.69 17271 150.38 142.86 164.29 161.00 161.00 157.78 # 17271 105.74 100.45 115.52 113.21 113.21 110.94 17272 172.13 163.52 188.05 184.29 184.29 180.61 # 17272 122.49 116.37 133.83 131.15 131.15 128.52 17273 192.38 182.76 210.17 205.97 205.97 201.85 # 17273 138.37 131.45 151.17 148.14 148.14 145.18 17274 228.04 216.64 249.14 244.16 244.16 239.27 # 17274 169.34 160.87 185.00 181.30 181.30 177.68 17276 264.96 251.71 289.47 283.68 283.68 278.01 # 17276 203.76 193.57 222.61 218.16 218.16 213.80 17280 129.36 122.89 141.32 138.49 138.49 135.72 # 17280 86.27 81.96 94.25 92.37 92.37 90.52 17281 164.44 156.22 179.65 176.07 176.07 172.55 # 17281 119.17 113.21 130.19 127.59 127.59 125.04 17282 189.50 180.03 207.03 202.89 202.89 198.84 # 17282 137.98 131.08 150.74 147.73 147.73 144.77 17283 227.62 216.24 248.68 243.71 243.71 238.83 # 17283 172.67 164.04 188.65 184.87 184.87 181.17 17284 260.67 247.64 284.79 279.09 279.09 273.52 # 17284 201.66 191.58 220.32 215.91 215.91 211.60 17286 336.21 319.40 367.31 359.96 359.96 352.76 # 17286 271.27 257.71 296.37 290.44 290.44 284.64 17311 610.29 579.78 666.75 653.41 653.41 640.34 # 17311 366.45 348.13 400.35 392.35 392.35 384.50 17312 357.18 339.32 390.22 382.41 382.41 374.76 # 17312 194.83 185.09 212.85 208.60 208.60 204.42 17313 569.54 541.06 622.22 609.78 609.78 597.59

Page 27: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 27Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 17313 328.51 312.08 358.89 351.72 351.72 344.68 17314 342.14 325.03 373.78 366.31 366.31 358.98 # 17314 180.73 171.69 197.44 193.50 193.50 189.62 17315 74.19 70.48 81.05 79.43 79.43 77.84 # 17315 51.40 48.83 56.15 55.03 55.03 53.92 17340 48.86 46.42 53.38 52.31 52.31 51.27 # 17340 46.99 44.64 51.34 50.31 50.31 49.31 17360 120.07 114.07 131.18 128.56 128.56 125.98 # 17360 94.16 89.45 102.87 100.81 100.81 98.80 19000 103.77 98.58 113.37 111.10 111.10 108.88 # 19000 42.89 40.75 46.86 45.93 45.93 45.01 19001 25.83 24.54 28.22 27.66 27.66 27.11 # 19001 21.46 20.39 23.45 22.98 22.98 22.52 19020 434.17 412.46 474.33 464.84 464.84 455.55 # 19020 288.99 274.54 315.72 309.41 309.41 303.22 19030 153.05 145.40 167.21 163.86 163.86 160.59 # 19030 76.56 72.73 83.64 81.97 81.97 80.33 19081 629.06 597.61 687.25 673.51 673.51 660.04 # 19081 166.99 158.64 182.44 178.79 178.79 175.21 19082 515.32 489.55 562.98 551.72 551.72 540.68 # 19082 83.53 79.35 91.25 89.42 89.42 87.63 19083 608.04 577.64 664.29 651.00 651.00 637.99 # 19083 156.58 148.75 171.06 167.65 167.65 164.29 19084 495.56 470.78 541.40 530.56 530.56 519.95 # 19084 78.44 74.52 85.70 83.98 83.98 82.31 19085 929.12 882.66 1,015.06 994.76 994.76 974.87 # 19085 183.86 174.67 200.87 196.86 196.86 192.92 19086 731.58 695.00 799.25 783.27 783.27 767.60 # 19086 91.23 86.67 99.67 97.68 97.68 95.73 19100 138.65 131.72 151.48 148.45 148.45 145.49 # 19100 68.09 64.69 74.39 72.91 72.91 71.45 19101 315.92 300.12 345.14 338.24 338.24 331.48 # 19101 211.64 201.06 231.22 226.60 226.60 222.07 19105 1,912.25 1,816.64 2,089.14 2,047.36 2,047.36 2,006.41 # 19105 191.02 181.47 208.69 204.52 204.52 200.42 19110 448.31 425.89 489.77 479.98 479.98 470.37 # 19110 324.05 307.85 354.03 346.94 346.94 340.01 19112 419.87 398.88 458.71 449.54 449.54 440.54 # 19112 293.42 278.75 320.56 314.16 314.16 307.88 19120 463.80 440.61 506.70 496.57 496.57 486.63 # 19120 394.49 374.77 430.99 422.36 422.36 413.91 19125 514.84 489.10 562.47 551.22 551.22 540.19 # 19125 438.97 417.02 479.57 469.98 469.98 460.59 19126 157.61 149.73 172.19 168.75 168.75 165.38 19260 1,153.45 1,095.78 1,260.15 1,234.94 1,234.94 1,210.24 19271 1,553.62 1,475.94 1,697.33 1,663.38 1,663.38 1,630.11 19272 1,702.40 1,617.28 1,859.87 1,822.67 1,822.67 1,786.21 19281 220.97 209.92 241.41 236.58 236.58 231.85 # 19281 100.15 95.14 109.41 107.23 107.23 105.09

Page 28: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 28Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

19282 152.92 145.27 167.06 163.71 163.71 160.44 # 19282 50.20 47.69 54.84 53.75 53.75 52.68 19283 247.43 235.06 270.32 264.91 264.91 259.61 # 19283 100.69 95.66 110.01 107.81 107.81 105.66 19284 184.40 175.18 201.46 197.43 197.43 193.49 # 19284 50.77 48.23 55.46 54.36 54.36 53.27 19285 463.78 440.59 506.68 496.55 496.55 486.61 # 19285 85.38 81.11 93.28 91.41 91.41 89.59 19286 404.53 384.30 441.95 433.10 433.10 424.44 # 19286 42.99 40.84 46.97 46.02 46.02 45.10 19287 774.05 735.35 845.65 828.74 828.74 812.16 # 19287 128.08 121.68 139.93 137.14 137.14 134.40 19288 620.94 589.89 678.37 664.80 664.80 651.51 # 19288 63.95 60.75 69.86 68.47 68.47 67.10 19296 3,516.73 3,340.89 3,842.02 3,765.18 3,765.18 3,689.88 # 19296 204.77 194.53 223.71 219.24 219.24 214.85 19297 92.61 87.98 101.18 99.15 99.15 97.18 19298 958.10 910.20 1,046.73 1,025.80 1,025.80 1,005.28 # 19298 319.63 303.65 349.20 342.22 342.22 335.37 19300 486.48 462.16 531.48 520.86 520.86 510.44 # 19300 390.95 371.40 427.11 418.57 418.57 410.19 19301 627.05 595.70 685.06 671.36 671.36 657.93 19302 864.14 820.93 944.07 925.19 925.19 906.68 19303 971.70 923.12 1,061.59 1,040.36 1,040.36 1,019.56 19304 546.74 519.40 597.31 585.36 585.36 573.65 19305 1,083.72 1,029.53 1,183.96 1,160.28 1,160.28 1,137.07 19306 1,150.62 1,093.09 1,257.05 1,231.91 1,231.91 1,207.28 19307 1,148.35 1,090.93 1,254.57 1,229.48 1,229.48 1,204.89 19316 734.94 698.19 802.92 786.86 786.86 771.13 19318 1,053.44 1,000.77 1,150.89 1,127.86 1,127.86 1,105.31 19324 466.29 442.98 509.43 499.24 499.24 489.26 19325 608.57 578.14 664.86 651.57 651.57 638.54 19328 469.87 446.38 513.34 503.07 503.07 493.01 19330 602.89 572.75 658.66 645.50 645.50 632.58 19340 956.33 908.51 1,044.79 1,023.89 1,023.89 1,003.41 19342 877.82 833.93 959.02 939.84 939.84 921.05 19350 769.85 731.36 841.06 824.24 824.24 807.76 # 19350 639.97 607.97 699.17 685.18 685.18 671.47 19355 661.17 628.11 722.33 707.88 707.88 693.73 # 19355 547.53 520.15 598.17 586.21 586.21 574.49 19357 1,423.22 1,352.06 1,554.87 1,523.77 1,523.77 1,493.30 19361 1,508.48 1,433.06 1,648.02 1,615.06 1,615.06 1,582.76 19364 2,649.00 2,516.55 2,894.03 2,836.15 2,836.15 2,779.44 19366 1,352.60 1,284.97 1,477.72 1,448.16 1,448.16 1,419.19 19367 1,716.22 1,630.41 1,874.97 1,837.47 1,837.47 1,800.72 19368 2,116.02 2,010.22 2,311.75 2,265.52 2,265.52 2,220.21 19369 1,964.46 1,866.24 2,146.18 2,103.26 2,103.26 2,061.19 19370 651.45 618.88 711.71 697.48 697.48 683.53 19371 745.45 708.18 814.41 798.12 798.12 782.16

Page 29: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 29Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

19380 734.61 697.88 802.56 786.51 786.51 770.78 19396 255.00 242.25 278.59 273.02 273.02 267.56 # 19396 134.80 128.06 147.27 144.33 144.33 141.44 20005 290.52 275.99 317.39 311.04 311.04 304.82 # 20005 224.64 213.41 245.42 240.51 240.51 235.70 20100 589.61 560.13 644.15 631.27 631.27 618.64 20101 412.00 391.40 450.11 441.11 441.11 432.29 # 20101 200.63 190.60 219.19 214.81 214.81 210.51 20102 452.83 430.19 494.72 484.83 484.83 475.13 # 20102 246.46 234.14 269.26 263.88 263.88 258.60 20103 539.53 512.55 589.43 577.65 577.65 566.09 # 20103 334.72 317.98 365.68 358.36 358.36 351.20 20150 872.13 828.52 952.80 933.74 933.74 915.07 20200 189.88 180.39 207.45 203.30 203.30 199.23 # 20200 91.84 87.25 100.34 98.34 98.34 96.37 20205 266.58 253.25 291.24 285.42 285.42 279.71 # 20205 149.81 142.32 163.67 160.39 160.39 157.18 20206 214.07 203.37 233.88 229.20 229.20 224.61 # 20206 57.65 54.77 62.99 61.72 61.72 60.49 20220 155.35 147.58 169.72 166.32 166.32 163.00 # 20220 71.05 67.50 77.63 76.07 76.07 74.55 20225 475.43 451.66 519.41 509.02 509.02 498.85 # 20225 106.08 100.78 115.90 113.57 113.57 111.30 20240 149.85 142.36 163.71 160.44 160.44 157.23 20245 502.96 477.81 549.48 538.49 538.49 527.72 20250 371.76 353.17 406.15 398.03 398.03 390.07 20251 404.15 383.94 441.53 432.70 432.70 424.04 20500 97.95 93.05 107.01 104.87 104.87 102.78 # 20500 81.09 77.04 88.60 86.83 86.83 85.09 20501 108.19 102.78 118.20 115.83 115.83 113.52 # 20501 37.63 35.75 41.11 40.30 40.30 39.49 20520 188.73 179.29 206.18 202.06 202.06 198.02 # 20520 138.78 131.84 151.62 148.58 148.58 145.61 20525 440.60 418.57 481.36 471.73 471.73 462.30 # 20525 237.66 225.78 259.65 254.45 254.45 249.35 20526 72.24 68.63 78.92 77.35 77.35 75.80 # 20526 55.38 52.61 60.50 59.29 59.29 58.11 20527 78.71 74.77 85.99 84.26 84.26 82.57 # 20527 63.72 60.53 69.61 68.22 68.22 66.85 20550 55.33 52.56 60.44 59.24 59.24 58.05 # 20550 40.65 38.62 44.41 43.53 43.53 42.65 20551 56.61 53.78 61.85 60.61 60.61 59.40 # 20551 41.31 39.24 45.13 44.23 44.23 43.34 20552 51.85 49.26 56.65 55.51 55.51 54.40 # 20552 36.86 35.02 40.27 39.47 39.47 38.67 20553 59.73 56.74 65.25 63.95 63.95 62.68 # 20553 41.93 39.83 45.80 44.88 44.88 43.99 20555 319.65 303.67 349.22 342.24 342.24 335.40 20600 44.98 42.73 49.14 48.16 48.16 47.20

Page 30: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 30Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 20600 34.68 32.95 37.89 37.13 37.13 36.39 20604 67.81 64.42 74.08 72.60 72.60 71.15 # 20604 45.02 42.77 49.19 48.20 48.20 47.23 20605 47.23 44.87 51.60 50.57 50.57 49.55 # 20605 36.30 34.49 39.66 38.87 38.87 38.09 20606 75.12 71.36 82.06 80.42 80.42 78.81 # 20606 51.40 48.83 56.15 55.03 55.03 53.92 20610 56.68 53.85 61.93 60.69 60.69 59.47 # 20610 44.50 42.28 48.62 47.64 47.64 46.69 20611 85.78 81.49 93.71 91.84 91.84 90.00 # 20611 59.86 56.87 65.40 64.09 64.09 62.81 20612 56.66 53.83 61.90 60.66 60.66 59.46 # 20612 40.43 38.41 44.17 43.29 43.29 42.42 20615 227.15 215.79 248.16 243.19 243.19 238.33 # 20615 156.28 148.47 170.74 167.33 167.33 163.98 20650 193.80 184.11 211.73 207.49 207.49 203.34 # 20650 149.78 142.29 163.63 160.36 160.36 157.15 20660 237.44 225.57 259.41 254.22 254.22 249.14 20661 474.47 450.75 518.36 508.00 508.00 497.85 20662 415.57 394.79 454.01 444.92 444.92 436.02 20663 443.29 421.13 484.30 474.62 474.62 465.13 20664 827.89 786.50 904.48 886.39 886.39 868.65 20665 99.62 94.64 108.84 106.66 106.66 104.54 # 20665 86.82 82.48 94.85 92.95 92.95 91.09 20670 344.00 326.80 375.82 368.30 368.30 360.93 # 20670 139.19 132.23 152.06 149.03 149.03 146.05 20680 575.56 546.78 628.80 616.22 616.22 603.89 # 20680 404.78 384.54 442.22 433.38 433.38 424.71 20690 569.41 540.94 622.08 609.64 609.64 597.45 20692 1,071.44 1,017.87 1,170.55 1,147.14 1,147.14 1,124.19 20693 424.93 403.68 464.23 454.95 454.95 445.86 20694 396.78 376.94 433.48 424.81 424.81 416.31 # 20694 320.91 304.86 350.59 343.57 343.57 336.70 20696 1,153.09 1,095.44 1,259.76 1,234.56 1,234.56 1,209.87 20697 1,756.15 1,668.34 1,918.59 1,880.22 1,880.22 1,842.61 20802 2,341.96 2,224.86 2,558.59 2,507.41 2,507.41 2,457.26 20805 3,180.70 3,021.67 3,474.92 3,405.43 3,405.43 3,337.32 20808 3,876.46 3,682.64 4,235.04 4,150.34 4,150.34 4,067.33 20816 1,992.70 1,893.07 2,177.03 2,133.49 2,133.49 2,090.83 20822 1,720.30 1,634.29 1,879.43 1,841.84 1,841.84 1,805.01 20824 1,961.30 1,863.24 2,142.73 2,099.88 2,099.88 2,057.88 20827 1,755.12 1,667.36 1,917.46 1,879.11 1,879.11 1,841.53 20838 2,365.20 2,246.94 2,583.98 2,532.30 2,532.30 2,481.65 20900 384.70 365.47 420.29 411.88 411.88 403.65 # 20900 183.33 174.16 200.28 196.28 196.28 192.36 20902 276.45 262.63 302.02 295.99 295.99 290.06 20910 391.83 372.24 428.08 419.52 419.52 411.13 20912 458.69 435.76 501.12 491.10 491.10 481.28 20920 376.81 357.97 411.67 403.43 403.43 395.36

Page 31: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 31Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

20922 571.17 542.61 624.00 611.52 611.52 599.29 # 20922 477.82 453.93 522.02 511.58 511.58 501.34 20924 480.84 456.80 525.32 514.81 514.81 504.52 20926 409.82 389.33 447.73 438.77 438.77 430.00 20931 109.33 103.86 119.44 117.05 117.05 114.70 20937 163.45 155.28 178.57 175.00 175.00 171.50 20938 179.90 170.91 196.55 192.61 192.61 188.76 20950 229.31 217.84 250.52 245.50 245.50 240.59 # 20950 87.25 82.89 95.32 93.41 93.41 91.55 20955 2,427.13 2,305.77 2,651.64 2,598.60 2,598.60 2,546.63 20956 2,558.99 2,431.04 2,795.70 2,739.78 2,739.78 2,684.99 20957 2,390.08 2,270.58 2,611.17 2,558.95 2,558.95 2,507.77 20962 2,075.48 1,971.71 2,267.47 2,222.12 2,222.12 2,177.67 20969 2,686.42 2,552.10 2,934.92 2,876.22 2,876.22 2,818.70 20970 2,813.68 2,673.00 3,073.95 3,012.47 3,012.47 2,952.22 20972 2,323.16 2,207.00 2,538.05 2,487.29 2,487.29 2,437.54 20973 2,576.62 2,447.79 2,814.96 2,758.65 2,758.65 2,703.48 20974 70.52 66.99 77.04 75.50 75.50 73.99 # 20974 47.73 45.34 52.14 51.09 51.09 50.07 20975 170.91 162.36 186.71 182.98 182.98 179.32 20979 49.14 46.68 53.68 52.61 52.61 51.57 # 20979 31.66 30.08 34.59 33.90 33.90 33.22 20982 2,714.53 2,578.80 2,965.62 2,906.30 2,906.30 2,848.18 # 20982 375.74 356.95 410.49 402.28 402.28 394.23 20983 6,477.22 6,153.36 7,076.36 6,934.83 6,934.83 6,796.13 # 20983 396.86 377.02 433.57 424.90 424.90 416.40 20985 143.08 135.93 156.32 153.19 153.19 150.13 21010 714.21 678.50 780.28 764.67 764.67 749.37 21011 322.53 306.40 352.36 345.31 345.31 338.40 # 21011 244.79 232.55 267.43 262.09 262.09 256.84 21012 322.29 306.18 352.11 345.07 345.07 338.17 21013 484.89 460.65 529.75 519.16 519.16 508.77 # 21013 382.49 363.37 417.88 409.52 409.52 401.33 21014 497.30 472.44 543.31 532.44 532.44 521.79 21015 678.50 644.58 741.27 726.44 726.44 711.92 21016 983.33 934.16 1,074.28 1,052.80 1,052.80 1,031.75 21025 847.16 804.80 925.52 907.01 907.01 888.87 # 21025 723.83 687.64 790.79 774.97 774.97 759.47 21026 579.92 550.92 633.56 620.89 620.89 608.47 # 21026 475.02 451.27 518.96 508.58 508.58 498.41 21029 722.93 686.78 789.80 774.00 774.00 758.52 # 21029 609.28 578.82 665.64 652.33 652.33 639.29 21030 488.85 464.41 534.07 523.39 523.39 512.92 # 21030 399.55 379.57 436.51 427.78 427.78 419.22 21031 370.44 351.92 404.71 396.61 396.61 388.68 # 21031 281.77 267.68 307.83 301.68 301.68 295.64 21032 376.53 357.70 411.36 403.13 403.13 395.07 # 21032 279.43 265.46 305.28 299.17 299.17 293.19 21034 1,258.02 1,195.12 1,374.39 1,346.90 1,346.90 1,319.97

Page 32: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 32Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 21034 1,119.40 1,063.43 1,222.94 1,198.48 1,198.48 1,174.52 21040 492.28 467.67 537.82 527.07 527.07 516.52 # 21040 400.18 380.17 437.20 428.46 428.46 419.89 21044 845.68 803.40 923.91 905.43 905.43 887.32 21045 1,187.19 1,127.83 1,297.00 1,271.06 1,271.06 1,245.63 21046 1,073.49 1,019.82 1,172.79 1,149.33 1,149.33 1,126.34 21047 1,280.28 1,216.27 1,398.71 1,370.73 1,370.73 1,343.32 21048 1,101.19 1,046.13 1,203.05 1,178.99 1,178.99 1,155.42 21049 1,177.52 1,118.64 1,286.44 1,260.71 1,260.71 1,235.49 21050 808.55 768.12 883.34 865.67 865.67 848.36 21060 765.36 727.09 836.15 819.43 819.43 803.05 21070 587.46 558.09 641.80 628.97 628.97 616.39 21073 362.64 344.51 396.19 388.26 388.26 380.50 # 21073 243.69 231.51 266.24 260.91 260.91 255.69 21076 963.67 915.49 1,052.81 1,031.76 1,031.76 1,011.13 # 21076 818.80 777.86 894.54 876.65 876.65 859.11 21077 2,417.49 2,296.62 2,641.11 2,588.29 2,588.29 2,536.53 # 21077 2,056.89 1,954.05 2,247.16 2,202.22 2,202.22 2,158.17 21079 1,625.36 1,544.09 1,775.70 1,740.19 1,740.19 1,705.39 # 21079 1,368.41 1,299.99 1,494.99 1,465.09 1,465.09 1,435.79 21080 1,824.53 1,733.30 1,993.30 1,953.42 1,953.42 1,914.36 # 21080 1,524.18 1,447.97 1,665.17 1,631.86 1,631.86 1,599.22 21081 1,683.81 1,599.62 1,839.56 1,802.77 1,802.77 1,766.72 # 21081 1,401.26 1,331.20 1,530.88 1,500.27 1,500.27 1,470.26 21082 1,588.41 1,508.99 1,735.34 1,700.63 1,700.63 1,666.61 # 21082 1,312.10 1,246.50 1,433.48 1,404.81 1,404.81 1,376.71 21083 1,511.08 1,435.53 1,650.86 1,617.84 1,617.84 1,585.48 # 21083 1,217.60 1,156.72 1,330.23 1,303.63 1,303.63 1,277.56 21084 1,738.43 1,651.51 1,899.24 1,861.25 1,861.25 1,824.03 # 21084 1,412.79 1,342.15 1,543.47 1,512.61 1,512.61 1,482.35 21085 725.44 689.17 792.55 776.70 776.70 761.16 # 21085 554.35 526.63 605.62 593.52 593.52 581.65 21086 1,797.31 1,707.44 1,963.56 1,924.28 1,924.28 1,885.79 # 21086 1,523.50 1,447.33 1,664.43 1,631.14 1,631.14 1,598.51 21087 1,794.53 1,704.80 1,960.52 1,921.31 1,921.31 1,882.88 # 21087 1,520.41 1,444.39 1,661.05 1,627.83 1,627.83 1,595.27 21100 941.15 894.09 1,028.20 1,007.64 1,007.64 987.49 # 21100 469.09 445.64 512.49 502.24 502.24 492.20 21110 751.79 714.20 821.33 804.91 804.91 788.81 # 21110 635.33 603.56 694.09 680.21 680.21 666.61 21116 133.32 126.65 145.65 142.74 142.74 139.89 # 21116 43.09 40.94 47.08 46.14 46.14 45.22 21120 613.24 582.58 669.97 656.57 656.57 643.44 # 21120 491.17 466.61 536.60 525.87 525.87 515.35 21121 762.71 724.57 833.26 816.59 816.59 800.26 # 21121 643.13 610.97 702.62 688.56 688.56 674.80 21122 630.15 598.64 688.44 674.67 674.67 661.18 21123 890.85 846.31 973.26 953.79 953.79 934.71 21125 2,780.29 2,641.28 3,037.47 2,976.72 2,976.72 2,917.18

Page 33: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 33Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 21125 754.64 716.91 824.45 807.96 807.96 791.80 21127 4,007.82 3,807.43 4,378.54 4,290.97 4,290.97 4,205.15 # 21127 861.02 817.97 940.67 921.85 921.85 903.42 21137 720.94 684.89 787.62 771.87 771.87 756.44 21138 854.62 811.89 933.67 915.00 915.00 896.70 21139 919.59 873.61 1,004.65 984.56 984.56 964.87 21141 1,293.71 1,229.02 1,413.37 1,385.11 1,385.11 1,357.40 21142 1,355.02 1,287.27 1,480.36 1,450.75 1,450.75 1,421.73 21143 1,366.94 1,298.59 1,493.38 1,463.51 1,463.51 1,434.25 21145 1,525.79 1,449.50 1,666.93 1,633.59 1,633.59 1,600.92 21146 1,502.48 1,427.36 1,641.46 1,608.63 1,608.63 1,576.45 21147 1,690.00 1,605.50 1,846.33 1,809.40 1,809.40 1,773.21 21150 1,627.24 1,545.88 1,777.76 1,742.20 1,742.20 1,707.36 21151 1,950.49 1,852.97 2,130.92 2,088.30 2,088.30 2,046.53 21154 2,012.16 1,911.55 2,198.28 2,154.32 2,154.32 2,111.23 21155 2,103.75 1,998.56 2,298.34 2,252.38 2,252.38 2,207.33 21159 2,440.62 2,318.59 2,666.38 2,613.05 2,613.05 2,560.80 21160 3,061.67 2,908.59 3,344.88 3,277.98 3,277.98 3,212.42 21172 1,754.88 1,667.14 1,917.21 1,878.87 1,878.87 1,841.29 21175 2,078.88 1,974.94 2,271.18 2,225.76 2,225.76 2,181.24 21179 1,405.35 1,335.08 1,535.34 1,504.64 1,504.64 1,474.54 21180 1,500.39 1,425.37 1,639.18 1,606.39 1,606.39 1,574.26 21181 706.34 671.02 771.67 756.24 756.24 741.12 21182 1,887.88 1,793.49 2,062.51 2,021.26 2,021.26 1,980.84 21183 2,229.88 2,118.39 2,436.15 2,387.42 2,387.42 2,339.68 21184 2,088.17 1,983.76 2,281.32 2,235.69 2,235.69 2,190.98 21188 1,553.46 1,475.79 1,697.16 1,663.21 1,663.21 1,629.94 21193 1,176.06 1,117.26 1,284.85 1,259.15 1,259.15 1,233.96 21194 1,389.50 1,320.03 1,518.03 1,487.67 1,487.67 1,457.92 21195 1,291.36 1,226.79 1,410.81 1,382.59 1,382.59 1,354.94 21196 1,429.20 1,357.74 1,561.40 1,530.18 1,530.18 1,499.58 21198 1,123.45 1,067.28 1,227.37 1,202.82 1,202.82 1,178.76 21199 1,037.27 985.41 1,133.22 1,110.56 1,110.56 1,088.35 21206 1,128.50 1,072.08 1,232.89 1,208.24 1,208.24 1,184.07 21208 1,747.91 1,660.51 1,909.59 1,871.40 1,871.40 1,833.96 # 21208 804.40 764.18 878.81 861.24 861.24 844.01 21209 762.65 724.52 833.20 816.53 816.53 800.20 # 21209 590.00 560.50 644.58 631.68 631.68 619.05 21210 2,110.60 2,005.07 2,305.83 2,259.72 2,259.72 2,214.52 # 21210 835.21 793.45 912.47 894.22 894.22 876.33 21215 3,712.27 3,526.66 4,055.66 3,974.55 3,974.55 3,895.06 # 21215 868.63 825.20 948.98 930.01 930.01 911.41 21230 689.60 655.12 753.39 738.32 738.32 723.56 21235 682.22 648.11 745.33 730.42 730.42 715.82 # 21235 542.35 515.23 592.51 580.67 580.67 569.05 21240 1,082.66 1,028.53 1,182.81 1,159.15 1,159.15 1,135.97 21242 991.02 941.47 1,082.69 1,061.04 1,061.04 1,039.82 21243 1,641.02 1,558.97 1,792.82 1,756.96 1,756.96 1,721.81 21244 1,021.23 970.17 1,115.70 1,093.39 1,093.39 1,071.51

Page 34: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 34Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

21245 1,054.26 1,001.55 1,151.78 1,128.75 1,128.75 1,106.17 # 21245 855.38 812.61 934.50 915.81 915.81 897.49 21246 840.85 798.81 918.63 900.25 900.25 882.25 21247 1,504.45 1,429.23 1,643.61 1,610.75 1,610.75 1,578.54 21248 1,057.79 1,004.90 1,155.64 1,132.52 1,132.52 1,109.87 # 21248 876.39 832.57 957.46 938.31 938.31 919.54 21249 1,454.69 1,381.96 1,589.25 1,557.47 1,557.47 1,526.31 # 21249 1,248.62 1,186.19 1,364.12 1,336.84 1,336.84 1,310.10 21255 1,331.63 1,265.05 1,454.81 1,425.71 1,425.71 1,397.20 21256 1,156.80 1,098.96 1,263.80 1,238.53 1,238.53 1,213.76 21260 1,327.78 1,261.39 1,450.60 1,421.58 1,421.58 1,393.16 21261 2,042.80 1,940.66 2,231.76 2,187.13 2,187.13 2,143.38 21263 1,884.76 1,790.52 2,059.10 2,017.92 2,017.92 1,977.56 21267 1,498.41 1,423.49 1,637.01 1,604.27 1,604.27 1,572.19 21268 1,681.17 1,597.11 1,836.68 1,799.95 1,799.95 1,763.95 21270 905.13 859.87 988.85 969.07 969.07 949.69 # 21270 691.57 656.99 755.54 740.43 740.43 725.62 21275 799.54 759.56 873.49 856.03 856.03 838.90 21280 536.84 510.00 586.50 574.77 574.77 563.27 21282 357.51 339.63 390.57 382.77 382.77 375.11 21295 169.69 161.21 185.39 181.69 181.69 178.05 21296 408.00 387.60 445.74 436.83 436.83 428.09 21310 119.83 113.84 130.92 128.29 128.29 125.73 # 21310 26.79 25.45 29.27 28.68 28.68 28.11 21315 255.54 242.76 279.17 273.59 273.59 268.11 # 21315 144.08 136.88 157.41 154.26 154.26 151.18 21320 237.63 225.75 259.61 254.43 254.43 249.34 # 21320 129.61 123.13 141.60 138.77 138.77 136.00 21325 442.57 420.44 483.51 473.83 473.83 464.36 21330 533.59 506.91 582.95 571.29 571.29 559.85 21335 692.07 657.47 756.09 740.97 740.97 726.14 21336 607.40 577.03 663.58 650.31 650.31 637.31 21337 376.24 357.43 411.04 402.82 402.82 394.76 # 21337 279.46 265.49 305.31 299.21 299.21 293.23 21338 676.93 643.08 739.54 724.75 724.75 710.26 21339 727.88 691.49 795.21 779.31 779.31 763.73 21340 727.30 690.94 794.58 778.69 778.69 763.12 21343 1,141.74 1,084.65 1,247.35 1,222.40 1,222.40 1,197.96 21344 1,347.82 1,280.43 1,472.49 1,443.04 1,443.04 1,414.18 21345 765.57 727.29 836.38 819.65 819.65 803.26 # 21345 626.63 595.30 684.60 670.90 670.90 657.48 21346 867.26 823.90 947.49 928.53 928.53 909.96 21347 1,077.83 1,023.94 1,177.53 1,153.98 1,153.98 1,130.90 21348 1,157.62 1,099.74 1,264.70 1,239.41 1,239.41 1,214.63 21355 403.90 383.71 441.27 432.45 432.45 423.80 # 21355 307.74 292.35 336.20 329.48 329.48 322.89 21356 469.57 446.09 513.00 502.75 502.75 492.69 # 21356 360.92 342.87 394.30 386.41 386.41 378.68 21360 515.02 489.27 562.66 551.40 551.40 540.37

Page 35: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 35Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

21365 1,072.32 1,018.70 1,171.51 1,148.08 1,148.08 1,125.11 21366 1,120.51 1,064.48 1,224.15 1,199.67 1,199.67 1,175.68 21385 653.75 621.06 714.22 699.94 699.94 685.94 21386 663.25 630.09 724.60 710.11 710.11 695.91 21387 683.57 649.39 746.80 731.86 731.86 717.22 21390 760.74 722.70 831.11 814.49 814.49 798.20 21395 962.11 914.00 1,051.10 1,030.08 1,030.08 1,009.48 21400 178.55 169.62 195.06 191.16 191.16 187.35 # 21400 146.40 139.08 159.94 156.75 156.75 153.61 21401 411.49 390.92 449.56 440.57 440.57 431.76 # 21401 272.87 259.23 298.11 292.16 292.16 286.32 21406 498.07 473.17 544.15 533.27 533.27 522.61 21407 617.90 587.01 675.06 661.56 661.56 648.32 21408 839.87 797.88 917.56 899.21 899.21 881.22 21421 705.69 670.41 770.97 755.55 755.55 740.44 # 21421 599.85 569.86 655.34 642.23 642.23 629.38 21422 643.69 611.51 703.24 689.17 689.17 675.38 21423 781.56 742.48 853.85 836.77 836.77 820.04 21431 699.56 664.58 764.27 748.98 748.98 734.00 21432 627.75 596.36 685.81 672.09 672.09 658.65 21433 1,669.22 1,585.76 1,823.62 1,787.15 1,787.15 1,751.40 21435 1,223.10 1,161.95 1,336.24 1,309.52 1,309.52 1,283.33 21436 1,996.23 1,896.42 2,180.88 2,137.26 2,137.26 2,094.52 21440 536.50 509.68 586.13 574.41 574.41 562.93 # 21440 438.15 416.24 478.68 469.11 469.11 459.72 21445 722.60 686.47 789.44 773.65 773.65 758.18 # 21445 593.66 563.98 648.58 635.61 635.61 622.90 21450 575.40 546.63 628.62 616.06 616.06 603.74 # 21450 463.94 440.74 506.85 496.72 496.72 486.78 21451 712.64 677.01 778.56 762.99 762.99 747.73 # 21451 602.43 572.31 658.16 644.99 644.99 632.09 21452 549.14 521.68 599.93 587.94 587.94 576.18 # 21452 328.10 311.70 358.46 351.29 351.29 344.26 21453 853.20 810.54 932.12 913.48 913.48 895.21 # 21453 735.81 699.02 803.87 787.80 787.80 772.04 21454 566.04 537.74 618.40 606.04 606.04 593.92 21461 1,968.92 1,870.47 2,151.04 2,108.02 2,108.02 2,065.86 # 21461 889.60 845.12 971.89 952.45 952.45 933.41 21462 2,093.90 1,989.21 2,287.59 2,241.84 2,241.84 2,197.01 # 21462 993.66 943.98 1,085.58 1,063.87 1,063.87 1,042.59 21465 920.40 874.38 1,005.54 985.42 985.42 965.71 21470 1,162.67 1,104.54 1,270.22 1,244.82 1,244.82 1,219.92 21480 90.90 86.36 99.31 97.32 97.32 95.38 # 21480 31.27 29.71 34.17 33.49 33.49 32.82 21485 654.67 621.94 715.23 700.93 700.93 686.91 # 21485 551.01 523.46 601.98 589.94 589.94 578.14 21490 880.62 836.59 962.08 942.84 942.84 923.98 21495 665.02 631.77 726.54 712.00 712.00 697.76 21497 683.79 649.60 747.04 732.10 732.10 717.46

Page 36: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 36Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 21497 572.33 543.71 625.27 612.77 612.77 600.51 21501 421.94 400.84 460.97 451.74 451.74 442.70 # 21501 305.48 290.21 333.74 327.07 327.07 320.53 21502 509.20 483.74 556.30 545.18 545.18 534.28 21510 427.63 406.25 467.19 457.85 457.85 448.70 21550 243.57 231.39 266.10 260.77 260.77 255.55 # 21550 150.84 143.30 164.80 161.49 161.49 158.26 21552 428.16 406.75 467.76 458.41 458.41 449.25 21554 704.52 669.29 769.68 754.29 754.29 739.20 21555 387.11 367.75 422.91 414.46 414.46 406.17 # 21555 291.26 276.70 318.21 311.85 311.85 305.61 21556 508.43 483.01 555.46 544.35 544.35 533.46 21557 923.70 877.52 1,009.15 988.97 988.97 969.19 21558 1,302.79 1,237.65 1,423.30 1,394.84 1,394.84 1,366.94 21600 531.38 504.81 580.53 568.92 568.92 557.54 21610 1,139.10 1,082.15 1,244.47 1,219.59 1,219.59 1,195.20 21615 601.07 571.02 656.67 643.54 643.54 630.67 21616 730.57 694.04 798.15 782.18 782.18 766.54 21620 483.56 459.38 528.29 517.72 517.72 507.37 21627 515.79 490.00 563.50 552.23 552.23 541.19 21630 1,169.65 1,111.17 1,277.85 1,252.29 1,252.29 1,227.25 21632 1,171.04 1,112.49 1,279.36 1,253.78 1,253.78 1,228.71 21685 967.67 919.29 1,057.18 1,036.04 1,036.04 1,015.31 21700 360.74 342.70 394.11 386.23 386.23 378.50 21705 539.34 512.37 589.23 577.44 577.44 565.89 21720 430.97 409.42 470.83 461.41 461.41 452.19 21725 505.00 479.75 551.71 540.68 540.68 529.87 21740 994.62 944.89 1,086.62 1,064.89 1,064.89 1,043.59 21742 744.11 706.90 812.94 796.67 796.67 780.74 21743 822.16 781.05 898.21 880.24 880.24 862.64 21750 663.83 630.64 725.24 710.73 710.73 696.52 21811 595.83 566.04 650.95 637.93 637.93 625.17 21812 714.71 678.97 780.82 765.20 765.20 749.89 21813 935.10 888.35 1,021.60 1,001.17 1,001.17 981.15 21820 131.08 124.53 143.21 140.35 140.35 137.54 # 21820 134.20 127.49 146.61 143.68 143.68 140.81 21825 518.70 492.77 566.69 555.35 555.35 544.24 21920 238.24 226.33 260.28 255.07 255.07 249.96 # 21920 153.00 145.35 167.15 163.81 163.81 160.53 21925 417.24 396.38 455.84 446.72 446.72 437.78 # 21925 337.00 320.15 368.17 360.81 360.81 353.60 21930 442.14 420.03 483.03 473.37 473.37 463.91 # 21930 347.85 330.46 380.03 372.43 372.43 364.98 21931 450.54 428.01 492.21 482.37 482.37 472.72 21932 635.44 603.67 694.22 680.34 680.34 666.74 21933 708.40 672.98 773.93 758.45 758.45 743.28 21935 986.97 937.62 1,078.26 1,056.70 1,056.70 1,035.56 21936 1,362.59 1,294.46 1,488.63 1,458.86 1,458.86 1,429.68 22010 908.91 863.46 992.98 973.12 973.12 953.66

Page 37: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 37Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

22015 881.71 837.62 963.26 944.00 944.00 925.12 22100 829.62 788.14 906.36 888.24 888.24 870.47 22101 810.98 770.43 885.99 868.27 868.27 850.91 22102 756.31 718.49 826.26 809.74 809.74 793.55 22103 136.11 129.30 148.70 145.72 145.72 142.81 22110 1,000.20 950.19 1,092.72 1,070.87 1,070.87 1,049.46 22112 948.40 900.98 1,036.13 1,015.40 1,015.40 995.10 22114 952.23 904.62 1,040.31 1,019.51 1,019.51 999.12 22116 137.93 131.03 150.68 147.67 147.67 144.72 22206 2,357.88 2,239.99 2,575.99 2,524.47 2,524.47 2,473.98 22207 2,312.70 2,197.07 2,526.63 2,476.10 2,476.10 2,426.58 22208 567.81 539.42 620.33 607.92 607.92 595.77 22210 1,715.30 1,629.54 1,873.97 1,836.49 1,836.49 1,799.76 22212 1,421.62 1,350.54 1,553.12 1,522.06 1,522.06 1,491.62 22214 1,426.59 1,355.26 1,558.55 1,527.37 1,527.37 1,496.83 22216 354.14 336.43 386.89 379.16 379.16 371.58 22220 1,534.87 1,458.13 1,676.85 1,643.32 1,643.32 1,610.45 22222 1,496.87 1,422.03 1,635.33 1,602.63 1,602.63 1,570.58 22224 1,521.46 1,445.39 1,662.20 1,628.95 1,628.95 1,596.37 22226 353.49 335.82 386.19 378.47 378.47 370.90 22305 179.13 170.17 195.70 191.79 191.79 187.94 # 22305 163.52 155.34 178.64 175.06 175.06 171.57 22310 290.94 276.39 317.85 311.49 311.49 305.26 # 22310 269.71 256.22 294.65 288.77 288.77 282.99 22315 833.49 791.82 910.59 892.38 892.38 874.53 # 22315 735.14 698.38 803.14 787.07 787.07 771.33 22318 1,577.54 1,498.66 1,723.46 1,688.99 1,688.99 1,655.22 22319 1,751.44 1,663.87 1,913.45 1,875.18 1,875.18 1,837.68 22325 1,378.55 1,309.62 1,506.06 1,475.94 1,475.94 1,446.42 22326 1,431.90 1,360.31 1,564.36 1,533.07 1,533.07 1,502.41 22327 1,441.14 1,369.08 1,574.44 1,542.96 1,542.96 1,512.10 22328 275.26 261.50 300.73 294.71 294.71 288.81 22505 122.44 116.32 133.77 131.09 131.09 128.47 22510 1,607.87 1,527.48 1,756.60 1,721.47 1,721.47 1,687.04 # 22510 443.31 421.14 484.31 474.63 474.63 465.14 22511 1,589.16 1,509.70 1,736.16 1,701.44 1,701.44 1,667.41 # 22511 415.86 395.07 454.33 445.25 445.25 436.34 22512 889.34 844.87 971.60 952.17 952.17 933.12 # 22512 206.84 196.50 225.98 221.46 221.46 217.03 22513 6,550.69 6,223.16 7,156.63 7,013.51 7,013.51 6,873.24 # 22513 523.41 497.24 571.83 560.40 560.40 549.18 22514 6,539.94 6,212.94 7,144.88 7,001.98 7,001.98 6,861.95 # 22514 487.68 463.30 532.80 522.13 522.13 511.69 22515 3,955.84 3,758.05 4,321.76 4,235.32 4,235.32 4,150.61 # 22515 221.76 210.67 242.27 237.43 237.43 232.68 22532 1,714.76 1,629.02 1,873.37 1,835.91 1,835.91 1,799.19 22533 1,594.67 1,514.94 1,742.18 1,707.34 1,707.34 1,673.19 22534 351.69 334.11 384.23 376.54 376.54 369.01 22548 1,898.13 1,803.22 2,073.70 2,032.23 2,032.23 1,991.59

Page 38: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 38Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

22551 1,653.03 1,570.38 1,805.94 1,769.82 1,769.82 1,734.42 22552 389.89 370.40 425.96 417.44 417.44 409.09 22554 1,207.39 1,147.02 1,319.07 1,292.69 1,292.69 1,266.84 22556 1,607.64 1,527.26 1,756.35 1,721.22 1,721.22 1,686.80 22558 1,488.54 1,414.11 1,626.23 1,593.70 1,593.70 1,561.83 22585 322.00 305.90 351.79 344.75 344.75 337.85 22586 1,757.81 1,669.92 1,920.41 1,882.00 1,882.00 1,844.36 22590 1,518.75 1,442.81 1,659.23 1,626.04 1,626.04 1,593.52 22595 1,448.41 1,375.99 1,582.39 1,550.74 1,550.74 1,519.73 22600 1,235.83 1,174.04 1,350.15 1,323.14 1,323.14 1,296.68 22610 1,211.86 1,151.27 1,323.96 1,297.48 1,297.48 1,271.53 22612 1,532.94 1,456.29 1,674.73 1,641.23 1,641.23 1,608.41 22614 382.26 363.15 417.62 409.27 409.27 401.09 22630 1,507.82 1,432.43 1,647.29 1,614.35 1,614.35 1,582.06 22632 313.34 297.67 342.32 335.48 335.48 328.77 22633 1,790.27 1,700.76 1,955.87 1,916.75 1,916.75 1,878.42 22634 485.20 460.94 530.08 519.48 519.48 509.09 22800 1,299.95 1,234.95 1,420.19 1,391.79 1,391.79 1,363.96 22802 2,026.82 1,925.48 2,214.30 2,170.02 2,170.02 2,126.61 22804 2,345.27 2,228.01 2,562.21 2,510.97 2,510.97 2,460.75 22808 1,772.47 1,683.85 1,936.43 1,897.70 1,897.70 1,859.75 22810 1,963.17 1,865.01 2,144.76 2,101.87 2,101.87 2,059.83 22812 2,307.97 2,192.57 2,521.46 2,471.03 2,471.03 2,421.61 22818 2,102.15 1,997.04 2,296.60 2,250.67 2,250.67 2,205.65 22819 2,664.79 2,531.55 2,911.28 2,853.06 2,853.06 2,796.00 22830 779.33 740.36 851.41 834.38 834.38 817.70 22840 743.05 705.90 811.79 795.55 795.55 779.63 22842 745.42 708.15 814.37 798.09 798.09 782.13 22843 796.64 756.81 870.33 852.92 852.92 835.87 22844 961.41 913.34 1,050.34 1,029.33 1,029.33 1,008.75 22845 714.23 678.52 780.30 764.69 764.69 749.40 22846 741.86 704.77 810.49 794.27 794.27 778.39 22847 808.56 768.13 883.35 865.69 865.69 848.37 22848 351.26 333.70 383.76 376.08 376.08 368.56 22849 1,253.62 1,190.94 1,369.58 1,342.19 1,342.19 1,315.35 22850 692.62 657.99 756.69 741.55 741.55 726.72 22851 398.23 378.32 435.07 426.36 426.36 417.84 22852 663.89 630.70 725.31 710.80 710.80 696.59 22855 1,066.52 1,013.19 1,165.17 1,141.87 1,141.87 1,119.03 22856 1,565.61 1,487.33 1,710.43 1,676.22 1,676.22 1,642.69 22857 1,880.85 1,786.81 2,054.83 2,013.73 2,013.73 1,973.46 22858 490.82 466.28 536.22 525.49 525.49 514.98 22861 1,960.08 1,862.08 2,141.39 2,098.57 2,098.57 2,056.59 22862 1,928.37 1,831.95 2,106.74 2,064.61 2,064.61 2,023.31 22864 1,985.10 1,885.85 2,168.73 2,125.35 2,125.35 2,082.85 22865 1,979.81 1,880.82 2,162.94 2,119.68 2,119.68 2,077.29 22900 541.49 514.42 591.58 579.75 579.75 568.16 22901 639.08 607.13 698.20 684.24 684.24 670.55 22902 409.61 389.13 447.50 438.55 438.55 429.78

Page 39: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 39Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 22902 315.32 299.55 344.48 337.59 337.59 330.84 22903 420.44 399.42 459.33 450.14 450.14 441.14 22904 1,011.90 961.31 1,105.51 1,083.39 1,083.39 1,061.73 22905 1,285.11 1,220.85 1,403.98 1,375.89 1,375.89 1,348.38 23000 539.19 512.23 589.06 577.29 577.29 565.74 # 23000 350.61 333.08 383.04 375.38 375.38 367.87 23020 655.38 622.61 716.00 701.68 701.68 687.65 23030 407.02 386.67 444.67 435.78 435.78 427.06 # 23030 243.73 231.54 266.27 260.95 260.95 255.73 23031 390.32 370.80 426.42 417.89 417.89 409.53 # 23031 207.99 197.59 227.23 222.69 222.69 218.24 23035 643.93 611.73 703.49 689.43 689.43 675.64 23040 684.63 650.40 747.96 733.00 733.00 718.34 23044 540.59 513.56 590.59 578.78 578.78 567.20 23065 203.09 192.94 221.88 217.44 217.44 213.10 # 23065 160.01 152.01 174.81 171.32 171.32 167.89 23066 512.71 487.07 560.13 548.93 548.93 537.95 # 23066 336.93 320.08 368.09 360.73 360.73 353.52 23071 401.14 381.08 438.24 429.48 429.48 420.89 23073 664.42 631.20 725.88 711.37 711.37 697.14 23075 434.81 413.07 475.03 465.53 465.53 456.22 # 23075 309.93 294.43 338.59 331.82 331.82 325.19 23076 514.99 489.24 562.63 551.38 551.38 540.35 23077 1,102.21 1,047.10 1,204.17 1,180.08 1,180.08 1,156.49 23078 1,383.53 1,314.35 1,511.50 1,481.27 1,481.27 1,451.65 23100 471.07 447.52 514.65 504.36 504.36 494.27 23101 430.06 408.56 469.84 460.45 460.45 451.24 23105 605.89 575.60 661.94 648.70 648.70 635.73 23106 465.15 441.89 508.17 498.01 498.01 488.05 23107 626.62 595.29 684.58 670.89 670.89 657.47 23120 553.11 525.45 604.27 592.18 592.18 580.34 23125 674.98 641.23 737.41 722.67 722.67 708.22 23130 577.91 549.01 631.36 618.73 618.73 606.36 23140 507.20 481.84 554.12 543.03 543.03 532.17 23145 661.22 628.16 722.38 707.94 707.94 693.78 23146 588.30 558.89 642.72 629.87 629.87 617.27 23150 624.67 593.44 682.46 668.81 668.81 655.43 23155 755.44 717.67 825.32 808.82 808.82 792.64 23156 642.77 610.63 702.22 688.18 688.18 674.42 23170 526.26 499.95 574.94 563.44 563.44 552.17 23172 536.51 509.68 586.13 574.41 574.41 562.93 23174 713.08 677.43 779.04 763.46 763.46 748.19 23180 633.88 602.19 692.52 678.67 678.67 665.10 23182 618.64 587.71 675.87 662.35 662.35 649.11 23184 698.68 663.75 763.31 748.05 748.05 733.09 23190 539.32 512.35 589.20 577.42 577.42 565.87 23195 716.70 680.87 783.00 767.34 767.34 752.00 23200 1,429.94 1,358.44 1,562.21 1,530.96 1,530.96 1,500.34 23210 1,706.74 1,621.40 1,864.61 1,827.32 1,827.32 1,790.77

Page 40: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 40Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

23220 1,870.10 1,776.60 2,043.09 2,002.23 2,002.23 1,962.19 23330 220.16 209.15 240.52 235.72 235.72 231.00 # 23330 142.73 135.59 155.93 152.81 152.81 149.75 23333 430.11 408.60 469.89 460.49 460.49 451.28 23334 1,030.27 978.76 1,125.57 1,103.06 1,103.06 1,081.00 23335 1,228.27 1,166.86 1,341.89 1,315.05 1,315.05 1,288.75 23350 120.17 114.16 131.28 128.66 128.66 126.09 # 23350 50.23 47.72 54.88 53.79 53.79 52.70 23395 1,230.12 1,168.61 1,343.90 1,317.03 1,317.03 1,290.69 23397 1,092.75 1,038.11 1,193.83 1,169.95 1,169.95 1,146.55 23400 928.32 881.90 1,014.19 993.90 993.90 974.02 23405 594.70 564.97 649.72 636.72 636.72 623.99 23406 734.31 697.59 802.23 786.19 786.19 770.47 23410 783.70 744.52 856.20 839.07 839.07 822.30 23412 813.40 772.73 888.64 870.87 870.87 853.45 23415 661.83 628.74 723.05 708.60 708.60 694.43 23420 924.75 878.51 1,010.29 990.08 990.08 970.28 23430 710.22 674.71 775.92 760.40 760.40 745.20 23440 720.82 684.78 787.50 771.74 771.74 756.31 23450 903.88 858.69 987.49 967.75 967.75 948.39 23455 957.27 909.41 1,045.82 1,024.90 1,024.90 1,004.41 23460 1,043.87 991.68 1,140.43 1,117.63 1,117.63 1,095.27 23462 1,016.12 965.31 1,110.11 1,087.90 1,087.90 1,066.14 23465 1,065.52 1,012.24 1,164.08 1,140.80 1,140.80 1,117.98 23466 1,068.79 1,015.35 1,167.65 1,144.30 1,144.30 1,121.41 23470 1,154.44 1,096.72 1,261.23 1,236.01 1,236.01 1,211.28 23472 1,400.89 1,330.85 1,530.48 1,499.86 1,499.86 1,469.87 23473 1,565.74 1,487.45 1,710.57 1,676.36 1,676.36 1,642.83 23474 1,692.42 1,607.80 1,848.97 1,811.99 1,811.99 1,775.75 23480 783.49 744.32 855.97 838.84 838.84 822.07 23485 913.53 867.85 998.03 978.06 978.06 958.50 23490 805.39 765.12 879.89 862.29 862.29 845.04 23491 968.21 919.80 1,057.77 1,036.61 1,036.61 1,015.88 23500 203.25 193.09 222.05 217.61 217.61 213.27 # 23500 206.68 196.35 225.80 221.28 221.28 216.86 23505 329.94 313.44 360.46 353.25 353.25 346.18 # 23505 312.77 297.13 341.70 334.87 334.87 328.18 23515 685.11 650.85 748.48 733.50 733.50 718.83 23520 208.79 198.35 228.10 223.54 223.54 219.06 # 23520 211.91 201.31 231.51 226.87 226.87 222.33 23525 350.02 332.52 382.40 374.75 374.75 367.25 # 23525 325.05 308.80 355.12 348.01 348.01 341.06 23530 523.92 497.72 572.38 560.94 560.94 549.71 23532 588.82 559.38 643.29 630.42 630.42 617.81 23540 209.22 198.76 228.57 224.00 224.00 219.51 # 23540 212.65 202.02 232.32 227.68 227.68 223.12 23545 316.14 300.33 345.38 338.47 338.47 331.69 # 23545 288.98 274.53 315.71 309.40 309.40 303.21 23550 536.06 509.26 585.65 573.93 573.93 562.45

Page 41: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 41Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

23552 622.64 591.51 680.24 666.63 666.63 653.30 23570 215.95 205.15 235.92 231.21 231.21 226.58 # 23570 222.19 211.08 242.74 237.89 237.89 233.13 23575 372.63 354.00 407.10 398.96 398.96 390.98 # 23575 350.77 333.23 383.21 375.56 375.56 368.05 23585 938.62 891.69 1,025.44 1,004.94 1,004.94 984.84 23600 302.25 287.14 330.21 323.61 323.61 317.14 # 23600 285.70 271.42 312.13 305.89 305.89 299.77 23605 433.26 411.60 473.34 463.88 463.88 454.60 # 23605 399.23 379.27 436.16 427.43 427.43 418.89 23615 843.63 801.45 921.67 903.23 903.23 885.17 23616 1,190.97 1,131.42 1,301.13 1,275.11 1,275.11 1,249.60 23620 249.83 237.34 272.94 267.48 267.48 262.13 # 23620 238.28 226.37 260.33 255.12 255.12 250.01 23625 353.83 336.14 386.56 378.83 378.83 371.25 # 23625 330.73 314.19 361.32 354.10 354.10 347.01 23630 743.63 706.45 812.42 796.17 796.17 780.24 23650 292.87 278.23 319.96 313.57 313.57 307.30 # 23650 270.39 256.87 295.40 289.49 289.49 283.71 23655 377.39 358.52 412.30 404.05 404.05 395.97 23660 551.77 524.18 602.81 590.76 590.76 578.94 23665 396.99 377.14 433.71 425.04 425.04 416.54 # 23665 371.39 352.82 405.74 397.62 397.62 389.67 23670 835.73 793.94 913.03 894.77 894.77 876.88 23675 516.20 490.39 563.95 552.67 552.67 541.62 # 23675 473.11 449.45 516.87 506.53 506.53 496.40 23680 886.45 842.13 968.45 949.08 949.08 930.10 23700 186.43 177.11 203.68 199.61 199.61 195.62 23800 981.40 932.33 1,072.18 1,050.73 1,050.73 1,029.72 23802 1,209.81 1,149.32 1,321.72 1,295.28 1,295.28 1,269.37 23900 1,332.83 1,266.19 1,456.12 1,427.00 1,427.00 1,398.46 23920 1,075.44 1,021.67 1,174.92 1,151.43 1,151.43 1,128.40 23921 442.26 420.15 483.17 473.51 473.51 464.05 23930 326.37 310.05 356.56 349.43 349.43 342.44 # 23930 205.54 195.26 224.55 220.05 220.05 215.65 23931 262.89 249.75 287.21 281.47 281.47 275.84 # 23931 150.49 142.97 164.42 161.13 161.13 157.91 23935 478.84 454.90 523.14 512.67 512.67 502.41 24000 451.12 428.56 492.84 482.99 482.99 473.33 24006 672.42 638.80 734.62 719.92 719.92 705.53 24065 237.05 225.20 258.98 253.81 253.81 248.73 # 24065 159.31 151.34 174.04 170.56 170.56 167.14 24066 578.28 549.37 631.78 619.14 619.14 606.75 # 24066 394.39 374.67 430.87 422.26 422.26 413.82 24071 387.91 368.51 423.79 415.31 415.31 407.01 24073 663.00 629.85 724.33 709.84 709.84 695.65 24075 454.33 431.61 496.35 486.43 486.43 476.70 # 24075 313.21 297.55 342.18 335.34 335.34 328.64 24076 517.31 491.44 565.16 553.85 553.85 542.78

Page 42: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 42Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

24077 994.88 945.14 1,086.91 1,065.18 1,065.18 1,043.88 24079 1,273.81 1,210.12 1,391.64 1,363.81 1,363.81 1,336.53 24100 394.37 374.65 430.85 422.23 422.23 413.79 24101 473.20 449.54 516.97 506.63 506.63 496.50 24102 585.47 556.20 639.63 626.84 626.84 614.31 24105 328.38 311.96 358.75 351.58 351.58 344.55 24110 550.21 522.70 601.11 589.09 589.09 577.31 24115 702.51 667.38 767.49 752.13 752.13 737.09 24116 823.70 782.52 899.90 881.90 881.90 864.26 24120 500.96 475.91 547.30 536.35 536.35 525.62 24125 582.80 553.66 636.71 623.98 623.98 611.50 24126 616.88 586.04 673.95 660.47 660.47 647.25 24130 480.53 456.50 524.98 514.48 514.48 504.18 24134 710.83 675.29 776.58 761.05 761.05 745.82 24136 595.23 565.47 650.29 637.28 637.28 624.54 24138 636.42 604.60 695.29 681.39 681.39 667.76 24140 666.19 632.88 727.81 713.25 713.25 698.99 24145 562.12 534.01 614.11 601.83 601.83 589.79 24147 587.97 558.57 642.36 629.51 629.51 616.92 24149 1,119.88 1,063.89 1,223.47 1,199.00 1,199.00 1,175.02 24150 1,497.26 1,422.40 1,635.76 1,603.04 1,603.04 1,570.98 24152 1,273.21 1,209.55 1,390.98 1,363.16 1,363.16 1,335.90 24155 806.42 766.10 881.02 863.40 863.40 846.12 24160 1,212.06 1,151.46 1,324.18 1,297.69 1,297.69 1,271.74 24164 695.80 661.01 760.16 744.96 744.96 730.05 24200 191.67 182.09 209.40 205.22 205.22 201.11 # 24200 132.67 126.04 144.95 142.05 142.05 139.21 24201 504.93 479.68 551.63 540.60 540.60 529.79 # 24201 342.58 325.45 374.27 366.78 366.78 359.44 24220 148.01 140.61 161.70 158.47 158.47 155.30 # 24220 67.78 64.39 74.05 72.57 72.57 71.12 24300 389.18 369.72 425.18 416.68 416.68 408.34 24301 714.00 678.30 780.05 764.44 764.44 749.16 24305 546.92 519.57 597.51 585.56 585.56 573.85 24310 446.82 424.48 488.15 478.39 478.39 468.82 24320 744.83 707.59 813.73 797.46 797.46 781.51 24330 683.39 649.22 746.60 731.68 731.68 717.05 24331 749.87 712.38 819.24 802.85 802.85 786.80 24332 579.98 550.98 633.63 620.95 620.95 608.53 24340 581.23 552.17 635.00 622.30 622.30 609.86 24341 707.13 671.77 772.54 757.08 757.08 741.93 24342 739.62 702.64 808.04 791.88 791.88 776.04 24343 669.39 635.92 731.31 716.68 716.68 702.35 24344 1,045.20 992.94 1,141.88 1,119.04 1,119.04 1,096.66 24345 667.15 633.79 728.86 714.28 714.28 699.99 24346 1,043.69 991.51 1,140.24 1,117.43 1,117.43 1,095.09 24357 406.16 385.85 443.73 434.85 434.85 426.16 24358 494.12 469.41 539.82 529.02 529.02 518.44 24359 626.89 595.55 684.88 671.19 671.19 657.77

Page 43: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 43Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

24360 846.12 803.81 924.38 905.89 905.89 887.78 24361 953.99 906.29 1,042.23 1,021.38 1,021.38 1,000.96 24362 1,014.69 963.96 1,108.55 1,086.38 1,086.38 1,064.66 24363 1,398.10 1,328.20 1,527.43 1,496.89 1,496.89 1,466.95 24365 605.12 574.86 661.09 647.86 647.86 634.90 24366 647.09 614.74 706.95 692.82 692.82 678.96 24370 1,493.04 1,418.39 1,631.15 1,598.52 1,598.52 1,566.55 24371 1,715.79 1,630.00 1,874.50 1,837.01 1,837.01 1,800.27 24400 778.20 739.29 850.18 833.18 833.18 816.51 24410 1,011.02 960.47 1,104.54 1,082.45 1,082.45 1,060.79 24420 936.22 889.41 1,022.82 1,002.36 1,002.36 982.32 24430 1,010.49 959.97 1,103.97 1,081.89 1,081.89 1,060.24 24435 1,027.49 976.12 1,122.54 1,100.09 1,100.09 1,078.09 24470 545.22 517.96 595.65 583.74 583.74 572.07 24495 617.93 587.03 675.08 661.58 661.58 648.35 24498 826.99 785.64 903.49 885.42 885.42 867.71 24500 332.04 315.44 362.76 355.50 355.50 348.39 # 24500 303.94 288.74 332.05 325.42 325.42 318.91 24505 466.11 442.80 509.22 499.03 499.03 489.05 # 24505 424.28 403.07 463.53 454.26 454.26 445.18 24515 835.11 793.35 912.35 894.10 894.10 876.22 24516 821.56 780.48 897.55 879.60 879.60 862.01 24530 353.11 335.45 385.77 378.05 378.05 370.50 # 24530 321.57 305.49 351.31 344.29 344.29 337.40 24535 576.04 547.24 629.33 616.75 616.75 604.41 # 24535 534.82 508.08 584.29 572.61 572.61 561.15 24538 705.53 670.25 770.79 755.38 755.38 740.27 24545 887.36 842.99 969.44 950.05 950.05 931.05 24546 993.46 943.79 1,085.36 1,063.65 1,063.65 1,042.37 24560 296.37 281.55 323.78 317.31 317.31 310.96 # 24560 267.02 253.67 291.72 285.89 285.89 280.17 24565 495.28 470.52 541.10 530.28 530.28 519.67 # 24565 457.19 434.33 499.48 489.49 489.49 479.70 24566 679.21 645.25 742.04 727.20 727.20 712.66 24575 693.69 659.01 757.86 742.70 742.70 727.85 24576 314.08 298.38 343.14 336.27 336.27 329.54 # 24576 283.79 269.60 310.04 303.84 303.84 297.77 24577 508.79 483.35 555.85 544.73 544.73 533.84 # 24577 469.45 445.98 512.88 502.62 502.62 492.57 24579 795.85 756.06 869.47 852.08 852.08 835.04 24582 762.51 724.38 833.04 816.37 816.37 800.04 24586 1,036.74 984.90 1,132.64 1,109.98 1,109.98 1,087.79 24587 1,034.85 983.11 1,130.58 1,107.97 1,107.97 1,085.81 24600 341.27 324.21 372.84 365.39 365.39 358.09 # 24600 314.42 298.70 343.51 336.64 336.64 329.91 24605 442.69 420.56 483.64 473.97 473.97 464.50 24615 678.23 644.32 740.97 726.14 726.14 711.62 24620 520.28 494.27 568.41 557.04 557.04 545.89 24635 638.44 606.52 697.50 683.55 683.55 669.88

Page 44: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 44Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

24640 124.76 118.52 136.30 133.57 133.57 130.90 # 24640 87.29 82.93 95.37 93.46 93.46 91.59 24650 241.43 229.36 263.76 258.49 258.49 253.31 # 24650 222.70 211.57 243.31 238.44 238.44 233.67 24655 405.43 385.16 442.93 434.08 434.08 425.40 # 24655 371.40 352.83 405.75 397.64 397.64 389.68 24665 617.37 586.50 674.48 660.99 660.99 647.76 24666 696.79 661.95 761.24 746.02 746.02 731.10 24670 269.18 255.72 294.08 288.20 288.20 282.44 # 24670 244.51 232.28 267.12 261.77 261.77 256.54 24675 423.69 402.51 462.89 453.63 453.63 444.56 # 24675 388.72 369.28 424.67 416.17 416.17 407.85 24685 619.52 588.54 676.82 663.29 663.29 650.01 24800 790.44 750.92 863.56 846.29 846.29 829.36 24802 937.09 890.24 1,023.78 1,003.31 1,003.31 983.24 24900 697.22 662.36 761.71 746.48 746.48 731.55 24920 696.79 661.95 761.24 746.02 746.02 731.10 24925 520.97 494.92 569.16 557.77 557.77 546.62 24930 733.39 696.72 801.23 785.21 785.21 769.50 24931 775.86 737.07 847.63 830.68 830.68 814.06 24935 1,063.02 1,009.87 1,161.35 1,138.12 1,138.12 1,115.36 25000 314.74 299.00 343.85 336.97 336.97 330.23 25001 320.47 304.45 350.12 343.11 343.11 336.25 25020 537.03 510.18 586.71 574.98 574.98 563.48 25023 1,040.40 988.38 1,136.64 1,113.90 1,113.90 1,091.63 25024 736.27 699.46 804.38 788.29 788.29 772.52 25025 1,155.32 1,097.55 1,262.18 1,236.94 1,236.94 1,212.20 25028 488.48 464.06 533.67 523.00 523.00 512.53 25031 337.85 320.96 369.10 361.72 361.72 354.49 25035 548.74 521.30 599.50 587.50 587.50 575.75 25040 533.54 506.86 582.89 571.23 571.23 559.81 25065 234.54 222.81 256.23 251.10 251.10 246.08 # 25065 154.92 147.17 169.25 165.86 165.86 162.55 25066 338.18 321.27 369.46 362.07 362.07 354.82 25071 406.05 385.75 443.61 434.75 434.75 426.05 25073 505.48 480.21 552.24 541.20 541.20 530.38 25075 441.75 419.66 482.61 472.96 472.96 463.50 # 25075 299.69 284.71 327.42 320.87 320.87 314.46 25076 489.69 465.21 534.99 524.30 524.30 513.81 25077 846.94 804.59 925.28 906.78 906.78 888.64 25078 1,117.44 1,061.57 1,220.81 1,196.39 1,196.39 1,172.46 25085 424.43 403.21 463.69 454.42 454.42 445.34 25100 324.35 308.13 354.35 347.27 347.27 340.32 25101 379.35 360.38 414.44 406.15 406.15 398.03 25105 455.13 432.37 497.23 487.28 487.28 477.54 25107 581.21 552.15 634.97 622.28 622.28 609.83 25109 508.60 483.17 555.65 544.54 544.54 533.65 25110 321.99 305.89 351.77 344.74 344.74 337.84 25111 299.95 284.95 327.69 321.14 321.14 314.72

Page 45: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 45Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

25112 363.92 345.72 397.58 389.63 389.63 381.83 25115 719.27 683.31 785.81 770.09 770.09 754.69 25116 566.37 538.05 618.76 606.38 606.38 594.25 25118 358.67 340.74 391.85 384.02 384.02 376.34 25119 466.81 443.47 509.99 499.79 499.79 489.80 25120 469.50 446.03 512.93 502.68 502.68 492.63 25125 550.43 522.91 601.35 589.32 589.32 577.53 25126 562.82 534.68 614.88 602.59 602.59 590.54 25130 420.31 399.29 459.18 450.00 450.00 440.99 25135 523.36 497.19 571.77 560.34 560.34 549.14 25136 462.39 439.27 505.16 495.05 495.05 485.15 25145 488.98 464.53 534.21 523.53 523.53 513.06 25150 536.23 509.42 585.83 574.11 574.11 562.64 25151 552.97 525.32 604.12 592.03 592.03 580.19 25170 1,421.69 1,350.61 1,553.20 1,522.14 1,522.14 1,491.70 25210 460.01 437.01 502.56 492.51 492.51 482.66 25215 584.91 555.66 639.01 626.23 626.23 613.71 25230 408.06 387.66 445.81 436.90 436.90 428.16 25240 403.32 383.15 440.62 431.81 431.81 423.18 25246 150.19 142.68 164.08 160.80 160.80 157.58 # 25246 74.01 70.31 80.86 79.24 79.24 77.65 25248 393.20 373.54 429.57 420.98 420.98 412.56 25250 495.72 470.93 541.57 530.74 530.74 520.12 25251 682.23 648.12 745.34 730.43 730.43 715.83 25259 386.39 367.07 422.13 413.69 413.69 405.42 25260 595.66 565.88 650.76 637.74 637.74 624.99 25263 587.94 558.54 642.32 629.48 629.48 616.88 25265 710.39 674.87 776.10 760.58 760.58 745.36 25270 462.03 438.93 504.77 494.67 494.67 484.78 25272 523.24 497.08 571.64 560.21 560.21 549.01 25274 629.97 598.47 688.24 674.48 674.48 660.99 25275 637.21 605.35 696.15 682.23 682.23 668.59 25280 533.29 506.63 582.62 570.98 570.98 559.56 25290 411.77 391.18 449.86 440.86 440.86 432.04 25295 494.76 470.02 540.52 529.71 529.71 519.12 25300 646.26 613.95 706.04 691.92 691.92 678.09 25301 610.03 579.53 666.46 653.13 653.13 640.07 25310 586.84 557.50 641.13 628.30 628.30 615.73 25312 679.85 645.86 742.74 727.88 727.88 713.32 25315 733.92 697.22 801.80 785.77 785.77 770.05 25316 872.28 828.67 952.97 933.92 933.92 915.24 25320 934.58 887.85 1,021.03 1,000.60 1,000.60 980.59 25332 801.25 761.19 875.37 857.87 857.87 840.71 25335 780.03 741.03 852.18 835.14 835.14 818.44 25337 843.04 800.89 921.02 902.60 902.60 884.55 25350 639.65 607.67 698.82 684.85 684.85 671.15 25355 716.68 680.85 782.98 767.31 767.31 751.97 25360 620.31 589.29 677.68 664.13 664.13 650.84 25365 870.14 826.63 950.62 931.62 931.62 912.99

Page 46: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 46Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

25370 959.88 911.89 1,048.67 1,027.70 1,027.70 1,007.15 25375 909.87 864.38 994.04 974.15 974.15 954.67 25390 732.38 695.76 800.12 784.12 784.12 768.43 25391 951.83 904.24 1,039.88 1,019.08 1,019.08 998.71 25392 841.24 799.18 919.06 900.68 900.68 882.67 25393 1,083.75 1,029.56 1,183.99 1,160.32 1,160.32 1,137.11 25394 742.48 705.36 811.16 794.94 794.94 779.04 25400 765.76 727.47 836.59 819.86 819.86 803.46 25405 990.79 941.25 1,082.44 1,060.79 1,060.79 1,039.58 25415 919.48 873.51 1,004.54 984.45 984.45 964.76 25420 1,116.45 1,060.63 1,219.72 1,195.33 1,195.33 1,171.42 25425 919.91 873.91 1,005.00 984.89 984.89 965.20 25426 1,076.37 1,022.55 1,175.93 1,152.42 1,152.42 1,129.37 25430 694.63 659.90 758.89 743.71 743.71 728.84 25431 748.67 711.24 817.93 801.57 801.57 785.54 25440 729.50 693.03 796.98 781.05 781.05 765.43 25441 891.48 846.91 973.95 954.47 954.47 935.38 25442 766.72 728.38 837.64 820.88 820.88 804.46 25443 743.71 706.52 812.50 796.25 796.25 780.32 25444 787.05 747.70 859.86 842.66 842.66 825.82 25445 686.35 652.03 749.83 734.84 734.84 720.14 25446 1,120.06 1,064.06 1,223.67 1,199.20 1,199.20 1,175.21 25447 785.72 746.43 858.39 841.23 841.23 824.40 25449 986.74 937.40 1,078.01 1,056.45 1,056.45 1,035.32 25450 497.86 472.97 543.92 533.04 533.04 522.38 25455 590.33 560.81 644.93 632.03 632.03 619.39 25490 683.77 649.58 747.02 732.08 732.08 717.44 25491 704.21 669.00 769.35 753.96 753.96 738.89 25492 862.58 819.45 942.37 923.52 923.52 905.05 25500 253.26 240.60 276.69 271.16 271.16 265.73 # 25500 233.60 221.92 255.21 250.10 250.10 245.10 25505 469.65 446.17 513.10 502.84 502.84 492.79 # 25505 432.50 410.88 472.51 463.06 463.06 453.80 25515 634.70 602.97 693.42 679.55 679.55 665.95 25520 524.53 498.30 573.05 561.58 561.58 550.34 # 25520 499.55 474.57 545.76 534.84 534.84 524.15 25525 745.49 708.22 814.45 798.17 798.17 782.21 25526 906.15 860.84 989.97 970.16 970.16 950.76 25530 241.73 229.64 264.09 258.81 258.81 253.63 # 25530 220.19 209.18 240.56 235.75 235.75 231.04 25535 456.98 434.13 499.25 489.27 489.27 479.48 # 25535 425.13 403.87 464.45 455.16 455.16 446.05 25545 589.44 559.97 643.97 631.09 631.09 618.46 25560 256.99 244.14 280.76 275.15 275.15 269.64 # 25560 233.58 221.90 255.19 250.08 250.08 245.08 25565 485.94 461.64 530.89 520.27 520.27 509.86 # 25565 442.54 420.41 483.47 473.80 473.80 464.32 25574 637.51 605.63 696.47 682.55 682.55 668.90 25575 857.32 814.45 936.62 917.88 917.88 899.53

Page 47: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 47Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

25600 302.35 287.23 330.31 323.71 323.71 317.24 # 25600 286.73 272.39 313.25 306.98 306.98 300.84 25605 511.28 485.72 558.58 547.41 547.41 536.46 # 25605 482.87 458.73 527.54 516.99 516.99 506.66 25606 626.63 595.30 684.60 670.90 670.90 657.48 25607 696.52 661.69 760.94 745.73 745.73 730.81 25608 782.59 743.46 854.98 837.88 837.88 821.12 25609 996.52 946.69 1,088.69 1,066.92 1,066.92 1,045.58 25622 281.22 267.16 307.23 301.09 301.09 295.07 # 25622 257.49 244.62 281.31 275.69 275.69 270.18 25624 442.01 419.91 482.90 473.24 473.24 463.77 # 25624 405.17 384.91 442.65 433.79 433.79 425.12 25628 684.36 650.14 747.66 732.71 732.71 718.06 25630 283.11 268.95 309.29 303.11 303.11 297.05 # 25630 261.57 248.49 285.76 280.05 280.05 274.45 25635 397.80 377.91 434.60 425.90 425.90 417.38 # 25635 357.84 339.95 390.94 383.12 383.12 375.46 25645 537.56 510.68 587.28 575.54 575.54 564.03 25650 297.40 282.53 324.91 318.41 318.41 312.04 # 25650 279.92 265.92 305.81 299.69 299.69 293.70 25651 456.19 433.38 498.39 488.42 488.42 478.65 25652 590.85 561.31 645.51 632.59 632.59 619.94 25660 383.90 364.71 419.42 411.03 411.03 402.81 25670 575.17 546.41 628.37 615.80 615.80 603.49 25671 499.96 474.96 546.20 535.28 535.28 524.57 25675 405.53 385.25 443.04 434.18 434.18 425.50 # 25675 372.12 353.51 406.54 398.41 398.41 390.44 25676 594.40 564.68 649.38 636.40 636.40 623.67 25680 447.60 425.22 489.00 479.23 479.23 469.65 25685 697.23 662.37 761.73 746.49 746.49 731.56 25690 448.05 425.65 489.50 479.71 479.71 470.12 25695 601.81 571.72 657.48 644.33 644.33 631.44 25800 696.07 661.27 760.46 745.25 745.25 730.34 25805 804.88 764.64 879.34 861.75 861.75 844.51 25810 825.29 784.03 901.63 883.60 883.60 865.93 25820 580.34 551.32 634.02 621.33 621.33 608.90 25825 716.18 680.37 782.43 766.77 766.77 751.43 25830 888.60 844.17 970.80 951.38 951.38 932.35 25900 673.30 639.64 735.59 720.88 720.88 706.46 25905 618.58 587.65 675.80 662.29 662.29 649.04 25907 553.72 526.03 604.93 592.84 592.84 580.98 25909 651.50 618.93 711.77 697.53 697.53 683.58 25915 1,130.22 1,073.71 1,234.77 1,210.08 1,210.08 1,185.88 25920 657.85 624.96 718.70 704.33 704.33 690.24 25922 543.96 516.76 594.27 582.38 582.38 570.73 25924 580.95 551.90 634.69 621.99 621.99 609.55 25927 762.63 724.50 833.18 816.51 816.51 800.18 25929 560.49 532.47 612.34 600.09 600.09 588.09 25931 624.99 593.74 682.80 669.15 669.15 655.76

Page 48: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 48Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

26010 240.19 228.18 262.41 257.16 257.16 252.02 # 26010 129.04 122.59 140.98 138.16 138.16 135.40 26011 354.16 336.45 386.92 379.18 379.18 371.60 # 26011 174.32 165.60 190.44 186.63 186.63 182.90 26020 407.78 387.39 445.50 436.59 436.59 427.86 26025 397.79 377.90 434.59 425.89 425.89 417.37 26030 464.78 441.54 507.77 497.62 497.62 487.67 26034 506.76 481.42 553.63 542.56 542.56 531.70 26035 810.77 770.23 885.76 868.05 868.05 850.69 26037 537.84 510.95 587.59 575.84 575.84 564.33 26040 291.71 277.12 318.69 312.32 312.32 306.07 26045 441.82 419.73 482.69 473.04 473.04 463.58 26055 506.86 481.52 553.75 542.67 542.67 531.82 # 26055 288.94 274.49 315.66 309.35 309.35 303.16 26060 247.91 235.51 270.84 265.42 265.42 260.11 26070 295.44 280.67 322.77 316.32 316.32 309.99 26075 312.56 296.93 341.47 334.64 334.64 327.95 26080 366.32 348.00 400.20 392.20 392.20 384.35 26100 312.81 297.17 341.75 334.91 334.91 328.22 26105 312.51 296.88 341.41 334.58 334.58 327.89 26110 301.18 286.12 329.04 322.46 322.46 316.01 26111 395.75 375.96 432.35 423.71 423.71 415.23 26113 519.24 493.28 567.27 555.92 555.92 544.80 26115 463.51 440.33 506.38 496.25 496.25 486.32 # 26115 313.34 297.67 342.32 335.48 335.48 328.77 26116 498.57 473.64 544.69 533.80 533.80 523.12 26117 711.82 676.23 777.66 762.12 762.12 746.88 26118 1,002.41 952.29 1,095.13 1,073.23 1,073.23 1,051.77 26121 565.00 536.75 617.26 604.92 604.92 592.83 26123 789.86 750.37 862.93 845.66 845.66 828.75 26125 265.70 252.42 290.28 284.48 284.48 278.78 26130 435.85 414.06 476.17 466.65 466.65 457.31 26135 519.66 493.68 567.73 556.38 556.38 545.25 26140 475.76 451.97 519.77 509.37 509.37 499.18 26145 483.15 458.99 527.84 517.28 517.28 506.93 26160 523.11 496.95 571.49 560.06 560.06 548.86 # 26160 312.05 296.45 340.92 334.10 334.10 327.42 26170 381.05 362.00 416.30 407.97 407.97 399.81 26180 416.59 395.76 455.12 446.02 446.02 437.09 26185 511.91 486.31 559.26 548.07 548.07 537.11 26200 424.87 403.63 464.17 454.89 454.89 445.80 26205 571.64 543.06 624.52 612.03 612.03 599.79 26210 416.01 395.21 454.49 445.41 445.41 436.49 26215 533.41 506.74 582.75 571.10 571.10 559.68 26230 471.67 448.09 515.30 505.00 505.00 494.90 26235 466.40 443.08 509.54 499.35 499.35 489.37 26236 416.25 395.44 454.76 445.66 445.66 436.75 26250 1,028.21 976.80 1,123.32 1,100.85 1,100.85 1,078.83 26260 763.03 724.88 833.61 816.94 816.94 800.60

Page 49: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 49Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

26262 593.64 563.96 648.55 635.58 635.58 622.87 26320 326.13 309.82 356.29 349.16 349.16 342.18 26340 308.31 292.89 336.82 330.08 330.08 323.48 26341 91.43 86.86 99.89 97.89 97.89 95.93 # 26341 70.52 66.99 77.04 75.50 75.50 73.99 26350 650.34 617.82 710.49 696.28 696.28 682.35 26352 752.79 715.15 822.42 805.98 805.98 789.85 26356 819.83 778.84 895.67 877.75 877.75 860.19 26357 810.43 769.91 885.40 867.69 867.69 850.33 26358 902.37 857.25 985.84 966.13 966.13 946.81 26370 695.05 660.30 759.35 744.15 744.15 729.27 26372 811.38 770.81 886.43 868.70 868.70 851.32 26373 778.23 739.32 850.22 833.21 833.21 816.55 26390 777.50 738.63 849.42 832.44 832.44 815.79 26392 895.95 851.15 978.82 959.25 959.25 940.07 26410 516.11 490.30 563.85 552.56 552.56 541.51 26412 625.19 593.93 683.02 669.36 669.36 655.97 26415 711.89 676.30 777.75 762.19 762.19 746.94 26416 677.93 644.03 740.63 725.82 725.82 711.31 26418 524.92 498.67 573.47 562.01 562.01 550.77 26420 649.98 617.48 710.10 695.90 695.90 681.98 26426 472.83 449.19 516.57 506.24 506.24 496.12 26428 693.74 659.05 757.91 742.75 742.75 727.89 26432 454.67 431.94 496.73 486.80 486.80 477.05 26433 485.59 461.31 530.51 519.89 519.89 509.50 26434 594.44 564.72 649.43 636.44 636.44 623.71 26437 571.39 542.82 624.24 611.75 611.75 599.52 26440 564.02 535.82 616.19 603.87 603.87 591.79 26442 888.06 843.66 970.21 950.81 950.81 931.79 26445 523.61 497.43 572.04 560.60 560.60 549.39 26449 654.89 622.15 715.47 701.17 701.17 687.15 26450 374.17 355.46 408.78 400.60 400.60 392.59 26455 368.55 350.12 402.64 394.59 394.59 386.70 26460 360.83 342.79 394.21 386.32 386.32 378.59 26471 563.08 534.93 615.17 602.86 602.86 590.81 26474 550.99 523.44 601.96 589.92 589.92 578.12 26476 529.81 503.32 578.82 567.24 567.24 555.90 26477 531.29 504.73 580.44 568.84 568.84 557.46 26478 569.22 540.76 621.87 609.43 609.43 597.24 26479 562.13 534.02 614.12 601.84 601.84 589.80 26480 687.79 653.40 751.41 736.38 736.38 721.65 26483 776.07 737.27 847.86 830.90 830.90 814.28 26485 741.88 704.79 810.51 794.29 794.29 778.41 26489 842.37 800.25 920.29 901.89 901.89 883.86 26490 727.14 690.78 794.40 778.50 778.50 762.93 26492 808.39 767.97 883.17 865.50 865.50 848.19 26494 730.35 693.83 797.90 781.94 781.94 766.30 26496 795.38 755.61 868.95 851.58 851.58 834.54 26497 804.74 764.50 879.18 861.59 861.59 844.36

Page 50: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 50Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

26498 1,070.23 1,016.72 1,169.23 1,145.85 1,145.85 1,122.93 26499 770.26 731.75 841.51 824.69 824.69 808.20 26500 572.03 543.43 624.94 612.44 612.44 600.20 26502 642.24 610.13 701.65 687.62 687.62 673.87 26508 590.01 560.51 644.59 631.70 631.70 619.06 26510 544.18 516.97 594.52 582.62 582.62 570.98 26516 644.85 612.61 704.50 690.41 690.41 676.60 26517 763.51 725.33 834.13 817.44 817.44 801.09 26518 763.99 725.79 834.66 817.96 817.96 801.60 26520 593.04 563.39 647.90 634.94 634.94 622.24 26525 593.77 564.08 648.69 635.72 635.72 623.00 26530 507.02 481.67 553.92 542.85 542.85 531.99 26531 590.51 560.98 645.13 632.22 632.22 619.57 26535 397.99 378.09 434.80 426.11 426.11 417.59 26536 652.62 619.99 712.99 698.73 698.73 684.76 26540 603.96 573.76 659.82 646.62 646.62 633.68 26541 740.94 703.89 809.47 793.28 793.28 777.41 26542 623.57 592.39 681.25 667.62 667.62 654.27 26545 635.17 603.41 693.92 680.04 680.04 666.44 26546 918.74 872.80 1,003.72 983.64 983.64 963.96 26548 701.81 666.72 766.73 751.40 751.40 736.37 26550 1,461.35 1,388.28 1,596.52 1,564.59 1,564.59 1,533.30 26551 2,749.07 2,611.62 3,003.36 2,943.30 2,943.30 2,884.43 26553 3,128.16 2,971.75 3,417.51 3,349.17 3,349.17 3,282.18 26554 3,200.15 3,040.14 3,496.16 3,426.24 3,426.24 3,357.71 26555 1,259.92 1,196.92 1,376.46 1,348.93 1,348.93 1,321.95 26556 3,249.08 3,086.63 3,549.62 3,478.64 3,478.64 3,409.06 26560 515.09 489.34 562.74 551.48 551.48 540.45 26561 866.44 823.12 946.59 927.66 927.66 909.11 26562 1,259.30 1,196.34 1,375.79 1,348.27 1,348.27 1,321.30 26565 623.02 591.87 680.65 667.03 667.03 653.69 26567 626.82 595.48 684.80 671.11 671.11 657.69 26568 831.31 789.74 908.20 890.04 890.04 872.24 26580 1,381.39 1,312.32 1,509.17 1,478.98 1,478.98 1,449.40 26587 875.94 832.14 956.96 937.83 937.83 919.07 26590 1,275.53 1,211.75 1,393.51 1,365.65 1,365.65 1,338.34 26591 395.70 375.92 432.31 423.66 423.66 415.18 26593 548.61 521.18 599.36 587.37 587.37 575.62 26596 702.34 667.22 767.30 751.96 751.96 736.92 26600 271.37 257.80 296.47 290.54 290.54 284.73 # 26600 256.39 243.57 280.11 274.51 274.51 269.02 26605 297.73 282.84 325.27 318.76 318.76 312.39 # 26605 272.76 259.12 297.99 292.03 292.03 286.19 26607 427.87 406.48 467.45 458.10 458.10 448.94 26608 447.49 425.12 488.89 479.11 479.11 469.53 26615 543.55 516.37 593.83 581.95 581.95 570.31 26641 343.40 326.23 375.16 367.67 367.67 360.32 # 26641 315.30 299.54 344.47 337.58 337.58 330.83 26645 393.53 373.85 429.93 421.33 421.33 412.90

Page 51: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 51Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 26645 363.56 345.38 397.19 389.24 389.24 381.46 26650 447.57 425.19 488.97 479.19 479.19 469.61 26665 597.60 567.72 652.88 639.83 639.83 627.03 26670 316.53 300.70 345.81 338.89 338.89 332.12 # 26670 289.06 274.61 315.80 309.49 309.49 303.30 26675 420.94 399.89 459.87 450.67 450.67 441.66 # 26675 388.78 369.34 424.74 416.24 416.24 407.92 26676 469.48 446.01 512.91 502.65 502.65 492.60 26685 543.60 516.42 593.88 582.00 582.00 570.37 26686 591.36 561.79 646.06 633.13 633.13 620.47 26700 301.63 286.55 329.53 322.94 322.94 316.48 # 26700 284.46 270.24 310.78 304.57 304.57 298.47 26705 388.15 368.74 424.05 415.58 415.58 407.26 # 26705 357.56 339.68 390.63 382.82 382.82 375.16 26706 414.09 393.39 452.40 443.35 443.35 434.48 26715 539.47 512.50 589.38 577.59 577.59 566.04 26720 182.73 173.59 199.63 195.64 195.64 191.73 # 26720 170.55 162.02 186.32 182.60 182.60 178.94 26725 313.06 297.41 342.02 335.18 335.18 328.47 # 26725 284.02 269.82 310.29 304.08 304.08 298.00 26727 440.08 418.08 480.79 471.18 471.18 461.76 26735 563.09 534.94 615.18 602.88 602.88 590.82 26740 212.34 201.72 231.98 227.34 227.34 222.80 # 26740 200.17 190.16 218.68 214.31 214.31 210.02 26742 343.22 326.06 374.97 367.47 367.47 360.12 # 26742 313.56 297.88 342.56 335.71 335.71 328.99 26746 703.04 667.89 768.07 752.71 752.71 737.66 26750 170.45 161.93 186.22 182.49 182.49 178.85 # 26750 170.77 162.23 186.56 182.84 182.84 179.18 26755 291.24 276.68 318.18 311.82 311.82 305.59 # 26755 255.33 242.56 278.94 273.37 273.37 267.90 26756 390.52 370.99 426.64 418.11 418.11 409.75 26765 470.94 447.39 514.50 504.21 504.21 494.12 26770 256.72 243.88 280.46 274.85 274.85 269.35 # 26770 238.93 226.98 261.03 255.81 255.81 250.69 26775 355.37 337.60 388.24 380.48 380.48 372.86 # 26775 323.53 307.35 353.45 346.38 346.38 339.46 26776 414.60 393.87 452.95 443.89 443.89 435.01 26785 515.76 489.97 563.47 552.20 552.20 541.16 26820 727.83 691.44 795.16 779.25 779.25 763.67 26841 668.10 634.70 729.91 715.31 715.31 701.01 26842 725.77 689.48 792.90 777.04 777.04 761.51 26843 682.83 648.69 745.99 731.08 731.08 716.46 26844 750.71 713.17 820.15 803.75 803.75 787.67 26850 636.82 604.98 695.73 681.81 681.81 668.17 26852 735.00 698.25 802.99 786.93 786.93 771.19 26860 515.37 489.60 563.04 551.78 551.78 540.74 26861 100.13 95.12 109.39 107.20 107.20 105.06 26862 669.06 635.61 730.95 716.34 716.34 702.01

Page 52: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 52Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

26863 223.24 212.08 243.89 239.02 239.02 234.23 26910 665.67 632.39 727.25 712.70 712.70 698.45 26951 599.27 569.31 654.71 641.61 641.61 628.77 26952 593.42 563.75 648.31 635.35 635.35 622.64 26990 591.34 561.77 646.04 633.11 633.11 620.45 26991 654.88 622.14 715.46 701.16 701.16 687.14 # 26991 495.65 470.87 541.50 530.67 530.67 520.05 26992 914.84 869.10 999.47 979.48 979.48 959.89 27000 396.50 376.68 433.18 424.52 424.52 416.04 27001 509.39 483.92 556.51 545.38 545.38 534.47 27003 565.01 536.76 617.27 604.92 604.92 592.83 27005 689.55 655.07 753.33 738.27 738.27 723.50 27006 700.04 665.04 764.80 749.50 749.50 734.52 27025 873.33 829.66 954.11 935.03 935.03 916.33 27027 861.17 818.11 940.83 922.01 922.01 903.58 27030 895.88 851.09 978.75 959.18 959.18 940.00 27033 930.18 883.67 1,016.22 995.90 995.90 975.98 27035 1,102.88 1,047.74 1,204.90 1,180.81 1,180.81 1,157.19 27036 964.74 916.50 1,053.98 1,032.90 1,032.90 1,012.24 27040 318.37 302.45 347.82 340.86 340.86 334.04 # 27040 191.61 182.03 209.33 205.15 205.15 201.04 27041 660.22 627.21 721.29 706.87 706.87 692.74 27043 450.48 427.96 492.15 482.31 482.31 472.66 27045 718.80 682.86 785.29 769.58 769.58 754.19 27047 436.47 414.65 476.85 467.31 467.31 457.96 # 27047 344.99 327.74 376.90 369.37 369.37 361.99 27048 584.99 555.74 639.10 626.32 626.32 613.80 27049 1,301.35 1,236.28 1,421.72 1,393.28 1,393.28 1,365.42 27050 362.84 344.70 396.41 388.48 388.48 380.71 27052 546.56 519.23 597.11 585.18 585.18 573.47 27054 651.03 618.48 711.25 697.03 697.03 683.09 27057 971.48 922.91 1,061.35 1,040.12 1,040.12 1,019.31 27059 1,757.98 1,670.08 1,920.59 1,882.18 1,882.18 1,844.54 27060 438.24 416.33 478.78 469.20 469.20 459.82 27062 432.10 410.50 472.08 462.63 462.63 453.38 27065 484.53 460.30 529.35 518.75 518.75 508.38 27066 772.44 733.82 843.89 827.01 827.01 810.47 27067 979.78 930.79 1,070.41 1,049.00 1,049.00 1,028.02 27070 806.65 766.32 881.27 863.64 863.64 846.37 27071 872.29 828.68 952.98 933.93 933.93 915.25 27075 2,021.09 1,920.04 2,208.05 2,163.89 2,163.89 2,120.61 27076 2,442.27 2,320.16 2,668.18 2,614.82 2,614.82 2,562.52 27077 2,745.37 2,608.10 2,999.32 2,939.33 2,939.33 2,880.54 27078 1,990.49 1,890.97 2,174.62 2,131.12 2,131.12 2,088.50 27080 487.87 463.48 533.00 522.34 522.34 511.90 27086 265.61 252.33 290.18 284.37 284.37 278.68 # 27086 156.34 148.52 170.80 167.38 167.38 164.04 27087 597.65 567.77 652.94 639.87 639.87 627.07 27090 792.43 752.81 865.73 848.41 848.41 831.45

Page 53: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 53Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27091 1,537.30 1,460.44 1,679.51 1,645.91 1,645.91 1,613.00 27093 172.29 163.68 188.23 184.47 184.47 180.78 # 27093 68.64 65.21 74.99 73.50 73.50 72.02 27095 220.84 209.80 241.27 236.44 236.44 231.71 # 27095 80.66 76.63 88.12 86.37 86.37 84.64 27096 149.73 142.24 163.58 160.31 160.31 157.10 # 27096 82.29 78.18 89.91 88.11 88.11 86.35 27097 640.95 608.90 700.24 686.23 686.23 672.51 27098 637.50 605.63 696.47 682.55 682.55 668.90 27100 780.05 741.05 852.21 835.16 835.16 818.47 27105 826.69 785.36 903.16 885.10 885.10 867.40 27110 924.33 878.11 1,009.83 989.63 989.63 969.84 27111 858.90 815.96 938.35 919.59 919.59 901.20 27120 1,247.79 1,185.40 1,363.21 1,335.94 1,335.94 1,309.23 27122 1,053.39 1,000.72 1,150.83 1,127.82 1,127.82 1,105.27 27125 1,087.05 1,032.70 1,187.61 1,163.86 1,163.86 1,140.58 27130 1,305.12 1,239.86 1,425.84 1,397.32 1,397.32 1,369.37 27132 1,612.43 1,531.81 1,761.58 1,726.35 1,726.35 1,691.82 27134 1,850.19 1,757.68 2,021.33 1,980.91 1,980.91 1,941.29 27137 1,418.93 1,347.98 1,550.18 1,519.17 1,519.17 1,488.79 27138 1,474.84 1,401.10 1,611.27 1,579.04 1,579.04 1,547.46 27140 854.69 811.96 933.75 915.08 915.08 896.78 27146 1,234.19 1,172.48 1,348.35 1,321.38 1,321.38 1,294.96 27147 1,414.26 1,343.55 1,545.08 1,514.18 1,514.18 1,483.90 27151 1,528.07 1,451.67 1,669.42 1,636.04 1,636.04 1,603.32 27156 1,652.94 1,570.29 1,805.83 1,769.71 1,769.71 1,734.32 27158 1,366.00 1,297.70 1,492.36 1,462.51 1,462.51 1,433.27 27161 1,165.00 1,106.75 1,272.76 1,247.31 1,247.31 1,222.37 27165 1,318.69 1,252.76 1,440.67 1,411.86 1,411.86 1,383.62 27170 1,129.12 1,072.66 1,233.56 1,208.89 1,208.89 1,184.72 27175 637.12 605.26 696.05 682.12 682.12 668.48 27176 860.56 817.53 940.16 921.36 921.36 902.93 27177 1,067.10 1,013.75 1,165.81 1,142.50 1,142.50 1,119.65 27178 877.06 833.21 958.19 939.03 939.03 920.25 27179 933.72 887.03 1,020.08 999.68 999.68 979.69 27181 934.14 887.43 1,020.54 1,000.13 1,000.13 980.13 27185 587.23 557.87 641.55 628.72 628.72 616.15 27187 948.42 901.00 1,036.15 1,015.43 1,015.43 995.12 27193 445.78 423.49 487.01 477.27 477.27 467.73 # 27193 451.40 428.83 493.15 483.29 483.29 473.63 27194 675.59 641.81 738.08 723.32 723.32 708.85 27200 168.65 160.22 184.25 180.57 180.57 176.96 # 27200 175.52 166.74 191.75 187.92 187.92 184.16 27202 504.83 479.59 551.53 540.50 540.50 529.69 27220 502.43 477.31 548.91 537.92 537.92 527.16 # 27220 498.37 473.45 544.47 533.58 533.58 522.91 27222 934.24 887.53 1,020.66 1,000.25 1,000.25 980.24 27226 1,013.22 962.56 1,106.94 1,084.81 1,084.81 1,063.11 27227 1,597.27 1,517.41 1,745.02 1,710.12 1,710.12 1,675.92

Page 54: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 54Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27228 1,822.87 1,731.73 1,991.49 1,951.67 1,951.67 1,912.63 27230 447.50 425.13 488.90 479.12 479.12 469.55 # 27230 445.00 422.75 486.16 476.45 476.45 466.91 27232 723.56 687.38 790.49 774.67 774.67 759.18 27235 869.93 826.43 950.39 931.39 931.39 912.76 27236 1,147.83 1,090.44 1,254.01 1,228.92 1,228.92 1,204.35 27238 434.73 412.99 474.94 465.44 465.44 456.14 27240 915.52 869.74 1,000.20 980.20 980.20 960.60 27244 1,181.61 1,122.53 1,290.91 1,265.09 1,265.09 1,239.79 27245 1,181.33 1,122.26 1,290.60 1,264.78 1,264.78 1,239.48 27246 363.86 345.67 397.52 389.57 389.57 381.78 # 27246 365.73 347.44 399.56 391.56 391.56 383.73 27248 711.02 675.47 776.79 761.25 761.25 746.03 27250 178.52 169.59 195.03 191.13 191.13 187.31 27252 725.82 689.53 792.96 777.10 777.10 761.56 27253 899.90 854.91 983.15 963.48 963.48 944.21 27254 1,216.98 1,156.13 1,329.55 1,302.96 1,302.96 1,276.90 27256 284.40 270.18 310.71 304.50 304.50 298.40 # 27256 227.89 216.50 248.98 244.00 244.00 239.12 27257 348.48 331.06 380.72 373.11 373.11 365.64 27258 1,064.08 1,010.88 1,162.51 1,139.26 1,139.26 1,116.48 27259 1,493.33 1,418.66 1,631.46 1,598.83 1,598.83 1,566.85 27265 377.31 358.44 412.21 403.96 403.96 395.88 27266 552.70 525.07 603.83 591.76 591.76 579.92 27267 411.27 390.71 449.32 440.34 440.34 431.53 27268 505.89 480.60 552.69 541.64 541.64 530.81 27269 1,193.31 1,133.64 1,303.69 1,277.62 1,277.62 1,252.06 27275 172.08 163.48 188.00 184.24 184.24 180.56 27279 660.22 627.21 721.29 706.87 706.87 692.74 27280 1,308.46 1,243.04 1,429.50 1,400.91 1,400.91 1,372.89 27282 789.21 749.75 862.21 844.97 844.97 828.07 27284 1,506.16 1,430.85 1,645.48 1,612.56 1,612.56 1,580.32 27286 1,575.38 1,496.61 1,721.10 1,686.68 1,686.68 1,652.95 27290 1,548.77 1,471.33 1,692.03 1,658.19 1,658.19 1,625.02 27295 1,213.80 1,153.11 1,326.08 1,299.56 1,299.56 1,273.57 27301 626.27 594.96 684.20 670.52 670.52 657.11 # 27301 477.03 453.18 521.16 510.74 510.74 500.53 27303 606.16 575.85 662.23 648.98 648.98 636.00 27305 455.92 433.12 498.09 488.13 488.13 478.37 27306 337.79 320.90 369.04 361.65 361.65 354.42 27307 437.69 415.81 478.18 468.61 468.61 459.24 27310 696.28 661.47 760.69 745.48 745.48 730.57 27323 250.89 238.35 274.10 268.62 268.62 263.25 # 27323 169.40 160.93 185.07 181.37 181.37 177.74 27324 377.47 358.60 412.39 404.14 404.14 396.06 27325 519.00 493.05 567.01 555.67 555.67 544.56 27326 490.26 465.75 535.61 524.91 524.91 514.41 27327 425.40 404.13 464.75 455.46 455.46 446.35 # 27327 297.71 282.82 325.24 318.73 318.73 312.36

Page 55: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 55Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27328 593.22 563.56 648.09 635.13 635.13 622.43 27329 995.70 945.92 1,087.81 1,066.05 1,066.05 1,044.73 27330 395.18 375.42 431.73 423.10 423.10 414.63 27331 449.52 427.04 491.10 481.28 481.28 471.65 27332 608.25 577.84 664.52 651.22 651.22 638.19 27333 555.44 527.67 606.82 594.69 594.69 582.80 27334 649.66 617.18 709.76 695.57 695.57 681.65 27335 727.30 690.94 794.58 778.69 778.69 763.12 27337 399.92 379.92 436.91 428.17 428.17 419.60 27339 722.75 686.61 789.60 773.81 773.81 758.33 27340 350.16 332.65 382.55 374.90 374.90 367.40 27345 455.12 432.36 497.21 487.27 487.27 477.53 27347 501.69 476.61 548.10 537.14 537.14 526.40 27350 618.50 587.58 675.72 662.20 662.20 648.96 27355 571.47 542.90 624.34 611.85 611.85 599.61 27356 701.06 666.01 765.91 750.59 750.59 735.59 27357 775.18 736.42 846.88 829.94 829.94 813.35 27358 270.16 256.65 295.15 289.25 289.25 283.46 27360 809.28 768.82 884.14 866.46 866.46 849.13 27364 1,506.64 1,431.31 1,646.01 1,613.08 1,613.08 1,580.82 27365 1,996.45 1,896.63 2,181.12 2,137.51 2,137.51 2,094.76 27370 141.78 134.69 154.89 151.80 151.80 148.76 # 27370 49.68 47.20 54.28 53.20 53.20 52.13 27372 561.17 533.11 613.08 600.82 600.82 588.80 # 27372 382.58 363.45 417.97 409.61 409.61 401.42 27380 561.76 533.67 613.72 601.45 601.45 589.42 27381 757.53 719.65 827.60 811.05 811.05 794.82 27385 542.51 515.38 592.69 580.83 580.83 569.22 27386 788.35 748.93 861.27 844.04 844.04 827.16 27390 423.17 402.01 462.31 453.07 453.07 444.00 27391 547.11 519.75 597.71 585.76 585.76 574.05 27392 675.72 641.93 738.22 723.45 723.45 708.99 27393 480.35 456.33 524.78 514.28 514.28 504.00 27394 607.11 576.75 663.26 650.00 650.00 637.01 27395 838.11 796.20 915.63 897.32 897.32 879.37 27396 585.03 555.78 639.15 626.36 626.36 613.84 27397 861.98 818.88 941.71 922.88 922.88 904.42 27400 660.33 627.31 721.41 706.97 706.97 692.83 27403 608.64 578.21 664.94 651.65 651.65 638.62 27405 641.15 609.09 700.45 686.45 686.45 672.72 27407 740.94 703.89 809.47 793.28 793.28 777.41 27409 911.53 865.95 995.84 975.92 975.92 956.41 27412 1,588.80 1,509.36 1,735.76 1,701.05 1,701.05 1,667.03 27415 1,314.05 1,248.35 1,435.60 1,406.89 1,406.89 1,378.75 27416 936.57 889.74 1,023.20 1,002.74 1,002.74 982.69 27418 790.60 751.07 863.73 846.46 846.46 829.53 27420 708.91 673.46 774.48 758.99 758.99 743.81 27422 706.58 671.25 771.94 756.50 756.50 741.37 27424 712.68 677.05 778.61 763.04 763.04 747.78

Page 56: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 56Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27425 422.84 401.70 461.96 452.72 452.72 443.67 27427 678.11 644.20 740.83 726.02 726.02 711.49 27428 1,063.47 1,010.30 1,161.85 1,138.60 1,138.60 1,115.83 27429 1,189.98 1,130.48 1,300.05 1,274.05 1,274.05 1,248.57 27430 704.22 669.01 769.36 753.97 753.97 738.90 27435 767.42 729.05 838.41 821.64 821.64 805.21 27437 628.46 597.04 686.60 672.87 672.87 659.41 27438 802.69 762.56 876.94 859.41 859.41 842.21 27440 761.35 723.28 831.77 815.13 815.13 798.82 27441 785.47 746.20 858.13 840.97 840.97 824.15 27442 830.50 788.98 907.33 889.18 889.18 871.40 27443 770.42 731.90 841.69 824.85 824.85 808.35 27445 1,198.38 1,138.46 1,309.23 1,283.04 1,283.04 1,257.39 27446 1,114.38 1,058.66 1,217.46 1,193.11 1,193.11 1,169.25 27447 1,304.81 1,239.57 1,425.51 1,397.00 1,397.00 1,369.05 27448 744.02 706.82 812.84 796.58 796.58 780.65 27450 966.99 918.64 1,056.44 1,035.31 1,035.31 1,014.60 27454 1,247.77 1,185.38 1,363.19 1,335.92 1,335.92 1,309.21 27455 899.57 854.59 982.78 963.13 963.13 943.86 27457 907.49 862.12 991.44 971.61 971.61 952.18 27465 1,187.06 1,127.71 1,296.87 1,270.93 1,270.93 1,245.52 27466 1,129.56 1,073.08 1,234.04 1,209.36 1,209.36 1,185.18 27468 1,190.66 1,131.13 1,300.80 1,274.79 1,274.79 1,249.29 27470 1,126.36 1,070.04 1,230.55 1,205.94 1,205.94 1,181.82 27472 1,211.68 1,151.10 1,323.77 1,297.29 1,297.29 1,271.35 27475 629.68 598.20 687.93 674.18 674.18 660.70 27477 697.15 662.29 761.63 746.40 746.40 731.47 27479 763.76 725.57 834.41 817.72 817.72 801.37 27485 638.29 606.38 697.34 683.39 683.39 669.73 27486 1,352.00 1,284.40 1,477.06 1,447.52 1,447.52 1,418.57 27487 1,693.75 1,609.06 1,850.42 1,813.41 1,813.41 1,777.14 27488 1,151.32 1,093.75 1,257.81 1,232.66 1,232.66 1,208.01 27495 1,081.03 1,026.98 1,181.03 1,157.41 1,157.41 1,134.26 27496 512.42 486.80 559.82 548.62 548.62 537.65 27497 550.52 522.99 601.44 589.41 589.41 577.62 27498 613.94 583.24 670.73 657.32 657.32 644.17 27499 663.77 630.58 725.17 710.67 710.67 696.45 27500 489.12 464.66 534.36 523.68 523.68 513.20 # 27500 455.09 432.34 497.19 487.24 487.24 477.50 27501 476.50 452.68 520.58 510.17 510.17 499.97 # 27501 473.07 449.42 516.83 506.49 506.49 496.36 27502 732.72 696.08 800.49 784.48 784.48 768.80 27503 766.01 727.71 836.87 820.13 820.13 803.74 27506 1,283.12 1,218.96 1,401.80 1,373.77 1,373.77 1,346.29 27507 933.56 886.88 1,019.91 999.51 999.51 979.52 27508 494.08 469.38 539.79 528.99 528.99 518.41 # 27508 466.92 443.57 510.11 499.91 499.91 489.91 27509 608.07 577.67 664.32 651.04 651.04 638.02 27510 652.04 619.44 712.36 698.11 698.11 684.15

Page 57: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 57Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27511 958.25 910.34 1,046.89 1,025.95 1,025.95 1,005.43 27513 1,195.33 1,135.56 1,305.89 1,279.78 1,279.78 1,254.18 27514 929.03 882.58 1,014.97 994.67 994.67 974.77 27516 476.41 452.59 520.48 510.07 510.07 499.87 # 27516 449.24 426.78 490.80 480.98 480.98 471.36 27517 641.80 609.71 701.17 687.15 687.15 673.41 27519 855.59 812.81 934.73 916.03 916.03 897.71 27520 299.62 284.64 327.34 320.79 320.79 314.38 # 27520 274.65 260.92 300.06 294.06 294.06 288.18 27524 717.14 681.28 783.47 767.80 767.80 752.45 27530 279.24 265.28 305.07 298.97 298.97 292.99 # 27530 260.51 247.48 284.60 278.91 278.91 273.33 27532 580.22 551.21 633.89 621.22 621.22 608.80 # 27532 547.12 519.76 597.72 585.76 585.76 574.05 27535 861.45 818.38 941.14 922.31 922.31 903.87 27536 1,141.00 1,083.95 1,246.54 1,221.61 1,221.61 1,197.17 27538 441.77 419.68 482.63 472.98 472.98 463.52 # 27538 415.55 394.77 453.99 444.90 444.90 436.00 27540 772.50 733.88 843.96 827.08 827.08 810.54 27550 474.67 450.94 518.58 508.21 508.21 498.04 # 27550 442.51 420.38 483.44 473.77 473.77 464.29 27552 593.42 563.75 648.31 635.35 635.35 622.64 27556 839.22 797.26 916.85 898.51 898.51 880.53 27557 1,007.88 957.49 1,101.11 1,079.09 1,079.09 1,057.51 27558 1,146.10 1,088.80 1,252.12 1,227.07 1,227.07 1,202.53 27560 338.02 321.12 369.29 361.91 361.91 354.67 # 27560 313.35 297.68 342.33 335.49 335.49 328.79 27562 443.57 421.39 484.60 474.90 474.90 465.41 27566 852.39 809.77 931.24 912.61 912.61 894.36 27570 142.68 135.55 155.88 152.77 152.77 149.71 27580 1,377.71 1,308.82 1,505.14 1,475.04 1,475.04 1,445.54 27590 784.19 744.98 856.73 839.59 839.59 822.80 27591 923.07 876.92 1,008.46 988.29 988.29 968.52 27592 663.96 630.76 725.37 710.86 710.86 696.65 27594 488.52 464.09 533.70 523.03 523.03 512.57 27596 701.98 666.88 766.91 751.57 751.57 736.54 27598 700.57 665.54 765.37 750.06 750.06 735.07 27600 395.41 375.64 431.99 423.35 423.35 414.89 27601 422.98 401.83 462.10 452.86 452.86 443.80 27602 477.17 453.31 521.31 510.88 510.88 500.66 27603 495.35 470.58 541.17 530.35 530.35 519.74 # 27603 370.47 351.95 404.74 396.65 396.65 388.71 27604 461.60 438.52 504.30 494.21 494.21 484.33 # 27604 329.85 313.36 360.36 353.15 353.15 346.09 27605 317.62 301.74 347.00 340.07 340.07 333.27 # 27605 178.06 169.16 194.53 190.65 190.65 186.83 27606 271.71 258.12 296.84 290.90 290.90 285.09 27607 580.56 551.53 634.26 621.58 621.58 609.14 27610 622.07 590.97 679.62 666.02 666.02 652.71

Page 58: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 58Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27612 533.78 507.09 583.15 571.49 571.49 560.06 27613 234.14 222.43 255.79 250.68 250.68 245.66 # 27613 155.15 147.39 169.50 166.11 166.11 162.78 27614 541.04 513.99 591.09 579.27 579.27 567.69 # 27614 387.43 368.06 423.27 414.81 414.81 406.51 27615 984.59 935.36 1,075.66 1,054.15 1,054.15 1,033.07 27616 1,223.91 1,162.71 1,337.12 1,310.38 1,310.38 1,284.17 27618 416.88 396.04 455.45 446.34 446.34 437.41 # 27618 291.68 277.10 318.67 312.29 312.29 306.05 27619 449.81 427.32 491.42 481.59 481.59 471.95 27620 432.87 411.23 472.91 463.46 463.46 454.19 27625 561.01 532.96 612.90 600.65 600.65 588.63 27626 592.62 562.99 647.44 634.49 634.49 621.81 27630 522.24 496.13 570.55 559.14 559.14 547.96 # 27630 349.28 331.82 381.59 373.96 373.96 366.48 27632 396.76 376.92 433.46 424.79 424.79 416.29 27634 658.67 625.74 719.60 705.21 705.21 691.12 27635 560.08 532.08 611.89 599.66 599.66 587.66 27637 714.52 678.79 780.61 764.99 764.99 749.70 27638 730.50 693.98 798.08 782.12 782.12 766.48 27640 799.57 759.59 873.53 856.06 856.06 838.94 27641 641.25 609.19 700.57 686.56 686.56 672.83 27645 1,708.64 1,623.21 1,866.69 1,829.36 1,829.36 1,792.78 27646 1,478.86 1,404.92 1,615.66 1,583.34 1,583.34 1,551.67 27647 1,008.17 957.76 1,101.42 1,079.39 1,079.39 1,057.80 27648 149.84 142.35 163.70 160.43 160.43 157.22 # 27648 51.50 48.93 56.27 55.14 55.14 54.04 27650 629.60 598.12 687.84 674.08 674.08 660.61 27652 659.30 626.34 720.29 705.88 705.88 691.76 27654 679.56 645.58 742.42 727.57 727.57 713.02 27656 585.89 556.60 640.09 627.29 627.29 614.74 # 27656 374.21 355.50 408.83 400.65 400.65 392.63 27658 356.15 338.34 389.09 381.31 381.31 373.68 27659 462.28 439.17 505.05 494.95 494.95 485.05 27664 343.46 326.29 375.23 367.72 367.72 360.36 27665 392.61 372.98 428.93 420.35 420.35 411.94 27675 467.85 444.46 511.13 500.91 500.91 490.89 27676 577.56 548.68 630.98 618.37 618.37 606.00 27680 409.88 389.39 447.80 438.84 438.84 430.07 27681 516.64 490.81 564.43 553.14 553.14 542.08 27685 622.97 591.82 680.59 666.98 666.98 653.64 # 27685 445.01 422.76 486.17 476.45 476.45 466.91 27686 532.59 505.96 581.85 570.22 570.22 558.81 27687 434.25 412.54 474.42 464.93 464.93 455.63 27690 603.71 573.52 659.55 646.36 646.36 633.43 27691 715.70 679.92 781.91 766.27 766.27 750.94 27692 102.29 97.18 111.76 109.53 109.53 107.34 27695 454.52 431.79 496.56 486.62 486.62 476.89 27696 535.52 508.74 585.05 573.36 573.36 561.89

Page 59: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 59Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27698 616.05 585.25 673.04 659.58 659.58 646.39 27700 575.07 546.32 628.27 615.70 615.70 603.38 27702 927.81 881.42 1,013.63 993.36 993.36 973.49 27703 1,067.28 1,013.92 1,166.01 1,142.69 1,142.69 1,119.84 27704 549.50 522.03 600.33 588.33 588.33 576.56 27705 726.42 690.10 793.62 777.75 777.75 762.19 27707 381.25 362.19 416.52 408.19 408.19 400.03 27709 1,121.19 1,065.13 1,224.90 1,200.40 1,200.40 1,176.39 27712 1,054.44 1,001.72 1,151.98 1,128.94 1,128.94 1,106.37 27715 1,025.47 974.20 1,120.33 1,097.93 1,097.93 1,075.97 27720 836.13 794.32 913.47 895.19 895.19 877.29 27722 839.81 797.82 917.49 899.14 899.14 881.15 27724 1,216.64 1,155.81 1,329.18 1,302.59 1,302.59 1,276.55 27725 1,155.67 1,097.89 1,262.57 1,237.32 1,237.32 1,212.57 27726 928.08 881.68 1,013.93 993.66 993.66 973.79 27727 992.16 942.55 1,083.93 1,062.26 1,062.26 1,041.01 27730 542.82 515.68 593.03 581.18 581.18 569.55 27732 386.16 366.85 421.88 413.44 413.44 405.17 27734 624.28 593.07 682.03 668.39 668.39 655.03 27740 674.25 640.54 736.62 721.89 721.89 707.46 27742 737.77 700.88 806.01 789.89 789.89 774.09 27745 720.52 684.49 787.16 771.42 771.42 755.99 27750 321.86 305.77 351.64 344.60 344.60 337.71 # 27750 296.89 282.05 324.36 317.87 317.87 311.51 27752 505.22 479.96 551.95 540.91 540.91 530.09 # 27752 469.00 445.55 512.38 502.14 502.14 492.10 27756 543.48 516.31 593.76 581.88 581.88 570.24 27758 850.78 808.24 929.48 910.89 910.89 892.68 27759 956.47 908.65 1,044.95 1,024.05 1,024.05 1,003.57 27760 309.83 294.34 338.49 331.72 331.72 325.08 # 27760 284.22 270.01 310.51 304.30 304.30 298.22 27762 445.84 423.55 487.08 477.34 477.34 467.80 # 27762 409.00 388.55 446.83 437.90 437.90 429.13 27766 579.82 550.83 633.45 620.78 620.78 608.36 27767 260.89 247.85 285.03 279.32 279.32 273.73 # 27767 262.45 249.33 286.73 280.99 280.99 275.37 27768 414.08 393.38 452.39 443.34 443.34 434.47 27769 696.52 661.69 760.94 745.73 745.73 730.81 27780 284.13 269.92 310.41 304.20 304.20 298.11 # 27780 259.77 246.78 283.80 278.12 278.12 272.55 27781 394.91 375.16 431.43 422.81 422.81 414.36 # 27781 367.75 349.36 401.76 393.73 393.73 385.85 27784 681.90 647.81 744.98 730.08 730.08 715.47 27786 293.71 279.02 320.87 314.46 314.46 308.17 # 27786 267.17 253.81 291.88 286.04 286.04 280.32 27788 393.97 374.27 430.41 421.80 421.80 413.36 # 27788 362.13 344.02 395.62 387.71 387.71 379.96 27792 621.47 590.40 678.96 665.38 665.38 652.07 27808 309.62 294.14 338.26 331.50 331.50 324.86

Page 60: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 60Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 27808 279.65 265.67 305.52 299.41 299.41 293.42 27810 437.69 415.81 478.18 468.61 468.61 459.24 # 27810 399.91 379.91 436.90 428.16 428.16 419.59 27814 736.39 699.57 804.51 788.42 788.42 772.65 27816 297.35 282.48 324.85 318.35 318.35 311.98 # 27816 268.31 254.89 293.12 287.26 287.26 281.51 27818 454.57 431.84 496.62 486.68 486.68 476.95 # 27818 410.55 390.02 448.52 439.55 439.55 430.77 27822 800.32 760.30 874.35 856.85 856.85 839.72 27823 910.93 865.38 995.19 975.28 975.28 955.78 27824 292.95 278.30 320.05 313.64 313.64 307.37 # 27824 285.14 270.88 311.51 305.28 305.28 299.17 27825 513.64 487.96 561.15 549.93 549.93 538.94 # 27825 469.00 445.55 512.38 502.14 502.14 492.10 27826 791.53 751.95 864.74 847.45 847.45 830.50 27827 1,030.46 978.94 1,125.78 1,103.26 1,103.26 1,081.20 27828 1,238.73 1,176.79 1,353.31 1,326.24 1,326.24 1,299.72 27829 649.20 616.74 709.25 695.07 695.07 681.17 27830 355.29 337.53 388.16 380.40 380.40 372.78 # 27830 332.50 315.88 363.26 355.99 355.99 348.88 27831 369.62 351.14 403.81 395.74 395.74 387.83 27832 720.20 684.19 786.82 771.09 771.09 755.67 27840 348.24 330.83 380.45 372.84 372.84 365.39 27842 470.18 446.67 513.67 503.40 503.40 493.34 27846 693.80 659.11 757.98 742.82 742.82 727.96 27848 776.51 737.68 848.33 831.37 831.37 814.74 27860 166.89 158.55 182.33 178.69 178.69 175.11 27870 990.03 940.53 1,081.61 1,059.98 1,059.98 1,038.78 27871 652.99 620.34 713.39 699.12 699.12 685.14 27880 897.38 852.51 980.39 960.78 960.78 941.56 27881 844.63 802.40 922.76 904.30 904.30 886.21 27882 587.05 557.70 641.36 628.53 628.53 615.96 27884 559.57 531.59 611.33 599.10 599.10 587.12 27886 639.22 607.26 698.35 684.38 684.38 670.69 27888 660.08 627.08 721.14 706.72 706.72 692.59 27889 635.99 604.19 694.82 680.93 680.93 667.31 27892 529.81 503.32 578.82 567.24 567.24 555.90 27893 574.00 545.30 627.10 614.55 614.55 602.26 27894 820.79 779.75 896.71 878.78 878.78 861.21 28001 260.66 247.63 284.77 279.08 279.08 273.50 # 28001 164.18 155.97 179.37 175.78 175.78 172.26 28002 420.85 399.81 459.78 450.58 450.58 441.57 # 28002 309.08 293.63 337.67 330.92 330.92 324.30 28003 676.10 642.30 738.65 723.87 723.87 709.39 # 28003 548.72 521.28 599.47 587.48 587.48 575.72 28005 560.25 532.24 612.08 599.84 599.84 587.85 28008 408.38 387.96 446.15 437.23 437.23 428.49 # 28008 282.87 268.73 309.04 302.86 302.86 296.80 28010 220.88 209.84 241.32 236.49 236.49 231.76

Page 61: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 61Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 28010 200.28 190.27 218.81 214.43 214.43 210.14 28011 307.59 292.21 336.04 329.33 329.33 322.74 # 28011 276.69 262.86 302.29 296.24 296.24 290.32 28020 509.12 483.66 556.21 545.09 545.09 534.19 # 28020 347.08 329.73 379.19 371.61 371.61 364.18 28022 460.57 437.54 503.17 493.11 493.11 483.24 # 28022 312.90 297.26 341.85 335.01 335.01 328.30 28024 435.09 413.34 475.34 465.83 465.83 456.52 # 28024 293.34 278.67 320.47 314.07 314.07 307.79 28035 495.97 471.17 541.85 531.01 531.01 520.40 # 28035 340.80 323.76 372.32 364.87 364.87 357.57 28039 482.63 458.50 527.28 516.73 516.73 506.39 # 28039 338.70 321.77 370.04 362.63 362.63 355.37 28041 445.29 423.03 486.48 476.76 476.76 467.22 28043 377.17 358.31 412.06 403.81 403.81 395.74 # 28043 252.90 240.26 276.30 270.77 270.77 265.35 28045 469.83 446.34 513.29 503.02 503.02 492.96 # 28045 335.89 319.10 366.97 359.63 359.63 352.44 28046 709.77 674.28 775.42 759.91 759.91 744.71 28047 1,036.68 984.85 1,132.58 1,109.92 1,109.92 1,087.73 28050 401.75 381.66 438.91 430.13 430.13 421.53 # 28050 270.31 256.79 295.31 289.40 289.40 283.61 28052 421.03 399.98 459.98 450.78 450.78 441.76 # 28052 273.98 260.28 299.32 293.33 293.33 287.47 28054 368.36 349.94 402.43 394.38 394.38 386.49 # 28054 235.05 223.30 256.80 251.65 251.65 246.62 28055 364.35 346.13 398.05 390.09 390.09 382.29 28060 490.33 465.81 535.68 524.96 524.96 514.46 # 28060 343.90 326.71 375.72 368.21 368.21 360.85 28062 557.04 529.19 608.57 596.40 596.40 584.48 # 28062 395.00 375.25 431.54 422.91 422.91 414.46 28070 502.86 477.72 549.38 538.40 538.40 527.63 # 28070 342.07 324.97 373.72 366.24 366.24 358.92 28072 476.20 452.39 520.25 509.84 509.84 499.64 # 28072 318.22 302.31 347.66 340.70 340.70 333.88 28080 492.76 468.12 538.34 527.57 527.57 517.02 # 28080 350.08 332.58 382.47 374.82 374.82 367.32 28086 514.82 489.08 562.44 551.20 551.20 540.17 # 28086 345.60 328.32 377.57 370.01 370.01 362.62 28088 420.69 399.66 459.61 450.42 450.42 441.42 # 28088 270.83 257.29 295.88 289.96 289.96 284.17 28090 443.91 421.71 484.97 475.27 475.27 465.76 # 28090 296.55 281.72 323.98 317.50 317.50 311.16 28092 397.54 377.66 434.31 425.63 425.63 417.12 # 28092 257.67 244.79 281.51 275.87 275.87 270.35 28100 571.57 542.99 624.44 611.95 611.95 599.71 # 28100 395.48 375.71 432.07 423.43 423.43 414.97 28102 574.85 546.11 628.03 615.47 615.47 603.16 28103 381.14 362.08 416.39 408.07 408.07 399.90

Page 62: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 62Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

28104 498.01 473.11 544.08 533.20 533.20 522.54 # 28104 339.72 322.73 371.14 363.72 363.72 356.44 28106 448.14 425.73 489.59 479.80 479.80 470.21 28107 528.34 501.92 577.21 565.66 565.66 554.35 # 28107 360.69 342.66 394.06 386.18 386.18 378.45 28108 415.82 395.03 454.28 445.20 445.20 436.30 # 28108 277.51 263.63 303.17 297.11 297.11 291.17 28110 435.67 413.89 475.97 466.45 466.45 457.13 # 28110 278.31 264.39 304.05 297.97 297.97 292.01 28111 466.65 443.32 509.82 499.62 499.62 489.62 # 28111 315.54 299.76 344.72 337.82 337.82 331.06 28112 461.03 437.98 503.68 493.60 493.60 483.74 # 28112 301.48 286.41 329.37 322.78 322.78 316.33 28113 559.38 531.41 611.12 598.90 598.90 586.91 # 28113 408.27 387.86 446.04 437.12 437.12 428.38 28114 1,018.16 967.25 1,112.34 1,090.10 1,090.10 1,068.29 # 28114 803.36 763.19 877.67 860.12 860.12 842.92 28116 719.21 683.25 785.74 770.03 770.03 754.63 # 28116 551.87 524.28 602.92 590.86 590.86 579.04 28118 561.19 533.13 613.10 600.84 600.84 588.82 # 28118 397.28 377.42 434.03 425.35 425.35 416.84 28119 497.70 472.82 543.74 532.86 532.86 522.20 # 28119 348.46 331.04 380.70 373.08 373.08 365.62 28120 641.88 609.79 701.26 687.23 687.23 673.49 # 28120 478.91 454.96 523.20 512.74 512.74 502.48 28122 568.61 540.18 621.21 608.79 608.79 596.61 # 28122 424.68 403.45 463.97 454.69 454.69 445.59 28124 451.45 428.88 493.21 483.35 483.35 473.67 # 28124 318.13 302.22 347.55 340.61 340.61 333.80 28126 372.66 354.03 407.13 398.99 398.99 391.01 # 28126 239.03 227.08 261.14 255.92 255.92 250.80 28130 615.96 585.16 672.93 659.48 659.48 646.29 28140 569.43 540.96 622.10 609.66 609.66 597.47 # 28140 427.06 405.71 466.57 457.24 457.24 448.10 28150 403.87 383.68 441.23 432.41 432.41 423.76 # 28150 270.86 257.32 295.92 290.00 290.00 284.20 28153 387.42 368.05 423.26 414.79 414.79 406.50 # 28153 253.16 240.50 276.58 271.04 271.04 265.63 28160 396.75 376.91 433.45 424.78 424.78 416.28 # 28160 259.38 246.41 283.37 277.70 277.70 272.15 28171 833.58 791.90 910.69 892.47 892.47 874.62 28173 747.55 710.17 816.70 800.37 800.37 784.36 28175 475.40 451.63 519.37 508.99 508.99 498.81 28190 239.75 227.76 261.92 256.68 256.68 251.55 # 28190 128.92 122.47 140.84 138.02 138.02 135.26 28192 445.56 423.28 486.77 477.03 477.03 467.49 # 28192 303.19 288.03 331.23 324.61 324.61 318.11 28193 503.32 478.15 549.87 538.88 538.88 528.10 # 28193 356.58 338.75 389.56 381.78 381.78 374.14

Page 63: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 63Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

28200 461.84 438.75 504.56 494.48 494.48 484.59 # 28200 309.17 293.71 337.77 331.02 331.02 324.39 28202 568.66 540.23 621.26 608.84 608.84 596.67 # 28202 413.81 393.12 452.09 443.05 443.05 434.18 28208 446.48 424.16 487.78 478.03 478.03 468.48 # 28208 299.12 284.16 326.78 320.25 320.25 313.85 28210 544.26 517.05 594.61 582.72 582.72 571.07 # 28210 395.02 375.27 431.56 422.92 422.92 414.46 28220 425.92 404.62 465.31 456.01 456.01 446.89 # 28220 291.04 276.49 317.96 311.60 311.60 305.37 28222 481.33 457.26 525.85 515.33 515.33 505.02 # 28222 338.33 321.41 369.62 362.23 362.23 354.98 28225 385.71 366.42 421.38 412.95 412.95 404.70 # 28225 249.27 236.81 272.33 266.88 266.88 261.54 28226 565.78 537.49 618.11 605.75 605.75 593.64 # 28226 370.65 352.12 404.94 396.84 396.84 388.91 28230 411.10 390.55 449.13 440.15 440.15 431.35 # 28230 273.10 259.45 298.37 292.40 292.40 286.55 28232 364.63 346.40 398.36 390.39 390.39 382.58 # 28232 233.50 221.83 255.10 250.00 250.00 245.00 28234 383.75 364.56 419.24 410.86 410.86 402.64 # 28234 252.00 239.40 275.31 269.80 269.80 264.41 28238 638.69 606.76 697.77 683.81 683.81 670.14 # 28238 471.97 448.37 515.63 505.31 505.31 495.20 28240 417.84 396.95 456.49 447.36 447.36 438.41 # 28240 280.15 266.14 306.06 299.94 299.94 293.94 28250 550.20 522.69 601.09 589.08 589.08 577.30 # 28250 390.65 371.12 426.79 418.26 418.26 409.89 28260 653.47 620.80 713.92 699.64 699.64 685.64 # 28260 493.61 468.93 539.27 528.48 528.48 517.91 28261 938.85 891.91 1,025.70 1,005.18 1,005.18 985.08 # 28261 753.40 715.73 823.09 806.63 806.63 790.50 28262 1,392.93 1,323.28 1,521.77 1,491.33 1,491.33 1,461.50 # 28262 1,134.41 1,077.69 1,239.34 1,214.56 1,214.56 1,190.27 28264 943.96 896.76 1,031.27 1,010.64 1,010.64 990.43 # 28264 729.15 692.69 796.59 780.67 780.67 765.05 28270 464.33 441.11 507.28 497.13 497.13 487.19 # 28270 321.02 304.97 350.72 343.70 343.70 336.82 28272 373.09 354.44 407.61 399.45 399.45 391.46 # 28272 245.71 233.42 268.43 263.06 263.06 257.81 28280 489.98 465.48 535.30 524.60 524.60 514.11 # 28280 337.62 320.74 368.85 361.48 361.48 354.25 28285 506.07 480.77 552.89 541.82 541.82 530.99 # 28285 363.39 345.22 397.00 389.07 389.07 381.28 28286 428.30 406.89 467.92 458.56 458.56 449.40 # 28286 289.68 275.20 316.48 310.16 310.16 303.96 28288 570.98 542.43 623.79 611.32 611.32 599.09 # 28288 412.06 391.46 450.18 441.17 441.17 432.35 28289 695.17 660.41 759.47 744.28 744.28 729.40

Page 64: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 64Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 28289 526.58 500.25 575.29 563.79 563.79 552.52 28290 555.92 528.12 607.34 595.19 595.19 583.29 # 28290 380.46 361.44 415.66 407.34 407.34 399.20 28292 749.53 712.05 818.86 802.48 802.48 786.43 # 28292 579.06 550.11 632.63 619.98 619.98 607.58 28293 993.72 944.03 1,085.63 1,063.92 1,063.92 1,042.65 # 28293 687.44 653.07 751.03 736.01 736.01 721.29 28294 729.86 693.37 797.38 781.43 781.43 765.80 # 28294 529.42 502.95 578.39 566.82 566.82 555.48 28296 678.19 644.28 740.92 726.10 726.10 711.57 # 28296 503.98 478.78 550.60 539.58 539.58 528.79 28297 771.78 733.19 843.17 826.31 826.31 809.78 # 28297 563.22 535.06 615.32 603.01 603.01 590.95 28298 685.26 651.00 748.65 733.68 733.68 719.00 # 28298 489.50 465.03 534.78 524.09 524.09 513.61 28299 857.04 814.19 936.32 917.60 917.60 899.24 # 28299 658.16 625.25 719.04 704.66 704.66 690.58 28300 626.77 595.43 684.74 671.05 671.05 657.63 28302 681.63 647.55 744.68 729.79 729.79 715.20 28304 783.97 744.77 856.49 839.35 839.35 822.56 # 28304 584.78 555.54 638.87 626.09 626.09 613.57 28305 644.63 612.40 704.26 690.17 690.17 676.37 28306 578.96 550.01 632.51 619.86 619.86 607.46 # 28306 388.51 369.08 424.44 415.96 415.96 407.64 28307 641.40 609.33 700.73 686.71 686.71 672.98 # 28307 431.91 410.31 471.86 462.42 462.42 453.17 28308 533.36 506.69 582.69 571.04 571.04 559.62 # 28308 362.27 344.16 395.78 387.87 387.87 380.11 28309 873.59 829.91 954.40 935.31 935.31 916.60 28310 517.62 491.74 565.50 554.20 554.20 543.11 # 28310 345.90 328.61 377.90 370.35 370.35 362.94 28312 479.44 455.47 523.79 513.31 513.31 503.04 # 28312 307.09 291.74 335.50 328.80 328.80 322.22 28313 498.90 473.96 545.05 534.15 534.15 523.47 # 28313 344.35 327.13 376.20 368.68 368.68 361.31 28315 455.91 433.11 498.08 488.12 488.12 478.35 # 28315 313.85 298.16 342.88 336.03 336.03 329.31 28320 587.94 558.54 642.32 629.48 629.48 616.88 28322 747.75 710.36 816.91 800.57 800.57 784.56 # 28322 556.05 528.25 607.49 595.34 595.34 583.44 28340 552.81 525.17 603.95 591.87 591.87 580.04 # 28340 402.33 382.21 439.54 430.76 430.76 422.14 28341 643.07 610.92 702.56 688.51 688.51 674.74 # 28341 480.09 456.09 524.50 514.02 514.02 503.73 28344 440.72 418.68 481.48 471.86 471.86 462.42 # 28344 299.59 284.61 327.30 320.76 320.76 314.34 28345 497.57 472.69 543.59 532.73 532.73 522.08 # 28345 354.26 336.55 387.03 379.29 379.29 371.70 28360 890.43 845.91 972.80 953.34 953.34 934.27

Page 65: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 65Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

28400 231.89 220.30 253.35 248.27 248.27 243.31 # 28400 213.16 202.50 232.88 228.22 228.22 223.65 28405 372.34 353.72 406.78 398.65 398.65 390.68 # 28405 339.87 322.88 371.31 363.88 363.88 356.60 28406 495.81 471.02 541.67 530.84 530.84 520.23 28415 1,060.99 1,007.94 1,159.13 1,135.95 1,135.95 1,113.22 28420 1,199.25 1,139.29 1,310.18 1,283.98 1,283.98 1,258.30 28430 221.20 210.14 241.66 236.83 236.83 232.09 # 28430 197.79 187.90 216.09 211.76 211.76 207.53 28435 299.58 284.60 327.29 320.75 320.75 314.33 # 28435 269.30 255.84 294.22 288.33 288.33 282.57 28436 422.14 401.03 461.18 451.96 451.96 442.92 28445 1,020.07 969.07 1,114.43 1,092.14 1,092.14 1,070.31 28446 1,160.74 1,102.70 1,268.11 1,242.75 1,242.75 1,217.90 28450 201.76 191.67 220.42 216.02 216.02 211.69 # 28450 180.85 171.81 197.58 193.63 193.63 189.75 28455 272.97 259.32 298.22 292.25 292.25 286.41 # 28455 247.05 234.70 269.91 264.51 264.51 259.22 28456 297.47 282.60 324.99 318.49 318.49 312.12 28465 596.49 566.67 651.67 638.64 638.64 625.86 28470 204.55 194.32 223.47 218.99 218.99 214.61 # 28470 191.75 182.16 209.48 205.30 205.30 201.19 28475 242.88 230.74 265.35 260.05 260.05 254.85 # 28475 216.96 206.11 237.03 232.29 232.29 227.64 28476 330.52 313.99 361.09 353.87 353.87 346.79 28485 503.03 477.88 549.56 538.57 538.57 527.79 28490 135.14 128.38 147.64 144.68 144.68 141.78 # 28490 117.03 111.18 127.86 125.30 125.30 122.80 28495 166.43 158.11 181.83 178.19 178.19 174.63 # 28495 141.14 134.08 154.19 151.11 151.11 148.09 28496 405.01 384.76 442.47 433.62 433.62 424.95 # 28496 220.18 209.17 240.55 235.74 235.74 231.02 28505 632.29 600.68 690.78 676.97 676.97 663.44 # 28505 480.24 456.23 524.66 514.18 514.18 503.90 28510 115.81 110.02 126.52 123.99 123.99 121.51 # 28510 113.00 107.35 123.45 120.98 120.98 118.57 28515 151.26 143.70 165.26 161.95 161.95 158.71 # 28515 134.40 127.68 146.83 143.90 143.90 141.02 28525 534.15 507.44 583.56 571.88 571.88 560.44 # 28525 382.10 363.00 417.45 409.10 409.10 400.92 28530 108.13 102.72 118.13 115.77 115.77 113.46 # 28530 96.57 91.74 105.50 103.40 103.40 101.33 28531 322.84 306.70 352.71 345.66 345.66 338.74 # 28531 176.42 167.60 192.74 188.89 188.89 185.12 28540 194.88 185.14 212.91 208.66 208.66 204.48 # 28540 176.78 167.94 193.13 189.27 189.27 185.48 28545 271.86 258.27 297.01 291.07 291.07 285.25 # 28545 242.51 230.38 264.94 259.64 259.64 254.44 28546 516.17 490.36 563.91 552.63 552.63 541.58

Page 66: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 66Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 28546 309.17 293.71 337.77 331.02 331.02 324.39 28555 833.03 791.38 910.09 891.88 891.88 874.05 # 28555 641.64 609.56 700.99 686.98 686.98 673.23 28570 206.32 196.00 225.40 220.89 220.89 216.48 # 28570 176.04 167.24 192.33 188.49 188.49 184.71 28575 340.90 323.86 372.44 364.99 364.99 357.68 # 28575 309.99 294.49 338.66 331.89 331.89 325.25 28576 368.25 349.84 402.32 394.27 394.27 386.38 28585 817.04 776.19 892.62 874.77 874.77 857.28 # 28585 650.32 617.80 710.47 696.26 696.26 682.33 28600 203.93 193.73 222.79 218.34 218.34 213.97 # 28600 176.77 167.93 193.12 189.26 189.26 185.47 28605 303.23 288.07 331.28 324.66 324.66 318.16 # 28605 274.19 260.48 299.55 293.56 293.56 287.68 28606 375.66 356.88 410.41 402.20 402.20 394.16 28615 753.51 715.83 823.20 806.74 806.74 790.60 28630 147.91 140.51 161.59 158.36 158.36 155.19 # 28630 105.76 100.47 115.54 113.23 113.23 110.96 28635 164.85 156.61 180.10 176.50 176.50 172.97 # 28635 126.14 119.83 137.80 135.04 135.04 132.34 28636 267.51 254.13 292.25 286.41 286.41 280.68 # 28636 175.72 166.93 191.97 188.13 188.13 184.37 28645 623.82 592.63 681.52 667.90 667.90 654.53 # 28645 468.03 444.63 511.32 501.10 501.10 491.08 28660 109.68 104.20 119.83 117.44 117.44 115.09 # 28660 85.01 80.76 92.87 91.01 91.01 89.19 28665 146.16 138.85 159.68 156.48 156.48 153.35 # 28665 125.87 119.58 137.52 134.77 134.77 132.08 28666 179.43 170.46 196.03 192.11 192.11 188.27 28675 549.85 522.36 600.71 588.70 588.70 576.92 # 28675 393.74 374.05 430.16 421.56 421.56 413.13 28705 1,212.57 1,151.94 1,324.73 1,298.24 1,298.24 1,272.27 28715 898.51 853.58 981.62 961.99 961.99 942.75 28725 745.76 708.47 814.74 798.45 798.45 782.47 28730 703.34 668.17 768.40 753.03 753.03 737.97 28735 754.18 716.47 823.94 807.46 807.46 791.32 28737 666.97 633.62 728.66 714.09 714.09 699.81 28740 801.55 761.47 875.69 858.18 858.18 841.02 # 28740 599.24 569.28 654.67 641.57 641.57 628.74 28750 769.10 730.65 840.25 823.45 823.45 806.98 # 28750 567.72 539.33 620.23 607.82 607.82 595.67 28755 479.57 455.59 523.93 513.45 513.45 503.18 # 28755 318.16 302.25 347.59 340.64 340.64 333.83 28760 750.75 713.21 820.19 803.79 803.79 787.72 # 28760 558.11 530.20 609.73 597.54 597.54 585.59 28800 526.30 499.99 574.99 563.49 563.49 552.22 28805 715.33 679.56 781.49 765.87 765.87 750.55 28810 417.92 397.02 456.57 447.44 447.44 438.50 28820 535.62 508.84 585.17 573.46 573.46 561.99

Page 67: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 67Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 28820 382.01 362.91 417.35 409.00 409.00 400.82 28825 510.05 484.55 557.23 546.09 546.09 535.16 # 28825 357.69 339.81 390.78 382.96 382.96 375.30 28890 304.72 289.48 332.90 326.24 326.24 319.72 # 28890 216.05 205.25 236.04 231.32 231.32 226.70 29000 265.90 252.61 290.50 284.69 284.69 279.00 # 29000 165.68 157.40 181.01 177.39 177.39 173.85 29010 220.78 209.74 241.20 236.38 236.38 231.66 # 29010 140.85 133.81 153.88 150.80 150.80 147.79 29015 264.42 251.20 288.88 283.11 283.11 277.45 # 29015 170.45 161.93 186.22 182.49 182.49 178.85 29035 181.35 172.28 198.12 194.15 194.15 190.27 # 29035 115.16 109.40 125.81 123.29 123.29 120.83 29040 211.04 200.49 230.56 225.95 225.95 221.43 # 29040 140.16 133.15 153.12 150.06 150.06 147.06 29044 261.58 248.50 285.78 280.06 280.06 274.46 # 29044 144.81 137.57 158.21 155.04 155.04 151.94 29046 227.12 215.76 248.12 243.16 243.16 238.29 # 29046 152.19 144.58 166.27 162.94 162.94 159.69 29049 78.60 74.67 85.87 84.16 84.16 82.48 # 29049 59.55 56.57 65.06 63.76 63.76 62.48 29055 206.33 196.01 225.41 220.90 220.90 216.49 # 29055 132.02 125.42 144.23 141.35 141.35 138.52 29058 114.64 108.91 125.25 122.74 122.74 120.29 # 29058 88.73 84.29 96.93 94.99 94.99 93.09 29065 89.40 84.93 97.67 95.71 95.71 93.81 # 29065 65.05 61.80 71.07 69.64 69.64 68.25 29075 80.57 76.54 88.02 86.26 86.26 84.54 # 29075 59.03 56.08 64.49 63.20 63.20 61.94 29085 88.81 84.37 97.03 95.08 95.08 93.18 # 29085 64.14 60.93 70.07 68.67 68.67 67.30 29086 72.56 68.93 79.27 77.68 77.68 76.13 # 29086 48.52 46.09 53.00 51.95 51.95 50.91 29105 81.99 77.89 89.57 87.78 87.78 86.02 # 29105 56.71 53.87 61.95 60.71 60.71 59.49 29125 59.55 56.57 65.06 63.76 63.76 62.48 # 29125 37.38 35.51 40.84 40.02 40.02 39.22 29126 71.24 67.68 77.83 76.28 76.28 74.75 # 29126 46.27 43.96 50.55 49.54 49.54 48.55 29130 38.63 36.70 42.21 41.37 41.37 40.54 # 29130 27.70 26.32 30.27 29.66 29.66 29.06 29131 47.60 45.22 52.00 50.97 50.97 49.94 # 29131 31.68 30.10 34.62 33.93 33.93 33.25 29200 27.96 26.56 30.54 29.93 29.93 29.34 # 29200 17.97 17.07 19.63 19.24 19.24 18.86 29240 27.33 25.96 29.85 29.26 29.26 28.67 # 29240 18.28 17.37 19.98 19.57 19.57 19.18 29260 27.59 26.21 30.14 29.54 29.54 28.96 # 29260 19.16 18.20 20.93 20.52 20.52 20.10

Page 68: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 68Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

29280 27.90 26.51 30.49 29.88 29.88 29.28 # 29280 19.79 18.80 21.62 21.18 21.18 20.76 29305 229.22 217.76 250.42 245.41 245.41 240.50 # 29305 151.48 143.91 165.50 162.18 162.18 158.94 29325 252.50 239.88 275.86 270.34 270.34 264.94 # 29325 169.45 160.98 185.13 181.42 181.42 177.79 29345 127.46 121.09 139.25 136.47 136.47 133.75 # 29345 96.24 91.43 105.14 103.04 103.04 100.98 29355 132.06 125.46 144.28 141.39 141.39 138.56 # 29355 101.78 96.69 111.19 108.97 108.97 106.79 29358 149.37 141.90 163.19 159.92 159.92 156.72 # 29358 99.42 94.45 108.62 106.44 106.44 104.32 29365 114.39 108.67 124.97 122.48 122.48 120.03 # 29365 83.48 79.31 91.21 89.38 89.38 87.60 29405 76.39 72.57 83.46 81.79 81.79 80.16 # 29405 57.04 54.19 62.32 61.08 61.08 59.86 29425 73.61 69.93 80.42 78.81 78.81 77.23 # 29425 54.25 51.54 59.27 58.09 58.09 56.93 29435 108.82 103.38 118.89 116.51 116.51 114.17 # 29435 79.16 75.20 86.48 84.76 84.76 83.06 29440 41.53 39.45 45.37 44.46 44.46 43.57 # 29440 28.42 27.00 31.05 30.43 30.43 29.82 29445 127.81 121.42 139.63 136.84 136.84 134.10 # 29445 100.96 95.91 110.30 108.09 108.09 105.93 29450 137.02 130.17 149.70 146.71 146.71 143.77 # 29450 109.85 104.36 120.01 117.61 117.61 115.25 29505 77.19 73.33 84.33 82.64 82.64 80.98 # 29505 47.53 45.15 51.92 50.89 50.89 49.88 29515 67.10 63.75 73.31 71.85 71.85 70.41 # 29515 47.43 45.06 51.82 50.78 50.78 49.77 29520 29.52 28.04 32.25 31.60 31.60 30.97 # 29520 18.28 17.37 19.98 19.57 19.57 19.18 29530 27.31 25.94 29.83 29.23 29.23 28.65 # 29530 18.25 17.34 19.94 19.54 19.54 19.15 29540 24.81 23.57 27.11 26.57 26.57 26.04 # 29540 17.94 17.04 19.60 19.21 19.21 18.83 29550 17.95 17.05 19.61 19.22 19.22 18.84 # 29550 11.39 10.82 12.44 12.19 12.19 11.95 29580 49.16 46.70 53.71 52.64 52.64 51.58 # 29580 34.17 32.46 37.33 36.58 36.58 35.85 29581 55.76 52.97 60.92 59.70 59.70 58.50 # 29581 12.36 11.74 13.50 13.24 13.24 12.97 29582 63.71 60.52 69.60 68.21 68.21 66.84 # 29582 15.63 14.85 17.08 16.73 16.73 16.40 29583 39.83 37.84 43.52 42.64 42.64 41.79 # 29583 11.11 10.55 12.13 11.89 11.89 11.65 29584 63.71 60.52 69.60 68.21 68.21 66.84 # 29584 15.63 14.85 17.08 16.73 16.73 16.40 29700 58.25 55.34 63.64 62.36 62.36 61.12

Page 69: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 69Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 29700 32.34 30.72 35.33 34.63 34.63 33.94 29705 62.76 59.62 68.56 67.19 67.19 65.85 # 29705 45.59 43.31 49.81 48.81 48.81 47.83 29710 114.39 108.67 124.97 122.48 122.48 120.03 # 29710 80.04 76.04 87.45 85.70 85.70 83.98 29720 78.60 74.67 85.87 84.16 84.16 82.48 # 29720 42.69 40.56 46.64 45.71 45.71 44.80 29730 60.87 57.83 66.50 65.17 65.17 63.87 # 29730 43.69 41.51 47.74 46.78 46.78 45.85 29740 93.48 88.81 102.13 100.08 100.08 98.08 # 29740 67.88 64.49 74.16 72.68 72.68 71.23 29750 84.98 80.73 92.84 90.99 90.99 89.17 # 29750 65.62 62.34 71.69 70.25 70.25 68.85 29800 486.11 461.80 531.07 520.44 520.44 510.04 29804 617.12 586.26 674.20 660.71 660.71 647.50 29805 448.23 425.82 489.69 479.90 479.90 470.29 29806 1,015.96 965.16 1,109.93 1,087.74 1,087.74 1,065.98 29807 990.92 941.37 1,082.58 1,060.92 1,060.92 1,039.70 29819 557.74 529.85 609.33 597.14 597.14 585.20 29820 509.10 483.65 556.20 545.08 545.08 534.18 29821 556.28 528.47 607.74 595.59 595.59 583.67 29822 540.18 513.17 590.15 578.35 578.35 566.78 29823 589.85 560.36 644.41 631.52 631.52 618.90 29824 635.82 604.03 694.63 680.74 680.74 667.13 29825 550.62 523.09 601.55 589.52 589.52 577.74 29826 171.04 162.49 186.86 183.13 183.13 179.47 29827 1,013.72 963.03 1,107.48 1,085.34 1,085.34 1,063.62 29828 873.30 829.64 954.09 935.01 935.01 916.31 29830 430.47 408.95 470.29 460.89 460.89 451.66 29834 462.27 439.16 505.03 494.94 494.94 485.04 29835 480.58 456.55 525.03 514.53 514.53 504.24 29836 542.29 515.18 592.46 580.61 580.61 569.00 29837 497.96 473.06 544.02 533.14 533.14 522.48 29838 558.51 530.58 610.17 597.97 597.97 586.01 29840 429.00 407.55 468.68 459.31 459.31 450.12 29843 459.31 436.34 501.79 491.75 491.75 481.92 29844 470.74 447.20 514.28 504.00 504.00 493.91 29845 547.46 520.09 598.10 586.14 586.14 574.43 29846 494.06 469.36 539.76 528.97 528.97 518.39 29847 507.89 482.50 554.88 543.78 543.78 532.90 29848 483.65 459.47 528.39 517.82 517.82 507.46 29850 587.98 558.58 642.37 629.52 629.52 616.93 29851 849.55 807.07 928.13 909.57 909.57 891.38 29855 746.26 708.95 815.29 798.99 798.99 783.00 29856 954.33 906.61 1,042.60 1,021.75 1,021.75 1,001.32 29860 629.88 598.39 688.15 674.38 674.38 660.89 29861 687.55 653.17 751.15 736.13 736.13 721.41 29862 770.83 732.29 842.13 825.29 825.29 808.78 29863 770.78 732.24 842.08 825.24 825.24 808.74

Page 70: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 70Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

29866 996.73 946.89 1,088.92 1,067.14 1,067.14 1,045.80 29867 1,211.42 1,150.85 1,323.48 1,297.00 1,297.00 1,271.06 29868 1,548.22 1,470.81 1,691.43 1,657.60 1,657.60 1,624.44 29870 542.91 515.76 593.12 581.26 581.26 569.63 # 29870 391.18 371.62 427.36 418.82 418.82 410.45 29871 489.27 464.81 534.53 523.84 523.84 513.36 29873 496.20 471.39 542.10 531.25 531.25 520.63 29874 511.75 486.16 559.08 547.91 547.91 536.95 29875 470.94 447.39 514.50 504.21 504.21 494.12 29876 627.28 595.92 685.31 671.60 671.60 658.17 29877 592.69 563.06 647.52 634.57 634.57 621.87 29879 631.68 600.10 690.12 676.32 676.32 662.79 29880 535.03 508.28 584.52 572.83 572.83 561.37 29881 515.13 489.37 562.78 551.52 551.52 540.49 29882 668.61 635.18 730.46 715.85 715.85 701.53 29883 804.27 764.06 878.67 861.10 861.10 843.87 29884 586.17 556.86 640.39 627.58 627.58 615.03 29885 716.77 680.93 783.07 767.41 767.41 752.05 29886 607.00 576.65 663.15 649.89 649.89 636.89 29887 712.11 676.50 777.98 762.42 762.42 747.17 29888 945.07 897.82 1,032.49 1,011.84 1,011.84 991.60 29889 1,169.65 1,111.17 1,277.85 1,252.29 1,252.29 1,227.25 29891 648.24 615.83 708.20 694.04 694.04 680.16 29892 568.30 539.89 620.87 608.45 608.45 596.29 29893 577.19 548.33 630.58 617.96 617.96 605.60 # 29893 411.41 390.84 449.47 440.47 440.47 431.66 29894 480.78 456.74 525.25 514.75 514.75 504.46 29895 458.56 435.63 500.97 490.96 490.96 481.14 29897 485.84 461.55 530.78 520.17 520.17 509.76 29898 544.06 516.86 594.39 582.50 582.50 570.85 29899 994.55 944.82 1,086.54 1,064.81 1,064.81 1,043.51 29900 433.13 411.47 473.19 463.73 463.73 454.46 29901 504.79 479.55 551.48 540.45 540.45 529.64 29902 532.65 506.02 581.92 570.29 570.29 558.88 29904 608.58 578.15 664.87 651.58 651.58 638.55 29905 653.25 620.59 713.68 699.41 699.41 685.42 29906 686.69 652.36 750.21 735.21 735.21 720.50 29907 837.55 795.67 915.02 896.72 896.72 878.78 29914 955.01 907.26 1,043.35 1,022.48 1,022.48 1,002.03 29915 971.84 923.25 1,061.74 1,040.51 1,040.51 1,019.69 29916 973.09 924.44 1,063.11 1,041.84 1,041.84 1,021.00 30000 211.64 201.06 231.22 226.60 226.60 222.07 # 30000 112.04 106.44 122.41 119.96 119.96 117.55 30020 214.42 203.70 234.26 229.57 229.57 224.99 # 30020 112.95 107.30 123.40 120.92 120.92 118.51 30100 130.08 123.58 142.12 139.28 139.28 136.49 # 30100 65.77 62.48 71.85 70.41 70.41 69.01 30110 213.10 202.45 232.82 228.16 228.16 223.59 # 30110 123.81 117.62 135.26 132.56 132.56 129.90

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 71Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

30115 405.42 385.15 442.92 434.07 434.07 425.39 30117 797.61 757.73 871.39 853.97 853.97 836.89 # 30117 318.68 302.75 348.16 341.21 341.21 334.39 30118 729.56 693.08 797.04 781.10 781.10 765.49 30120 486.02 461.72 530.98 520.36 520.36 509.96 # 30120 414.53 393.80 452.87 443.81 443.81 434.93 30124 269.10 255.65 294.00 288.12 288.12 282.36 30125 574.35 545.63 627.47 614.93 614.93 602.63 30130 354.89 337.15 387.72 379.97 379.97 372.37 30140 408.94 388.49 446.76 437.83 437.83 429.08 30150 728.40 691.98 795.78 779.86 779.86 764.27 30160 732.29 695.68 800.03 784.04 784.04 768.35 30200 105.05 99.80 114.77 112.47 112.47 110.22 # 30200 56.66 53.83 61.90 60.66 60.66 59.46 30210 138.68 131.75 151.51 148.49 148.49 145.52 # 30210 93.72 89.03 102.38 100.34 100.34 98.34 30220 277.65 263.77 303.34 297.26 297.26 291.32 # 30220 118.74 112.80 129.72 127.12 127.12 124.58 30300 170.71 162.17 186.50 182.77 182.77 179.11 # 30300 99.21 94.25 108.39 106.23 106.23 104.10 30310 192.96 183.31 210.81 206.59 206.59 202.46 30320 416.24 395.43 454.74 445.65 445.65 436.74 30400 948.93 901.48 1,036.70 1,015.97 1,015.97 995.65 30410 1,115.75 1,059.96 1,218.95 1,194.57 1,194.57 1,170.68 30420 1,295.91 1,231.11 1,415.78 1,387.46 1,387.46 1,359.71 30430 892.55 847.92 975.11 955.60 955.60 936.49 30435 1,045.79 993.50 1,142.53 1,119.67 1,119.67 1,097.28 30450 1,419.54 1,348.56 1,550.84 1,519.83 1,519.83 1,489.43 30460 680.75 646.71 743.72 728.85 728.85 714.27 30462 1,476.47 1,402.65 1,613.05 1,580.79 1,580.79 1,549.18 30465 928.27 881.86 1,014.14 993.85 993.85 973.98 30520 586.64 557.31 640.91 628.08 628.08 615.53 30540 652.84 620.20 713.23 698.97 698.97 684.99 30545 835.34 793.57 912.61 894.36 894.36 876.47 30560 245.57 233.29 268.28 262.91 262.91 257.66 # 30560 128.49 122.07 140.38 137.57 137.57 134.83 30580 614.10 583.40 670.91 657.49 657.49 644.35 # 30580 488.90 464.46 534.13 523.45 523.45 512.98 30600 552.86 525.22 604.00 591.93 591.93 580.09 # 30600 425.79 404.50 465.18 455.87 455.87 446.75 30620 583.59 554.41 637.57 624.82 624.82 612.32 30630 586.85 557.51 641.14 628.31 628.31 615.74 30801 209.62 199.14 229.01 224.43 224.43 219.95 # 30801 126.89 120.55 138.63 135.86 135.86 133.15 30802 268.47 255.05 293.31 287.44 287.44 281.69 # 30802 178.86 169.92 195.41 191.50 191.50 187.67 30901 89.52 85.04 97.80 95.84 95.84 93.92 # 30901 55.49 52.72 60.63 59.42 59.42 58.24 30903 203.46 193.29 222.28 217.83 217.83 213.47

Page 72: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 72Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 30903 78.88 74.94 86.18 84.46 84.46 82.77 30905 249.88 237.39 273.00 267.54 267.54 262.19 # 30905 104.39 99.17 114.05 111.77 111.77 109.54 30906 321.23 305.17 350.95 343.93 343.93 337.05 # 30906 133.90 127.21 146.29 143.37 143.37 140.51 30915 546.30 518.99 596.84 584.90 584.90 573.21 30920 794.00 754.30 867.45 850.09 850.09 833.09 30930 115.72 109.93 126.42 123.89 123.89 121.42 31000 169.26 160.80 184.92 181.22 181.22 177.59 # 31000 99.94 94.94 109.18 107.00 107.00 104.86 31002 181.26 172.20 198.03 194.07 194.07 190.19 31020 445.90 423.61 487.15 477.41 477.41 467.87 # 31020 334.44 317.72 365.38 358.08 358.08 350.91 31030 643.81 611.62 703.36 689.30 689.30 675.51 # 31030 499.26 474.30 545.45 534.53 534.53 523.84 31032 542.15 515.04 592.30 580.45 580.45 568.85 31040 722.65 686.52 789.50 773.71 773.71 758.23 31050 457.92 435.02 500.27 490.27 490.27 480.46 31051 607.30 576.94 663.48 650.21 650.21 637.20 31070 411.48 390.91 449.55 440.55 440.55 431.74 31075 742.32 705.20 810.98 794.77 794.77 778.87 31080 980.41 931.39 1,071.10 1,049.67 1,049.67 1,028.68 31081 1,372.44 1,303.82 1,499.39 1,469.40 1,469.40 1,440.02 31084 1,098.68 1,043.75 1,200.31 1,176.31 1,176.31 1,152.78 31085 1,465.26 1,392.00 1,600.80 1,568.78 1,568.78 1,537.41 31086 1,069.14 1,015.68 1,168.03 1,144.68 1,144.68 1,121.78 31087 1,029.57 978.09 1,124.80 1,102.31 1,102.31 1,080.26 31090 962.87 914.73 1,051.94 1,030.91 1,030.91 1,010.29 31200 528.75 502.31 577.66 566.10 566.10 554.77 31201 697.60 662.72 762.13 746.89 746.89 731.95 31205 842.35 800.23 920.26 901.86 901.86 883.83 31225 1,791.81 1,702.22 1,957.55 1,918.41 1,918.41 1,880.04 31230 1,994.19 1,894.48 2,178.65 2,135.08 2,135.08 2,092.38 31231 191.96 182.36 209.71 205.52 205.52 201.41 # 31231 63.01 59.86 68.84 67.46 67.46 66.11 31233 243.92 231.72 266.48 261.15 261.15 255.93 # 31233 132.15 125.54 144.37 141.48 141.48 138.66 31235 278.65 264.72 304.43 298.34 298.34 292.38 # 31235 156.88 149.04 171.40 167.97 167.97 164.61 31237 242.25 230.14 264.66 259.37 259.37 254.18 # 31237 156.39 148.57 170.86 167.44 167.44 164.09 31238 242.52 230.39 264.95 259.65 259.65 254.45 # 31238 163.84 155.65 179.00 175.42 175.42 171.91 31239 588.90 559.46 643.38 630.51 630.51 617.90 31240 156.09 148.29 170.53 167.12 167.12 163.77 31254 265.44 252.17 290.00 284.20 284.20 278.52 31255 389.70 370.22 425.75 417.24 417.24 408.89 31256 192.06 182.46 209.83 205.63 205.63 201.51 31267 309.10 293.65 337.70 330.95 330.95 324.32

Page 73: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 73Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

31276 492.19 467.58 537.72 526.96 526.96 516.43 31287 225.56 214.28 246.42 241.49 241.49 236.66 31288 261.40 248.33 285.58 279.86 279.86 274.26 31290 1,117.53 1,061.65 1,220.90 1,196.48 1,196.48 1,172.55 31291 1,189.94 1,130.44 1,300.01 1,274.00 1,274.00 1,248.52 31292 966.56 918.23 1,055.96 1,034.85 1,034.85 1,014.15 31293 1,049.75 997.26 1,146.85 1,123.91 1,123.91 1,101.42 31294 1,201.17 1,141.11 1,312.28 1,286.03 1,286.03 1,260.31 31295 1,833.69 1,742.01 2,003.31 1,963.25 1,963.25 1,923.98 # 31295 159.29 151.33 174.03 170.55 170.55 167.13 31296 1,871.74 1,778.15 2,044.87 2,003.98 2,003.98 1,963.90 # 31296 191.09 181.54 208.77 204.60 204.60 200.50 31297 1,835.94 1,744.14 2,005.76 1,965.65 1,965.65 1,926.33 # 31297 155.92 148.12 170.34 166.93 166.93 163.60 31300 1,241.13 1,179.07 1,355.93 1,328.81 1,328.81 1,302.24 31320 644.65 612.42 704.28 690.20 690.20 676.40 31360 2,030.18 1,928.67 2,217.97 2,173.62 2,173.62 2,130.15 31365 2,513.20 2,387.54 2,745.67 2,690.76 2,690.76 2,636.94 31367 2,146.83 2,039.49 2,345.41 2,298.51 2,298.51 2,252.54 31368 2,395.58 2,275.80 2,617.17 2,564.82 2,564.82 2,513.52 31370 2,017.64 1,916.76 2,204.27 2,160.18 2,160.18 2,116.98 31375 1,904.29 1,809.08 2,080.44 2,038.84 2,038.84 1,998.06 31380 1,884.13 1,789.92 2,058.41 2,017.24 2,017.24 1,976.90 31382 2,076.76 1,972.92 2,268.86 2,223.48 2,223.48 2,179.01 31390 2,799.81 2,659.82 3,058.79 2,997.61 2,997.61 2,937.66 31395 2,954.49 2,806.77 3,227.79 3,163.22 3,163.22 3,099.96 31400 931.50 884.93 1,017.67 997.31 997.31 977.37 31420 796.83 756.99 870.54 853.13 853.13 836.06 31500 108.57 103.14 118.61 116.24 116.24 113.92 31502 34.29 32.58 37.47 36.72 36.72 35.98 31505 76.88 73.04 84.00 82.32 82.32 80.67 # 31505 46.91 44.56 51.24 50.22 50.22 49.22 31510 196.60 186.77 214.79 210.48 210.48 206.28 # 31510 117.61 111.73 128.49 125.93 125.93 123.41 31511 198.53 188.60 216.89 212.55 212.55 208.30 # 31511 126.41 120.09 138.10 135.34 135.34 132.64 31512 191.96 182.36 209.71 205.52 205.52 201.41 # 31512 125.46 119.19 137.07 134.33 134.33 131.64 31513 128.06 121.66 139.91 137.11 137.11 134.38 31515 173.20 164.54 189.22 185.44 185.44 181.73 # 31515 102.33 97.21 111.79 109.56 109.56 107.36 31520 152.20 144.59 166.28 162.96 162.96 159.70 31525 237.98 226.08 259.99 254.79 254.79 249.70 # 31525 156.18 148.37 170.63 167.21 167.21 163.86 31526 153.44 145.77 167.64 164.28 164.28 160.99 31527 189.75 180.26 207.30 203.15 203.15 199.09 31528 141.05 134.00 154.10 151.02 151.02 147.99 31529 157.95 150.05 172.56 169.11 169.11 165.73 31530 193.66 183.98 211.58 207.35 207.35 203.19

Page 74: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 74Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

31531 207.92 197.52 227.15 222.61 222.61 218.16 31535 185.24 175.98 202.38 198.33 198.33 194.36 31536 206.25 195.94 225.33 220.82 220.82 216.41 31540 236.71 224.87 258.60 253.43 253.43 248.35 31541 258.70 245.77 282.64 276.98 276.98 271.43 31545 355.46 337.69 388.34 380.58 380.58 372.97 31546 541.36 514.29 591.43 579.60 579.60 568.01 31560 307.25 291.89 335.67 328.96 328.96 322.38 31561 336.64 319.81 367.78 360.42 360.42 353.21 31570 320.76 304.72 350.43 343.42 343.42 336.56 # 31570 224.59 213.36 245.36 240.45 240.45 235.65 31571 244.79 232.55 267.43 262.09 262.09 256.84 31575 106.72 101.38 116.59 114.25 114.25 111.96 # 31575 73.63 69.95 80.44 78.83 78.83 77.26 31576 209.04 198.59 228.38 223.81 223.81 219.34 # 31576 120.06 114.06 131.17 128.55 128.55 125.97 31577 227.03 215.68 248.03 243.08 243.08 238.21 # 31577 145.86 138.57 159.36 156.17 156.17 153.04 31578 261.97 248.87 286.20 280.47 280.47 274.86 # 31578 167.68 159.30 183.20 179.53 179.53 175.94 31579 198.05 188.15 216.37 212.05 212.05 207.81 # 31579 136.86 130.02 149.52 146.53 146.53 143.60 31580 1,158.15 1,100.24 1,265.28 1,239.98 1,239.98 1,215.18 31582 1,799.37 1,709.40 1,965.81 1,926.49 1,926.49 1,887.97 31584 1,444.64 1,372.41 1,578.27 1,546.70 1,546.70 1,515.77 31587 963.95 915.75 1,053.11 1,032.06 1,032.06 1,011.41 31588 1,086.18 1,031.87 1,186.65 1,162.91 1,162.91 1,139.66 31590 835.99 794.19 913.32 895.06 895.06 877.15 31595 723.54 687.36 790.46 774.65 774.65 759.16 31600 388.44 369.02 424.37 415.89 415.89 407.57 31601 247.25 234.89 270.12 264.72 264.72 259.43 31603 219.30 208.34 239.59 234.80 234.80 230.10 31605 180.67 171.64 197.39 193.44 193.44 189.58 31610 681.84 647.75 744.91 730.02 730.02 715.42 31611 509.97 484.47 557.14 546.00 546.00 535.07 31612 79.00 75.05 86.31 84.58 84.58 82.89 # 31612 47.78 45.39 52.20 51.15 51.15 50.13 31613 427.81 406.42 467.38 458.03 458.03 448.87 31614 714.35 678.63 780.42 764.82 764.82 749.52 31615 171.78 163.19 187.67 183.92 183.92 180.24 # 31615 124.64 118.41 136.17 133.45 133.45 130.78 31622 282.58 268.45 308.72 302.54 302.54 296.49 # 31622 141.77 134.68 154.88 151.79 151.79 148.75 31623 306.93 291.58 335.32 328.61 328.61 322.05 # 31623 144.26 137.05 157.61 154.46 154.46 151.36 31624 291.32 276.75 318.26 311.90 311.90 305.67 # 31624 145.51 138.23 158.96 155.79 155.79 152.67 31625 366.72 348.38 400.64 392.62 392.62 384.77 # 31625 166.90 158.56 182.34 178.70 178.70 175.12

Page 75: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 75Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

31626 826.09 784.79 902.51 884.45 884.45 866.77 # 31626 208.22 197.81 227.48 222.93 222.93 218.47 31627 1,263.37 1,200.20 1,380.23 1,352.63 1,352.63 1,325.58 # 31627 96.32 91.50 105.23 103.12 103.12 101.06 31628 387.50 368.13 423.35 414.89 414.89 406.58 # 31628 186.12 176.81 203.33 199.26 199.26 195.27 31629 459.75 436.76 502.27 492.22 492.22 482.38 # 31629 196.86 187.02 215.07 210.77 210.77 206.55 31630 196.62 186.79 214.81 210.51 210.51 206.30 31631 225.95 214.65 246.85 241.91 241.91 237.07 31632 71.00 67.45 77.57 76.02 76.02 74.50 # 31632 48.83 46.39 53.35 52.28 52.28 51.23 31633 87.86 83.47 95.99 94.07 94.07 92.18 # 31633 62.88 59.74 68.70 67.33 67.33 65.99 31634 1,668.87 1,585.43 1,823.24 1,786.78 1,786.78 1,751.05 # 31634 203.03 192.88 221.81 217.37 217.37 213.03 31635 326.06 309.76 356.22 349.09 349.09 342.11 # 31635 185.56 176.28 202.72 198.66 198.66 194.70 31636 218.06 207.16 238.23 233.47 233.47 228.80 31637 73.72 70.03 80.53 78.92 78.92 77.35 31638 248.88 236.44 271.91 266.47 266.47 261.14 31640 250.42 237.90 273.59 268.11 268.11 262.75 31641 254.06 241.36 277.56 272.01 272.01 266.57 31643 174.37 165.65 190.50 186.69 186.69 182.95 31645 301.57 286.49 329.46 322.87 322.87 316.41 # 31645 158.89 150.95 173.59 170.12 170.12 166.72 31646 270.00 256.50 294.98 289.08 289.08 283.29 # 31646 137.31 130.44 150.01 147.00 147.00 144.06 31647 218.54 207.61 238.75 233.98 233.98 229.30 31648 202.77 192.63 221.52 217.10 217.10 212.75 31649 68.94 65.49 75.31 73.81 73.81 72.34 31651 78.13 74.22 85.35 83.65 83.65 81.98 31652 823.10 781.95 899.24 881.26 881.26 863.63 # 31652 231.14 219.58 252.52 247.47 247.47 242.52 31653 875.83 832.04 956.85 937.71 937.71 918.95 # 31653 255.15 242.39 278.75 273.17 273.17 267.71 31654 134.07 127.37 146.48 143.54 143.54 140.67 # 31654 66.94 63.59 73.13 71.67 71.67 70.23 31660 207.46 197.09 226.65 222.12 222.12 217.68 31661 217.94 207.04 238.10 233.34 233.34 228.67 31717 240.94 228.89 263.22 257.96 257.96 252.79 # 31717 106.69 101.36 116.56 114.23 114.23 111.94 31720 50.82 48.28 55.52 54.41 54.41 53.31 31725 89.04 84.59 97.28 95.34 95.34 93.43 31730 1,105.34 1,050.07 1,207.58 1,183.43 1,183.43 1,159.76 # 31730 145.59 138.31 159.06 155.87 155.87 152.75 31750 1,333.64 1,266.96 1,457.00 1,427.86 1,427.86 1,399.31 31755 1,664.20 1,580.99 1,818.14 1,781.78 1,781.78 1,746.14 31760 1,354.03 1,286.33 1,479.28 1,449.69 1,449.69 1,420.70

Page 76: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 76Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

31766 1,743.44 1,656.27 1,904.71 1,866.61 1,866.61 1,829.28 31770 1,307.21 1,241.85 1,428.13 1,399.56 1,399.56 1,371.57 31775 1,277.98 1,214.08 1,396.19 1,368.27 1,368.27 1,340.90 31780 1,148.49 1,091.07 1,254.73 1,229.64 1,229.64 1,205.05 31781 1,410.34 1,339.82 1,540.79 1,509.97 1,509.97 1,479.77 31785 1,057.20 1,004.34 1,154.99 1,131.89 1,131.89 1,109.26 31786 1,403.74 1,333.55 1,533.58 1,502.91 1,502.91 1,472.85 31800 695.96 661.16 760.33 745.13 745.13 730.23 31805 800.91 760.86 874.99 857.49 857.49 840.34 31820 408.95 388.50 446.78 437.84 437.84 429.09 # 31820 314.97 299.22 344.10 337.23 337.23 330.49 31825 568.07 539.67 620.62 608.21 608.21 596.05 # 31825 460.99 437.94 503.63 493.56 493.56 483.69 31830 417.12 396.26 455.70 446.58 446.58 437.64 # 31830 328.45 312.03 358.83 351.66 351.66 344.62 32035 694.97 660.22 759.25 744.07 744.07 729.19 32036 751.10 713.55 820.58 804.17 804.17 788.08 32096 784.23 745.02 856.77 839.64 839.64 822.85 32097 783.97 744.77 856.49 839.35 839.35 822.56 32098 743.13 705.97 811.87 795.63 795.63 779.71 32100 787.33 747.96 860.15 842.95 842.95 826.09 32110 1,424.64 1,353.41 1,556.42 1,525.29 1,525.29 1,494.78 32120 845.50 803.23 923.71 905.25 905.25 887.14 32124 899.88 854.89 983.12 963.46 963.46 944.18 32140 968.95 920.50 1,058.58 1,037.40 1,037.40 1,016.66 32141 1,490.44 1,415.92 1,628.31 1,595.74 1,595.74 1,563.83 32150 976.72 927.88 1,067.06 1,045.72 1,045.72 1,024.80 32151 976.01 927.21 1,066.29 1,044.97 1,044.97 1,024.08 32160 766.36 728.04 837.25 820.50 820.50 804.09 32200 1,103.34 1,048.17 1,205.40 1,181.29 1,181.29 1,157.67 32215 773.95 735.25 845.54 828.63 828.63 812.06 32220 1,540.45 1,463.43 1,682.94 1,649.28 1,649.28 1,616.30 32225 967.48 919.11 1,056.98 1,035.84 1,035.84 1,015.13 32310 885.83 841.54 967.77 948.42 948.42 929.45 32320 1,555.70 1,477.92 1,699.61 1,665.61 1,665.61 1,632.30 32400 142.50 135.38 155.69 152.57 152.57 149.52 # 32400 86.30 81.99 94.29 92.40 92.40 90.55 32405 408.01 387.61 445.75 436.84 436.84 428.10 # 32405 102.04 96.94 111.48 109.25 109.25 107.07 32440 1,527.60 1,451.22 1,668.90 1,635.53 1,635.53 1,602.82 32442 3,128.67 2,972.24 3,418.08 3,349.72 3,349.72 3,282.72 32445 3,470.44 3,296.92 3,791.46 3,715.63 3,715.63 3,641.31 32480 1,441.95 1,369.85 1,575.33 1,543.82 1,543.82 1,512.94 32482 1,542.52 1,465.39 1,685.20 1,651.49 1,651.49 1,618.46 32484 1,403.54 1,333.36 1,533.36 1,502.69 1,502.69 1,472.64 32486 2,304.43 2,189.21 2,517.59 2,467.24 2,467.24 2,417.90 32488 2,341.08 2,224.03 2,557.63 2,506.48 2,506.48 2,456.35 32491 1,436.25 1,364.44 1,569.11 1,537.72 1,537.72 1,506.97 32501 241.36 229.29 263.68 258.41 258.41 253.24

Page 77: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 77Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

32503 1,765.15 1,676.89 1,928.42 1,889.85 1,889.85 1,852.05 32504 2,015.49 1,914.72 2,201.93 2,157.89 2,157.89 2,114.74 32505 907.31 861.94 991.23 971.41 971.41 951.98 32506 154.50 146.78 168.80 165.42 165.42 162.10 32507 154.22 146.51 168.49 165.12 165.12 161.82 32540 1,694.41 1,609.69 1,851.14 1,814.13 1,814.13 1,777.84 32550 712.36 676.74 778.25 762.69 762.69 747.44 # 32550 218.13 207.22 238.30 233.54 233.54 228.87 32551 167.23 158.87 182.70 179.04 179.04 175.47 32552 176.62 167.79 192.96 189.09 189.09 185.31 # 32552 154.45 146.73 168.74 165.37 165.37 162.06 32553 542.56 515.43 592.74 580.89 580.89 569.27 # 32553 191.94 182.34 209.69 205.49 205.49 201.39 32554 185.81 176.52 203.00 198.94 198.94 194.96 # 32554 88.71 84.27 96.91 94.97 94.97 93.07 32555 267.43 254.06 292.17 286.33 286.33 280.60 # 32555 111.32 105.75 121.61 119.19 119.19 116.81 32556 490.67 466.14 536.06 525.34 525.34 514.83 # 32556 122.26 116.15 133.57 130.90 130.90 128.28 32557 471.83 448.24 515.48 505.17 505.17 495.06 # 32557 152.43 144.81 166.53 163.20 163.20 159.93 32560 223.67 212.49 244.36 239.48 239.48 234.69 # 32560 76.93 73.08 84.04 82.36 82.36 80.72 32561 88.67 84.24 96.88 94.94 94.94 93.05 # 32561 67.75 64.36 74.01 72.53 72.53 71.08 32562 79.83 75.84 87.22 85.47 85.47 83.75 # 32562 61.10 58.05 66.76 65.42 65.42 64.11 32601 301.87 286.78 329.80 323.20 323.20 316.73 32604 472.58 448.95 516.29 505.97 505.97 495.85 32606 453.06 430.41 494.97 485.07 485.07 475.36 32607 302.13 287.02 330.07 323.47 323.47 317.00 32608 370.82 352.28 405.12 397.01 397.01 389.08 32609 253.33 240.66 276.76 271.23 271.23 265.80 32650 646.05 613.75 705.81 691.70 691.70 677.87 32651 1,068.11 1,014.70 1,166.91 1,143.57 1,143.57 1,120.70 32652 1,623.11 1,541.95 1,773.24 1,737.78 1,737.78 1,703.02 32653 1,032.14 980.53 1,127.61 1,105.06 1,105.06 1,082.96 32654 1,155.20 1,097.44 1,262.06 1,236.81 1,236.81 1,212.08 32655 930.78 884.24 1,016.88 996.54 996.54 976.61 32656 780.33 741.31 852.51 835.45 835.45 818.74 32658 693.28 658.62 757.41 742.27 742.27 727.42 32659 710.23 674.72 775.93 760.41 760.41 745.21 32661 778.84 739.90 850.89 833.87 833.87 817.19 32662 868.39 824.97 948.72 929.74 929.74 911.15 32663 1,368.80 1,300.36 1,495.41 1,465.50 1,465.50 1,436.19 32664 829.02 787.57 905.71 887.59 887.59 869.84 32665 1,196.38 1,136.56 1,307.04 1,280.90 1,280.90 1,255.28 32666 847.06 804.71 925.42 906.91 906.91 888.78 32667 154.81 147.07 169.13 165.75 165.75 162.44

Page 78: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 78Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

32668 154.50 146.78 168.80 165.42 165.42 162.10 32669 1,314.96 1,249.21 1,436.59 1,407.86 1,407.86 1,379.71 32670 1,565.92 1,487.62 1,710.76 1,676.55 1,676.55 1,643.02 32671 1,733.98 1,647.28 1,894.37 1,856.48 1,856.48 1,819.35 32672 1,488.96 1,414.51 1,626.69 1,594.15 1,594.15 1,562.28 32673 1,189.30 1,129.84 1,299.32 1,273.33 1,273.33 1,247.87 32674 212.62 201.99 232.29 227.64 227.64 223.09 32701 213.91 203.21 233.69 229.02 229.02 224.45 32800 919.00 873.05 1,004.01 983.93 983.93 964.25 32810 876.39 832.57 957.46 938.31 938.31 919.54 32815 2,737.49 2,600.62 2,990.71 2,930.90 2,930.90 2,872.29 32820 1,299.79 1,234.80 1,420.02 1,391.62 1,391.62 1,363.79 32851 3,228.58 3,067.15 3,527.22 3,456.68 3,456.68 3,387.54 32852 3,532.55 3,355.92 3,859.31 3,782.12 3,782.12 3,706.47 32853 4,503.90 4,278.71 4,920.52 4,822.11 4,822.11 4,725.67 32854 4,789.45 4,549.98 5,232.48 5,127.83 5,127.83 5,025.27 32855 208.20 197.79 227.46 222.90 222.90 218.44 32856 312.27 296.66 341.16 334.34 334.34 327.66 32900 1,366.61 1,298.28 1,493.02 1,463.16 1,463.16 1,433.89 32905 1,308.92 1,243.47 1,429.99 1,401.39 1,401.39 1,373.36 32906 1,619.50 1,538.53 1,769.31 1,733.92 1,733.92 1,699.24 32940 1,203.70 1,143.52 1,315.05 1,288.75 1,288.75 1,262.98 32960 133.94 127.24 146.33 143.41 143.41 140.54 # 32960 97.72 92.83 106.75 104.62 104.62 102.52 32997 341.31 324.24 372.88 365.42 365.42 358.11 32998 2,148.61 2,041.18 2,347.36 2,300.41 2,300.41 2,254.40 # 32998 281.89 267.80 307.97 301.81 301.81 295.77 33010 117.88 111.99 128.79 126.21 126.21 123.69 33011 118.47 112.55 129.43 126.85 126.85 124.30 33015 495.44 470.67 541.27 530.45 530.45 519.83 33020 856.45 813.63 935.67 916.96 916.96 898.62 33025 778.13 739.22 850.10 833.11 833.11 816.44 33030 1,960.61 1,862.58 2,141.97 2,099.13 2,099.13 2,057.14 33031 2,422.79 2,301.65 2,646.90 2,593.96 2,593.96 2,542.09 33050 972.66 924.03 1,062.63 1,041.38 1,041.38 1,020.56 33120 2,057.79 1,954.90 2,248.14 2,203.17 2,203.17 2,159.10 33130 1,347.53 1,280.15 1,472.17 1,442.73 1,442.73 1,413.88 33140 1,539.45 1,462.48 1,681.85 1,648.21 1,648.21 1,615.26 33141 129.93 123.43 141.94 139.10 139.10 136.32 33202 755.91 718.11 825.83 809.31 809.31 793.13 33203 786.44 747.12 859.19 842.01 842.01 825.17 33206 446.95 424.60 488.29 478.53 478.53 468.96 33207 477.58 453.70 521.76 511.32 511.32 501.10 33208 517.25 491.39 565.10 553.79 553.79 542.72 33210 175.43 166.66 191.66 187.83 187.83 184.07 33211 179.54 170.56 196.14 192.22 192.22 188.38 33212 322.65 306.52 352.50 345.45 345.45 338.54 33213 336.53 319.70 367.66 360.31 360.31 353.10 33214 474.05 450.35 517.90 507.54 507.54 497.39

Page 79: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 79Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33215 299.75 284.76 327.47 320.92 320.92 314.50 33216 369.40 350.93 403.57 395.50 395.50 387.58 33217 362.73 344.59 396.28 388.36 388.36 380.59 33218 386.38 367.06 422.12 413.68 413.68 405.41 33220 387.35 367.98 423.18 414.71 414.71 406.42 33221 360.36 342.34 393.69 385.81 385.81 378.10 33222 335.46 318.69 366.49 359.17 359.17 351.98 33223 405.79 385.50 443.33 434.46 434.46 425.76 33224 502.68 477.55 549.18 538.20 538.20 527.44 33225 457.13 434.27 499.41 489.42 489.42 479.63 33226 481.98 457.88 526.56 516.03 516.03 505.71 33227 338.89 321.95 370.24 362.84 362.84 355.58 33228 353.70 336.02 386.42 378.70 378.70 371.12 33229 372.54 353.91 407.00 398.85 398.85 390.87 33230 383.90 364.71 419.42 411.03 411.03 402.81 33231 399.68 379.70 436.66 427.93 427.93 419.37 33233 232.53 220.90 254.04 248.95 248.95 243.97 33234 480.45 456.43 524.89 514.40 514.40 504.10 33235 625.72 594.43 683.59 669.92 669.92 656.52 33236 760.02 722.02 830.32 813.72 813.72 797.44 33237 817.60 776.72 893.23 875.37 875.37 857.87 33238 906.49 861.17 990.35 970.54 970.54 951.13 33240 366.05 347.75 399.91 391.92 391.92 384.08 33241 219.33 208.36 239.61 234.82 234.82 230.13 33243 1,333.84 1,267.15 1,457.22 1,428.08 1,428.08 1,399.52 33244 841.91 799.81 919.78 901.38 901.38 883.35 33249 899.02 854.07 982.18 962.54 962.54 943.29 33250 1,432.45 1,360.83 1,564.95 1,533.65 1,533.65 1,502.98 33251 1,588.81 1,509.37 1,735.78 1,701.06 1,701.06 1,667.04 33254 1,338.70 1,271.77 1,462.54 1,433.28 1,433.28 1,404.61 33255 1,585.12 1,505.86 1,731.74 1,697.10 1,697.10 1,663.16 33256 1,912.33 1,816.71 2,089.22 2,047.44 2,047.44 2,006.49 33257 566.36 538.04 618.75 606.37 606.37 594.24 33258 636.52 604.69 695.39 681.49 681.49 667.86 33259 821.81 780.72 897.83 879.88 879.88 862.28 33261 1,602.93 1,522.78 1,751.20 1,716.17 1,716.17 1,681.84 33262 372.32 353.70 406.76 398.62 398.62 390.66 33263 387.13 367.77 422.94 414.47 414.47 406.18 33264 403.47 383.30 440.80 431.97 431.97 423.34 33265 1,328.46 1,262.04 1,451.35 1,422.32 1,422.32 1,393.87 33266 1,807.94 1,717.54 1,975.17 1,935.67 1,935.67 1,896.96 33270 570.88 542.34 623.69 611.21 611.21 598.99 33271 479.99 455.99 524.39 513.90 513.90 503.62 33272 339.12 322.16 370.48 363.08 363.08 355.82 33273 391.75 372.16 427.98 419.43 419.43 411.04 33282 229.55 218.07 250.78 245.77 245.77 240.86 33284 202.58 192.45 221.32 216.89 216.89 212.55 33300 2,403.59 2,283.41 2,625.92 2,573.40 2,573.40 2,521.94 33305 4,032.30 3,830.69 4,405.29 4,317.19 4,317.19 4,230.85

Page 80: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 80Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33310 1,147.41 1,090.04 1,253.55 1,228.48 1,228.48 1,203.91 33315 1,875.13 1,781.37 2,048.58 2,007.60 2,007.60 1,967.45 33320 1,037.91 986.01 1,133.91 1,111.23 1,111.23 1,089.00 33321 1,198.92 1,138.97 1,309.82 1,283.62 1,283.62 1,257.95 33322 1,358.05 1,290.15 1,483.67 1,454.00 1,454.00 1,424.92 33330 1,394.26 1,324.55 1,523.23 1,492.77 1,492.77 1,462.92 33335 1,834.10 1,742.40 2,003.76 1,963.68 1,963.68 1,924.41 33361 1,334.27 1,267.56 1,457.69 1,428.54 1,428.54 1,399.98 33362 1,458.46 1,385.54 1,593.37 1,561.50 1,561.50 1,530.27 33363 1,514.94 1,439.19 1,655.07 1,621.97 1,621.97 1,589.53 33364 1,588.43 1,509.01 1,735.36 1,700.65 1,700.65 1,666.64 33365 1,749.39 1,661.92 1,911.21 1,872.98 1,872.98 1,835.53 33366 1,893.11 1,798.45 2,068.22 2,026.85 2,026.85 1,986.31 33367 615.63 584.85 672.58 659.12 659.12 645.94 33368 736.89 700.05 805.06 788.96 788.96 773.18 33369 973.84 925.15 1,063.92 1,042.65 1,042.65 1,021.80 33400 2,233.20 2,121.54 2,439.77 2,390.98 2,390.98 2,343.16 33401 1,408.30 1,337.89 1,538.57 1,507.80 1,507.80 1,477.65 33403 1,447.55 1,375.17 1,581.45 1,549.82 1,549.82 1,518.83 33404 1,722.47 1,636.35 1,881.80 1,844.16 1,844.16 1,807.28 33405 2,225.62 2,114.34 2,431.49 2,382.86 2,382.86 2,335.20 33406 2,822.97 2,681.82 3,084.09 3,022.41 3,022.41 2,961.96 33410 2,487.10 2,362.75 2,717.16 2,662.83 2,662.83 2,609.57 33411 3,295.94 3,131.14 3,600.81 3,528.80 3,528.80 3,458.22 33412 3,117.02 2,961.17 3,405.35 3,337.24 3,337.24 3,270.50 33413 3,191.95 3,032.35 3,487.20 3,417.46 3,417.46 3,349.11 33414 2,121.15 2,015.09 2,317.35 2,271.01 2,271.01 2,225.58 33415 1,988.68 1,889.25 2,172.64 2,129.19 2,129.19 2,086.61 33416 1,991.08 1,891.53 2,175.26 2,131.76 2,131.76 2,089.12 33417 1,638.44 1,556.52 1,790.00 1,754.20 1,754.20 1,719.11 33418 1,760.38 1,672.36 1,923.21 1,884.75 1,884.75 1,847.05 33419 415.93 395.13 454.40 445.31 445.31 436.41 33420 1,427.04 1,355.69 1,559.04 1,527.87 1,527.87 1,497.31 33422 1,637.55 1,555.67 1,789.02 1,753.24 1,753.24 1,718.18 33425 2,682.36 2,548.24 2,930.48 2,871.87 2,871.87 2,814.43 33426 2,335.54 2,218.76 2,551.57 2,500.54 2,500.54 2,450.52 33427 2,398.53 2,278.60 2,620.39 2,567.98 2,567.98 2,516.63 33430 2,743.81 2,606.62 2,997.61 2,937.66 2,937.66 2,878.91 33460 2,394.97 2,275.22 2,616.50 2,564.18 2,564.18 2,512.90 33463 3,034.96 2,883.21 3,315.69 3,249.38 3,249.38 3,184.40 33464 2,395.51 2,275.73 2,617.09 2,564.75 2,564.75 2,513.46 33465 2,706.26 2,570.95 2,956.59 2,897.46 2,897.46 2,839.51 33468 2,419.45 2,298.48 2,643.25 2,590.39 2,590.39 2,538.58 33470 1,262.53 1,199.40 1,379.31 1,351.72 1,351.72 1,324.69 33471 1,349.30 1,281.84 1,474.12 1,444.63 1,444.63 1,415.74 33474 2,146.24 2,038.93 2,344.77 2,297.87 2,297.87 2,251.92 33475 2,285.28 2,171.02 2,496.67 2,446.74 2,446.74 2,397.81 33476 1,494.89 1,420.15 1,633.17 1,600.51 1,600.51 1,568.51 33477 1,277.19 1,213.33 1,395.33 1,367.42 1,367.42 1,340.07

Page 81: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 81Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33478 1,544.91 1,467.66 1,687.81 1,654.06 1,654.06 1,620.97 33496 1,636.20 1,554.39 1,787.55 1,751.80 1,751.80 1,716.75 33500 1,534.50 1,457.78 1,676.45 1,642.91 1,642.91 1,610.06 33501 1,105.93 1,050.63 1,208.22 1,184.06 1,184.06 1,160.38 33502 1,251.27 1,188.71 1,367.02 1,339.68 1,339.68 1,312.89 33503 1,299.75 1,234.76 1,419.97 1,391.57 1,391.57 1,363.74 33504 1,439.03 1,367.08 1,572.14 1,540.70 1,540.70 1,509.89 33505 2,038.35 1,936.43 2,226.89 2,182.36 2,182.36 2,138.71 33506 2,028.07 1,926.67 2,215.67 2,171.36 2,171.36 2,127.94 33507 1,699.91 1,614.91 1,857.15 1,820.00 1,820.00 1,783.60 33508 15.90 15.11 17.38 17.03 17.03 16.69 33510 1,894.05 1,799.35 2,069.25 2,027.86 2,027.86 1,987.30 33511 2,081.63 1,977.55 2,274.18 2,228.70 2,228.70 2,184.13 33512 2,367.29 2,248.93 2,586.27 2,534.54 2,534.54 2,483.85 33513 2,436.18 2,314.37 2,661.53 2,608.29 2,608.29 2,556.13 33514 2,565.98 2,437.68 2,803.33 2,747.27 2,747.27 2,692.32 33516 2,676.05 2,542.25 2,923.59 2,865.12 2,865.12 2,807.82 33517 184.75 175.51 201.84 197.80 197.80 193.84 33518 406.04 385.74 443.60 434.73 434.73 426.04 33519 537.00 510.15 586.67 574.94 574.94 563.44 33521 643.98 611.78 703.55 689.47 689.47 675.68 33522 722.58 686.45 789.42 773.63 773.63 758.16 33523 821.82 780.73 897.84 879.89 879.89 862.29 33530 518.96 493.01 566.96 555.62 555.62 544.51 33533 1,831.37 1,739.80 2,000.77 1,960.75 1,960.75 1,921.54 33534 2,155.64 2,047.86 2,355.04 2,307.94 2,307.94 2,261.77 33535 2,404.83 2,284.59 2,627.28 2,574.74 2,574.74 2,523.24 33536 2,593.45 2,463.78 2,833.35 2,776.68 2,776.68 2,721.14 33542 2,578.40 2,449.48 2,816.90 2,760.56 2,760.56 2,705.35 33545 3,042.25 2,890.14 3,323.66 3,257.19 3,257.19 3,192.04 33548 2,906.20 2,760.89 3,175.02 3,111.52 3,111.52 3,049.29 33572 227.37 216.00 248.40 243.43 243.43 238.57 33600 1,689.41 1,604.94 1,845.68 1,808.77 1,808.77 1,772.59 33602 1,639.39 1,557.42 1,791.03 1,755.21 1,755.21 1,720.10 33606 1,823.12 1,731.96 1,991.75 1,951.92 1,951.92 1,912.88 33608 1,770.49 1,681.97 1,934.27 1,895.58 1,895.58 1,857.66 33610 1,745.80 1,658.51 1,907.29 1,869.14 1,869.14 1,831.75 33611 2,016.01 1,915.21 2,202.49 2,158.45 2,158.45 2,115.28 33612 1,976.54 1,877.71 2,159.37 2,116.18 2,116.18 2,073.86 33615 1,966.37 1,868.05 2,148.26 2,105.29 2,105.29 2,063.19 33617 2,131.61 2,025.03 2,328.78 2,282.21 2,282.21 2,236.57 33619 2,683.77 2,549.58 2,932.02 2,873.38 2,873.38 2,815.91 33620 1,627.02 1,545.67 1,777.52 1,741.97 1,741.97 1,707.13 33621 914.60 868.87 999.20 979.21 979.21 959.63 33622 3,566.92 3,388.57 3,896.86 3,818.92 3,818.92 3,742.54 33641 1,615.69 1,534.91 1,765.15 1,729.84 1,729.84 1,695.25 33645 1,705.49 1,620.22 1,863.25 1,825.99 1,825.99 1,789.47 33647 1,792.67 1,703.04 1,958.50 1,919.33 1,919.33 1,880.94 33660 1,732.20 1,645.59 1,892.43 1,854.58 1,854.58 1,817.49

Page 82: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 82Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33665 1,887.98 1,793.58 2,062.62 2,021.37 2,021.37 1,980.94 33670 1,949.62 1,852.14 2,129.96 2,087.37 2,087.37 2,045.62 33675 1,945.70 1,848.42 2,125.68 2,083.17 2,083.17 2,041.50 33676 2,092.30 1,987.69 2,285.84 2,240.13 2,240.13 2,195.33 33677 2,174.05 2,065.35 2,375.15 2,327.65 2,327.65 2,281.09 33681 1,807.89 1,717.50 1,975.13 1,935.62 1,935.62 1,896.91 33684 1,950.72 1,853.18 2,131.16 2,088.54 2,088.54 2,046.77 33688 1,860.73 1,767.69 2,032.84 1,992.19 1,992.19 1,952.34 33690 1,175.81 1,117.02 1,284.57 1,258.88 1,258.88 1,233.71 33692 2,028.90 1,927.46 2,216.58 2,172.25 2,172.25 2,128.80 33694 2,016.01 1,915.21 2,202.49 2,158.45 2,158.45 2,115.28 33697 2,028.23 1,926.82 2,215.84 2,171.52 2,171.52 2,128.09 33702 1,520.00 1,444.00 1,660.60 1,627.39 1,627.39 1,594.84 33710 2,121.31 2,015.24 2,317.53 2,271.18 2,271.18 2,225.76 33720 1,520.71 1,444.67 1,661.37 1,628.15 1,628.15 1,595.58 33722 1,601.10 1,521.05 1,749.21 1,714.22 1,714.22 1,679.94 33724 1,516.23 1,440.42 1,656.48 1,623.35 1,623.35 1,590.89 33726 2,006.17 1,905.86 2,191.74 2,147.90 2,147.90 2,104.95 33730 1,975.47 1,876.70 2,158.21 2,115.05 2,115.05 2,072.75 33732 1,619.79 1,538.80 1,769.62 1,734.22 1,734.22 1,699.54 33735 1,270.76 1,207.22 1,388.30 1,360.54 1,360.54 1,333.33 33736 1,380.23 1,311.22 1,507.90 1,477.75 1,477.75 1,448.20 33737 1,322.69 1,256.56 1,445.04 1,416.14 1,416.14 1,387.82 33750 1,240.54 1,178.51 1,355.29 1,328.18 1,328.18 1,301.62 33755 1,291.36 1,226.79 1,410.81 1,382.59 1,382.59 1,354.94 33762 1,312.28 1,246.67 1,433.67 1,405.00 1,405.00 1,376.91 33764 1,291.36 1,226.79 1,410.81 1,382.59 1,382.59 1,354.94 33766 1,309.85 1,244.36 1,431.01 1,402.39 1,402.39 1,374.34 33767 1,399.07 1,329.12 1,528.49 1,497.92 1,497.92 1,467.96 33768 412.92 392.27 451.11 442.08 442.08 433.24 33770 2,194.27 2,084.56 2,397.24 2,349.30 2,349.30 2,302.31 33771 2,263.78 2,150.59 2,473.18 2,423.72 2,423.72 2,375.24 33774 1,769.26 1,680.80 1,932.92 1,894.26 1,894.26 1,856.38 33775 1,902.53 1,807.40 2,078.51 2,036.94 2,036.94 1,996.20 33776 2,009.66 1,909.18 2,195.56 2,151.65 2,151.65 2,108.62 33777 1,949.00 1,851.55 2,129.28 2,086.70 2,086.70 2,044.96 33778 2,425.10 2,303.85 2,649.43 2,596.44 2,596.44 2,544.50 33779 2,414.80 2,294.06 2,638.17 2,585.41 2,585.41 2,533.70 33780 2,340.00 2,223.00 2,556.45 2,505.32 2,505.32 2,455.22 33781 2,404.43 2,284.21 2,626.84 2,574.31 2,574.31 2,522.82 33782 3,190.91 3,031.36 3,486.06 3,416.34 3,416.34 3,348.02 33783 3,625.79 3,444.50 3,961.18 3,881.95 3,881.95 3,804.32 33786 2,246.19 2,133.88 2,453.96 2,404.88 2,404.88 2,356.79 33788 1,575.04 1,496.29 1,720.73 1,686.31 1,686.31 1,652.58 33800 970.44 921.92 1,060.21 1,039.00 1,039.00 1,018.22 33802 1,062.14 1,009.03 1,160.38 1,137.18 1,137.18 1,114.43 33803 1,130.96 1,074.41 1,235.57 1,210.86 1,210.86 1,186.64 33813 1,261.84 1,198.75 1,378.56 1,351.00 1,351.00 1,323.97 33814 1,496.45 1,421.63 1,634.87 1,602.18 1,602.18 1,570.14

Page 83: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 83Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33820 950.95 903.40 1,038.91 1,018.13 1,018.13 997.76 33822 1,041.76 989.67 1,138.12 1,115.36 1,115.36 1,093.05 33824 1,156.56 1,098.73 1,263.54 1,238.27 1,238.27 1,213.50 33840 1,215.54 1,154.76 1,327.97 1,301.41 1,301.41 1,275.38 33845 1,308.58 1,243.15 1,429.62 1,401.03 1,401.03 1,373.01 33851 1,248.35 1,185.93 1,363.82 1,336.54 1,336.54 1,309.82 33852 1,373.71 1,305.02 1,500.77 1,470.76 1,470.76 1,441.34 33853 1,802.94 1,712.79 1,969.71 1,930.31 1,930.31 1,891.70 33860 3,156.16 2,998.35 3,448.10 3,379.14 3,379.14 3,311.55 33863 3,097.62 2,942.74 3,384.15 3,316.47 3,316.47 3,250.14 33864 3,167.37 3,009.00 3,460.35 3,391.14 3,391.14 3,323.32 33870 2,471.35 2,347.78 2,699.95 2,645.94 2,645.94 2,593.02 33875 2,702.58 2,567.45 2,952.57 2,893.52 2,893.52 2,835.65 33877 3,593.52 3,413.84 3,925.92 3,847.39 3,847.39 3,770.45 33880 1,790.26 1,700.75 1,955.86 1,916.75 1,916.75 1,878.42 33881 1,537.20 1,460.34 1,679.39 1,645.80 1,645.80 1,612.89 33883 1,111.72 1,056.13 1,214.55 1,190.26 1,190.26 1,166.46 33884 408.47 388.05 446.26 437.33 437.33 428.58 33886 959.11 911.15 1,047.82 1,026.87 1,026.87 1,006.33 33889 787.89 748.50 860.78 843.56 843.56 826.69 33891 971.49 922.92 1,061.36 1,040.13 1,040.13 1,019.33 33910 2,582.00 2,452.90 2,820.84 2,764.42 2,764.42 2,709.12 33915 1,258.46 1,195.54 1,374.87 1,347.37 1,347.37 1,320.43 33916 4,139.21 3,932.25 4,522.09 4,431.65 4,431.65 4,343.02 33917 1,430.60 1,359.07 1,562.93 1,531.67 1,531.67 1,501.04 33920 1,865.33 1,772.06 2,037.87 1,997.11 1,997.11 1,957.17 33922 1,364.21 1,296.00 1,490.40 1,460.59 1,460.59 1,431.38 33924 283.18 269.02 309.37 303.19 303.19 297.13 33925 1,694.25 1,609.54 1,850.97 1,813.95 1,813.95 1,777.67 33926 2,506.85 2,381.51 2,738.74 2,683.96 2,683.96 2,630.28 33933 208.20 197.79 227.46 222.90 222.90 218.44 33935 4,915.73 4,669.94 5,370.43 5,263.02 5,263.02 5,157.76 33944 208.20 197.79 227.46 222.90 222.90 218.44 33945 4,772.29 4,533.68 5,213.73 5,109.46 5,109.46 5,007.27 33946 302.59 287.46 330.58 323.97 323.97 317.49 33947 334.50 317.78 365.45 358.13 358.13 350.97 33948 238.88 226.94 260.98 255.76 255.76 250.64 33949 232.40 220.78 253.90 248.81 248.81 243.83 33951 413.61 392.93 451.87 442.83 442.83 433.98 33952 423.32 402.15 462.47 453.23 453.23 444.16 33953 461.96 438.86 504.69 494.59 494.59 484.70 33954 473.29 449.63 517.07 506.74 506.74 496.60 33955 828.78 787.34 905.44 887.33 887.33 869.58 33956 826.57 785.24 903.03 884.97 884.97 867.27 33957 183.98 174.78 201.00 196.97 196.97 193.03 33958 181.37 172.30 198.15 194.18 194.18 190.29 33959 233.61 221.93 255.22 250.11 250.11 245.11 33962 235.11 223.35 256.85 251.71 251.71 246.68 33963 467.46 444.09 510.70 500.49 500.49 490.49

Page 84: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 84Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33964 487.08 462.73 532.14 521.50 521.50 511.07 33965 183.98 174.78 201.00 196.97 196.97 193.03 33966 232.36 220.74 253.85 248.78 248.78 243.80 33967 255.15 242.39 278.75 273.17 273.17 267.71 33968 33.17 31.51 36.24 35.51 35.51 34.80 33969 272.05 258.45 297.22 291.27 291.27 285.44 33970 349.78 332.29 382.13 374.49 374.49 367.00 33971 692.82 658.18 756.91 741.77 741.77 726.94 33973 506.94 481.59 553.83 542.75 542.75 531.90 33974 867.37 824.00 947.60 928.65 928.65 910.08 33975 1,298.53 1,233.60 1,418.64 1,390.27 1,390.27 1,362.46 33976 1,582.46 1,503.34 1,728.84 1,694.26 1,694.26 1,660.37 33977 1,111.60 1,056.02 1,214.42 1,190.14 1,190.14 1,166.33 33978 1,316.30 1,250.49 1,438.06 1,409.30 1,409.30 1,381.12 33979 1,929.00 1,832.55 2,107.43 2,065.29 2,065.29 2,023.98 33980 1,761.13 1,673.07 1,924.03 1,885.55 1,885.55 1,847.84 33981 825.75 784.46 902.13 884.09 884.09 866.40 33982 1,956.38 1,858.56 2,137.34 2,094.60 2,094.60 2,052.70 33983 2,289.16 2,174.70 2,500.91 2,450.89 2,450.89 2,401.88 33984 281.71 267.62 307.76 301.61 301.61 295.57 33985 513.36 487.69 560.84 549.63 549.63 538.64 33986 522.50 496.38 570.84 559.42 559.42 548.23 33987 205.86 195.57 224.91 220.41 220.41 216.00 33988 767.58 729.20 838.58 821.81 821.81 805.38 33989 495.79 471.00 541.65 530.82 530.82 520.20 33990 432.32 410.70 472.31 462.86 462.86 453.61 33991 629.66 598.18 687.91 674.15 674.15 660.68 33992 204.71 194.47 223.64 219.17 219.17 214.79 33993 179.69 170.71 196.32 192.40 192.40 188.54 34001 966.92 918.57 1,056.36 1,035.23 1,035.23 1,014.53 34051 969.08 920.63 1,058.72 1,037.55 1,037.55 1,016.81 34101 598.20 568.29 653.53 640.46 640.46 627.65 34111 596.41 566.59 651.58 638.55 638.55 625.77 34151 1,396.07 1,326.27 1,525.21 1,494.70 1,494.70 1,464.81 34201 1,029.09 977.64 1,124.29 1,101.80 1,101.80 1,079.77 34203 953.09 905.44 1,041.26 1,020.43 1,020.43 1,000.02 34401 1,436.99 1,365.14 1,569.91 1,538.52 1,538.52 1,507.74 34421 726.39 690.07 793.58 777.71 777.71 762.15 34451 1,445.75 1,373.46 1,579.48 1,547.89 1,547.89 1,516.93 34471 1,080.13 1,026.12 1,180.04 1,156.44 1,156.44 1,133.31 34490 604.67 574.44 660.61 647.39 647.39 634.44 34501 964.49 916.27 1,053.71 1,032.63 1,032.63 1,011.98 34502 1,517.19 1,441.33 1,657.53 1,624.38 1,624.38 1,591.89 34510 1,168.44 1,110.02 1,276.52 1,250.99 1,250.99 1,225.97 34520 1,001.17 951.11 1,093.78 1,071.90 1,071.90 1,050.47 34530 1,073.78 1,020.09 1,173.10 1,149.64 1,149.64 1,126.66 34800 1,128.14 1,071.73 1,232.49 1,207.85 1,207.85 1,183.68 34802 1,244.92 1,182.67 1,360.07 1,332.87 1,332.87 1,306.22 34803 1,287.44 1,223.07 1,406.53 1,378.40 1,378.40 1,350.84

Page 85: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 85Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

34804 1,243.25 1,181.09 1,358.25 1,331.09 1,331.09 1,304.47 34805 1,190.23 1,130.72 1,300.33 1,274.33 1,274.33 1,248.84 34806 100.56 95.53 109.86 107.66 107.66 105.51 34808 207.25 196.89 226.42 221.89 221.89 217.45 34812 337.87 320.98 369.13 361.74 361.74 354.51 34813 237.44 225.57 259.41 254.22 254.22 249.14 34820 492.05 467.45 537.57 526.82 526.82 516.28 34825 692.54 657.91 756.60 741.46 741.46 726.64 34826 205.83 195.54 224.87 220.37 220.37 215.97 34830 1,769.20 1,680.74 1,932.85 1,894.20 1,894.20 1,856.32 34831 1,905.27 1,810.01 2,081.51 2,039.88 2,039.88 1,999.08 34832 1,894.81 1,800.07 2,070.08 2,028.68 2,028.68 1,988.11 34833 608.94 578.49 665.26 651.96 651.96 638.92 34834 272.75 259.11 297.98 292.02 292.02 286.18 34841 1,160.32 1,102.30 1,267.65 1,242.29 1,242.29 1,217.45 34842 1,410.94 1,340.39 1,541.45 1,510.62 1,510.62 1,480.41 34843 1,375.67 1,306.89 1,502.92 1,472.86 1,472.86 1,443.41 34844 1,424.18 1,352.97 1,555.92 1,524.80 1,524.80 1,494.30 34845 1,160.32 1,102.30 1,267.65 1,242.29 1,242.29 1,217.45 34846 1,410.94 1,340.39 1,541.45 1,510.62 1,510.62 1,480.41 34847 1,375.67 1,306.89 1,502.92 1,472.86 1,472.86 1,443.41 34848 1,424.18 1,352.97 1,555.92 1,524.80 1,524.80 1,494.30 34900 893.54 848.86 976.19 956.66 956.66 937.53 35001 1,116.19 1,060.38 1,219.44 1,195.05 1,195.05 1,171.15 35002 1,137.00 1,080.15 1,242.17 1,217.33 1,217.33 1,192.99 35005 1,074.67 1,020.94 1,174.08 1,150.60 1,150.60 1,127.59 35011 998.90 948.96 1,091.30 1,069.48 1,069.48 1,048.09 35013 1,248.98 1,186.53 1,364.51 1,337.22 1,337.22 1,310.47 35021 1,235.14 1,173.38 1,349.39 1,322.40 1,322.40 1,295.95 35022 1,382.48 1,313.36 1,510.36 1,480.15 1,480.15 1,450.55 35045 986.96 937.61 1,078.25 1,056.69 1,056.69 1,035.55 35081 1,746.44 1,659.12 1,907.99 1,869.83 1,869.83 1,832.43 35082 2,193.76 2,084.07 2,396.68 2,348.75 2,348.75 2,301.77 35091 1,796.94 1,707.09 1,963.15 1,923.89 1,923.89 1,885.41 35092 2,602.71 2,472.57 2,843.46 2,786.59 2,786.59 2,730.86 35102 1,891.52 1,796.94 2,066.48 2,025.15 2,025.15 1,984.65 35103 2,247.94 2,135.54 2,455.87 2,406.75 2,406.75 2,358.62 35111 1,505.22 1,429.96 1,644.45 1,611.56 1,611.56 1,579.33 35112 1,820.24 1,729.23 1,988.61 1,948.85 1,948.85 1,909.87 35121 1,641.92 1,559.82 1,793.79 1,757.91 1,757.91 1,722.76 35122 2,121.76 2,015.67 2,318.02 2,271.66 2,271.66 2,226.23 35131 1,387.14 1,317.78 1,515.45 1,485.13 1,485.13 1,455.43 35132 1,636.20 1,554.39 1,787.55 1,751.80 1,751.80 1,716.75 35141 1,105.30 1,050.04 1,207.55 1,183.40 1,183.40 1,159.73 35142 1,321.97 1,255.87 1,444.25 1,415.36 1,415.36 1,387.06 35151 1,242.29 1,180.18 1,357.21 1,330.07 1,330.07 1,303.47 35152 1,403.33 1,333.16 1,533.13 1,502.48 1,502.48 1,472.43 35180 915.23 869.47 999.89 979.89 979.89 960.30 35182 1,757.33 1,669.46 1,919.88 1,881.48 1,881.48 1,843.85

Page 86: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 86Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

35184 1,035.18 983.42 1,130.93 1,108.31 1,108.31 1,086.15 35188 1,129.49 1,073.02 1,233.97 1,209.29 1,209.29 1,185.11 35189 1,533.29 1,456.63 1,675.12 1,641.63 1,641.63 1,608.79 35190 753.77 716.08 823.49 807.02 807.02 790.88 35201 940.06 893.06 1,027.02 1,006.48 1,006.48 986.36 35206 768.49 730.07 839.58 822.79 822.79 806.33 35207 727.23 690.87 794.50 778.61 778.61 763.04 35211 1,354.26 1,286.55 1,479.53 1,449.94 1,449.94 1,420.94 35216 2,015.24 1,914.48 2,201.65 2,157.62 2,157.62 2,114.47 35221 1,439.96 1,367.96 1,573.15 1,541.69 1,541.69 1,510.86 35226 828.12 786.71 904.72 886.63 886.63 868.89 35231 1,200.83 1,140.79 1,311.91 1,285.67 1,285.67 1,259.95 35236 974.40 925.68 1,064.53 1,043.25 1,043.25 1,022.38 35241 1,364.21 1,296.00 1,490.40 1,460.59 1,460.59 1,431.38 35246 1,550.27 1,472.76 1,693.67 1,659.80 1,659.80 1,626.59 35251 1,689.07 1,604.62 1,845.31 1,808.41 1,808.41 1,772.24 35256 1,015.41 964.64 1,109.34 1,087.15 1,087.15 1,065.41 35261 1,050.18 997.67 1,147.32 1,124.38 1,124.38 1,101.90 35266 865.70 822.42 945.78 926.87 926.87 908.33 35271 1,349.65 1,282.17 1,474.50 1,445.01 1,445.01 1,416.11 35276 1,430.63 1,359.10 1,562.97 1,531.71 1,531.71 1,501.07 35281 1,608.35 1,527.93 1,757.12 1,721.98 1,721.98 1,687.53 35286 931.39 884.82 1,017.54 997.19 997.19 977.25 35301 1,129.27 1,072.81 1,233.73 1,209.05 1,209.05 1,184.87 35302 1,124.92 1,068.67 1,228.97 1,204.40 1,204.40 1,180.30 35303 1,244.92 1,182.67 1,360.07 1,332.87 1,332.87 1,306.22 35304 1,284.57 1,220.34 1,403.39 1,375.32 1,375.32 1,347.81 35305 1,230.35 1,168.83 1,344.15 1,317.27 1,317.27 1,290.92 35306 459.57 436.59 502.08 492.04 492.04 482.20 35311 1,457.64 1,384.76 1,592.47 1,560.62 1,560.62 1,529.41 35321 887.79 843.40 969.91 950.51 950.51 931.50 35331 1,449.21 1,376.75 1,583.26 1,551.60 1,551.60 1,520.58 35341 1,367.05 1,298.70 1,493.51 1,463.64 1,463.64 1,434.37 35351 1,281.07 1,217.02 1,399.57 1,371.58 1,371.58 1,344.15 35355 1,036.57 984.74 1,132.45 1,109.81 1,109.81 1,087.61 35361 1,540.54 1,463.51 1,683.04 1,649.38 1,649.38 1,616.39 35363 1,741.31 1,654.24 1,902.38 1,864.33 1,864.33 1,827.05 35371 818.15 777.24 893.83 875.96 875.96 858.44 35372 981.24 932.18 1,072.01 1,050.57 1,050.57 1,029.56 35390 159.66 151.68 174.43 170.95 170.95 167.53 35400 149.51 142.03 163.33 160.07 160.07 156.87 35450 506.37 481.05 553.21 542.14 542.14 531.30 35452 342.03 324.93 373.67 366.19 366.19 358.87 35458 491.88 467.29 537.38 526.63 526.63 516.10 35460 313.20 297.54 342.17 335.33 335.33 328.62 35471 2,315.25 2,199.49 2,529.41 2,478.83 2,478.83 2,429.25 # 35471 519.40 493.43 567.44 556.09 556.09 544.97 35472 1,666.09 1,582.79 1,820.21 1,783.80 1,783.80 1,748.13 # 35472 353.55 335.87 386.25 378.52 378.52 370.96

Page 87: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 87Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

35475 1,414.88 1,344.14 1,545.76 1,514.85 1,514.85 1,484.55 # 35475 332.12 315.51 362.84 355.58 355.58 348.47 35476 1,293.06 1,228.41 1,412.67 1,384.42 1,384.42 1,356.72 # 35476 267.13 253.77 291.84 285.99 285.99 280.28 35500 319.85 303.86 349.44 342.45 342.45 335.59 35501 1,495.62 1,420.84 1,633.97 1,601.28 1,601.28 1,569.26 35506 1,279.11 1,215.15 1,397.42 1,369.48 1,369.48 1,342.08 35508 1,355.74 1,287.95 1,481.14 1,451.52 1,451.52 1,422.49 35509 1,415.32 1,344.55 1,546.23 1,515.31 1,515.31 1,485.01 35510 1,234.50 1,172.78 1,348.70 1,321.72 1,321.72 1,295.28 35511 1,124.38 1,068.16 1,228.38 1,203.82 1,203.82 1,179.74 35512 1,222.16 1,161.05 1,335.21 1,308.50 1,308.50 1,282.33 35515 1,433.82 1,362.13 1,566.45 1,535.12 1,535.12 1,504.42 35516 1,224.74 1,163.50 1,338.03 1,311.26 1,311.26 1,285.04 35518 1,161.62 1,103.54 1,269.07 1,243.69 1,243.69 1,218.82 35521 1,237.79 1,175.90 1,352.29 1,325.24 1,325.24 1,298.73 35522 1,208.92 1,148.47 1,320.74 1,294.33 1,294.33 1,268.44 35523 1,281.43 1,217.36 1,399.96 1,371.96 1,371.96 1,344.52 35525 1,143.90 1,086.71 1,249.72 1,224.73 1,224.73 1,200.23 35526 1,690.86 1,606.32 1,847.27 1,810.32 1,810.32 1,774.12 35531 2,024.36 1,923.14 2,211.61 2,167.38 2,167.38 2,124.04 35533 1,503.37 1,428.20 1,642.43 1,609.59 1,609.59 1,577.40 35535 1,922.08 1,825.98 2,099.88 2,057.88 2,057.88 2,016.72 35536 1,696.22 1,611.41 1,853.12 1,816.06 1,816.06 1,779.74 35537 2,190.31 2,080.79 2,392.91 2,345.05 2,345.05 2,298.15 35538 2,356.57 2,238.74 2,574.55 2,523.07 2,523.07 2,472.60 35539 2,204.44 2,094.22 2,408.35 2,360.19 2,360.19 2,312.98 35540 2,463.82 2,340.63 2,691.72 2,637.89 2,637.89 2,585.13 35556 1,402.91 1,332.76 1,532.67 1,502.02 1,502.02 1,471.98 35558 1,232.33 1,170.71 1,346.32 1,319.40 1,319.40 1,293.00 35560 1,722.51 1,636.38 1,881.84 1,844.20 1,844.20 1,807.32 35563 1,334.04 1,267.34 1,457.44 1,428.29 1,428.29 1,399.72 35565 1,324.59 1,258.36 1,447.11 1,418.17 1,418.17 1,389.81 35566 1,675.99 1,592.19 1,831.02 1,794.40 1,794.40 1,758.51 35570 1,522.33 1,446.21 1,663.14 1,629.88 1,629.88 1,597.28 35571 1,332.71 1,266.07 1,455.98 1,426.86 1,426.86 1,398.33 35572 345.91 328.61 377.90 370.35 370.35 362.94 35583 1,450.26 1,377.75 1,584.41 1,552.73 1,552.73 1,521.68 35585 1,683.37 1,599.20 1,839.08 1,802.30 1,802.30 1,766.26 35587 1,368.10 1,299.70 1,494.66 1,464.77 1,464.77 1,435.48 35600 252.23 239.62 275.56 270.05 270.05 264.65 35601 1,405.19 1,334.93 1,535.17 1,504.46 1,504.46 1,474.38 35606 1,175.18 1,116.42 1,283.88 1,258.20 1,258.20 1,233.04 35612 1,072.98 1,019.33 1,172.23 1,148.78 1,148.78 1,125.80 35616 1,106.65 1,051.32 1,209.02 1,184.83 1,184.83 1,161.13 35621 1,100.51 1,045.48 1,202.30 1,178.26 1,178.26 1,154.69 35623 1,318.58 1,252.65 1,440.55 1,411.74 1,411.74 1,383.51 35626 1,565.20 1,486.94 1,709.98 1,675.78 1,675.78 1,642.27 35631 1,854.96 1,762.21 2,026.54 1,986.02 1,986.02 1,946.29

Page 88: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 88Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

35632 1,811.76 1,721.17 1,979.35 1,939.76 1,939.76 1,900.97 35633 2,009.82 1,909.33 2,195.73 2,151.81 2,151.81 2,108.78 35634 1,774.42 1,685.70 1,938.56 1,899.79 1,899.79 1,861.79 35636 1,607.41 1,527.04 1,756.10 1,720.98 1,720.98 1,686.56 35637 1,727.71 1,641.32 1,887.52 1,849.76 1,849.76 1,812.77 35638 1,764.11 1,675.90 1,927.29 1,888.74 1,888.74 1,850.96 35642 986.96 937.61 1,078.25 1,056.69 1,056.69 1,035.55 35645 1,012.23 961.62 1,105.86 1,083.75 1,083.75 1,062.07 35646 1,720.07 1,634.07 1,879.18 1,841.60 1,841.60 1,804.76 35647 1,558.43 1,480.51 1,702.59 1,668.54 1,668.54 1,635.16 35650 1,078.71 1,024.77 1,178.49 1,154.91 1,154.91 1,131.81 35654 1,372.57 1,303.94 1,499.53 1,469.54 1,469.54 1,440.15 35656 1,085.50 1,031.23 1,185.91 1,162.20 1,162.20 1,138.96 35661 1,085.35 1,031.08 1,185.74 1,162.03 1,162.03 1,138.79 35663 1,257.21 1,194.35 1,373.50 1,346.03 1,346.03 1,319.11 35665 1,174.87 1,116.13 1,283.55 1,257.88 1,257.88 1,232.72 35666 1,267.33 1,203.96 1,384.55 1,356.86 1,356.86 1,329.72 35671 1,117.11 1,061.25 1,220.44 1,196.03 1,196.03 1,172.11 35681 80.33 76.31 87.76 86.00 86.00 84.27 35682 355.32 337.55 388.18 380.42 380.42 372.81 35683 414.72 393.98 453.08 444.02 444.02 435.14 35685 199.84 189.85 218.33 213.96 213.96 209.68 35686 162.39 154.27 177.41 173.86 173.86 170.38 35691 960.30 912.29 1,049.13 1,028.15 1,028.15 1,007.58 35693 817.25 776.39 892.85 874.99 874.99 857.49 35694 991.16 941.60 1,082.84 1,061.19 1,061.19 1,039.96 35695 1,050.29 997.78 1,147.45 1,124.49 1,124.49 1,102.00 35697 148.28 140.87 162.00 158.76 158.76 155.58 35700 153.59 145.91 167.80 164.44 164.44 161.15 35701 557.10 529.25 608.64 596.47 596.47 584.55 35721 450.71 428.17 492.40 482.55 482.55 472.90 35741 509.30 483.84 556.42 545.28 545.28 534.38 35761 381.10 362.05 416.36 408.03 408.03 399.87 35800 701.68 666.60 766.59 751.26 751.26 736.23 35820 1,976.13 1,877.32 2,158.92 2,115.74 2,115.74 2,073.42 35840 1,166.71 1,108.37 1,274.63 1,249.13 1,249.13 1,224.15 35860 835.72 793.93 913.02 894.76 894.76 876.86 35870 1,246.75 1,184.41 1,362.07 1,334.83 1,334.83 1,308.14 35875 592.33 562.71 647.12 634.18 634.18 621.49 35876 944.90 897.66 1,032.31 1,011.67 1,011.67 991.44 35879 923.32 877.15 1,008.72 988.55 988.55 968.78 35881 1,021.17 970.11 1,115.63 1,093.32 1,093.32 1,071.46 35883 1,210.66 1,150.13 1,322.65 1,296.20 1,296.20 1,270.28 35884 1,243.22 1,181.06 1,358.22 1,331.06 1,331.06 1,304.43 35901 469.90 446.41 513.37 503.10 503.10 493.04 35903 559.26 531.30 611.00 598.77 598.77 586.80 35905 1,689.77 1,605.28 1,846.07 1,809.15 1,809.15 1,772.97 35907 1,916.25 1,820.44 2,093.51 2,051.63 2,051.63 2,010.60 36002 153.08 145.43 167.24 163.90 163.90 160.62

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 89Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 36002 105.00 99.75 114.71 112.42 112.42 110.17 36005 292.11 277.50 319.13 312.74 312.74 306.49 # 36005 47.96 45.56 52.39 51.35 51.35 50.32 36010 456.50 433.68 498.73 488.76 488.76 478.99 # 36010 121.49 115.42 132.73 130.08 130.08 127.48 36011 754.91 717.16 824.73 808.24 808.24 792.07 # 36011 156.09 148.29 170.53 167.12 167.12 163.77 36012 780.88 741.84 853.12 836.05 836.05 819.33 # 36012 173.31 164.64 189.34 185.55 185.55 181.84 36013 709.06 673.61 774.65 759.16 759.16 743.98 # 36013 124.60 118.37 136.13 133.40 133.40 130.73 36014 734.01 697.31 801.91 785.86 785.86 770.14 # 36014 149.23 141.77 163.04 159.77 159.77 156.57 36015 788.11 748.70 861.01 843.79 843.79 826.92 # 36015 171.17 162.61 187.00 183.26 183.26 179.60 36100 458.34 435.42 500.73 490.72 490.72 480.91 # 36100 153.62 145.94 167.83 164.47 164.47 161.18 36120 385.03 365.78 420.65 412.23 412.23 403.98 # 36120 99.67 94.69 108.89 106.72 106.72 104.58 36140 397.75 377.86 434.54 425.85 425.85 417.32 # 36140 102.09 96.99 111.54 109.31 109.31 107.12 36147 761.81 723.72 832.28 815.64 815.64 799.33 # 36147 185.15 175.89 202.27 198.23 198.23 194.26 36148 237.45 225.58 259.42 254.23 254.23 249.15 # 36148 48.87 46.43 53.39 52.33 52.33 51.28 36160 450.03 427.53 491.66 481.83 481.83 472.19 # 36160 123.15 116.99 134.54 131.85 131.85 129.21 36200 567.19 538.83 619.65 607.26 607.26 595.11 # 36200 151.95 144.35 166.00 162.68 162.68 159.42 36215 1,020.12 969.11 1,114.48 1,092.19 1,092.19 1,070.35 # 36215 233.34 221.67 254.92 249.83 249.83 244.84 36216 1,082.53 1,028.40 1,182.66 1,159.00 1,159.00 1,135.82 # 36216 272.33 258.71 297.52 291.57 291.57 285.74 36217 1,772.01 1,683.41 1,935.92 1,897.20 1,897.20 1,859.26 # 36217 323.97 307.77 353.94 346.85 346.85 339.92 36218 175.51 166.73 191.74 187.91 187.91 184.15 # 36218 52.50 49.88 57.36 56.21 56.21 55.09 36221 993.34 943.67 1,085.22 1,063.52 1,063.52 1,042.25 # 36221 213.12 202.46 232.83 228.17 228.17 223.61 36222 1,193.20 1,133.54 1,303.57 1,277.50 1,277.50 1,251.95 # 36222 291.22 276.66 318.16 311.80 311.80 305.57 36223 1,393.65 1,323.97 1,522.57 1,492.11 1,492.11 1,462.27 # 36223 318.07 302.17 347.50 340.55 340.55 333.74 36224 1,639.57 1,557.59 1,791.23 1,755.41 1,755.41 1,720.30 # 36224 353.25 335.59 385.93 378.21 378.21 370.65 36225 1,362.91 1,294.76 1,488.97 1,459.19 1,459.19 1,430.00 # 36225 313.87 298.18 342.91 336.05 336.05 329.34 36226 1,663.87 1,580.68 1,817.78 1,781.43 1,781.43 1,745.80 # 36226 354.13 336.42 386.88 379.14 379.14 371.57

Page 90: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 90Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

36227 232.79 221.15 254.32 249.24 249.24 244.26 # 36227 111.97 106.37 122.33 119.88 119.88 117.48 36228 1,099.30 1,044.34 1,200.99 1,176.97 1,176.97 1,153.43 # 36228 228.85 217.41 250.02 245.02 245.02 240.12 36245 1,238.99 1,177.04 1,353.60 1,326.53 1,326.53 1,299.99 # 36245 250.53 238.00 273.70 268.23 268.23 262.87 36246 814.99 774.24 890.38 872.57 872.57 855.12 # 36246 266.74 253.40 291.41 285.58 285.58 279.86 36247 1,430.73 1,359.19 1,563.07 1,531.81 1,531.81 1,501.18 # 36247 315.81 300.02 345.02 338.12 338.12 331.36 36248 140.74 133.70 153.76 150.68 150.68 147.67 # 36248 49.57 47.09 54.15 53.07 53.07 52.01 36251 1,289.78 1,225.29 1,409.08 1,380.90 1,380.90 1,353.27 # 36251 278.21 264.30 303.95 297.86 297.86 291.90 36252 1,403.69 1,333.51 1,533.54 1,502.87 1,502.87 1,472.81 # 36252 369.64 351.16 403.83 395.76 395.76 387.85 36253 2,049.22 1,946.76 2,238.77 2,193.99 2,193.99 2,150.11 # 36253 375.76 356.97 410.52 402.30 402.30 394.25 36254 1,993.43 1,893.76 2,177.82 2,134.26 2,134.26 2,091.57 # 36254 429.55 408.07 469.28 459.90 459.90 450.70 36260 607.71 577.32 663.92 650.64 650.64 637.62 36261 384.19 364.98 419.73 411.33 411.33 403.11 36262 292.76 278.12 319.84 313.44 313.44 307.18 36400 28.14 26.73 30.74 30.13 30.13 29.53 # 36400 19.71 18.72 21.53 21.10 21.10 20.68 36405 24.75 23.51 27.04 26.50 26.50 25.97 # 36405 16.01 15.21 17.49 17.15 17.15 16.80 36406 15.44 14.67 16.87 16.54 16.54 16.20 # 36406 8.26 7.85 9.03 8.84 8.84 8.67 36410 15.76 14.97 17.22 16.87 16.87 16.54 # 36410 9.20 8.74 10.05 9.86 9.86 9.66 36420 51.39 48.82 56.14 55.02 55.02 53.91 36425 39.11 37.15 42.72 41.87 41.87 41.03 36430 30.54 29.01 33.36 32.69 32.69 32.04 36440 55.96 53.16 61.13 59.92 59.92 58.72 36450 114.64 108.91 125.25 122.74 122.74 120.29 36455 123.74 117.55 135.18 132.48 132.48 129.84 36460 338.35 321.43 369.64 362.25 362.25 355.01 36470 137.81 130.92 150.56 147.55 147.55 144.59 # 36470 80.05 76.05 87.46 85.71 85.71 84.00 36471 162.53 154.40 177.56 174.01 174.01 170.52 # 36471 97.59 92.71 106.62 104.49 104.49 102.40 36475 1,388.75 1,319.31 1,517.21 1,486.86 1,486.86 1,457.12 # 36475 277.58 263.70 303.26 297.19 297.19 291.25 36476 276.29 262.48 301.85 295.81 295.81 289.90 # 36476 134.86 128.12 147.34 144.39 144.39 141.51 36478 1,095.10 1,040.35 1,196.40 1,172.47 1,172.47 1,149.02 # 36478 276.16 262.35 301.70 295.67 295.67 289.75 36479 286.40 272.08 312.89 306.64 306.64 300.51

Page 91: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 91Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 36479 134.97 128.22 147.45 144.51 144.51 141.62 36481 1,842.54 1,750.41 2,012.97 1,972.71 1,972.71 1,933.25 # 36481 346.73 329.39 378.80 371.22 371.22 363.79 36500 179.96 170.96 196.60 192.67 192.67 188.82 36510 85.27 81.01 93.16 91.30 91.30 89.47 # 36510 54.67 51.94 59.73 58.54 58.54 57.36 36511 91.63 87.05 100.11 98.11 98.11 96.14 36512 92.25 87.64 100.79 98.77 98.77 96.80 36513 94.70 89.97 103.47 101.40 101.40 99.37 36514 485.82 461.53 530.76 520.15 520.15 509.74 # 36514 91.18 86.62 99.61 97.62 97.62 95.67 36515 1,841.00 1,748.95 2,011.29 1,971.07 1,971.07 1,931.64 # 36515 86.36 82.04 94.35 92.46 92.46 90.61 36516 1,852.13 1,759.52 2,023.45 1,982.98 1,982.98 1,943.32 # 36516 67.52 64.14 73.76 72.29 72.29 70.84 36522 1,249.31 1,186.84 1,364.87 1,337.57 1,337.57 1,310.82 # 36522 98.80 93.86 107.94 105.78 105.78 103.66 36555 240.53 228.50 262.78 257.52 257.52 252.37 # 36555 118.14 112.23 129.06 126.49 126.49 123.96 36556 218.59 207.66 238.81 234.04 234.04 229.36 # 36556 119.62 113.64 130.69 128.08 128.08 125.51 36557 917.83 871.94 1,002.73 982.68 982.68 963.02 # 36557 318.38 302.46 347.83 340.87 340.87 334.05 36558 717.22 681.36 783.56 767.89 767.89 752.54 # 36558 271.38 257.81 296.48 290.55 290.55 284.74 36560 1,222.51 1,161.38 1,335.59 1,308.87 1,308.87 1,282.70 # 36560 378.28 359.37 413.28 405.01 405.01 396.91 36561 1,071.61 1,018.03 1,170.73 1,147.32 1,147.32 1,124.38 # 36561 346.03 328.73 378.04 370.48 370.48 363.08 36563 1,208.20 1,147.79 1,319.96 1,293.55 1,293.55 1,267.68 # 36563 371.47 352.90 405.84 397.72 397.72 389.76 36565 891.63 847.05 974.11 954.63 954.63 935.54 # 36565 341.82 324.73 373.44 365.98 365.98 358.66 36566 4,869.42 4,625.95 5,319.84 5,213.44 5,213.44 5,109.17 # 36566 376.04 357.24 410.83 402.62 402.62 394.57 36568 276.21 262.40 301.76 295.72 295.72 289.81 # 36568 96.06 91.26 104.95 102.84 102.84 100.79 36569 230.51 218.98 251.83 246.79 246.79 241.86 # 36569 90.64 86.11 99.03 97.05 97.05 95.11 36570 1,053.21 1,000.55 1,150.63 1,127.62 1,127.62 1,105.07 # 36570 304.53 289.30 332.70 326.04 326.04 319.52 36571 1,182.42 1,123.30 1,291.80 1,265.95 1,265.95 1,240.63 # 36571 314.77 299.03 343.88 337.01 337.01 330.27 36575 151.12 143.56 165.09 161.79 161.79 158.56 # 36575 34.67 32.94 37.88 37.12 37.12 36.37 36576 360.01 342.01 393.31 385.45 385.45 377.74 # 36576 192.66 183.03 210.48 206.28 206.28 202.15 36578 477.72 453.83 521.90 511.46 511.46 501.24 # 36578 210.78 200.24 230.28 225.68 225.68 221.17

Page 92: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 92Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

36580 196.98 187.13 215.20 210.90 210.90 206.68 # 36580 66.16 62.85 72.28 70.83 70.83 69.41 36581 699.47 664.50 764.18 748.89 748.89 733.92 # 36581 192.75 183.11 210.58 206.37 206.37 202.24 36582 1,002.17 952.06 1,094.87 1,072.97 1,072.97 1,051.51 # 36582 299.38 284.41 327.07 320.53 320.53 314.12 36583 1,237.38 1,175.51 1,351.84 1,324.80 1,324.80 1,298.30 # 36583 328.22 311.81 358.58 351.41 351.41 344.38 36584 187.53 178.15 204.87 200.78 200.78 196.77 # 36584 65.45 62.18 71.51 70.08 70.08 68.68 36585 1,045.06 992.81 1,141.73 1,118.89 1,118.89 1,096.51 # 36585 277.95 264.05 303.66 297.59 297.59 291.63 36589 157.22 149.36 171.76 168.33 168.33 164.96 # 36589 134.11 127.40 146.51 143.58 143.58 140.70 36590 276.22 262.41 301.77 295.73 295.73 289.82 # 36590 199.41 189.44 217.86 213.50 213.50 209.23 36591 20.58 19.55 22.48 22.03 22.03 21.60 36592 23.08 21.93 25.22 24.71 24.71 24.22 36593 27.42 26.05 29.96 29.36 29.36 28.77 36595 536.77 509.93 586.42 574.69 574.69 563.20 # 36595 182.41 173.29 199.28 195.29 195.29 191.38 36596 121.80 115.71 133.07 130.41 130.41 127.80 # 36596 43.75 41.56 47.79 46.84 46.84 45.91 36597 118.55 112.62 129.51 126.93 126.93 124.38 # 36597 60.79 57.75 66.41 65.09 65.09 63.79 36598 101.55 96.47 110.94 108.72 108.72 106.55 # 36598 36.61 34.78 40.00 39.19 39.19 38.41 36600 29.48 28.01 32.21 31.57 31.57 30.94 # 36600 15.43 14.66 16.86 16.53 16.53 16.19 36620 50.89 48.35 55.60 54.49 54.49 53.39 36625 102.99 97.84 112.52 110.26 110.26 108.05 36640 115.96 110.16 126.68 124.15 124.15 121.67 36660 63.87 60.68 69.78 68.39 68.39 67.02 36680 57.77 54.88 63.11 61.85 61.85 60.61 36800 122.20 116.09 133.50 130.84 130.84 128.21 36810 212.86 202.22 232.55 227.91 227.91 223.35 36815 143.64 136.46 156.93 153.79 153.79 150.72 36818 688.88 654.44 752.61 737.55 737.55 722.80 36819 728.96 692.51 796.39 780.46 780.46 764.85 36820 726.18 689.87 793.35 777.48 777.48 761.93 36821 660.12 627.11 721.18 706.76 706.76 692.62 36823 1,314.66 1,248.93 1,436.27 1,407.54 1,407.54 1,379.39 36825 795.19 755.43 868.74 851.37 851.37 834.34 36830 664.37 631.15 725.82 711.31 711.31 697.08 36831 613.43 582.76 670.17 656.77 656.77 643.63 36832 752.88 715.24 822.53 806.08 806.08 789.96 36833 807.38 767.01 882.06 864.42 864.42 847.14 36835 480.24 456.23 524.66 514.18 514.18 503.90 36838 1,142.09 1,084.99 1,247.74 1,222.78 1,222.78 1,198.32

Page 93: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 93Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

36860 194.20 184.49 212.16 207.92 207.92 203.76 # 36860 108.34 102.92 118.36 115.99 115.99 113.67 36861 130.26 123.75 142.31 139.47 139.47 136.68 36870 1,655.80 1,573.01 1,808.96 1,772.78 1,772.78 1,737.33 # 36870 294.55 279.82 321.79 315.35 315.35 309.05 37140 2,242.13 2,130.02 2,449.52 2,400.53 2,400.53 2,352.52 37145 2,096.63 1,991.80 2,290.57 2,244.75 2,244.75 2,199.86 37160 2,153.63 2,045.95 2,352.84 2,305.78 2,305.78 2,259.67 37180 1,997.04 1,897.19 2,181.77 2,138.14 2,138.14 2,095.38 37181 2,267.52 2,154.14 2,477.26 2,427.72 2,427.72 2,379.17 37182 830.81 789.27 907.66 889.50 889.50 871.71 37183 5,297.67 5,032.79 5,787.71 5,671.95 5,671.95 5,558.51 # 37183 392.17 372.56 428.44 419.88 419.88 411.48 37184 2,063.26 1,960.10 2,254.12 2,209.04 2,209.04 2,164.85 # 37184 455.67 432.89 497.82 487.86 487.86 478.11 37185 656.89 624.05 717.66 703.31 703.31 689.24 # 37185 166.71 158.37 182.13 178.48 178.48 174.92 37186 1,248.38 1,185.96 1,363.85 1,336.58 1,336.58 1,309.85 # 37186 248.05 235.65 271.00 265.58 265.58 260.27 37187 1,871.19 1,777.63 2,044.27 2,003.39 2,003.39 1,963.33 # 37187 405.35 385.08 442.84 433.99 433.99 425.30 37188 1,606.83 1,526.49 1,755.46 1,720.35 1,720.35 1,685.95 # 37188 291.47 276.90 318.44 312.06 312.06 305.82 37191 2,362.87 2,244.73 2,581.44 2,529.82 2,529.82 2,479.22 # 37191 237.32 225.45 259.27 254.08 254.08 249.00 37192 1,410.79 1,340.25 1,541.29 1,510.47 1,510.47 1,480.26 # 37192 365.50 347.23 399.31 391.33 391.33 383.50 37193 1,456.70 1,383.87 1,591.45 1,559.62 1,559.62 1,528.43 # 37193 364.57 346.34 398.29 390.32 390.32 382.51 37195 126.64 120.31 138.36 135.59 135.59 132.87 37197 1,380.45 1,311.43 1,508.14 1,477.98 1,477.98 1,448.43 # 37197 314.56 298.83 343.65 336.78 336.78 330.04 37200 219.57 208.59 239.88 235.08 235.08 230.38 37211 397.86 377.97 434.67 425.97 425.97 417.45 37212 350.11 332.60 382.49 374.84 374.84 367.34 37213 246.35 234.03 269.13 263.75 263.75 258.47 37214 135.09 128.34 147.59 144.64 144.64 141.74 37215 989.58 940.10 1,081.12 1,059.50 1,059.50 1,038.30 37217 1,086.38 1,032.06 1,186.87 1,163.13 1,163.13 1,139.87 37218 811.55 770.97 886.62 868.88 868.88 851.51 37220 2,845.60 2,703.32 3,108.82 3,046.64 3,046.64 2,985.71 # 37220 414.08 393.38 452.39 443.34 443.34 434.47 37221 4,187.14 3,977.78 4,574.45 4,482.95 4,482.95 4,393.30 # 37221 508.96 483.51 556.04 544.92 544.92 534.01 37222 805.07 764.82 879.54 861.95 861.95 844.71 # 37222 186.89 177.55 204.18 200.10 200.10 196.10 37223 2,323.29 2,207.13 2,538.20 2,487.44 2,487.44 2,437.69 # 37223 214.29 203.58 234.12 229.44 229.44 224.85 37224 3,449.29 3,276.83 3,768.35 3,692.98 3,692.98 3,619.12

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 94Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 37224 456.10 433.30 498.30 488.32 488.32 478.56 37225 9,852.84 9,360.20 10,764.23 10,548.95 10,548.95 10,337.97 # 37225 617.25 586.39 674.35 660.86 660.86 647.65 37226 8,105.72 7,700.43 8,855.49 8,678.38 8,678.38 8,504.81 # 37226 535.48 508.71 585.02 573.32 573.32 561.86 37227 13,300.28 12,635.27 14,530.56 14,239.94 14,239.94 13,955.15 # 37227 742.43 705.31 811.11 794.88 794.88 778.99 37228 4,893.66 4,648.98 5,346.33 5,239.40 5,239.40 5,134.61 # 37228 557.01 529.16 608.53 596.37 596.37 584.44 37229 9,721.83 9,235.74 10,621.10 10,408.68 10,408.68 10,200.51 # 37229 720.09 684.09 786.70 770.97 770.97 755.55 37230 7,443.82 7,071.63 8,132.37 7,969.73 7,969.73 7,810.34 # 37230 709.06 673.61 774.65 759.16 759.16 743.98 37231 11,952.65 11,355.02 13,058.27 12,797.11 12,797.11 12,541.16 # 37231 771.35 732.78 842.70 825.84 825.84 809.32 37232 1,095.96 1,041.16 1,197.33 1,173.39 1,173.39 1,149.92 # 37232 202.41 192.29 221.13 216.71 216.71 212.37 37233 1,330.70 1,264.17 1,453.80 1,424.72 1,424.72 1,396.23 # 37233 329.43 312.96 359.90 352.71 352.71 345.66 37234 3,473.70 3,300.02 3,795.02 3,719.12 3,719.12 3,644.74 # 37234 283.19 269.03 309.38 303.20 303.20 297.14 37235 3,666.69 3,483.36 4,005.86 3,925.74 3,925.74 3,847.23 # 37235 403.13 382.97 440.42 431.61 431.61 422.97 37236 3,701.42 3,516.35 4,043.80 3,962.92 3,962.92 3,883.67 # 37236 452.22 429.61 494.05 484.17 484.17 474.49 37237 2,207.94 2,097.54 2,412.17 2,363.93 2,363.93 2,316.65 # 37237 212.89 202.25 232.59 227.94 227.94 223.39 37238 3,763.01 3,574.86 4,111.09 4,028.86 4,028.86 3,948.28 # 37238 313.67 297.99 342.69 335.83 335.83 329.12 37239 1,820.04 1,729.04 1,988.40 1,948.63 1,948.63 1,909.66 # 37239 149.07 141.62 162.86 159.61 159.61 156.41 37241 4,288.17 4,073.76 4,684.82 4,591.12 4,591.12 4,499.29 # 37241 449.51 427.03 491.08 481.26 481.26 471.64 37242 6,869.81 6,526.32 7,505.27 7,355.16 7,355.16 7,208.05 # 37242 493.48 468.81 539.13 528.34 528.34 517.78 37243 8,722.12 8,286.01 9,528.91 9,338.33 9,338.33 9,151.56 # 37243 583.65 554.47 637.64 624.89 624.89 612.39 37244 6,101.16 5,796.10 6,665.52 6,532.21 6,532.21 6,401.57 # 37244 683.00 648.85 746.18 731.25 731.25 716.62 37252 1,250.38 1,187.86 1,366.04 1,338.72 1,338.72 1,311.94 # 37252 91.44 86.87 99.90 97.90 97.90 95.94 37253 198.95 189.00 217.35 213.00 213.00 208.75 # 37253 73.13 69.47 79.89 78.29 78.29 76.73 37500 740.41 703.39 808.90 792.72 792.72 776.86 37565 709.58 674.10 775.22 759.71 759.71 744.52 37600 697.22 662.36 761.71 746.48 746.48 731.55 37605 787.21 747.85 860.03 842.82 842.82 825.96 37606 563.36 535.19 615.47 603.16 603.16 591.10 37607 370.29 351.78 404.55 396.45 396.45 388.53

Page 95: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 95Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

37609 290.74 276.20 317.63 311.28 311.28 305.06 # 37609 200.51 190.48 219.05 214.67 214.67 210.38 37615 496.39 471.57 542.31 531.46 531.46 520.84 37616 1,077.35 1,023.48 1,177.00 1,153.46 1,153.46 1,130.39 37617 1,312.93 1,247.28 1,434.37 1,405.68 1,405.68 1,377.56 37618 374.53 355.80 409.17 400.98 400.98 392.97 37619 1,614.16 1,533.45 1,763.47 1,728.20 1,728.20 1,693.63 37650 498.99 474.04 545.15 534.24 534.24 523.56 37660 1,150.80 1,093.26 1,257.25 1,232.10 1,232.10 1,207.45 37700 243.93 231.73 266.49 261.17 261.17 255.94 37718 429.27 407.81 468.98 459.60 459.60 450.41 37722 472.95 449.30 516.70 506.36 506.36 496.23 37735 672.44 638.82 734.64 719.95 719.95 705.55 37760 608.58 578.15 664.87 651.58 651.58 638.55 37761 542.49 515.37 592.68 580.82 580.82 569.20 37765 620.69 589.66 678.11 664.55 664.55 651.26 # 37765 443.05 420.90 484.04 474.35 474.35 464.86 37766 740.33 703.31 808.81 792.63 792.63 776.78 # 37766 542.39 515.27 592.56 580.70 580.70 569.09 37780 248.73 236.29 271.73 266.29 266.29 260.97 37785 337.14 320.28 368.32 360.95 360.95 353.73 # 37785 255.65 242.87 279.30 273.71 273.71 268.24 37788 1,261.32 1,198.25 1,377.99 1,350.43 1,350.43 1,323.42 37790 488.01 463.61 533.15 522.49 522.49 512.04 38100 1,122.60 1,066.47 1,226.44 1,201.91 1,201.91 1,177.88 38101 1,126.05 1,069.75 1,230.21 1,205.61 1,205.61 1,181.50 38102 256.85 244.01 280.61 275.00 275.00 269.50 38115 1,234.43 1,172.71 1,348.62 1,321.65 1,321.65 1,295.21 38120 1,020.88 969.84 1,115.32 1,093.01 1,093.01 1,071.14 38200 116.68 110.85 127.48 124.92 124.92 122.43 38205 80.91 76.86 88.39 86.62 86.62 84.88 38206 81.22 77.16 88.73 86.96 86.96 85.23 38220 150.68 143.15 164.62 161.33 161.33 158.10 # 38220 59.83 56.84 65.37 64.06 64.06 62.78 38221 154.64 146.91 168.95 165.57 165.57 162.25 # 38221 73.16 69.50 79.93 78.33 78.33 76.76 38230 193.41 183.74 211.30 207.08 207.08 202.94 38232 192.79 183.15 210.62 206.41 206.41 202.29 38240 218.37 207.45 238.57 233.80 233.80 229.11 38241 163.71 155.52 178.85 175.27 175.27 171.76 38242 114.84 109.10 125.47 122.96 122.96 120.50 38243 114.62 108.89 125.22 122.72 122.72 120.27 38300 256.48 243.66 280.21 274.61 274.61 269.11 # 38300 175.93 167.13 192.20 188.36 188.36 184.59 38305 455.97 433.17 498.15 488.19 488.19 478.42 38308 429.64 408.16 469.38 460.00 460.00 450.80 38380 549.26 521.80 600.07 588.06 588.06 576.30 38381 779.58 740.60 851.69 834.66 834.66 817.96 38382 600.50 570.48 656.05 642.93 642.93 630.07

Page 96: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 96Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

38500 312.17 296.56 341.04 334.22 334.22 327.54 # 38500 244.42 232.20 267.03 261.69 261.69 256.46 38505 117.94 112.04 128.85 126.27 126.27 123.74 # 38505 69.24 65.78 75.65 74.13 74.13 72.65 38510 494.32 469.60 540.04 529.24 529.24 518.66 # 38510 407.53 387.15 445.22 436.32 436.32 427.59 38520 447.07 424.72 488.43 478.66 478.66 469.10 38525 419.52 398.54 458.32 449.16 449.16 440.17 38530 529.37 502.90 578.34 566.77 566.77 555.43 38542 500.92 475.87 547.25 536.30 536.30 525.57 38550 484.67 460.44 529.51 518.91 518.91 508.54 38555 968.46 920.04 1,058.05 1,036.89 1,036.89 1,016.15 38562 677.28 643.42 739.93 725.13 725.13 710.63 38564 680.90 646.86 743.89 729.01 729.01 714.43 38570 488.90 464.46 534.13 523.45 523.45 512.98 38571 651.37 618.80 711.62 697.38 697.38 683.43 38572 902.23 857.12 985.69 965.98 965.98 946.66 38700 781.98 742.88 854.31 837.22 837.22 820.48 38720 1,307.72 1,242.33 1,428.68 1,400.10 1,400.10 1,372.10 38724 1,415.28 1,344.52 1,546.20 1,515.27 1,515.27 1,484.97 38740 669.24 635.78 731.15 716.52 716.52 702.19 38745 846.30 803.99 924.59 906.10 906.10 887.97 38746 212.02 201.42 231.63 227.00 227.00 222.46 38747 261.50 248.43 285.69 279.98 279.98 274.38 38760 814.39 773.67 889.72 871.93 871.93 854.50 38765 1,254.47 1,191.75 1,370.51 1,343.11 1,343.11 1,316.24 38770 785.71 746.42 858.38 841.21 841.21 824.39 38780 995.48 945.71 1,087.57 1,065.82 1,065.82 1,044.50 38790 80.24 76.23 87.66 85.92 85.92 84.20 38792 38.09 36.19 41.62 40.79 40.79 39.97 38794 289.77 275.28 316.57 310.24 310.24 304.03 38900 135.00 128.25 147.49 144.54 144.54 141.66 39000 480.61 456.58 525.07 514.57 514.57 504.28 39010 766.13 727.82 836.99 820.25 820.25 803.84 39200 859.06 816.11 938.53 919.76 919.76 901.36 39220 1,110.09 1,054.59 1,212.78 1,188.53 1,188.53 1,164.75 39401 303.93 288.73 332.04 325.40 325.40 318.90 39402 397.52 377.64 434.29 425.60 425.60 417.09 39501 823.12 781.96 899.25 881.27 881.27 863.64 39503 5,993.14 5,693.48 6,547.50 6,416.55 6,416.55 6,288.22 39540 841.30 799.24 919.13 900.75 900.75 882.73 39541 916.85 871.01 1,001.66 981.63 981.63 962.00 39545 868.05 824.65 948.35 929.38 929.38 910.80 39560 772.25 733.64 843.69 826.82 826.82 810.28 39561 1,200.09 1,140.09 1,311.10 1,284.88 1,284.88 1,259.18 40490 120.02 114.02 131.12 128.50 128.50 125.94 # 40490 71.31 67.74 77.90 76.35 76.35 74.82 40500 473.76 450.07 517.58 507.23 507.23 497.09 # 40500 348.57 331.14 380.81 373.20 373.20 365.73

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 97Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

40510 456.44 433.62 498.66 488.69 488.69 478.92 # 40510 343.73 326.54 375.52 368.01 368.01 360.65 40520 460.67 437.64 503.29 493.22 493.22 483.36 # 40520 345.16 327.90 377.09 369.54 369.54 362.15 40525 531.50 504.93 580.67 569.05 569.05 557.67 40527 599.10 569.15 654.52 641.44 641.44 628.60 40530 509.02 483.57 556.11 544.99 544.99 534.08 # 40530 388.82 369.38 424.79 416.29 416.29 407.96 40650 412.58 391.95 450.74 441.73 441.73 432.89 # 40650 286.75 272.41 313.27 307.00 307.00 300.86 40652 456.41 433.59 498.63 488.66 488.66 478.88 # 40652 336.52 319.69 367.64 360.30 360.30 353.08 40654 534.66 507.93 584.12 572.44 572.44 560.98 # 40654 407.28 386.92 444.96 436.06 436.06 427.34 40700 878.22 834.31 959.46 940.26 940.26 921.46 40701 990.99 941.44 1,082.66 1,061.00 1,061.00 1,039.78 40702 834.97 793.22 912.20 893.96 893.96 876.08 40720 983.42 934.25 1,074.39 1,052.91 1,052.91 1,031.85 40761 1,041.41 989.34 1,137.74 1,114.98 1,114.98 1,092.68 40800 198.66 188.73 217.04 212.70 212.70 208.45 # 40800 125.91 119.61 137.55 134.80 134.80 132.11 40801 298.70 283.77 326.34 319.80 319.80 313.41 # 40801 215.03 204.28 234.92 230.22 230.22 225.62 40804 178.71 169.77 195.24 191.33 191.33 187.50 # 40804 112.52 106.89 122.92 120.46 120.46 118.06 40805 346.84 329.50 378.93 371.35 371.35 363.92 # 40805 216.02 205.22 236.00 231.29 231.29 226.67 40806 104.06 98.86 113.69 111.41 111.41 109.18 # 40806 30.69 29.16 33.53 32.87 32.87 32.21 40808 174.34 165.62 190.46 186.66 186.66 182.92 # 40808 103.78 98.59 113.38 111.11 111.11 108.89 40810 193.92 184.22 211.85 207.62 207.62 203.47 # 40810 122.73 116.59 134.08 131.40 131.40 128.77 40812 273.29 259.63 298.57 292.61 292.61 286.75 # 40812 191.49 181.92 209.21 205.02 205.02 200.92 40814 366.71 348.37 400.63 392.61 392.61 384.76 # 40814 295.21 280.45 322.52 316.07 316.07 309.74 40816 383.41 364.24 418.88 410.50 410.50 402.29 # 40816 306.92 291.57 335.31 328.60 328.60 322.03 40818 337.93 321.03 369.18 361.80 361.80 354.57 # 40818 261.12 248.06 285.27 279.57 279.57 273.98 40819 299.43 284.46 327.13 320.59 320.59 314.17 # 40819 231.36 219.79 252.76 247.70 247.70 242.74 40820 247.56 235.18 270.46 265.05 265.05 259.75 # 40820 163.57 155.39 178.70 175.12 175.12 171.61 40830 249.28 236.82 272.34 266.89 266.89 261.56 # 40830 158.74 150.80 173.42 169.95 169.95 166.54 40831 317.58 301.70 346.96 340.02 340.02 333.22 # 40831 216.42 205.60 236.44 231.71 231.71 227.08

Page 98: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 98Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

40840 775.04 736.29 846.73 829.79 829.79 813.20 # 40840 611.45 580.88 668.01 654.65 654.65 641.55 40842 746.96 709.61 816.05 799.73 799.73 783.74 # 40842 587.74 558.35 642.10 629.26 629.26 616.68 40843 1,036.16 984.35 1,132.00 1,109.36 1,109.36 1,087.18 # 40843 828.54 787.11 905.18 887.08 887.08 869.33 40844 1,250.00 1,187.50 1,365.63 1,338.31 1,338.31 1,311.55 # 40844 1,025.83 974.54 1,120.72 1,098.31 1,098.31 1,076.34 40845 1,405.37 1,335.10 1,535.37 1,504.66 1,504.66 1,474.56 # 40845 1,195.25 1,135.49 1,305.81 1,279.70 1,279.70 1,254.10 41000 153.60 145.92 167.81 164.45 164.45 161.16 # 41000 108.64 103.21 118.69 116.32 116.32 114.00 41005 212.48 201.86 232.14 227.49 227.49 222.94 # 41005 120.06 114.06 131.17 128.55 128.55 125.97 41006 340.22 323.21 371.69 364.26 364.26 356.98 # 41006 244.68 232.45 267.32 261.97 261.97 256.73 41007 332.51 315.88 363.26 355.99 355.99 348.88 # 41007 235.72 223.93 257.52 252.37 252.37 247.32 41008 360.22 342.21 393.54 385.68 385.68 377.96 # 41008 262.18 249.07 286.43 280.70 280.70 275.09 41009 382.48 363.36 417.86 409.50 409.50 401.32 # 41009 284.14 269.93 310.42 304.21 304.21 298.13 41010 189.16 179.70 206.66 202.53 202.53 198.48 # 41010 103.62 98.44 113.21 110.94 110.94 108.72 41015 429.54 408.06 469.27 459.89 459.89 450.69 # 41015 338.69 321.76 370.02 362.62 362.62 355.36 41016 420.37 399.35 459.25 450.06 450.06 441.06 # 41016 340.75 323.71 372.27 364.83 364.83 357.54 41017 424.09 402.89 463.32 454.05 454.05 444.97 # 41017 342.29 325.18 373.96 366.48 366.48 359.16 41018 483.91 459.71 528.67 518.10 518.10 507.74 # 41018 401.49 381.42 438.63 429.86 429.86 421.26 41019 461.04 437.99 503.69 493.61 493.61 483.75 41100 158.89 150.95 173.59 170.12 170.12 166.72 # 41100 104.56 99.33 114.23 111.94 111.94 109.70 41105 161.59 153.51 176.54 173.01 173.01 169.54 # 41105 108.20 102.79 118.21 115.84 115.84 113.53 41108 139.45 132.48 152.35 149.30 149.30 146.31 # 41108 87.62 83.24 95.73 93.82 93.82 91.94 41110 199.78 189.79 218.26 213.89 213.89 209.61 # 41110 127.03 120.68 138.78 136.01 136.01 133.29 41112 317.39 301.52 346.75 339.81 339.81 333.02 # 41112 244.33 232.11 266.93 261.59 261.59 256.36 41113 348.00 330.60 380.19 372.59 372.59 365.14 # 41113 271.19 257.63 296.27 290.35 290.35 284.54 41114 617.33 586.46 674.43 660.94 660.94 647.73 41115 233.11 221.45 254.67 249.57 249.57 244.58 # 41115 147.56 140.18 161.21 157.99 157.99 154.82 41116 313.01 297.36 341.96 335.12 335.12 328.42

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 99Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 41116 212.79 202.15 232.47 227.83 227.83 223.27 41120 1,038.07 986.17 1,134.10 1,111.42 1,111.42 1,089.19 41130 1,285.25 1,220.99 1,404.14 1,376.06 1,376.06 1,348.54 41135 2,124.23 2,018.02 2,320.72 2,274.31 2,274.31 2,228.83 41140 2,139.20 2,032.24 2,337.08 2,290.34 2,290.34 2,244.54 41145 2,719.64 2,583.66 2,971.21 2,911.79 2,911.79 2,853.55 41150 2,154.42 2,046.70 2,353.71 2,306.64 2,306.64 2,260.50 41153 2,350.22 2,232.71 2,567.62 2,516.27 2,516.27 2,465.95 41155 2,953.83 2,806.14 3,227.06 3,162.52 3,162.52 3,099.27 41250 251.14 238.58 274.37 268.88 268.88 263.50 # 41250 148.11 140.70 161.81 158.57 158.57 155.40 41251 274.37 260.65 299.75 293.76 293.76 287.88 # 41251 176.33 167.51 192.64 188.78 188.78 185.01 41252 298.56 283.63 326.17 319.65 319.65 313.26 # 41252 204.58 194.35 223.50 219.03 219.03 214.65 41500 394.24 374.53 430.71 422.10 422.10 413.66 41510 400.97 380.92 438.06 429.30 429.30 420.70 41512 636.28 604.47 695.14 681.24 681.24 667.61 41520 335.10 318.35 366.10 358.78 358.78 351.60 # 41520 249.24 236.78 272.30 266.85 266.85 261.51 41530 908.81 863.37 992.88 973.02 973.02 953.56 # 41530 359.32 341.35 392.55 384.70 384.70 377.00 41800 251.97 239.37 275.28 269.77 269.77 264.37 # 41800 139.58 132.60 152.49 149.44 149.44 146.45 41805 240.94 228.89 263.22 257.96 257.96 252.79 # 41805 166.01 157.71 181.37 177.74 177.74 174.19 41806 335.54 318.76 366.57 359.24 359.24 352.05 # 41806 251.24 238.68 274.48 269.00 269.00 263.61 41822 277.79 263.90 303.49 297.41 297.41 291.47 # 41822 177.89 169.00 194.35 190.46 190.46 186.66 41823 407.34 386.97 445.02 436.11 436.11 427.40 # 41823 313.68 298.00 342.70 335.85 335.85 329.13 41825 199.09 189.14 217.51 213.16 213.16 208.90 # 41825 118.22 112.31 129.16 126.57 126.57 124.04 41826 298.43 283.51 326.04 319.52 319.52 313.12 # 41826 206.01 195.71 225.07 220.57 220.57 216.15 41827 418.91 397.96 457.65 448.50 448.50 439.53 # 41827 298.71 283.77 326.34 319.80 319.80 313.41 41828 295.77 280.98 323.13 316.66 316.66 310.33 # 41828 208.97 198.52 228.30 223.73 223.73 219.26 41830 375.10 356.35 409.80 401.60 401.60 393.58 # 41830 277.07 263.22 302.70 296.65 296.65 290.72 41872 347.53 330.15 379.67 372.08 372.08 364.64 # 41872 248.87 236.43 271.89 266.46 266.46 261.13 41874 357.81 339.92 390.91 383.09 383.09 375.43 # 41874 249.48 237.01 272.56 267.11 267.11 261.76 42000 149.90 142.41 163.77 160.49 160.49 157.29 # 42000 100.26 95.25 109.54 107.35 107.35 105.20 42100 142.40 135.28 155.57 152.46 152.46 149.41

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 100Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 42100 106.19 100.88 116.01 113.69 113.69 111.41 42104 203.72 193.53 222.56 218.11 218.11 213.75 # 42104 134.72 127.98 147.18 144.23 144.23 141.35 42106 258.97 246.02 282.92 277.27 277.27 271.72 # 42106 173.11 164.45 189.12 185.33 185.33 181.63 42107 440.43 418.41 481.17 471.55 471.55 462.12 # 42107 337.09 320.24 368.28 360.92 360.92 353.69 42120 983.33 934.16 1,074.28 1,052.80 1,052.80 1,031.75 42140 237.52 225.64 259.49 254.30 254.30 249.22 # 42140 148.53 141.10 162.27 159.02 159.02 155.84 42145 681.28 647.22 744.30 729.42 729.42 714.83 42160 219.08 208.13 239.35 234.57 234.57 229.87 # 42160 142.27 135.16 155.43 152.33 152.33 149.28 42180 232.65 221.02 254.17 249.09 249.09 244.11 # 42180 178.64 169.71 195.17 191.27 191.27 187.44 42182 307.15 291.79 335.56 328.84 328.84 322.26 # 42182 249.39 236.92 272.46 267.01 267.01 261.67 42200 825.79 784.50 902.18 884.13 884.13 866.44 42205 862.99 819.84 942.82 923.96 923.96 905.48 42210 962.51 914.38 1,051.54 1,030.50 1,030.50 1,009.90 42215 634.46 602.74 693.15 679.29 679.29 665.71 42220 482.20 458.09 526.80 516.27 516.27 505.94 42225 840.15 798.14 917.86 899.51 899.51 881.52 42226 860.65 817.62 940.26 921.46 921.46 903.03 42227 815.74 774.95 891.19 873.37 873.37 855.90 42235 702.07 666.97 767.02 751.67 751.67 736.64 42260 782.34 743.22 854.70 837.61 837.61 820.86 # 42260 647.15 614.79 707.01 692.86 692.86 679.01 42280 157.34 149.47 171.89 168.45 168.45 165.08 # 42280 107.39 102.02 117.32 114.98 114.98 112.68 42281 194.67 184.94 212.68 208.43 208.43 204.26 # 42281 145.96 138.66 159.46 156.27 156.27 153.15 42300 198.72 188.78 217.10 212.75 212.75 208.50 # 42300 147.52 140.14 161.16 157.94 157.94 154.78 42305 418.70 397.77 457.44 448.28 448.28 439.31 42310 152.86 145.22 167.00 163.67 163.67 160.39 # 42310 119.45 113.48 130.50 127.89 127.89 125.34 42320 237.01 225.16 258.93 253.76 253.76 248.69 # 42320 169.89 161.40 185.61 181.90 181.90 178.26 42330 220.50 209.48 240.90 236.08 236.08 231.36 # 42330 159.93 151.93 174.72 171.22 171.22 167.80 42335 355.16 337.40 388.01 380.25 380.25 372.65 # 42335 249.63 237.15 272.72 267.27 267.27 261.92 42340 441.25 419.19 482.07 472.43 472.43 462.98 # 42340 325.41 309.14 355.51 348.40 348.40 341.44 42400 99.18 94.22 108.35 106.19 106.19 104.06 # 42400 53.28 50.62 58.21 57.05 57.05 55.91 42405 284.65 270.42 310.98 304.76 304.76 298.67 # 42405 219.70 208.72 240.03 235.23 235.23 230.53

Page 101: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 101Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

42408 429.76 408.27 469.51 460.12 460.12 450.92 # 42408 316.11 300.30 345.35 338.43 338.43 331.66 42409 314.12 298.41 343.17 336.31 336.31 329.58 # 42409 213.90 203.21 233.69 229.02 229.02 224.45 42410 604.38 574.16 660.28 647.08 647.08 634.14 42415 1,029.82 978.33 1,125.08 1,102.57 1,102.57 1,080.52 42420 1,157.71 1,099.82 1,264.79 1,239.49 1,239.49 1,214.70 42425 814.36 773.64 889.69 871.90 871.90 854.46 42426 1,318.10 1,252.20 1,440.03 1,411.23 1,411.23 1,383.01 42440 399.95 379.95 436.94 428.20 428.20 419.64 42450 430.01 408.51 469.79 460.39 460.39 451.18 # 42450 346.03 328.73 378.04 370.48 370.48 363.08 42500 412.45 391.83 450.60 441.59 441.59 432.76 # 42500 330.65 314.12 361.24 354.02 354.02 346.93 42505 530.94 504.39 580.05 568.45 568.45 557.07 # 42505 439.46 417.49 480.11 470.51 470.51 461.10 42507 494.86 470.12 540.64 529.83 529.83 519.24 42509 816.94 776.09 892.50 874.66 874.66 857.16 42510 619.20 588.24 676.48 662.95 662.95 649.69 42550 126.25 119.94 137.93 135.17 135.17 132.47 # 42550 62.56 59.43 68.34 66.98 66.98 65.64 42600 454.97 432.22 497.05 487.12 487.12 477.38 # 42600 337.27 320.41 368.47 361.10 361.10 353.88 42650 79.09 75.14 86.41 84.69 84.69 83.00 # 42650 56.61 53.78 61.85 60.61 60.61 59.40 42660 120.38 114.36 131.51 128.88 128.88 126.30 # 42660 85.73 81.44 93.66 91.78 91.78 89.94 42665 291.32 276.75 318.26 311.90 311.90 305.67 # 42665 197.34 187.47 215.59 211.28 211.28 207.06 42700 179.02 170.07 195.58 191.67 191.67 187.84 # 42700 130.32 123.80 142.37 139.52 139.52 136.72 42720 438.48 416.56 479.04 469.46 469.46 460.08 # 42720 383.21 364.05 418.66 410.29 410.29 402.07 42725 795.27 755.51 868.84 851.46 851.46 834.43 42800 149.95 142.45 163.82 160.54 160.54 157.33 # 42800 107.80 102.41 117.77 115.41 115.41 113.10 42804 182.73 173.59 199.63 195.64 195.64 191.73 # 42804 108.42 103.00 118.45 116.08 116.08 113.76 42806 206.00 195.70 225.06 220.56 220.56 216.14 # 42806 127.01 120.66 138.76 135.99 135.99 133.27 42808 215.89 205.10 235.87 231.15 231.15 226.53 # 42808 157.51 149.63 172.07 168.64 168.64 165.27 42809 191.05 181.50 208.73 204.55 204.55 200.46 # 42809 118.93 112.98 129.93 127.33 127.33 124.79 42810 365.69 347.41 399.52 391.53 391.53 383.70 # 42810 277.02 263.17 302.65 296.60 296.60 290.66 42815 538.78 511.84 588.62 576.84 576.84 565.31 42820 281.48 267.41 307.52 301.37 301.37 295.34 42821 292.06 277.46 319.08 312.70 312.70 306.44

Page 102: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 102Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

42825 252.90 240.26 276.30 270.77 270.77 265.35 42826 242.97 230.82 265.44 260.13 260.13 254.93 42830 199.36 189.39 217.80 213.44 213.44 209.17 42831 215.31 204.54 235.22 230.52 230.52 225.91 42835 184.81 175.57 201.91 197.87 197.87 193.91 42836 232.51 220.88 254.01 248.93 248.93 243.95 42842 983.41 934.24 1,074.38 1,052.89 1,052.89 1,031.84 42844 1,352.03 1,284.43 1,477.09 1,447.55 1,447.55 1,418.61 42845 2,193.81 2,084.12 2,396.74 2,348.81 2,348.81 2,301.83 42860 180.72 171.68 197.43 193.49 193.49 189.62 42870 572.93 544.28 625.92 613.40 613.40 601.13 42890 1,398.23 1,328.32 1,527.57 1,497.01 1,497.01 1,467.08 42892 1,849.89 1,757.40 2,021.01 1,980.59 1,980.59 1,940.98 42894 2,329.03 2,212.58 2,544.47 2,493.58 2,493.58 2,443.70 42900 328.77 312.33 359.18 351.99 351.99 344.95 42950 786.38 747.06 859.12 841.94 841.94 825.10 42953 944.50 897.28 1,031.87 1,011.23 1,011.23 991.00 42955 743.88 706.69 812.69 796.44 796.44 780.52 42960 164.49 156.27 179.71 176.11 176.11 172.59 42961 409.34 388.87 447.20 438.25 438.25 429.49 42962 502.09 476.99 548.54 537.57 537.57 526.82 42970 391.56 371.98 427.78 419.22 419.22 410.84 42971 442.45 420.33 483.38 473.71 473.71 464.23 42972 496.30 471.49 542.21 531.37 531.37 520.74 43020 512.11 486.50 559.48 548.29 548.29 537.31 43030 504.27 479.06 550.92 539.90 539.90 529.10 43045 1,271.67 1,208.09 1,389.30 1,361.52 1,361.52 1,334.29 43100 606.66 576.33 662.78 649.52 649.52 636.53 43101 990.62 941.09 1,082.25 1,060.61 1,060.61 1,039.39 43107 2,494.89 2,370.15 2,725.67 2,671.16 2,671.16 2,617.75 43108 4,497.91 4,273.01 4,913.96 4,815.68 4,815.68 4,719.37 43112 2,637.35 2,505.48 2,881.30 2,823.68 2,823.68 2,767.20 43113 4,442.30 4,220.19 4,853.22 4,756.16 4,756.16 4,661.03 43116 4,978.47 4,729.55 5,438.98 5,330.20 5,330.20 5,223.60 43117 2,416.69 2,295.86 2,640.24 2,587.43 2,587.43 2,535.68 43118 3,621.37 3,440.30 3,956.35 3,877.21 3,877.21 3,799.67 43121 2,815.07 2,674.32 3,075.47 3,013.95 3,013.95 2,953.67 43122 2,506.35 2,381.03 2,738.18 2,683.42 2,683.42 2,629.75 43123 4,624.61 4,393.38 5,052.39 4,951.34 4,951.34 4,852.31 43124 3,755.87 3,568.08 4,103.29 4,021.23 4,021.23 3,940.81 43130 765.81 727.52 836.65 819.92 819.92 803.52 43135 1,453.91 1,381.21 1,588.39 1,556.63 1,556.63 1,525.50 43180 537.03 510.18 586.71 574.98 574.98 563.48 43191 150.26 142.75 164.16 160.89 160.89 157.67 43192 166.23 157.92 181.61 177.97 177.97 174.41 43193 165.55 157.27 180.86 177.24 177.24 173.70 43194 189.92 180.42 207.48 203.33 203.33 199.26 43195 180.18 171.17 196.85 192.91 192.91 189.06 43196 192.97 183.32 210.82 206.60 206.60 202.47

Page 103: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 103Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

43197 175.24 166.48 191.45 187.62 187.62 183.87 # 43197 81.58 77.50 89.13 87.34 87.34 85.59 43198 195.21 185.45 213.27 209.00 209.00 204.83 # 43198 97.80 92.91 106.85 104.71 104.71 102.61 43200 247.99 235.59 270.93 265.51 265.51 260.20 # 43200 91.57 86.99 100.04 98.04 98.04 96.08 43201 253.02 240.37 276.43 270.89 270.89 265.48 # 43201 106.91 101.56 116.79 114.46 114.46 112.17 43202 329.49 313.02 359.97 352.77 352.77 345.71 # 43202 106.88 101.54 116.77 114.44 114.44 112.15 43204 138.91 131.96 151.75 148.72 148.72 145.74 43205 144.67 137.44 158.06 154.89 154.89 151.80 43206 303.50 288.33 331.58 324.94 324.94 318.45 # 43206 138.34 131.42 151.13 148.11 148.11 145.14 43210 419.93 398.93 458.77 449.59 449.59 440.60 43211 238.90 226.96 261.00 255.78 255.78 250.67 43212 193.28 183.62 211.16 206.94 206.94 202.80 43213 1,104.85 1,049.61 1,207.05 1,182.91 1,182.91 1,159.26 # 43213 261.25 248.19 285.42 279.71 279.71 274.13 43214 195.20 185.44 213.26 208.99 208.99 204.82 43215 382.36 363.24 417.73 409.38 409.38 401.19 # 43215 145.39 138.12 158.84 155.66 155.66 152.55 43216 377.31 358.44 412.21 403.96 403.96 395.88 # 43216 137.53 130.65 150.25 147.25 147.25 144.30 43217 408.59 388.16 446.38 437.46 437.46 428.71 # 43217 164.13 155.92 179.31 175.72 175.72 172.20 43220 1,012.56 961.93 1,106.22 1,084.09 1,084.09 1,062.42 # 43220 121.82 115.73 133.09 130.43 130.43 127.82 43226 347.55 330.17 379.70 372.11 372.11 364.67 # 43226 134.30 127.59 146.73 143.80 143.80 140.92 43227 628.57 597.14 686.71 672.98 672.98 659.53 # 43227 168.99 160.54 184.62 180.93 180.93 177.31 43229 655.14 622.38 715.74 701.42 701.42 687.39 # 43229 200.87 190.83 219.45 215.06 215.06 210.76 43231 367.88 349.49 401.91 393.88 393.88 386.00 # 43231 164.01 155.81 179.18 175.59 175.59 172.09 43232 440.00 418.00 480.70 471.09 471.09 461.67 # 43232 202.09 191.99 220.79 216.37 216.37 212.05 43233 231.07 219.52 252.45 247.40 247.40 242.45 43235 285.21 270.95 311.59 305.36 305.36 299.25 # 43235 126.29 119.98 137.98 135.22 135.22 132.51 43236 353.94 336.24 386.68 378.95 378.95 371.37 # 43236 142.57 135.44 155.76 152.64 152.64 149.59 43237 199.30 189.34 217.74 213.38 213.38 209.12 43238 236.24 224.43 258.09 252.93 252.93 247.87 43239 362.65 344.52 396.20 388.27 388.27 380.51 # 43239 142.54 135.41 155.72 152.61 152.61 149.56 43240 395.61 375.83 432.20 423.56 423.56 415.08 43241 146.38 139.06 159.92 156.72 156.72 153.58

Page 104: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 104Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

43242 266.79 253.45 291.47 285.64 285.64 279.92 43243 240.72 228.68 262.98 257.73 257.73 252.57 43244 249.15 236.69 272.19 266.75 266.75 261.42 43245 557.13 529.27 608.66 596.48 596.48 584.56 # 43245 179.35 170.38 195.94 192.02 192.02 188.17 43246 203.49 193.32 222.32 217.87 217.87 213.51 43247 382.51 363.38 417.89 409.53 409.53 401.34 # 43247 180.82 171.78 197.55 193.59 193.59 189.72 43248 374.89 356.15 409.57 401.38 401.38 393.36 # 43248 170.08 161.58 185.82 182.10 182.10 178.46 43249 962.68 914.55 1,051.73 1,030.70 1,030.70 1,010.08 # 43249 157.17 149.31 171.71 168.27 168.27 164.90 43250 416.78 395.94 455.33 446.22 446.22 437.30 # 43250 173.56 164.88 189.61 185.82 185.82 182.10 43251 457.13 434.27 499.41 489.42 489.42 479.63 # 43251 199.87 189.88 218.36 213.99 213.99 209.71 43252 338.48 321.56 369.79 362.40 362.40 355.15 # 43252 171.76 163.17 187.65 183.90 183.90 180.22 43253 266.19 252.88 290.81 284.99 284.99 279.29 43254 274.19 260.48 299.55 293.56 293.56 287.68 43255 662.07 628.97 723.32 708.85 708.85 694.67 # 43255 204.37 194.15 223.27 218.81 218.81 214.43 43257 236.46 224.64 258.34 253.17 253.17 248.11 43259 229.84 218.35 251.10 246.08 246.08 241.16 43260 325.86 309.57 356.01 348.89 348.89 341.91 43261 342.09 324.99 373.74 366.26 366.26 358.94 43262 360.75 342.71 394.12 386.24 386.24 378.51 43263 361.04 342.99 394.44 386.55 386.55 378.82 43264 367.56 349.18 401.56 393.53 393.53 385.66 43265 436.43 414.61 476.80 467.27 467.27 457.92 43266 229.79 218.30 251.05 246.02 246.02 241.10 43270 683.96 649.76 747.22 732.27 732.27 717.62 # 43270 236.24 224.43 258.09 252.93 252.93 247.87 43273 119.05 113.10 130.07 127.47 127.47 124.91 43274 465.92 442.62 509.01 498.84 498.84 488.85 43275 380.06 361.06 415.22 406.92 406.92 398.77 43276 485.23 460.97 530.12 519.51 519.51 509.13 43277 382.12 363.01 417.46 409.11 409.11 400.94 43278 436.07 414.27 476.41 466.88 466.88 457.54 43279 1,259.51 1,196.53 1,376.01 1,348.49 1,348.49 1,321.52 43280 1,051.50 998.93 1,148.77 1,125.79 1,125.79 1,103.28 43281 1,505.78 1,430.49 1,645.06 1,612.16 1,612.16 1,579.92 43282 1,693.52 1,608.84 1,850.17 1,813.16 1,813.16 1,776.90 43283 155.83 148.04 170.25 166.84 166.84 163.51 43300 598.52 568.59 653.88 640.80 640.80 627.99 43305 1,071.30 1,017.74 1,170.40 1,147.00 1,147.00 1,124.06 43310 1,455.29 1,382.53 1,589.91 1,558.11 1,558.11 1,526.95 43312 1,585.15 1,505.89 1,731.77 1,697.14 1,697.14 1,663.19 43313 2,657.76 2,524.87 2,903.60 2,845.53 2,845.53 2,788.61

Page 105: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 105Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

43314 3,020.86 2,869.82 3,300.29 3,234.28 3,234.28 3,169.60 43320 1,353.64 1,285.96 1,478.85 1,449.28 1,449.28 1,420.30 43325 1,303.53 1,238.35 1,424.10 1,395.62 1,395.62 1,367.71 43327 796.14 756.33 869.78 852.38 852.38 835.34 43328 1,109.64 1,054.16 1,212.28 1,188.04 1,188.04 1,164.28 43330 1,291.74 1,227.15 1,411.22 1,383.00 1,383.00 1,355.34 43331 1,312.57 1,246.94 1,433.98 1,405.30 1,405.30 1,377.19 43332 1,130.19 1,073.68 1,234.73 1,210.04 1,210.04 1,185.85 43333 1,231.99 1,170.39 1,345.95 1,319.03 1,319.03 1,292.65 43334 1,225.71 1,164.42 1,339.08 1,312.30 1,312.30 1,286.06 43335 1,314.72 1,248.98 1,436.33 1,407.60 1,407.60 1,379.45 43336 1,475.12 1,401.36 1,611.56 1,579.33 1,579.33 1,547.74 43337 1,588.96 1,509.51 1,735.94 1,701.22 1,701.22 1,667.19 43338 114.54 108.81 125.13 122.62 122.62 120.18 43340 1,326.70 1,260.37 1,449.43 1,420.43 1,420.43 1,392.03 43341 1,373.00 1,304.35 1,500.00 1,470.00 1,470.00 1,440.59 43351 1,258.13 1,195.22 1,374.50 1,347.02 1,347.02 1,320.07 43352 1,042.05 989.95 1,138.44 1,115.67 1,115.67 1,093.36 43360 2,305.77 2,190.48 2,519.05 2,468.67 2,468.67 2,419.30 43361 2,502.29 2,377.18 2,733.76 2,679.09 2,679.09 2,625.51 43400 1,453.78 1,381.09 1,588.25 1,556.49 1,556.49 1,525.36 43401 1,516.98 1,441.13 1,657.30 1,624.16 1,624.16 1,591.67 43405 1,423.98 1,352.78 1,555.70 1,524.58 1,524.58 1,494.09 43410 1,017.93 967.03 1,112.08 1,089.84 1,089.84 1,068.05 43415 2,515.89 2,390.10 2,748.62 2,693.65 2,693.65 2,639.77 43420 992.28 942.67 1,084.07 1,062.39 1,062.39 1,041.14 43425 1,407.82 1,337.43 1,538.04 1,507.28 1,507.28 1,477.14 43450 193.47 183.80 211.37 207.14 207.14 203.00 # 43450 83.26 79.10 90.97 89.15 89.15 87.37 43453 863.73 820.54 943.62 924.75 924.75 906.26 # 43453 89.76 85.27 98.06 96.09 96.09 94.17 43460 211.15 200.59 230.68 226.07 226.07 221.55 43500 759.97 721.97 830.27 813.66 813.66 797.39 43501 1,306.88 1,241.54 1,427.77 1,399.22 1,399.22 1,371.24 43502 1,480.17 1,406.16 1,617.08 1,584.75 1,584.75 1,553.05 43510 912.83 867.19 997.27 977.33 977.33 957.78 43520 666.65 633.32 728.32 713.75 713.75 699.48 43605 810.86 770.32 885.87 868.15 868.15 850.78 43610 951.64 904.06 1,039.67 1,018.88 1,018.88 998.50 43611 1,187.85 1,128.46 1,297.73 1,271.77 1,271.77 1,246.34 43620 1,907.42 1,812.05 2,083.86 2,042.18 2,042.18 2,001.33 43621 2,214.21 2,103.50 2,419.03 2,370.64 2,370.64 2,323.23 43622 2,257.09 2,144.24 2,465.88 2,416.56 2,416.56 2,368.23 43631 1,409.56 1,339.08 1,539.94 1,509.15 1,509.15 1,478.96 43632 1,980.42 1,881.40 2,163.61 2,120.34 2,120.34 2,077.92 43633 1,870.85 1,777.31 2,043.91 2,003.02 2,003.02 1,962.96 43634 2,062.14 1,959.03 2,252.88 2,207.83 2,207.83 2,163.67 43635 110.18 104.67 120.37 117.97 117.97 115.61 43640 1,144.68 1,087.45 1,250.57 1,225.56 1,225.56 1,201.05

Page 106: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 106Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

43641 1,154.68 1,096.95 1,261.49 1,236.26 1,236.26 1,211.54 43644 1,686.04 1,601.74 1,842.00 1,805.17 1,805.17 1,769.07 43645 1,802.26 1,712.15 1,968.97 1,929.60 1,929.60 1,891.00 43647 303.37 288.20 331.43 324.81 324.81 318.31 43648 303.37 288.20 331.43 324.81 324.81 318.31 43651 630.20 598.69 688.49 674.73 674.73 661.24 43652 740.54 703.51 809.04 792.86 792.86 777.00 43653 551.26 523.70 602.26 590.21 590.21 578.42 43752 40.33 38.31 44.06 43.17 43.17 42.31 43753 21.57 20.49 23.56 23.09 23.09 22.63 43754 96.27 91.46 105.18 103.07 103.07 101.02 # 43754 31.64 30.06 34.57 33.88 33.88 33.20 43755 128.64 122.21 140.54 137.74 137.74 134.98 # 43755 59.33 56.36 64.81 63.51 63.51 62.25 43756 185.59 176.31 202.76 198.70 198.70 194.72 # 43756 49.46 46.99 54.04 52.96 52.96 51.90 43757 262.91 249.76 287.22 281.47 281.47 275.84 # 43757 75.58 71.80 82.57 80.91 80.91 79.29 43760 435.87 414.08 476.19 466.67 466.67 457.33 # 43760 46.23 43.92 50.51 49.50 49.50 48.51 43761 113.22 107.56 123.69 121.22 121.22 118.80 # 43761 101.36 96.29 110.73 108.51 108.51 106.34 43770 1,084.14 1,029.93 1,184.42 1,160.73 1,160.73 1,137.51 43771 1,234.95 1,173.20 1,349.18 1,322.20 1,322.20 1,295.76 43772 921.10 875.05 1,006.31 986.18 986.18 966.46 43773 1,231.28 1,169.72 1,345.18 1,318.28 1,318.28 1,291.91 43774 930.89 884.35 1,017.00 996.66 996.66 976.73 43775 1,080.67 1,026.64 1,180.64 1,157.03 1,157.03 1,133.89 43800 902.12 857.01 985.56 965.85 965.85 946.53 43810 987.67 938.29 1,079.03 1,057.45 1,057.45 1,036.30 43820 1,303.41 1,238.24 1,423.98 1,395.50 1,395.50 1,367.59 43825 1,267.97 1,204.57 1,385.26 1,357.55 1,357.55 1,330.40 43830 675.63 641.85 738.13 723.36 723.36 708.89 43831 560.25 532.24 612.08 599.84 599.84 587.85 43832 1,010.39 959.87 1,103.85 1,081.77 1,081.77 1,060.14 43840 1,320.54 1,254.51 1,442.69 1,413.83 1,413.83 1,385.55 43843 1,241.00 1,178.95 1,355.79 1,328.68 1,328.68 1,302.10 43845 1,910.37 1,814.85 2,087.08 2,045.33 2,045.33 2,004.43 43846 1,569.02 1,490.57 1,714.16 1,679.87 1,679.87 1,646.27 43847 1,728.28 1,641.87 1,888.15 1,850.38 1,850.38 1,813.38 43848 1,873.17 1,779.51 2,046.44 2,005.51 2,005.51 1,965.40 43850 1,580.07 1,501.07 1,726.23 1,691.71 1,691.71 1,657.87 43855 1,605.88 1,525.59 1,754.43 1,719.34 1,719.34 1,684.96 43860 1,591.61 1,512.03 1,738.83 1,704.06 1,704.06 1,669.97 43865 1,657.13 1,574.27 1,810.41 1,774.20 1,774.20 1,738.71 43870 689.25 654.79 753.01 737.94 737.94 723.19 43880 1,555.08 1,477.33 1,698.93 1,664.95 1,664.95 1,631.64 43881 609.82 579.33 666.23 652.90 652.90 639.85 43882 609.82 579.33 666.23 652.90 652.90 639.85

Page 107: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 107Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

43886 344.81 327.57 376.71 369.17 369.17 361.79 43887 309.16 293.70 337.76 331.00 331.00 324.38 43888 439.32 417.35 479.95 470.35 470.35 460.94 44005 1,063.46 1,010.29 1,161.83 1,138.59 1,138.59 1,115.82 44010 838.24 796.33 915.78 897.46 897.46 879.51 44015 139.55 132.57 152.46 149.41 149.41 146.42 44020 946.51 899.18 1,034.06 1,013.38 1,013.38 993.12 44021 946.86 899.52 1,034.45 1,013.76 1,013.76 993.49 44025 957.94 910.04 1,046.55 1,025.62 1,025.62 1,005.10 44050 908.78 863.34 992.84 972.98 972.98 953.52 44055 1,452.54 1,379.91 1,586.90 1,555.16 1,555.16 1,524.05 44100 107.13 101.77 117.04 114.69 114.69 112.40 44110 826.97 785.62 903.46 885.40 885.40 867.69 44111 957.38 909.51 1,045.94 1,025.02 1,025.02 1,004.51 44120 1,190.49 1,130.97 1,300.62 1,274.60 1,274.60 1,249.11 44121 237.65 225.77 259.64 254.44 254.44 249.35 44125 1,149.66 1,092.18 1,256.01 1,230.89 1,230.89 1,206.27 44126 2,400.92 2,280.87 2,623.00 2,570.54 2,570.54 2,519.13 44127 2,762.23 2,624.12 3,017.74 2,957.39 2,957.39 2,898.24 44128 239.67 227.69 261.84 256.61 256.61 251.48 44130 1,276.66 1,212.83 1,394.75 1,366.86 1,366.86 1,339.52 44139 119.05 113.10 130.07 127.47 127.47 124.91 44140 1,304.41 1,239.19 1,425.07 1,396.57 1,396.57 1,368.64 44141 1,772.64 1,684.01 1,936.61 1,897.88 1,897.88 1,859.92 44143 1,618.44 1,537.52 1,768.15 1,732.79 1,732.79 1,698.12 44144 1,723.31 1,637.14 1,882.71 1,845.06 1,845.06 1,808.16 44145 1,616.29 1,535.48 1,765.80 1,730.49 1,730.49 1,695.87 44146 2,060.17 1,957.16 2,250.73 2,205.72 2,205.72 2,161.61 44147 1,895.92 1,801.12 2,071.29 2,029.87 2,029.87 1,989.27 44150 1,813.97 1,723.27 1,981.76 1,942.12 1,942.12 1,903.27 44151 2,076.23 1,972.42 2,268.28 2,222.92 2,222.92 2,178.46 44155 2,024.76 1,923.52 2,212.05 2,167.81 2,167.81 2,124.45 44156 2,229.73 2,118.24 2,435.98 2,387.26 2,387.26 2,339.51 44157 2,093.18 1,988.52 2,286.80 2,241.06 2,241.06 2,196.25 44158 2,079.84 1,975.85 2,272.23 2,226.78 2,226.78 2,182.24 44160 1,207.63 1,147.25 1,319.34 1,292.96 1,292.96 1,267.09 44180 892.12 847.51 974.64 955.14 955.14 936.04 44186 631.47 599.90 689.89 676.09 676.09 662.56 44187 1,070.63 1,017.10 1,169.67 1,146.27 1,146.27 1,123.34 44188 1,187.02 1,127.67 1,296.82 1,270.89 1,270.89 1,245.47 44202 1,349.36 1,281.89 1,474.17 1,444.69 1,444.69 1,415.80 44203 236.79 224.95 258.69 253.52 253.52 248.45 44204 1,499.46 1,424.49 1,638.16 1,605.40 1,605.40 1,573.29 44205 1,304.05 1,238.85 1,424.68 1,396.18 1,396.18 1,368.26 44206 1,708.03 1,622.63 1,866.02 1,828.71 1,828.71 1,792.14 44207 1,778.10 1,689.20 1,942.58 1,903.73 1,903.73 1,865.66 44208 1,937.06 1,840.21 2,116.24 2,073.92 2,073.92 2,032.44 44210 1,734.98 1,648.23 1,895.46 1,857.56 1,857.56 1,820.40 44211 2,126.94 2,020.59 2,323.68 2,277.21 2,277.21 2,231.67

Page 108: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 108Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

44212 1,994.80 1,895.06 2,179.32 2,135.73 2,135.73 2,093.02 44213 184.84 175.60 201.94 197.90 197.90 193.95 44227 1,625.06 1,543.81 1,775.38 1,739.87 1,739.87 1,705.07 44300 816.56 775.73 892.09 874.25 874.25 856.77 44310 1,015.58 964.80 1,109.52 1,087.33 1,087.33 1,065.58 44312 571.12 542.56 623.94 611.47 611.47 599.24 44314 975.09 926.34 1,065.29 1,043.98 1,043.98 1,023.10 44316 1,375.46 1,306.69 1,502.69 1,472.64 1,472.64 1,443.19 44320 1,166.76 1,108.42 1,274.68 1,249.19 1,249.19 1,224.21 44322 956.08 908.28 1,044.52 1,023.63 1,023.63 1,003.16 44340 602.21 572.10 657.92 644.76 644.76 631.87 44345 1,020.60 969.57 1,115.01 1,092.71 1,092.71 1,070.86 44346 1,149.22 1,091.76 1,255.52 1,230.41 1,230.41 1,205.80 44360 147.40 140.03 161.03 157.81 157.81 154.66 44361 162.62 154.49 177.66 174.11 174.11 170.63 44363 195.16 185.40 213.21 208.94 208.94 204.77 44364 207.81 197.42 227.03 222.49 222.49 218.04 44365 183.14 173.98 200.08 196.08 196.08 192.15 44366 244.04 231.84 266.62 261.28 261.28 256.06 44369 249.51 237.03 272.58 267.13 267.13 261.79 44370 269.90 256.41 294.87 288.97 288.97 283.19 44372 243.56 231.38 266.09 260.76 260.76 255.55 44373 195.70 185.92 213.81 209.53 209.53 205.34 44376 287.51 273.13 314.10 307.82 307.82 301.67 44377 303.31 288.14 331.36 324.74 324.74 318.24 44378 388.26 368.85 424.18 415.69 415.69 407.38 44379 412.42 391.80 450.57 441.55 441.55 432.72 44380 199.53 189.55 217.98 213.62 213.62 209.35 # 44380 60.60 57.57 66.21 64.88 64.88 63.58 44381 891.90 847.31 974.41 954.91 954.91 935.81 # 44381 88.57 84.14 96.76 94.83 94.83 92.93 44382 288.53 274.10 315.22 308.91 308.91 302.74 # 44382 77.16 73.30 84.30 82.60 82.60 80.95 44384 155.86 148.07 170.28 166.88 166.88 163.54 44385 220.89 209.85 241.33 236.50 236.50 231.77 # 44385 75.40 71.63 82.37 80.73 80.73 79.12 44386 309.89 294.40 338.56 331.79 331.79 325.15 # 44386 92.58 87.95 101.14 99.12 99.12 97.14 44388 324.83 308.59 354.88 347.78 347.78 340.83 # 44388 159.67 151.69 174.44 170.96 170.96 167.54 44388 53 161.42 153.35 176.35 172.82 172.82 169.36 # 44388 53 79.00 75.05 86.31 84.58 84.58 82.89 44389 407.70 387.32 445.42 436.51 436.51 427.78 # 44389 175.41 166.64 191.64 187.81 187.81 184.05 44390 410.23 389.72 448.18 439.22 439.22 430.43 # 44390 214.16 203.45 233.97 229.29 229.29 224.70 44391 697.46 662.59 761.98 746.74 746.74 731.80 # 44391 234.13 222.42 255.78 250.67 250.67 245.65 44392 386.34 367.02 422.07 413.63 413.63 405.36

Page 109: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 109Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 44392 201.82 191.73 220.49 216.09 216.09 211.76 44394 434.70 412.97 474.92 465.42 465.42 456.11 # 44394 229.27 217.81 250.48 245.47 245.47 240.56 44401 2,903.35 2,758.18 3,171.91 3,108.47 3,108.47 3,046.30 # 44401 245.48 233.21 268.19 262.83 262.83 257.58 44402 265.73 252.44 290.31 284.50 284.50 278.81 44403 305.70 290.42 333.98 327.30 327.30 320.76 44404 391.07 371.52 427.25 418.70 418.70 410.33 # 44404 175.64 166.86 191.89 188.05 188.05 184.29 44405 556.17 528.36 607.61 595.46 595.46 583.54 # 44405 186.82 177.48 204.10 200.02 200.02 196.02 44406 232.91 221.26 254.45 249.35 249.35 244.36 44407 278.93 264.98 304.73 298.63 298.63 292.66 44408 235.25 223.49 257.01 251.87 251.87 246.84 44500 24.30 23.09 26.55 26.02 26.02 25.51 44602 1,377.65 1,308.77 1,505.09 1,474.98 1,474.98 1,445.48 44603 1,579.18 1,500.22 1,725.25 1,690.75 1,690.75 1,656.94 44604 1,029.77 978.28 1,125.02 1,102.52 1,102.52 1,080.47 44605 1,270.10 1,206.60 1,387.59 1,359.84 1,359.84 1,332.64 44615 1,046.94 994.59 1,143.78 1,120.91 1,120.91 1,098.49 44620 843.74 801.55 921.78 903.35 903.35 885.28 44625 990.12 940.61 1,081.70 1,060.07 1,060.07 1,038.86 44626 1,564.07 1,485.87 1,708.75 1,674.57 1,674.57 1,641.08 44640 1,366.92 1,298.57 1,493.36 1,463.49 1,463.49 1,434.22 44650 1,413.81 1,343.12 1,544.59 1,513.70 1,513.70 1,483.42 44660 1,301.49 1,236.42 1,421.88 1,393.44 1,393.44 1,365.58 44661 1,514.98 1,439.23 1,655.11 1,622.02 1,622.02 1,589.58 44680 1,036.68 984.85 1,132.58 1,109.92 1,109.92 1,087.73 44700 994.09 944.39 1,086.05 1,064.33 1,064.33 1,043.04 44701 165.32 157.05 180.61 177.00 177.00 173.45 44720 269.63 256.15 294.57 288.68 288.68 282.91 44721 377.36 358.49 412.26 404.02 404.02 395.93 44800 738.37 701.45 806.67 790.53 790.53 774.72 44820 814.05 773.35 889.35 871.56 871.56 854.13 44850 728.09 691.69 795.44 779.54 779.54 763.95 44900 748.66 711.23 817.91 801.56 801.56 785.53 44950 623.65 592.47 681.34 667.71 667.71 654.36 44955 82.25 78.14 89.86 88.07 88.07 86.31 44960 848.77 806.33 927.28 908.73 908.73 890.56 44970 581.01 551.96 634.75 622.06 622.06 609.62 45000 407.12 386.76 444.77 435.87 435.87 427.16 45005 253.13 240.47 276.54 271.01 271.01 265.59 # 45005 153.54 145.86 167.74 164.38 164.38 161.09 45020 550.02 522.52 600.90 588.88 588.88 577.10 45100 286.12 271.81 312.58 306.33 306.33 300.20 45108 350.79 333.25 383.24 375.58 375.58 368.07 45110 1,795.66 1,705.88 1,961.76 1,922.52 1,922.52 1,884.07 45111 1,054.76 1,002.02 1,152.32 1,129.28 1,129.28 1,106.69 45112 1,835.00 1,743.25 2,004.74 1,964.65 1,964.65 1,925.35

Page 110: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 110Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

45113 1,850.78 1,758.24 2,021.98 1,981.54 1,981.54 1,941.91 45114 1,766.95 1,678.60 1,930.39 1,891.78 1,891.78 1,853.95 45116 1,599.59 1,519.61 1,747.55 1,712.60 1,712.60 1,678.36 45119 1,898.16 1,803.25 2,073.74 2,032.27 2,032.27 1,991.63 45120 1,469.84 1,396.35 1,605.80 1,573.68 1,573.68 1,542.21 45121 1,687.97 1,603.57 1,844.11 1,807.23 1,807.23 1,771.08 45123 1,089.60 1,035.12 1,190.39 1,166.58 1,166.58 1,143.25 45126 2,726.73 2,590.39 2,978.95 2,919.37 2,919.37 2,860.98 45130 1,059.07 1,006.12 1,157.04 1,133.90 1,133.90 1,111.22 45135 1,327.49 1,261.12 1,450.29 1,421.29 1,421.29 1,392.86 45136 1,765.27 1,677.01 1,928.56 1,889.99 1,889.99 1,852.19 45150 376.33 357.51 411.14 402.91 402.91 394.85 45160 988.55 939.12 1,079.99 1,058.39 1,058.39 1,037.22 45171 575.39 546.62 628.61 616.04 616.04 603.73 45172 779.68 740.70 851.81 834.77 834.77 818.08 45190 668.64 635.21 730.49 715.89 715.89 701.57 45300 112.58 106.95 122.99 120.53 120.53 118.12 # 45300 52.01 49.41 56.82 55.68 55.68 54.57 45303 857.82 814.93 937.17 918.42 918.42 900.06 # 45303 89.46 84.99 97.74 95.78 95.78 93.86 45305 178.69 169.76 195.22 191.31 191.31 187.48 # 45305 76.28 72.47 83.34 81.67 81.67 80.04 45307 214.59 203.86 234.44 229.75 229.75 225.15 # 45307 102.82 97.68 112.33 110.09 110.09 107.89 45308 197.55 187.67 215.82 211.51 211.51 207.28 # 45308 86.08 81.78 94.05 92.16 92.16 90.32 45309 206.97 196.62 226.11 221.59 221.59 217.17 # 45309 91.77 87.18 100.26 98.26 98.26 96.29 45315 208.90 198.46 228.23 223.66 223.66 219.19 # 45315 102.44 97.32 111.92 109.68 109.68 107.48 45317 224.62 213.39 245.40 240.49 240.49 235.68 # 45317 114.41 108.69 124.99 122.50 122.50 120.05 45320 223.68 212.50 244.38 239.49 239.49 234.70 # 45320 106.91 101.56 116.79 114.46 114.46 112.17 45321 104.15 98.94 113.78 111.50 111.50 109.27 45327 118.42 112.50 129.38 126.79 126.79 124.26 45330 151.51 143.93 165.52 162.21 162.21 158.96 # 45330 54.41 51.69 59.44 58.26 58.26 57.10 45331 231.79 220.20 253.23 248.17 248.17 243.20 # 45331 70.38 66.86 76.89 75.35 75.35 73.84 45332 283.12 268.96 309.30 303.12 303.12 297.06 # 45332 108.91 103.46 118.98 116.60 116.60 114.26 45333 315.96 300.16 345.18 338.28 338.28 331.52 # 45333 97.41 92.54 106.42 104.29 104.29 102.21 45334 548.67 521.24 599.43 587.44 587.44 575.69 # 45334 121.56 115.48 132.80 130.15 130.15 127.55 45335 260.80 247.76 284.92 279.22 279.22 273.63 # 45335 70.35 66.83 76.85 75.31 75.31 73.81 45337 119.41 113.44 130.46 127.85 127.85 125.29

Page 111: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 111Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

45338 296.57 281.74 324.00 317.53 317.53 311.18 # 45338 123.92 117.72 135.38 132.68 132.68 130.02 45340 439.61 417.63 480.27 470.67 470.67 461.25 # 45340 81.50 77.43 89.04 87.26 87.26 85.51 45341 127.70 121.32 139.52 136.72 136.72 133.99 45342 173.52 164.84 189.57 185.77 185.77 182.06 45346 2,773.76 2,635.07 3,030.33 2,969.73 2,969.73 2,910.33 # 45346 163.97 155.77 179.14 175.55 175.55 172.04 45347 158.30 150.39 172.95 169.49 169.49 166.09 45349 201.52 191.44 220.16 215.75 215.75 211.44 45350 524.47 498.25 572.99 561.53 561.53 550.30 # 45350 104.23 99.02 113.87 111.60 111.60 109.37 45378 350.33 332.81 382.73 375.07 375.07 367.57 # 45378 188.29 178.88 205.71 201.60 201.60 197.56 45378 53 175.01 166.26 191.20 187.37 187.37 183.62 # 45378 53 94.15 89.44 102.86 100.80 100.80 98.79 45379 442.38 420.26 483.30 473.63 473.63 464.15 # 45379 242.56 230.43 264.99 259.69 259.69 254.50 45380 430.98 409.43 470.84 461.43 461.43 452.20 # 45380 204.31 194.09 223.20 218.74 218.74 214.37 45381 415.08 394.33 453.48 444.41 444.41 435.52 # 45381 204.34 194.12 223.24 218.78 218.78 214.41 45382 723.21 687.05 790.11 774.31 774.31 758.82 # 45382 263.01 249.86 287.34 281.59 281.59 275.95 45384 473.52 449.84 517.32 506.97 506.97 496.82 # 45384 231.55 219.97 252.97 247.91 247.91 242.95 45385 455.52 432.74 497.65 487.70 487.70 477.95 # 45385 258.20 245.29 282.08 276.44 276.44 270.91 45386 596.94 567.09 652.15 639.11 639.11 626.34 # 45386 215.41 204.64 235.34 230.63 230.63 226.02 45388 2,922.27 2,776.16 3,192.58 3,128.74 3,128.74 3,066.16 # 45388 274.07 260.37 299.43 293.43 293.43 287.57 45389 293.43 278.76 320.57 314.16 314.16 307.88 45390 335.06 318.31 366.06 358.73 358.73 351.56 45391 261.38 248.31 285.56 279.84 279.84 274.24 45392 307.74 292.35 336.20 329.48 329.48 322.89 45393 256.66 243.83 280.40 274.79 274.79 269.30 45395 1,924.17 1,827.96 2,102.15 2,060.11 2,060.11 2,018.91 45397 2,099.07 1,994.12 2,293.24 2,247.38 2,247.38 2,202.43 45398 666.98 633.63 728.67 714.10 714.10 699.82 # 45398 238.31 226.39 260.35 255.14 255.14 250.03 45400 1,110.28 1,054.77 1,212.99 1,188.72 1,188.72 1,164.95 45402 1,482.60 1,408.47 1,619.74 1,587.35 1,587.35 1,555.59 45500 501.91 476.81 548.33 537.36 537.36 526.61 45505 568.67 540.24 621.28 608.86 608.86 596.68 45520 141.89 134.80 155.02 151.92 151.92 148.88 # 45520 38.54 36.61 42.10 41.26 41.26 40.43 45540 1,030.88 979.34 1,126.24 1,103.71 1,103.71 1,081.64 45541 911.94 866.34 996.29 976.36 976.36 956.83

Page 112: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 112Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

45550 1,420.61 1,349.58 1,552.02 1,520.98 1,520.98 1,490.56 45560 667.09 633.74 728.80 714.23 714.23 699.95 45562 1,084.26 1,030.05 1,184.56 1,160.87 1,160.87 1,137.65 45563 1,596.37 1,516.55 1,744.03 1,709.15 1,709.15 1,674.98 45800 1,169.61 1,111.13 1,277.80 1,252.25 1,252.25 1,227.20 45805 1,415.94 1,345.14 1,546.91 1,515.98 1,515.98 1,485.66 45820 1,161.14 1,103.08 1,268.54 1,243.17 1,243.17 1,218.31 45825 1,351.49 1,283.92 1,476.51 1,446.98 1,446.98 1,418.04 45900 195.03 185.28 213.07 208.81 208.81 204.63 45905 162.20 154.09 177.20 173.66 173.66 170.19 45910 186.83 177.49 204.11 200.03 200.03 196.03 45915 309.22 293.76 337.82 331.06 331.06 324.44 # 45915 217.12 206.26 237.20 232.45 232.45 227.80 45990 104.41 99.19 114.07 111.79 111.79 109.56 46020 259.42 246.45 283.42 277.75 277.75 272.19 # 46020 223.21 212.05 243.86 238.98 238.98 234.20 46030 129.40 122.93 141.37 138.54 138.54 135.77 # 46030 86.32 82.00 94.30 92.41 92.41 90.56 46040 500.12 475.11 546.38 535.45 535.45 524.75 # 46040 394.59 374.86 431.09 422.46 422.46 414.01 46045 414.06 393.36 452.36 443.31 443.31 434.45 46050 184.26 175.05 201.31 197.28 197.28 193.34 # 46050 92.47 87.85 101.03 99.00 99.00 97.03 46060 454.73 431.99 496.79 486.85 486.85 477.11 46070 215.61 204.83 235.55 230.84 230.84 226.23 46080 231.47 219.90 252.89 247.83 247.83 242.87 # 46080 153.73 146.04 167.95 164.59 164.59 161.30 46083 162.71 154.57 177.76 174.20 174.20 170.72 # 46083 101.52 96.44 110.91 108.69 108.69 106.51 46200 411.43 390.86 449.49 440.50 440.50 431.69 # 46200 306.84 291.50 335.23 328.52 328.52 321.95 46220 190.11 180.60 207.69 203.54 203.54 199.47 # 46220 113.30 107.64 123.79 121.31 121.31 118.89 46221 248.64 236.21 271.64 266.21 266.21 260.89 # 46221 180.58 171.55 197.28 193.34 193.34 189.47 46230 254.21 241.50 277.73 272.17 272.17 266.73 # 46230 165.85 157.56 181.19 177.57 177.57 174.02 46250 431.36 409.79 471.26 461.83 461.83 452.59 # 46250 301.17 286.11 329.03 322.45 322.45 316.00 46255 472.66 449.03 516.38 506.06 506.06 495.94 # 46255 338.72 321.78 370.05 362.64 362.64 355.38 46257 402.93 382.78 440.20 431.39 431.39 422.76 46258 445.63 423.35 486.85 477.11 477.11 467.57 46260 455.42 432.65 497.55 487.60 487.60 477.85 46261 501.79 476.70 548.21 537.25 537.25 526.50 46262 528.99 502.54 577.92 566.36 566.36 555.04 46270 473.98 450.28 517.82 507.46 507.46 497.31 # 46270 372.51 353.88 406.96 398.82 398.82 390.84 46275 502.27 477.16 548.73 537.76 537.76 527.01

Page 113: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 113Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 46275 393.93 374.23 430.36 421.76 421.76 413.33 46280 448.20 425.79 489.66 479.86 479.86 470.26 46285 497.98 473.08 544.04 533.16 533.16 522.50 # 46285 392.76 373.12 429.09 420.51 420.51 412.10 46288 527.02 500.67 575.77 564.26 564.26 552.98 46320 170.29 161.78 186.05 182.32 182.32 178.68 # 46320 106.29 100.98 116.13 113.80 113.80 111.53 46500 179.15 170.19 195.72 191.81 191.81 187.97 # 46500 116.40 110.58 127.17 124.63 124.63 122.13 46505 268.05 254.65 292.85 286.99 286.99 281.26 # 46505 227.78 216.39 248.85 243.87 243.87 238.99 46600 80.95 76.90 88.44 86.66 86.66 84.93 # 46600 39.11 37.15 42.72 41.87 41.87 41.03 46601 128.77 122.33 140.68 137.86 137.86 135.10 # 46601 91.30 86.74 99.75 97.76 97.76 95.81 46604 553.12 525.46 604.28 592.19 592.19 580.35 # 46604 64.20 60.99 70.14 68.74 68.74 67.36 46606 205.70 195.42 224.73 220.24 220.24 215.83 # 46606 73.64 69.96 80.45 78.84 78.84 77.27 46607 179.97 170.97 196.62 192.68 192.68 188.83 # 46607 123.15 116.99 134.54 131.85 131.85 129.21 46608 211.64 201.06 231.22 226.60 226.60 222.07 # 46608 78.33 74.41 85.57 83.86 83.86 82.18 46610 206.21 195.90 225.29 220.78 220.78 216.36 # 46610 78.21 74.30 85.45 83.73 83.73 82.05 46611 161.77 153.68 176.73 173.20 173.20 169.74 # 46611 78.72 74.78 86.00 84.27 84.27 82.58 46612 235.16 223.40 256.91 251.77 251.77 246.73 # 46612 90.29 85.78 98.65 96.67 96.67 94.74 46614 118.41 112.49 129.36 126.78 126.78 124.25 # 46614 62.53 59.40 68.31 66.94 66.94 65.61 46615 134.42 127.70 146.86 143.92 143.92 141.05 # 46615 89.78 85.29 98.08 96.12 96.12 94.20 46700 629.08 597.63 687.27 673.53 673.53 660.07 46705 482.08 457.98 526.68 516.14 516.14 505.82 46706 159.46 151.49 174.21 170.73 170.73 167.31 46707 454.60 431.87 496.65 486.71 486.71 476.99 46710 1,020.01 969.01 1,114.36 1,092.07 1,092.07 1,070.24 46712 2,080.39 1,976.37 2,272.83 2,227.37 2,227.37 2,182.82 46715 518.72 492.78 566.70 555.36 555.36 544.25 46716 1,072.54 1,018.91 1,171.75 1,148.31 1,148.31 1,125.34 46730 1,772.10 1,683.50 1,936.03 1,897.30 1,897.30 1,859.35 46735 2,055.26 1,952.50 2,245.38 2,200.47 2,200.47 2,156.46 46740 2,074.84 1,971.10 2,266.77 2,221.43 2,221.43 2,177.01 46742 2,359.35 2,241.38 2,577.59 2,526.03 2,526.03 2,475.51 46744 3,424.11 3,252.90 3,740.84 3,666.02 3,666.02 3,592.69 46746 3,572.49 3,393.87 3,902.95 3,824.89 3,824.89 3,748.39 46748 3,881.44 3,687.37 4,240.48 4,155.66 4,155.66 4,072.55 46750 729.44 692.97 796.92 780.98 780.98 765.36

Page 114: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 114Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

46751 576.13 547.32 629.42 616.83 616.83 604.49 46753 586.13 556.82 640.34 627.53 627.53 614.99 46754 273.67 259.99 298.99 293.01 293.01 287.14 # 46754 217.16 206.30 237.25 232.50 232.50 227.85 46760 1,056.35 1,003.53 1,154.06 1,130.98 1,130.98 1,108.36 46761 895.50 850.73 978.34 958.78 958.78 939.61 46762 895.92 851.12 978.79 959.22 959.22 940.03 46900 223.72 212.53 244.41 239.52 239.52 234.73 # 46900 131.31 124.74 143.45 140.59 140.59 137.78 46910 236.36 224.54 258.22 253.06 253.06 248.00 # 46910 128.33 121.91 140.20 137.39 137.39 134.64 46916 212.22 201.61 231.85 227.22 227.22 222.67 # 46916 136.67 129.84 149.32 146.33 146.33 143.41 46917 407.98 387.58 445.72 436.80 436.80 428.06 # 46917 126.37 120.05 138.06 135.30 135.30 132.60 46922 245.33 233.06 268.02 262.66 262.66 257.40 # 46922 129.50 123.03 141.48 138.66 138.66 135.88 46924 485.24 460.98 530.13 519.52 519.52 509.13 # 46924 176.77 167.93 193.12 189.26 189.26 185.47 46930 189.73 180.24 207.28 203.14 203.14 199.08 # 46930 138.53 131.60 151.34 148.32 148.32 145.35 46940 213.29 202.63 233.02 228.37 228.37 223.80 # 46940 141.48 134.41 154.57 151.48 151.48 148.45 46942 200.93 190.88 219.51 215.12 215.12 210.82 # 46942 126.62 120.29 138.33 135.56 135.56 132.85 46945 284.34 270.12 310.64 304.43 304.43 298.34 # 46945 211.60 201.02 231.17 226.55 226.55 222.02 46946 290.50 275.98 317.38 311.03 311.03 304.81 # 46946 213.07 202.42 232.78 228.13 228.13 223.56 46947 366.90 348.56 400.84 392.83 392.83 384.97 47000 330.76 314.22 361.35 354.13 354.13 347.05 # 47000 101.28 96.22 110.65 108.45 108.45 106.27 47001 101.76 96.67 111.17 108.95 108.95 106.78 47010 1,166.61 1,108.28 1,274.52 1,249.03 1,249.03 1,224.05 47015 1,109.77 1,054.28 1,212.42 1,188.17 1,188.17 1,164.41 47100 814.15 773.44 889.46 871.67 871.67 854.23 47120 2,263.05 2,149.90 2,472.39 2,422.94 2,422.94 2,374.47 47122 3,346.37 3,179.05 3,655.91 3,582.79 3,582.79 3,511.13 47125 2,991.93 2,842.33 3,268.68 3,203.30 3,203.30 3,139.24 47130 3,214.56 3,053.83 3,511.90 3,441.66 3,441.66 3,372.84 47135 5,218.89 4,957.95 5,701.64 5,587.61 5,587.61 5,475.85 47140 3,469.93 3,296.43 3,790.89 3,715.08 3,715.08 3,640.77 47141 4,149.49 3,942.02 4,533.32 4,442.66 4,442.66 4,353.81 47142 4,577.38 4,348.51 5,000.79 4,900.77 4,900.77 4,802.76 47143 341.35 324.28 372.92 365.46 365.46 358.14 47144 341.35 324.28 372.92 365.46 365.46 358.14 47145 341.35 324.28 372.92 365.46 365.46 358.14 47146 322.57 306.44 352.41 345.36 345.36 338.45 47147 375.62 356.84 410.37 402.16 402.16 394.12

Page 115: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 115Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

47300 1,095.42 1,040.65 1,196.75 1,172.82 1,172.82 1,149.36 47350 1,328.79 1,262.35 1,451.70 1,422.67 1,422.67 1,394.21 47360 1,807.64 1,717.26 1,974.85 1,935.35 1,935.35 1,896.64 47361 2,946.26 2,798.95 3,218.79 3,154.42 3,154.42 3,091.33 47362 1,404.71 1,334.47 1,534.64 1,503.95 1,503.95 1,473.86 47370 1,210.98 1,150.43 1,322.99 1,296.53 1,296.53 1,270.60 47371 1,111.27 1,055.71 1,214.07 1,189.79 1,189.79 1,166.00 47380 1,402.85 1,332.71 1,532.62 1,501.97 1,501.97 1,471.93 47381 1,315.09 1,249.34 1,436.74 1,408.00 1,408.00 1,379.84 47382 4,519.44 4,293.47 4,937.49 4,838.74 4,838.74 4,741.97 # 47382 763.83 725.64 834.49 817.80 817.80 801.45 47383 6,733.68 6,397.00 7,356.55 7,209.42 7,209.42 7,065.23 # 47383 481.91 457.81 526.48 515.95 515.95 505.63 47400 2,092.19 1,987.58 2,285.72 2,240.00 2,240.00 2,195.20 47420 1,301.68 1,236.60 1,422.09 1,393.65 1,393.65 1,365.77 47425 1,313.41 1,247.74 1,434.90 1,406.21 1,406.21 1,378.08 47460 1,215.39 1,154.62 1,327.81 1,301.26 1,301.26 1,275.24 47480 843.67 801.49 921.71 903.28 903.28 885.21 47490 320.38 304.36 350.01 343.01 343.01 336.15 47531 338.41 321.49 369.71 362.32 362.32 355.07 # 47531 94.58 89.85 103.33 101.26 101.26 99.23 47532 746.03 708.73 815.04 798.74 798.74 782.77 # 47532 214.02 203.32 233.82 229.14 229.14 224.56 47533 1,212.89 1,152.25 1,325.09 1,298.59 1,298.59 1,272.62 # 47533 302.79 287.65 330.80 324.19 324.19 317.70 47534 1,497.55 1,422.67 1,636.07 1,603.35 1,603.35 1,571.29 # 47534 402.00 381.90 439.19 430.40 430.40 421.79 47535 1,000.62 950.59 1,093.18 1,071.32 1,071.32 1,049.89 # 47535 230.71 219.17 252.05 247.01 247.01 242.06 47536 736.82 699.98 804.98 788.88 788.88 773.10 # 47536 146.11 138.80 159.62 156.42 156.42 153.30 47537 365.83 347.54 399.67 391.68 391.68 383.85 # 47537 97.95 93.05 107.01 104.87 104.87 102.78 47538 4,025.92 3,824.62 4,398.31 4,310.35 4,310.35 4,224.15 # 47538 326.81 310.47 357.04 349.90 349.90 342.90 47539 4,407.25 4,186.89 4,814.92 4,718.62 4,718.62 4,624.25 # 47539 442.14 420.03 483.03 473.37 473.37 463.91 47540 4,588.13 4,358.72 5,012.53 4,912.28 4,912.28 4,814.04 # 47540 527.80 501.41 576.62 565.09 565.09 553.78 47541 1,072.52 1,018.89 1,171.72 1,148.29 1,148.29 1,125.32 # 47541 280.44 266.42 306.38 300.25 300.25 294.25 47542 468.78 445.34 512.14 501.89 501.89 491.86 # 47542 130.97 124.42 143.08 140.22 140.22 137.41 47543 1,189.10 1,129.65 1,299.10 1,273.12 1,273.12 1,247.66 # 47543 164.42 156.20 179.63 176.04 176.04 172.52 47544 742.79 705.65 811.50 795.27 795.27 779.37 # 47544 213.28 202.62 233.01 228.36 228.36 223.79 47550 162.34 154.22 177.35 173.81 173.81 170.34 47552 308.33 292.91 336.85 330.11 330.11 323.51

Page 116: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 116Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

47553 306.01 290.71 334.32 327.64 327.64 321.08 47554 470.99 447.44 514.56 504.26 504.26 494.18 47555 366.23 347.92 400.11 392.10 392.10 384.26 47556 416.46 395.64 454.99 445.89 445.89 436.98 47562 636.23 604.42 695.08 681.18 681.18 667.55 47563 691.63 657.05 755.61 740.50 740.50 725.68 47564 1,078.49 1,024.57 1,178.26 1,154.69 1,154.69 1,131.60 47570 742.23 705.12 810.89 794.67 794.67 778.78 47600 1,035.02 983.27 1,130.76 1,108.14 1,108.14 1,085.98 47605 1,090.09 1,035.59 1,190.93 1,167.11 1,167.11 1,143.77 47610 1,218.32 1,157.40 1,331.01 1,304.39 1,304.39 1,278.31 47612 1,233.79 1,172.10 1,347.92 1,320.96 1,320.96 1,294.54 47620 1,336.81 1,269.97 1,460.47 1,431.26 1,431.26 1,402.63 47700 1,005.33 955.06 1,098.32 1,076.35 1,076.35 1,054.83 47701 1,651.69 1,569.11 1,804.48 1,768.39 1,768.39 1,733.03 47711 1,509.85 1,434.36 1,649.51 1,616.52 1,616.52 1,584.19 47712 1,934.31 1,837.59 2,113.23 2,070.97 2,070.97 2,029.54 47715 1,290.37 1,225.85 1,409.73 1,381.53 1,381.53 1,353.90 47720 1,113.47 1,057.80 1,216.47 1,192.14 1,192.14 1,168.30 47721 1,314.25 1,248.54 1,435.82 1,407.11 1,407.11 1,378.97 47740 1,262.39 1,199.27 1,379.16 1,351.57 1,351.57 1,324.54 47741 1,425.55 1,354.27 1,557.41 1,526.26 1,526.26 1,495.74 47760 2,196.50 2,086.68 2,399.68 2,351.69 2,351.69 2,304.66 47765 2,953.70 2,806.02 3,226.92 3,162.39 3,162.39 3,099.14 47780 2,405.49 2,285.22 2,628.00 2,575.45 2,575.45 2,523.94 47785 3,163.10 3,004.95 3,455.69 3,386.58 3,386.58 3,318.84 47800 1,528.95 1,452.50 1,670.38 1,636.97 1,636.97 1,604.23 47801 976.65 927.82 1,066.99 1,045.65 1,045.65 1,024.73 47802 1,466.14 1,392.83 1,601.75 1,569.72 1,569.72 1,538.32 47900 1,328.29 1,261.88 1,451.16 1,422.14 1,422.14 1,393.70 48000 1,820.43 1,729.41 1,988.82 1,949.04 1,949.04 1,910.06 48001 2,230.00 2,118.50 2,436.28 2,387.55 2,387.55 2,339.80 48020 1,135.64 1,078.86 1,240.69 1,215.87 1,215.87 1,191.55 48100 859.45 816.48 938.95 920.17 920.17 901.77 48102 495.57 470.79 541.41 530.58 530.58 519.96 # 48102 239.87 227.88 262.06 256.82 256.82 251.68 48105 2,777.14 2,638.28 3,034.02 2,973.34 2,973.34 2,913.87 48120 1,075.58 1,021.80 1,175.07 1,151.56 1,151.56 1,128.53 48140 1,518.97 1,443.02 1,659.47 1,626.28 1,626.28 1,593.76 48145 1,580.55 1,501.52 1,726.75 1,692.21 1,692.21 1,658.37 48146 1,820.06 1,729.06 1,988.42 1,948.65 1,948.65 1,909.68 48148 1,208.16 1,147.75 1,319.91 1,293.52 1,293.52 1,267.65 48150 3,027.35 2,875.98 3,307.38 3,241.23 3,241.23 3,176.40 48152 2,792.43 2,652.81 3,050.73 2,989.71 2,989.71 2,929.92 48153 3,012.18 2,861.57 3,290.81 3,224.99 3,224.99 3,160.49 48154 2,823.42 2,682.25 3,084.59 3,022.90 3,022.90 2,962.45 48155 1,762.44 1,674.32 1,925.47 1,886.95 1,886.95 1,849.21 48400 103.78 98.59 113.38 111.11 111.11 108.89 48500 1,092.26 1,037.65 1,193.30 1,169.44 1,169.44 1,146.04

Page 117: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 117Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

48510 1,053.02 1,000.37 1,150.43 1,127.41 1,127.41 1,104.86 48520 1,061.41 1,008.34 1,159.59 1,136.40 1,136.40 1,113.67 48540 1,263.20 1,200.04 1,380.05 1,352.45 1,352.45 1,325.40 48545 1,294.84 1,230.10 1,414.62 1,386.33 1,386.33 1,358.60 48547 1,740.70 1,653.67 1,901.72 1,863.69 1,863.69 1,826.42 48548 1,617.14 1,536.28 1,766.72 1,731.38 1,731.38 1,696.76 48551 370.50 351.98 404.78 396.68 396.68 388.75 48552 229.62 218.14 250.86 245.85 245.85 240.93 48554 2,460.33 2,337.31 2,687.91 2,634.14 2,634.14 2,581.46 48556 1,224.53 1,163.30 1,337.80 1,311.03 1,311.03 1,284.81 49000 747.10 709.75 816.21 799.89 799.89 783.90 49002 1,016.63 965.80 1,110.67 1,088.45 1,088.45 1,066.68 49010 909.11 863.65 993.20 973.34 973.34 953.87 49020 1,546.07 1,468.77 1,689.09 1,655.30 1,655.30 1,622.19 49040 970.17 921.66 1,059.91 1,038.71 1,038.71 1,017.95 49060 1,069.27 1,015.81 1,168.18 1,144.81 1,144.81 1,121.92 49062 713.68 678.00 779.70 764.11 764.11 748.82 49082 175.71 166.92 191.96 188.12 188.12 184.36 # 49082 72.37 68.75 79.06 77.49 77.49 75.93 49083 269.68 256.20 294.63 288.74 288.74 282.97 # 49083 107.02 101.67 116.92 114.59 114.59 112.30 49084 106.33 101.01 116.16 113.84 113.84 111.56 49180 153.01 145.36 167.16 163.82 163.82 160.54 # 49180 84.94 80.69 92.79 90.94 90.94 89.13 49185 892.74 848.10 975.32 955.81 955.81 936.70 # 49185 121.57 115.49 132.81 130.16 130.16 127.56 49203 1,163.30 1,105.14 1,270.91 1,245.50 1,245.50 1,220.59 49204 1,489.70 1,415.22 1,627.50 1,594.96 1,594.96 1,563.06 49205 1,710.57 1,625.04 1,868.80 1,831.42 1,831.42 1,794.79 49215 2,158.74 2,050.80 2,358.42 2,311.25 2,311.25 2,265.02 49220 870.70 827.17 951.25 932.22 932.22 913.58 49250 566.06 537.76 618.42 606.05 606.05 593.93 49255 764.95 726.70 835.71 819.00 819.00 802.62 49320 314.45 298.73 343.54 336.67 336.67 329.94 49321 333.61 316.93 364.47 357.18 357.18 350.04 49322 356.26 338.45 389.22 381.43 381.43 373.81 49323 616.33 585.51 673.34 659.87 659.87 646.67 49324 378.11 359.20 413.08 404.82 404.82 396.73 49325 403.48 383.31 440.81 431.99 431.99 423.35 49326 185.78 176.49 202.96 198.90 198.90 194.93 49327 128.26 121.85 140.13 137.32 137.32 134.57 49400 129.46 122.99 141.44 138.61 138.61 135.84 # 49400 92.93 88.28 101.52 99.49 99.49 97.50 49402 830.50 788.98 907.33 889.18 889.18 871.40 49405 796.18 756.37 869.83 852.43 852.43 835.38 # 49405 210.16 199.65 229.60 225.01 225.01 220.51 49406 796.49 756.67 870.17 852.77 852.77 835.72 # 49406 210.16 199.65 229.60 225.01 225.01 220.51 49407 668.73 635.29 730.58 715.97 715.97 701.65

Page 118: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 118Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 49407 225.08 213.83 245.90 240.98 240.98 236.16 49411 503.62 478.44 550.21 539.20 539.20 528.41 # 49411 195.47 185.70 213.56 209.29 209.29 205.10 49412 81.10 77.05 88.61 86.84 86.84 85.10 49418 1,295.03 1,230.28 1,414.82 1,386.52 1,386.52 1,358.79 # 49418 216.02 205.22 236.00 231.29 231.29 226.67 49419 430.35 408.83 470.15 460.75 460.75 451.54 49421 225.83 214.54 246.72 241.79 241.79 236.96 49422 369.28 350.82 403.44 395.37 395.37 387.46 49423 494.63 469.90 540.39 529.58 529.58 518.98 # 49423 71.59 68.01 78.21 76.65 76.65 75.12 49424 133.48 126.81 145.83 142.91 142.91 140.05 # 49424 37.95 36.05 41.46 40.63 40.63 39.81 49425 711.71 676.12 777.54 761.99 761.99 746.75 49426 595.12 565.36 650.16 637.16 637.16 624.42 49427 45.58 43.30 49.80 48.79 48.79 47.82 49428 417.49 396.62 456.11 446.99 446.99 438.06 49429 444.04 421.84 485.12 475.41 475.41 465.90 49435 118.10 112.20 129.03 126.45 126.45 123.92 49436 179.61 170.63 196.22 192.30 192.30 188.46 49440 942.83 895.69 1,030.04 1,009.45 1,009.45 989.25 # 49440 218.81 207.87 239.05 234.27 234.27 229.59 49441 1,063.00 1,009.85 1,161.33 1,138.10 1,138.10 1,115.34 # 49441 252.81 240.17 276.20 270.68 270.68 265.26 49442 877.49 833.62 958.66 939.49 939.49 920.70 # 49442 218.09 207.19 238.27 233.51 233.51 228.84 49446 904.15 858.94 987.78 968.02 968.02 948.66 # 49446 161.71 153.62 176.66 173.13 173.13 169.67 49450 599.70 569.72 655.18 642.08 642.08 629.23 # 49450 66.76 63.42 72.93 71.47 71.47 70.05 49451 655.78 622.99 716.44 702.11 702.11 688.07 # 49451 90.36 85.84 98.72 96.74 96.74 94.81 49452 813.25 772.59 888.48 870.71 870.71 853.30 # 49452 139.18 132.22 152.05 149.02 149.02 146.04 49460 657.27 624.41 718.07 703.71 703.71 689.63 # 49460 47.83 45.44 52.26 51.21 51.21 50.19 49465 147.57 140.19 161.22 158.00 158.00 154.84 # 49465 30.80 29.26 33.65 32.97 32.97 32.32 49491 767.42 729.05 838.41 821.64 821.64 805.21 49492 926.74 880.40 1,012.46 992.21 992.21 972.36 49495 369.84 351.35 404.05 395.97 395.97 388.04 49496 592.57 562.94 647.38 634.43 634.43 621.75 49500 349.17 331.71 381.47 373.84 373.84 366.37 49501 564.33 536.11 616.53 604.20 604.20 592.11 49505 501.80 476.71 548.22 537.26 537.26 526.52 49507 564.62 536.39 616.85 604.51 604.51 592.42 49520 610.60 580.07 667.08 653.74 653.74 640.67 49521 692.64 658.01 756.71 741.58 741.58 726.74 49525 552.79 525.15 603.92 591.85 591.85 580.01

Page 119: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 119Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

49540 649.01 616.56 709.04 694.86 694.86 680.97 49550 555.19 527.43 606.54 594.41 594.41 582.52 49553 609.40 578.93 665.77 652.45 652.45 639.40 49555 577.33 548.46 630.73 618.11 618.11 605.75 49557 700.02 665.02 764.77 749.48 749.48 734.49 49560 713.85 678.16 779.88 764.29 764.29 749.01 49561 901.92 856.82 985.34 965.63 965.63 946.32 49565 743.14 705.98 811.88 795.64 795.64 779.72 49566 910.36 864.84 994.57 974.67 974.67 955.18 49568 261.81 248.72 286.03 280.31 280.31 274.71 49570 399.72 379.73 436.69 427.96 427.96 419.41 49572 497.07 472.22 543.05 532.20 532.20 521.55 49580 317.52 301.64 346.89 339.95 339.95 333.16 49582 464.35 441.13 507.30 497.16 497.16 487.21 49585 427.43 406.06 466.97 457.63 457.63 448.48 49587 457.42 434.55 499.73 489.74 489.74 479.94 49590 552.36 524.74 603.45 591.39 591.39 579.57 49600 681.43 647.36 744.46 729.57 729.57 714.98 49605 4,825.21 4,583.95 5,271.54 5,166.11 5,166.11 5,062.78 49606 1,086.39 1,032.07 1,186.88 1,163.14 1,163.14 1,139.88 49610 665.53 632.25 727.09 712.55 712.55 698.30 49611 584.45 555.23 638.51 625.75 625.75 613.24 49650 411.84 391.25 449.94 440.94 440.94 432.12 49651 535.61 508.83 585.15 573.45 573.45 561.98 49652 720.01 684.01 786.61 770.88 770.88 755.46 49653 898.28 853.37 981.38 961.75 961.75 942.51 49654 819.02 778.07 894.78 876.89 876.89 859.35 49655 1,000.35 950.33 1,092.88 1,071.02 1,071.02 1,049.59 49656 890.41 845.89 972.77 953.32 953.32 934.25 49657 1,281.52 1,217.44 1,400.06 1,372.05 1,372.05 1,344.61 49900 785.01 745.76 857.62 840.47 840.47 823.65 49904 1,377.64 1,308.76 1,505.07 1,474.97 1,474.97 1,445.47 49905 346.47 329.15 378.52 370.96 370.96 363.54 50010 715.22 679.46 781.38 765.75 765.75 750.43 50020 990.29 940.78 1,081.90 1,060.25 1,060.25 1,039.05 50040 902.43 857.31 985.91 966.18 966.18 946.86 50045 934.73 887.99 1,021.19 1,000.76 1,000.76 980.75 50060 1,115.64 1,059.86 1,218.84 1,194.46 1,194.46 1,170.57 50065 1,180.40 1,121.38 1,289.59 1,263.79 1,263.79 1,238.52 50070 1,157.46 1,099.59 1,264.53 1,239.24 1,239.24 1,214.46 50075 1,424.03 1,352.83 1,555.75 1,524.64 1,524.64 1,494.14 50080 847.82 805.43 926.24 907.72 907.72 889.56 50081 1,246.30 1,183.99 1,361.59 1,334.36 1,334.36 1,307.67 50100 1,025.07 973.82 1,119.89 1,097.49 1,097.49 1,075.54 50120 925.61 879.33 1,011.23 991.00 991.00 971.19 50125 1,001.28 951.22 1,093.90 1,072.03 1,072.03 1,050.59 50130 1,007.14 956.78 1,100.30 1,078.29 1,078.29 1,056.72 50135 1,109.27 1,053.81 1,211.88 1,187.64 1,187.64 1,163.89 50200 557.40 529.53 608.96 596.78 596.78 584.84

Page 120: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 120Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 50200 139.66 132.68 152.58 149.53 149.53 146.54 50205 729.45 692.98 796.93 780.99 780.99 765.37 50220 1,019.20 968.24 1,113.48 1,091.21 1,091.21 1,069.39 50225 1,173.75 1,115.06 1,282.32 1,256.67 1,256.67 1,231.54 50230 1,252.16 1,189.55 1,367.98 1,340.62 1,340.62 1,313.81 50234 1,270.21 1,206.70 1,387.71 1,359.96 1,359.96 1,332.76 50236 1,432.49 1,360.87 1,565.00 1,533.70 1,533.70 1,503.03 50240 1,291.91 1,227.31 1,411.41 1,383.17 1,383.17 1,355.51 50250 1,187.17 1,127.81 1,296.98 1,271.04 1,271.04 1,245.62 50280 929.02 882.57 1,014.96 994.66 994.66 974.76 50290 875.19 831.43 956.14 937.02 937.02 918.28 50320 1,398.17 1,328.26 1,527.50 1,496.94 1,496.94 1,467.01 50323 163.36 155.19 178.47 174.90 174.90 171.41 50325 163.36 155.19 178.47 174.90 174.90 171.41 50327 212.55 201.92 232.21 227.56 227.56 223.01 50328 186.52 177.19 203.77 199.70 199.70 195.71 50329 174.87 166.13 191.05 187.23 187.23 183.48 50340 900.91 855.86 984.24 964.55 964.55 945.27 50360 2,346.05 2,228.75 2,563.06 2,511.81 2,511.81 2,461.58 50365 2,742.13 2,605.02 2,995.77 2,935.86 2,935.86 2,877.14 50370 1,158.87 1,100.93 1,266.07 1,240.75 1,240.75 1,215.93 50380 1,913.35 1,817.68 2,090.33 2,048.53 2,048.53 2,007.56 50382 1,079.42 1,025.45 1,179.27 1,155.68 1,155.68 1,132.57 # 50382 268.60 255.17 293.45 287.58 287.58 281.83 50384 863.69 820.51 943.59 924.72 924.72 906.22 # 50384 243.94 231.74 266.50 261.18 261.18 255.96 50385 1,034.11 982.40 1,129.76 1,107.16 1,107.16 1,085.03 # 50385 228.60 217.17 249.75 244.75 244.75 239.86 50386 675.71 641.92 738.21 723.44 723.44 708.98 # 50386 173.36 164.69 189.39 185.61 185.61 181.90 50387 492.94 468.29 538.53 527.76 527.76 517.20 # 50387 96.74 91.90 105.69 103.57 103.57 101.50 50389 268.59 255.16 293.43 287.57 287.57 281.82 # 50389 53.78 51.09 58.75 57.58 57.58 56.43 50390 95.93 91.13 104.80 102.71 102.71 100.65 50391 117.08 111.23 127.91 125.36 125.36 122.85 # 50391 96.48 91.66 105.41 103.30 103.30 101.23 50395 175.98 167.18 192.26 188.42 188.42 184.64 50396 115.55 109.77 126.24 123.71 123.71 121.23 50400 1,130.97 1,074.42 1,235.58 1,210.87 1,210.87 1,186.65 50405 1,364.94 1,296.69 1,491.19 1,461.37 1,461.37 1,432.14 50430 476.36 452.54 520.42 510.01 510.01 499.81 # 50430 164.78 156.54 180.02 176.42 176.42 172.89 50431 148.70 141.27 162.46 159.21 159.21 156.02 # 50431 64.71 61.47 70.69 69.28 69.28 67.90 50432 768.71 730.27 839.81 823.01 823.01 806.55 # 50432 218.27 207.36 238.46 233.69 233.69 229.02 50433 1,032.69 981.06 1,128.22 1,105.66 1,105.66 1,083.54 # 50433 269.33 255.86 294.24 288.35 288.35 282.59

Page 121: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 121Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

50434 816.29 775.48 891.80 873.97 873.97 856.49 # 50434 206.23 195.92 225.31 220.80 220.80 216.38 50435 427.20 405.84 466.72 457.38 457.38 448.24 # 50435 99.69 94.71 108.92 106.74 106.74 104.60 50500 1,235.16 1,173.40 1,349.41 1,322.42 1,322.42 1,295.97 50520 1,093.56 1,038.88 1,194.71 1,170.82 1,170.82 1,147.40 50525 1,385.50 1,316.23 1,513.66 1,483.40 1,483.40 1,453.73 50526 1,445.05 1,372.80 1,578.72 1,547.14 1,547.14 1,516.19 50540 1,123.40 1,067.23 1,227.31 1,202.77 1,202.77 1,178.72 50541 897.47 852.60 980.49 960.88 960.88 941.67 50542 1,138.72 1,081.78 1,244.05 1,219.16 1,219.16 1,194.78 50543 1,452.21 1,379.60 1,586.54 1,554.81 1,554.81 1,523.72 50544 1,217.69 1,156.81 1,330.33 1,303.72 1,303.72 1,277.65 50545 1,310.29 1,244.78 1,431.50 1,402.86 1,402.86 1,374.80 50546 1,173.47 1,114.80 1,282.02 1,256.38 1,256.38 1,231.25 50547 1,559.14 1,481.18 1,703.36 1,669.29 1,669.29 1,635.91 50548 1,318.45 1,252.53 1,440.41 1,411.60 1,411.60 1,383.37 50551 345.49 328.22 377.45 369.91 369.91 362.51 # 50551 288.98 274.53 315.71 309.40 309.40 303.21 50553 367.20 348.84 401.17 393.14 393.14 385.27 # 50553 305.70 290.42 333.98 327.30 327.30 320.76 50555 395.06 375.31 431.61 422.97 422.97 414.51 # 50555 333.87 317.18 364.76 357.47 357.47 350.31 50557 403.22 383.06 440.52 431.71 431.71 423.07 # 50557 339.84 322.85 371.28 363.85 363.85 356.57 50561 457.94 435.04 500.30 490.29 490.29 480.48 # 50561 388.01 368.61 423.90 415.43 415.43 407.12 50562 568.95 540.50 621.58 609.14 609.14 596.97 50570 483.16 459.00 527.85 517.29 517.29 506.94 50572 522.79 496.65 571.15 559.73 559.73 548.54 50574 555.96 528.16 607.38 595.24 595.24 583.34 50575 702.55 667.42 767.53 752.18 752.18 737.14 50576 555.42 527.65 606.80 594.67 594.67 582.77 50580 598.50 568.58 653.87 640.79 640.79 627.98 50590 682.74 648.60 745.89 730.97 730.97 716.36 # 50590 551.30 523.74 602.30 590.26 590.26 578.45 50592 2,287.72 2,173.33 2,499.33 2,449.34 2,449.34 2,400.35 # 50592 356.06 338.26 389.00 381.21 381.21 373.59 50593 4,156.12 3,948.31 4,540.56 4,449.74 4,449.74 4,360.74 # 50593 472.62 448.99 516.34 506.01 506.01 495.89 50600 919.88 873.89 1,004.97 984.87 984.87 965.17 50605 954.87 907.13 1,043.20 1,022.34 1,022.34 1,001.89 50606 482.46 458.34 527.09 516.55 516.55 506.22 # 50606 155.89 148.10 170.32 166.91 166.91 163.58 50610 950.77 903.23 1,038.71 1,017.95 1,017.95 997.59 50620 884.60 840.37 966.43 947.09 947.09 928.15 50630 869.11 825.65 949.50 930.51 930.51 911.90 50650 1,010.04 959.54 1,103.47 1,081.40 1,081.40 1,059.77 50660 1,121.31 1,065.24 1,225.03 1,200.53 1,200.53 1,176.52

Page 122: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 122Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

50684 97.55 92.67 106.57 104.44 104.44 102.35 # 50684 48.53 46.10 53.02 51.96 51.96 50.92 50686 133.83 127.14 146.21 143.29 143.29 140.43 # 50686 85.75 81.46 93.68 91.80 91.80 89.96 50688 77.01 73.16 84.13 82.46 82.46 80.81 50690 92.74 88.10 101.32 99.29 99.29 97.30 # 50690 68.39 64.97 74.72 73.22 73.22 71.76 50693 958.04 910.14 1,046.66 1,025.73 1,025.73 1,005.22 # 50693 215.91 205.11 235.88 231.16 231.16 226.54 50694 1,058.84 1,005.90 1,156.79 1,133.65 1,133.65 1,110.97 # 50694 279.25 265.29 305.08 298.98 298.98 293.00 50695 1,292.57 1,227.94 1,412.13 1,383.89 1,383.89 1,356.21 # 50695 354.68 336.95 387.49 379.74 379.74 372.15 50700 907.11 861.75 991.01 971.20 971.20 951.77 50705 1,530.16 1,453.65 1,671.70 1,638.27 1,638.27 1,605.50 # 50705 199.51 189.53 217.96 213.60 213.60 209.33 50706 695.17 660.41 759.47 744.28 744.28 729.40 # 50706 185.95 176.65 203.15 199.09 199.09 195.11 50715 1,181.38 1,122.31 1,290.66 1,264.84 1,264.84 1,239.54 50722 993.05 943.40 1,084.91 1,063.21 1,063.21 1,041.95 50725 1,098.75 1,043.81 1,200.38 1,176.37 1,176.37 1,152.84 50727 490.06 465.56 535.39 524.69 524.69 514.20 50728 680.81 646.77 743.79 728.90 728.90 714.32 50740 1,185.92 1,126.62 1,295.61 1,269.70 1,269.70 1,244.31 50750 1,126.04 1,069.74 1,230.20 1,205.60 1,205.60 1,181.49 50760 1,099.71 1,044.72 1,201.43 1,177.40 1,177.40 1,153.85 50770 1,124.15 1,067.94 1,228.13 1,203.57 1,203.57 1,179.50 50780 1,079.83 1,025.84 1,179.72 1,156.12 1,156.12 1,132.99 50782 1,025.66 974.38 1,120.54 1,098.12 1,098.12 1,076.16 50783 1,104.94 1,049.69 1,207.14 1,183.01 1,183.01 1,159.35 50785 1,184.23 1,125.02 1,293.77 1,267.90 1,267.90 1,242.54 50800 899.38 854.41 982.57 962.92 962.92 943.66 50810 1,228.08 1,166.68 1,341.68 1,314.85 1,314.85 1,288.55 50815 1,194.32 1,134.60 1,304.79 1,278.70 1,278.70 1,253.12 50820 1,283.14 1,218.98 1,401.83 1,373.79 1,373.79 1,346.32 50825 1,618.95 1,538.00 1,768.70 1,733.33 1,733.33 1,698.67 50830 1,770.79 1,682.25 1,934.59 1,895.90 1,895.90 1,857.99 50840 1,201.41 1,141.34 1,312.54 1,286.29 1,286.29 1,260.56 50845 1,218.05 1,157.15 1,330.72 1,304.11 1,304.11 1,278.03 50860 921.32 875.25 1,006.54 986.41 986.41 966.69 50900 836.18 794.37 913.53 895.25 895.25 877.35 50920 860.25 817.24 939.83 921.04 921.04 902.61 50930 1,141.30 1,084.24 1,246.88 1,221.94 1,221.94 1,197.51 50940 864.12 820.91 944.05 925.16 925.16 906.66 50945 949.87 902.38 1,037.74 1,016.98 1,016.98 996.64 50947 1,358.13 1,290.22 1,483.75 1,454.08 1,454.08 1,425.00 50948 1,248.17 1,185.76 1,363.62 1,336.35 1,336.35 1,309.62 50951 360.56 342.53 393.91 386.03 386.03 378.32 # 50951 300.92 285.87 328.75 322.17 322.17 315.73

Page 123: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 123Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

50953 381.04 361.99 416.29 407.96 407.96 399.81 # 50953 319.22 303.26 348.75 341.77 341.77 334.94 50955 408.79 388.35 446.60 437.67 437.67 428.92 # 50955 346.03 328.73 378.04 370.48 370.48 363.08 50957 412.40 391.78 450.55 441.53 441.53 432.70 # 50957 348.09 330.69 380.29 372.69 372.69 365.24 50961 371.45 352.88 405.81 397.69 397.69 389.74 # 50961 311.51 295.93 340.32 333.51 333.51 326.84 50970 365.50 347.23 399.31 391.33 391.33 383.50 50972 355.11 337.35 387.95 380.19 380.19 372.59 50974 465.03 441.78 508.05 497.88 497.88 487.92 50976 457.67 434.79 500.01 490.00 490.00 480.21 50980 348.05 330.65 380.25 372.65 372.65 365.19 51020 453.71 431.02 495.67 485.76 485.76 476.04 51030 460.33 437.31 502.91 492.84 492.84 482.99 51040 278.31 264.39 304.05 297.97 297.97 292.01 51045 473.41 449.74 517.20 506.86 506.86 496.73 51050 457.43 434.56 499.74 489.75 489.75 479.95 51060 565.87 537.58 618.22 605.85 605.85 593.73 51065 561.13 533.07 613.03 600.77 600.77 588.75 51080 396.08 376.28 432.72 424.06 424.06 415.59 51100 57.65 54.77 62.99 61.72 61.72 60.49 # 51100 38.61 36.68 42.18 41.34 41.34 40.51 51101 114.56 108.83 125.15 122.65 122.65 120.20 # 51101 51.18 48.62 55.91 54.80 54.80 53.71 51102 213.26 202.60 232.99 228.33 228.33 223.77 # 51102 141.77 134.68 154.88 151.79 151.79 148.75 51500 619.68 588.70 677.01 663.47 663.47 650.20 51520 580.07 551.07 633.73 621.06 621.06 608.64 51525 836.96 795.11 914.38 896.09 896.09 878.17 51530 772.34 733.72 843.78 826.91 826.91 810.37 51535 758.79 720.85 828.98 812.39 812.39 796.15 51550 938.84 891.90 1,025.69 1,005.17 1,005.17 985.07 51555 1,237.59 1,175.71 1,352.07 1,325.03 1,325.03 1,298.53 51565 1,268.21 1,204.80 1,385.52 1,357.81 1,357.81 1,330.65 51570 1,444.53 1,372.30 1,578.15 1,546.58 1,546.58 1,515.64 51575 1,783.22 1,694.06 1,948.17 1,909.21 1,909.21 1,871.03 51580 1,853.11 1,760.45 2,024.52 1,984.03 1,984.03 1,944.35 51585 2,062.95 1,959.80 2,253.77 2,208.69 2,208.69 2,164.52 51590 1,892.39 1,797.77 2,067.44 2,026.08 2,026.08 1,985.56 51595 2,142.24 2,035.13 2,340.40 2,293.59 2,293.59 2,247.72 51596 2,301.26 2,186.20 2,514.13 2,463.85 2,463.85 2,414.57 51597 2,246.33 2,134.01 2,454.11 2,405.03 2,405.03 2,356.93 51600 166.45 158.13 181.85 178.22 178.22 174.65 # 51600 43.75 41.56 47.79 46.84 46.84 45.91 51605 37.08 35.23 40.51 39.71 39.71 38.92 51610 99.14 94.18 108.31 106.15 106.15 104.02 # 51610 62.30 59.19 68.07 66.71 66.71 65.38 51700 77.44 73.57 84.61 82.92 82.92 81.26

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 124Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 51700 44.03 41.83 48.10 47.14 47.14 46.20 51701 50.52 47.99 55.19 54.08 54.08 53.00 # 51701 27.10 25.75 29.61 29.03 29.03 28.45 51702 64.26 61.05 70.21 68.80 68.80 67.42 # 51702 29.29 27.83 32.00 31.36 31.36 30.73 51703 121.19 115.13 132.40 129.75 129.75 127.16 # 51703 79.35 75.38 86.69 84.95 84.95 83.25 51705 84.40 80.18 92.21 90.37 90.37 88.56 # 51705 50.37 47.85 55.03 53.92 53.92 52.84 51710 119.73 113.74 130.80 128.19 128.19 125.63 # 51710 77.58 73.70 84.76 83.06 83.06 81.41 51715 274.14 260.43 299.49 293.50 293.50 287.64 # 51715 195.46 185.69 213.54 209.28 209.28 205.09 51720 103.22 98.06 112.77 110.52 110.52 108.31 # 51720 78.24 74.33 85.48 83.77 83.77 82.09 51725 172.01 163.41 187.92 184.16 184.16 180.48 51725 TC 97.07 92.22 106.05 103.94 103.94 101.86 51725 26 74.94 71.19 81.87 80.24 80.24 78.63 51726 239.68 227.70 261.86 256.62 256.62 251.49 51726 TC 155.74 147.95 170.14 166.74 166.74 163.40 51726 26 83.94 79.74 91.70 89.87 89.87 88.08 51727 284.18 269.97 310.47 304.26 304.26 298.17 51727 TC 179.16 170.20 195.73 191.82 191.82 187.98 51727 26 105.02 99.77 114.74 112.44 112.44 110.18 51728 286.70 272.37 313.23 306.96 306.96 300.82 51728 TC 183.84 174.65 200.85 196.83 196.83 192.90 51728 26 102.87 97.73 112.39 110.15 110.15 107.94 51729 310.91 295.36 339.66 332.87 332.87 326.21 51729 TC 186.65 177.32 203.92 199.84 199.84 195.83 51729 26 124.26 118.05 135.76 133.04 133.04 130.39 51736 14.46 13.74 15.80 15.49 15.49 15.18 51736 TC 6.22 5.91 6.80 6.66 6.66 6.52 51736 26 8.24 7.83 9.00 8.82 8.82 8.65 51741 14.77 14.03 16.13 15.81 15.81 15.50 51741 TC 6.53 6.20 7.13 6.99 6.99 6.85 51741 26 8.24 7.83 9.00 8.82 8.82 8.65 51784 176.44 167.62 192.76 188.91 188.91 185.13 51784 TC 101.10 96.05 110.46 108.25 108.25 106.09 51784 26 75.34 71.57 82.31 80.66 80.66 79.05 51785 239.47 227.50 261.63 256.39 256.39 251.26 51785 TC 154.49 146.77 168.79 165.40 165.40 162.09 51785 26 84.98 80.73 92.84 90.99 90.99 89.17 51792 191.41 181.84 209.12 204.93 204.93 200.84 51792 TC 137.01 130.16 149.68 146.69 146.69 143.76 51792 26 54.41 51.69 59.44 58.26 58.26 57.10 51797 102.13 97.02 111.57 109.34 109.34 107.16 51797 TC 62.75 59.61 68.55 67.18 67.18 65.84 51797 26 39.38 37.41 43.02 42.16 42.16 41.32 51798 16.80 15.96 18.35 17.99 17.99 17.63

Page 125: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 125Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

51800 1,015.10 964.35 1,109.00 1,086.82 1,086.82 1,065.08 51820 1,079.78 1,025.79 1,179.66 1,156.06 1,156.06 1,132.93 51840 636.89 605.05 695.81 681.89 681.89 668.25 51841 756.82 718.98 826.83 810.29 810.29 794.09 51845 569.00 540.55 621.63 609.20 609.20 597.02 51860 722.29 686.18 789.11 773.33 773.33 757.86 51865 870.37 826.85 950.88 931.86 931.86 913.22 51880 453.81 431.12 495.79 485.88 485.88 476.16 51900 812.05 771.45 887.17 869.42 869.42 852.04 51920 831.10 789.55 907.98 889.82 889.82 872.02 51925 1,049.23 996.77 1,146.29 1,123.35 1,123.35 1,100.88 51940 1,613.85 1,533.16 1,763.13 1,727.88 1,727.88 1,693.32 51960 1,358.50 1,290.58 1,484.17 1,454.49 1,454.49 1,425.39 51980 693.19 658.53 757.31 742.16 742.16 727.32 51990 729.23 692.77 796.69 780.75 780.75 765.13 51992 817.26 776.40 892.86 875.00 875.00 857.50 52000 190.61 181.08 208.24 204.08 204.08 200.00 # 52000 122.86 116.72 134.23 131.55 131.55 128.92 52001 353.88 336.19 386.62 378.89 378.89 371.31 # 52001 281.76 267.67 307.82 301.67 301.67 295.63 52005 245.21 232.95 267.89 262.53 262.53 257.28 # 52005 129.69 123.21 141.69 138.86 138.86 136.09 52007 404.42 384.20 441.83 433.00 433.00 424.34 # 52007 161.83 153.74 176.80 173.27 173.27 169.81 52010 341.89 324.80 373.52 366.05 366.05 358.72 # 52010 163.00 154.85 178.08 174.51 174.51 171.03 52204 336.71 319.87 367.85 360.49 360.49 353.28 # 52204 138.45 131.53 151.26 148.24 148.24 145.27 52214 596.93 567.08 652.14 639.10 639.10 626.32 # 52214 173.57 164.89 189.62 185.83 185.83 182.11 52224 626.45 595.13 684.40 670.71 670.71 657.31 # 52224 200.59 190.56 219.14 214.76 214.76 210.47 52234 241.10 229.05 263.41 258.14 258.14 252.98 52235 283.01 268.86 309.19 303.00 303.00 296.94 52240 384.86 365.62 420.46 412.06 412.06 403.81 52250 234.91 223.16 256.63 251.51 251.51 246.48 52260 205.91 195.61 224.95 220.46 220.46 216.05 52265 335.99 319.19 367.07 359.73 359.73 352.53 # 52265 158.96 151.01 173.66 170.19 170.19 166.78 52270 328.78 312.34 359.19 352.00 352.00 344.97 # 52270 177.67 168.79 194.11 190.22 190.22 186.42 52275 444.05 421.85 485.13 475.42 475.42 465.91 # 52275 243.61 231.43 266.14 260.82 260.82 255.60 52276 259.54 246.56 283.54 277.87 277.87 272.32 52277 317.31 301.44 346.66 339.72 339.72 332.93 52281 252.78 240.14 276.16 270.64 270.64 265.22 # 52281 148.50 141.08 162.24 159.00 159.00 155.81 52282 330.12 313.61 360.65 353.44 353.44 346.37 52283 261.65 248.57 285.86 280.14 280.14 274.54

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 126Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 52283 197.02 187.17 215.25 210.94 210.94 206.72 52285 263.27 250.11 287.63 281.88 281.88 276.24 # 52285 191.46 181.89 209.17 204.99 204.99 200.89 52287 289.36 274.89 316.12 309.80 309.80 303.60 # 52287 165.72 157.43 181.04 177.42 177.42 173.87 52290 239.07 227.12 261.19 255.97 255.97 250.85 52300 275.24 261.48 300.70 294.69 294.69 288.80 52301 284.53 270.30 310.85 304.62 304.62 298.53 52305 273.66 259.98 298.98 293.00 293.00 287.13 52310 227.74 216.35 248.80 243.82 243.82 238.95 # 52310 148.43 141.01 162.16 158.92 158.92 155.74 52315 388.46 369.04 424.40 415.91 415.91 407.59 # 52315 269.19 255.73 294.09 288.21 288.21 282.45 52317 738.66 701.73 806.99 790.86 790.86 775.04 # 52317 341.52 324.44 373.11 365.64 365.64 358.33 52318 465.72 442.43 508.79 498.62 498.62 488.65 52320 242.04 229.94 264.43 259.14 259.14 253.95 52325 315.36 299.59 344.53 337.64 337.64 330.89 52327 257.86 244.97 281.72 276.08 276.08 270.56 52330 458.30 435.39 500.70 490.68 490.68 480.87 # 52330 258.79 245.85 282.73 277.07 277.07 271.53 52332 443.21 421.05 484.21 474.52 474.52 465.04 # 52332 151.91 144.31 165.96 162.63 162.63 159.38 52334 251.33 238.76 274.57 269.08 269.08 263.70 52341 278.57 264.64 304.34 298.25 298.25 292.28 52342 303.20 288.04 331.25 324.62 324.62 318.12 52343 337.72 320.83 368.95 361.57 361.57 354.34 52344 362.92 344.77 396.49 388.55 388.55 380.78 52345 387.56 368.18 423.41 414.94 414.94 406.64 52346 438.21 416.30 478.75 469.17 469.17 459.78 52351 297.15 282.29 324.63 318.14 318.14 311.78 52352 347.64 330.26 379.80 372.20 372.20 364.76 52353 384.86 365.62 420.46 412.06 412.06 403.81 52354 409.49 389.02 447.37 438.43 438.43 429.66 52355 459.04 436.09 501.50 491.48 491.48 481.64 52356 408.55 388.12 446.34 437.41 437.41 428.66 52400 466.45 443.13 509.60 499.41 499.41 489.42 52402 262.62 249.49 286.91 281.18 281.18 275.55 52441 1,116.23 1,060.42 1,219.48 1,195.09 1,195.09 1,171.19 # 52441 224.54 213.31 245.31 240.40 240.40 235.59 52442 844.03 801.83 922.10 903.66 903.66 885.58 # 52442 59.75 56.76 65.27 63.96 63.96 62.69 52450 454.75 432.01 496.81 486.88 486.88 477.14 52500 472.52 448.89 516.22 505.90 505.90 495.78 52601 824.21 783.00 900.45 882.44 882.44 864.79 52630 386.43 367.11 422.18 413.74 413.74 405.46 52640 302.73 287.59 330.73 324.12 324.12 317.63 52647 1,619.68 1,538.70 1,769.51 1,734.12 1,734.12 1,699.44 # 52647 629.03 597.58 687.22 673.47 673.47 660.01

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 127Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

52648 1,669.82 1,586.33 1,824.28 1,787.79 1,787.79 1,752.04 # 52648 671.36 637.79 733.46 718.78 718.78 704.41 52649 800.65 760.62 874.71 857.22 857.22 840.08 52700 427.30 405.94 466.83 457.49 457.49 448.34 53000 142.65 135.52 155.85 152.73 152.73 149.67 53010 283.77 269.58 310.02 303.82 303.82 297.75 53020 94.67 89.94 103.43 101.36 101.36 99.34 53025 69.39 65.92 75.81 74.29 74.29 72.81 53040 379.59 360.61 414.70 406.41 406.41 398.28 53060 174.72 165.98 190.88 187.06 187.06 183.32 # 53060 158.48 150.56 173.14 169.68 169.68 166.29 53080 406.12 385.81 443.68 434.80 434.80 426.11 53085 647.50 615.13 707.40 693.25 693.25 679.39 53200 150.57 143.04 164.50 161.21 161.21 157.99 # 53200 138.71 131.77 151.54 148.50 148.50 145.53 53210 749.59 712.11 818.93 802.55 802.55 786.50 53215 906.16 860.85 989.98 970.17 970.17 950.77 53220 440.55 418.52 481.30 471.67 471.67 462.24 53230 587.56 558.18 641.91 629.07 629.07 616.49 53235 614.30 583.59 671.13 657.71 657.71 644.55 53240 413.50 392.83 451.75 442.72 442.72 433.86 53250 397.69 377.81 434.48 425.79 425.79 417.28 53260 192.73 183.09 210.55 206.34 206.34 202.22 # 53260 174.62 165.89 190.77 186.96 186.96 183.22 53265 207.73 197.34 226.94 222.40 222.40 217.95 # 53265 180.26 171.25 196.94 193.00 193.00 189.14 53270 199.08 189.13 217.50 213.15 213.15 208.89 # 53270 180.04 171.04 196.70 192.76 192.76 188.91 53275 254.95 242.20 278.53 272.96 272.96 267.50 53400 779.35 740.38 851.44 834.41 834.41 817.72 53405 850.63 808.10 929.32 910.73 910.73 892.52 53410 953.23 905.57 1,041.41 1,020.58 1,020.58 1,000.17 53415 1,102.85 1,047.71 1,204.87 1,180.77 1,180.77 1,157.15 53420 830.93 789.38 907.79 889.63 889.63 871.84 53425 913.47 867.80 997.97 978.01 978.01 958.44 53430 938.89 891.95 1,025.74 1,005.23 1,005.23 985.12 53431 1,129.64 1,073.16 1,234.13 1,209.46 1,209.46 1,185.27 53440 732.15 695.54 799.87 783.87 783.87 768.20 53442 759.54 721.56 829.79 813.20 813.20 796.94 53444 771.64 733.06 843.02 826.16 826.16 809.63 53445 730.59 694.06 798.17 782.21 782.21 766.57 53446 623.12 591.96 680.75 667.14 667.14 653.80 53447 786.02 746.72 858.73 841.56 841.56 824.72 53448 1,254.10 1,191.40 1,370.11 1,342.71 1,342.71 1,315.85 53449 593.39 563.72 648.28 635.32 635.32 622.61 53450 395.75 375.96 432.35 423.71 423.71 415.23 53460 443.40 421.23 484.41 474.73 474.73 465.23 53500 726.39 690.07 793.58 777.71 777.71 762.15 53502 471.48 447.91 515.10 504.79 504.79 494.70

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 128Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

53505 472.67 449.04 516.40 506.07 506.07 495.95 53510 613.19 582.53 669.91 656.51 656.51 643.38 53515 774.22 735.51 845.84 828.92 828.92 812.34 53520 539.47 512.50 589.38 577.59 577.59 566.04 53600 79.18 75.22 86.50 84.78 84.78 83.09 # 53600 62.32 59.20 68.08 66.72 66.72 65.39 53601 76.00 72.20 83.03 81.37 81.37 79.74 # 53601 52.27 49.66 57.11 55.97 55.97 54.86 53605 63.52 60.34 69.39 68.00 68.00 66.64 53620 109.96 104.46 120.13 117.73 117.73 115.37 # 53620 85.29 81.03 93.18 91.32 91.32 89.49 53621 102.87 97.73 112.39 110.15 110.15 107.94 # 53621 70.71 67.17 77.25 75.70 75.70 74.19 53660 65.48 62.21 71.54 70.12 70.12 68.71 # 53660 40.50 38.48 44.25 43.37 43.37 42.50 53661 64.27 61.06 70.22 68.82 68.82 67.44 # 53661 39.30 37.34 42.94 42.08 42.08 41.24 53665 37.89 36.00 41.40 40.57 40.57 39.76 53850 1,871.09 1,777.54 2,044.17 2,003.29 2,003.29 1,963.22 # 53850 587.27 557.91 641.60 628.76 628.76 616.19 53852 1,731.31 1,644.74 1,891.45 1,853.63 1,853.63 1,816.55 # 53852 604.54 574.31 660.46 647.24 647.24 634.29 53855 690.46 655.94 754.33 739.24 739.24 724.45 # 53855 81.33 77.26 88.85 87.07 87.07 85.33 53860 1,379.45 1,310.48 1,507.05 1,476.91 1,476.91 1,447.37 # 53860 220.20 209.19 240.57 235.76 235.76 231.05 54000 138.23 131.32 151.02 147.99 147.99 145.04 # 54000 103.58 98.40 113.16 110.89 110.89 108.68 54001 173.49 164.82 189.54 185.75 185.75 182.03 # 54001 133.53 126.85 145.88 142.96 142.96 140.09 54015 300.98 285.93 328.82 322.24 322.24 315.80 54050 122.52 116.39 133.85 131.17 131.17 128.55 # 54050 99.42 94.45 108.62 106.44 106.44 104.32 54055 110.50 104.98 120.73 118.31 118.31 115.94 # 54055 88.02 83.62 96.16 94.24 94.24 92.36 54056 131.55 124.97 143.72 140.84 140.84 138.02 # 54056 104.70 99.47 114.39 112.10 112.10 109.86 54057 125.70 119.42 137.33 134.58 134.58 131.89 # 54057 90.42 85.90 98.79 96.81 96.81 94.88 54060 167.67 159.29 183.18 179.52 179.52 175.93 # 54060 125.21 118.95 136.79 134.06 134.06 131.38 54065 204.92 194.67 223.87 219.40 219.40 215.00 # 54065 165.58 157.30 180.90 177.27 177.27 173.73 54100 184.08 174.88 201.11 197.09 197.09 193.14 # 54100 121.01 114.96 132.20 129.56 129.56 126.97 54105 250.22 237.71 273.37 267.90 267.90 262.55 # 54105 206.20 195.89 225.27 220.77 220.77 216.35 54110 613.44 582.77 670.19 656.78 656.78 643.64 54111 779.77 740.78 851.90 834.85 834.85 818.16

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 129Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

54112 915.76 869.97 1,000.47 980.46 980.46 960.85 54115 433.99 412.29 474.13 464.65 464.65 455.35 # 54115 410.57 390.04 448.55 439.58 439.58 430.79 54120 613.73 583.04 670.50 657.09 657.09 643.94 54125 790.80 751.26 863.95 846.66 846.66 829.74 54130 1,162.29 1,104.18 1,269.81 1,244.42 1,244.42 1,219.53 54135 1,468.27 1,394.86 1,604.09 1,572.00 1,572.00 1,540.56 54150 144.82 137.58 158.22 155.05 155.05 151.95 # 54150 95.81 91.02 104.67 102.58 102.58 100.53 54160 208.71 198.27 228.01 223.45 223.45 218.97 # 54160 141.59 134.51 154.69 151.59 151.59 148.56 54161 190.57 181.04 208.20 204.03 204.03 199.95 54162 243.02 230.87 265.50 260.19 260.19 254.99 # 54162 192.75 183.11 210.58 206.37 206.37 202.24 54163 210.24 199.73 229.69 225.10 225.10 220.60 54164 185.01 175.76 202.12 198.08 198.08 194.12 54200 99.67 94.69 108.89 106.72 106.72 104.58 # 54200 79.69 75.71 87.07 85.33 85.33 83.63 54205 515.73 489.94 563.43 552.16 552.16 541.12 54220 191.66 182.08 209.39 205.21 205.21 201.10 # 54220 130.78 124.24 142.88 140.02 140.02 137.22 54230 91.90 87.31 100.41 98.39 98.39 96.43 # 54230 77.22 73.36 84.36 82.67 82.67 81.02 54231 133.60 126.92 145.96 143.04 143.04 140.17 # 54231 112.99 107.34 123.44 120.97 120.97 118.55 54235 85.33 81.06 93.22 91.36 91.36 89.53 # 54235 70.97 67.42 77.53 75.98 75.98 74.46 54240 96.36 91.54 105.27 103.17 103.17 101.11 54240 TC 30.88 29.34 33.74 33.06 33.06 32.41 54240 26 65.48 62.21 71.54 70.12 70.12 68.71 54250 117.68 111.80 128.57 125.99 125.99 123.48 54250 TC 9.65 9.17 10.55 10.34 10.34 10.13 54250 26 108.03 102.63 118.02 115.67 115.67 113.36 54300 622.70 591.57 680.31 666.70 666.70 653.37 54304 729.60 693.12 797.09 781.15 781.15 765.52 54308 695.58 660.80 759.92 744.72 744.72 729.82 54312 832.83 791.19 909.87 891.68 891.68 873.84 54316 1,016.92 966.07 1,110.98 1,088.76 1,088.76 1,066.99 54318 723.23 687.07 790.13 774.33 774.33 758.84 54322 749.49 712.02 818.82 802.45 802.45 786.39 54324 970.85 922.31 1,060.66 1,039.44 1,039.44 1,018.65 54326 921.39 875.32 1,006.62 986.48 986.48 966.75 54328 915.51 869.73 1,000.19 980.19 980.19 960.58 54332 1,037.44 985.57 1,133.41 1,110.74 1,110.74 1,088.52 54336 1,212.71 1,152.07 1,324.88 1,298.38 1,298.38 1,272.42 54340 552.62 524.99 603.74 591.66 591.66 579.83 54344 1,001.98 951.88 1,094.66 1,072.77 1,072.77 1,051.31 54348 988.13 938.72 1,079.53 1,057.94 1,057.94 1,036.78 54352 1,383.38 1,314.21 1,511.34 1,481.12 1,481.12 1,451.50

Page 130: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 130Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

54360 700.94 665.89 765.77 750.46 750.46 735.45 54380 777.78 738.89 849.72 832.73 832.73 816.07 54385 945.08 897.83 1,032.50 1,011.85 1,011.85 991.61 54390 1,265.33 1,202.06 1,382.37 1,354.72 1,354.72 1,327.63 54400 514.37 488.65 561.95 550.71 550.71 539.70 54401 633.12 601.46 691.68 677.84 677.84 664.29 54405 787.38 748.01 860.21 843.01 843.01 826.15 54406 710.44 674.92 776.16 760.63 760.63 745.42 54408 768.20 729.79 839.26 822.47 822.47 806.02 54410 835.77 793.98 913.08 894.82 894.82 876.92 54411 998.28 948.37 1,090.63 1,068.81 1,068.81 1,047.43 54415 511.57 485.99 558.89 547.71 547.71 536.75 54416 688.27 653.86 751.94 736.90 736.90 722.15 54417 874.73 830.99 955.64 936.53 936.53 917.79 54420 685.21 650.95 748.59 733.62 733.62 718.95 54430 621.46 590.39 678.95 665.37 665.37 652.06 54435 401.93 381.83 439.10 430.32 430.32 421.72 54437 660.08 627.08 721.14 706.72 706.72 692.59 54438 1,335.35 1,268.58 1,458.87 1,429.69 1,429.69 1,401.10 54450 67.22 63.86 73.44 71.97 71.97 70.53 # 54450 56.60 53.77 61.84 60.59 60.59 59.39 54500 72.43 68.81 79.13 77.54 77.54 75.99 54505 203.54 193.36 222.36 217.91 217.91 213.56 54512 524.00 497.80 572.47 561.02 561.02 549.79 54520 315.01 299.26 344.15 337.26 337.26 330.51 54522 599.02 569.07 654.43 641.34 641.34 628.52 54530 489.40 464.93 534.67 523.97 523.97 513.50 54535 723.65 687.47 790.59 774.78 774.78 759.29 54550 478.59 454.66 522.86 512.41 512.41 502.16 54560 668.04 634.64 729.84 715.24 715.24 700.94 54600 441.33 419.26 482.15 472.50 472.50 463.05 54620 292.94 278.29 320.03 313.63 313.63 307.36 54640 462.95 439.80 505.77 495.65 495.65 485.74 54650 689.72 655.23 753.51 738.45 738.45 723.68 54660 344.87 327.63 376.77 369.24 369.24 361.86 54670 391.28 371.72 427.48 418.93 418.93 410.55 54680 770.56 732.03 841.83 825.00 825.00 808.50 54690 711.71 676.12 777.54 761.99 761.99 746.75 54692 823.65 782.47 899.84 881.84 881.84 864.20 54700 206.99 196.64 226.14 221.62 221.62 217.19 54800 124.52 118.29 136.03 133.31 133.31 130.64 54830 359.99 341.99 393.29 385.42 385.42 377.72 54840 310.67 295.14 339.41 332.63 332.63 325.98 54860 405.29 385.03 442.78 433.93 433.93 425.25 54861 549.45 521.98 600.28 588.27 588.27 576.51 54865 346.26 328.95 378.29 370.73 370.73 363.31 54900 814.97 774.22 890.35 872.55 872.55 855.11 54901 1,076.30 1,022.49 1,175.86 1,152.35 1,152.35 1,129.30 55000 110.36 104.84 120.57 118.15 118.15 115.79

Page 131: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 131Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 55000 82.58 78.45 90.22 88.41 88.41 86.64 55040 326.63 310.30 356.85 349.70 349.70 342.71 55041 493.49 468.82 539.14 528.36 528.36 517.79 55060 367.73 349.34 401.74 393.70 393.70 385.83 55100 202.67 192.54 221.42 216.99 216.99 212.66 # 55100 159.58 151.60 174.34 170.86 170.86 167.44 55110 374.72 355.98 409.38 401.19 401.19 393.16 55120 344.36 327.14 376.21 368.69 368.69 361.32 55150 475.73 451.94 519.73 509.34 509.34 499.15 55175 350.10 332.60 382.49 374.84 374.84 367.34 55180 671.43 637.86 733.54 718.87 718.87 704.49 55200 406.28 385.97 443.87 434.99 434.99 426.29 # 55200 269.22 255.76 294.12 288.24 288.24 282.47 55250 355.02 337.27 387.86 380.10 380.10 372.50 # 55250 217.96 207.06 238.12 233.36 233.36 228.69 55300 183.25 174.09 200.20 196.20 196.20 192.28 55400 493.88 469.19 539.57 528.78 528.78 518.20 55450 337.72 320.83 368.95 361.57 361.57 354.34 # 55450 249.68 237.20 272.78 267.33 267.33 261.98 55500 382.15 363.04 417.50 409.15 409.15 400.96 55520 434.76 413.02 474.97 465.47 465.47 456.16 55530 339.84 322.85 371.28 363.85 363.85 356.57 55535 416.64 395.81 455.18 446.07 446.07 437.15 55540 521.27 495.21 569.49 558.11 558.11 546.94 55550 416.04 395.24 454.53 445.44 445.44 436.53 55600 408.07 387.67 445.82 436.91 436.91 428.17 55605 529.20 502.74 578.15 566.59 566.59 555.27 55650 698.75 663.81 763.38 748.11 748.11 733.15 55680 342.83 325.69 374.54 367.06 367.06 359.72 55700 204.28 194.07 223.18 218.72 218.72 214.35 # 55700 136.22 129.41 148.82 145.84 145.84 142.92 55705 258.54 245.61 282.45 276.81 276.81 271.27 55706 361.83 343.74 395.30 387.40 387.40 379.65 55720 439.56 417.58 480.22 470.61 470.61 461.21 55725 574.98 546.23 628.16 615.61 615.61 603.29 55801 1,072.00 1,018.40 1,171.16 1,147.73 1,147.73 1,124.78 55810 1,288.15 1,223.74 1,407.30 1,379.16 1,379.16 1,351.57 55812 1,572.73 1,494.09 1,718.20 1,683.84 1,683.84 1,650.17 55815 1,730.84 1,644.30 1,890.95 1,853.12 1,853.12 1,816.06 55821 851.63 809.05 930.41 911.80 911.80 893.56 55831 922.08 875.98 1,007.38 987.23 987.23 967.48 55840 1,143.41 1,086.24 1,249.18 1,224.20 1,224.20 1,199.71 55842 1,142.84 1,085.70 1,248.56 1,223.59 1,223.59 1,199.12 55845 1,332.72 1,266.08 1,455.99 1,426.87 1,426.87 1,398.33 55860 853.56 810.88 932.51 913.86 913.86 895.59 55862 1,118.34 1,062.42 1,221.78 1,197.35 1,197.35 1,173.40 55865 1,302.73 1,237.59 1,423.23 1,394.77 1,394.77 1,366.87 55866 1,349.58 1,282.10 1,474.42 1,444.93 1,444.93 1,416.03 55870 167.44 159.07 182.93 179.27 179.27 175.69

Page 132: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 132Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 55870 139.03 132.08 151.89 148.86 148.86 145.88 55873 6,319.39 6,003.42 6,903.93 6,765.85 6,765.85 6,630.53 # 55873 747.00 709.65 816.10 799.78 799.78 783.78 55875 742.12 705.01 810.76 794.55 794.55 778.65 55876 127.95 121.55 139.78 136.99 136.99 134.25 # 55876 97.66 92.78 106.70 104.56 104.56 102.47 55920 438.32 416.40 478.86 469.28 469.28 459.90 56405 102.78 97.64 112.29 110.04 110.04 107.85 # 56405 102.15 97.04 111.60 109.37 109.37 107.18 56420 113.50 107.83 124.00 121.52 121.52 119.09 # 56420 86.97 82.62 95.01 93.12 93.12 91.25 56440 173.67 164.99 189.74 185.94 185.94 182.23 56441 135.98 129.18 148.56 145.59 145.59 142.68 # 56441 131.30 124.74 143.45 140.59 140.59 137.78 56442 45.36 43.09 49.55 48.56 48.56 47.60 56501 122.21 116.10 133.52 130.85 130.85 128.23 # 56501 108.47 103.05 118.51 116.14 116.14 113.82 56515 213.34 202.67 233.07 228.41 228.41 223.85 # 56515 191.80 182.21 209.54 205.36 205.36 201.25 56605 77.40 73.53 84.56 82.87 82.87 81.21 # 56605 58.36 55.44 63.76 62.48 62.48 61.23 56606 35.71 33.92 39.01 38.23 38.23 37.47 # 56606 28.84 27.40 31.51 30.88 30.88 30.26 56620 494.97 470.22 540.75 529.94 529.94 519.34 56625 601.14 571.08 656.74 643.61 643.61 630.74 56630 890.50 845.98 972.88 953.42 953.42 934.35 56631 1,138.01 1,081.11 1,243.28 1,218.41 1,218.41 1,194.05 56632 1,320.63 1,254.60 1,442.79 1,413.94 1,413.94 1,385.66 56633 1,166.54 1,108.21 1,274.44 1,248.96 1,248.96 1,223.98 56634 1,256.58 1,193.75 1,372.81 1,345.36 1,345.36 1,318.45 56637 1,452.89 1,380.25 1,587.29 1,555.55 1,555.55 1,524.44 56640 1,461.99 1,388.89 1,597.22 1,565.28 1,565.28 1,533.97 56700 176.95 168.10 193.32 189.45 189.45 185.67 56740 287.66 273.28 314.27 307.98 307.98 301.82 56800 230.19 218.68 251.48 246.46 246.46 241.52 56805 1,116.09 1,060.29 1,219.33 1,194.94 1,194.94 1,171.05 56810 248.90 236.46 271.93 266.49 266.49 261.17 56820 105.81 100.52 115.60 113.29 113.29 111.02 # 56820 83.64 79.46 91.38 89.55 89.55 87.76 56821 139.70 132.72 152.63 149.58 149.58 146.59 # 56821 111.60 106.02 121.92 119.49 119.49 117.09 57000 179.60 170.62 196.21 192.29 192.29 188.45 57010 412.77 392.13 450.95 441.93 441.93 433.09 57020 88.49 84.07 96.68 94.75 94.75 92.85 # 57020 78.19 74.28 85.42 83.71 83.71 82.03 57022 162.06 153.96 177.05 173.51 173.51 170.04 57023 296.49 281.67 323.92 317.45 317.45 311.10 57061 106.02 100.72 115.83 113.52 113.52 111.25 # 57061 92.60 87.97 101.17 99.14 99.14 97.16

Page 133: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 133Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

57065 183.71 174.52 200.70 196.68 196.68 192.75 # 57065 166.23 157.92 181.61 177.97 177.97 174.41 57100 83.99 79.79 91.76 89.92 89.92 88.12 # 57100 64.64 61.41 70.62 69.21 69.21 67.83 57105 128.08 121.68 139.93 137.14 137.14 134.40 # 57105 119.34 113.37 130.38 127.77 127.77 125.21 57106 471.15 447.59 514.73 504.44 504.44 494.35 57107 1,400.07 1,330.07 1,529.58 1,498.99 1,498.99 1,469.01 57109 1,668.37 1,584.95 1,822.69 1,786.24 1,786.24 1,750.52 57110 856.68 813.85 935.93 917.21 917.21 898.86 57111 1,549.38 1,471.91 1,692.70 1,658.84 1,658.84 1,625.66 57112 1,782.48 1,693.36 1,947.36 1,908.41 1,908.41 1,870.25 57120 486.05 461.75 531.01 520.40 520.40 509.99 57130 166.58 158.25 181.99 178.35 178.35 174.79 # 57130 150.97 143.42 164.93 161.63 161.63 158.40 57135 181.23 172.17 198.00 194.04 194.04 190.16 # 57135 164.99 156.74 180.25 176.65 176.65 173.12 57150 42.01 39.91 45.90 44.98 44.98 44.08 # 57150 27.96 26.56 30.54 29.93 29.93 29.34 57155 405.89 385.60 443.44 434.57 434.57 425.88 # 57155 283.19 269.03 309.38 303.20 303.20 297.14 57156 187.24 177.88 204.56 200.47 200.47 196.45 # 57156 142.59 135.46 155.78 152.66 152.66 149.62 57160 70.93 67.38 77.49 75.93 75.93 74.42 # 57160 45.33 43.06 49.52 48.53 48.53 47.56 57170 57.57 54.69 62.89 61.64 61.64 60.41 # 57170 46.95 44.60 51.29 50.27 50.27 49.27 57180 130.87 124.33 142.98 140.12 140.12 137.31 # 57180 100.27 95.26 109.55 107.35 107.35 105.20 57200 286.68 272.35 313.20 306.94 306.94 300.79 57210 349.48 332.01 381.81 374.18 374.18 366.69 57220 302.87 287.73 330.89 324.28 324.28 317.79 57230 376.14 357.33 410.93 402.71 402.71 394.66 57240 643.75 611.56 703.29 689.23 689.23 675.44 57250 647.13 614.77 706.99 692.84 692.84 678.98 57260 798.57 758.64 872.44 854.99 854.99 837.89 57265 874.91 831.16 955.83 936.72 936.72 917.99 57267 248.40 235.98 271.38 265.95 265.95 260.62 57268 460.72 437.68 503.33 493.27 493.27 483.40 57270 767.04 728.69 837.99 821.24 821.24 804.82 57280 916.16 870.35 1,000.90 980.88 980.88 961.26 57282 477.28 453.42 521.43 511.00 511.00 500.78 57283 659.30 626.34 720.29 705.88 705.88 691.76 57284 783.79 744.60 856.29 839.17 839.17 822.39 57285 645.12 612.86 704.79 690.69 690.69 676.88 57287 651.39 618.82 711.64 697.41 697.41 683.46 57288 686.77 652.43 750.29 735.29 735.29 720.58 57289 707.98 672.58 773.47 758.00 758.00 742.84 57291 580.69 551.66 634.41 621.72 621.72 609.29

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 134Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

57292 788.12 748.71 861.02 843.80 843.80 826.93 57295 456.35 433.53 498.56 488.59 488.59 478.81 57296 909.58 864.10 993.72 973.84 973.84 954.36 57300 536.77 509.93 586.42 574.69 574.69 563.20 57305 898.09 853.19 981.17 961.55 961.55 942.32 57307 1,035.16 983.40 1,130.91 1,108.29 1,108.29 1,086.13 57308 630.34 598.82 688.64 674.87 674.87 661.37 57310 445.15 422.89 486.32 476.59 476.59 467.06 57311 509.44 483.97 556.57 545.43 545.43 534.52 57320 514.16 488.45 561.72 550.48 550.48 539.48 57330 718.46 682.54 784.92 769.22 769.22 753.84 57335 1,094.23 1,039.52 1,195.45 1,171.54 1,171.54 1,148.11 57400 129.36 122.89 141.32 138.49 138.49 135.72 57410 103.21 98.05 112.76 110.50 110.50 108.30 57415 152.64 145.01 166.76 163.43 163.43 160.16 57420 110.92 105.37 121.18 118.75 118.75 116.37 # 57420 88.44 84.02 96.62 94.69 94.69 92.79 57421 149.02 141.57 162.81 159.55 159.55 156.37 # 57421 120.29 114.28 131.42 128.79 128.79 126.21 57423 876.04 832.24 957.08 937.94 937.94 919.18 57425 931.32 884.75 1,017.46 997.12 997.12 977.18 57426 807.95 767.55 882.68 865.03 865.03 847.73 57452 102.80 97.66 112.31 110.07 110.07 107.87 # 57452 88.44 84.02 96.62 94.69 94.69 92.79 57454 145.09 137.84 158.52 155.34 155.34 152.24 # 57454 130.42 123.90 142.49 139.63 139.63 136.84 57455 134.57 127.84 147.02 144.07 144.07 141.19 # 57455 106.78 101.44 116.66 114.32 114.32 112.03 57456 126.80 120.46 138.53 135.76 135.76 133.04 # 57456 99.32 94.35 108.50 106.33 106.33 104.20 57460 261.46 248.39 285.65 279.93 279.93 274.33 # 57460 156.56 148.73 171.04 167.62 167.62 164.27 57461 296.46 281.64 323.89 317.41 317.41 311.06 # 57461 181.26 172.20 198.03 194.07 194.07 190.19 57500 117.80 111.91 128.70 126.12 126.12 123.60 # 57500 72.52 68.89 79.22 77.64 77.64 76.08 57505 95.24 90.48 104.05 101.97 101.97 99.94 # 57505 86.81 82.47 94.84 92.94 92.94 91.08 57510 123.90 117.71 135.37 132.66 132.66 130.01 # 57510 110.48 104.96 120.70 118.29 118.29 115.92 57511 136.31 129.49 148.91 145.94 145.94 143.01 # 57511 125.07 118.82 136.64 133.91 133.91 131.23 57513 136.48 129.66 149.11 146.13 146.13 143.21 # 57513 127.12 120.76 138.87 136.09 136.09 133.37 57520 289.15 274.69 315.89 309.58 309.58 303.39 # 57520 261.67 248.59 285.88 280.16 280.16 274.56 57522 248.12 235.71 271.07 265.65 265.65 260.34 # 57522 231.26 219.70 252.66 247.61 247.61 242.65 57530 330.27 313.76 360.82 353.60 353.60 346.53

Page 135: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 135Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

57531 1,758.06 1,670.16 1,920.68 1,882.27 1,882.27 1,844.62 57540 749.22 711.76 818.52 802.15 802.15 786.11 57545 808.67 768.24 883.48 865.81 865.81 848.49 57550 386.71 367.37 422.48 414.02 414.02 405.74 57555 572.47 543.85 625.43 612.92 612.92 600.66 57556 541.85 514.76 591.97 580.13 580.13 568.53 57558 117.23 111.37 128.08 125.51 125.51 123.00 # 57558 107.55 102.17 117.50 115.15 115.15 112.85 57700 299.73 284.74 327.45 320.91 320.91 314.49 57720 290.95 276.40 317.86 311.50 311.50 305.27 57800 56.64 53.81 61.88 60.64 60.64 59.43 # 57800 46.34 44.02 50.62 49.61 49.61 48.62 58100 102.96 97.81 112.48 110.23 110.23 108.02 # 58100 84.23 80.02 92.02 90.18 90.18 88.38 58110 45.74 43.45 49.97 48.97 48.97 47.99 # 58110 39.50 37.53 43.16 42.30 42.30 41.45 58120 243.67 231.49 266.21 260.89 260.89 255.67 # 58120 209.33 198.86 228.69 224.11 224.11 219.63 58140 884.53 840.30 966.35 947.01 947.01 928.07 58145 523.61 497.43 572.04 560.60 560.60 549.39 58146 1,103.51 1,048.33 1,205.58 1,181.46 1,181.46 1,157.83 58150 973.10 924.45 1,063.12 1,041.85 1,041.85 1,021.02 58152 1,198.84 1,138.90 1,309.74 1,283.54 1,283.54 1,257.87 58180 924.35 878.13 1,009.85 989.66 989.66 969.86 58200 1,317.84 1,251.95 1,439.74 1,410.95 1,410.95 1,382.73 58210 1,777.58 1,688.70 1,942.01 1,903.17 1,903.17 1,865.10 58240 2,808.73 2,668.29 3,068.53 3,007.16 3,007.16 2,947.01 58260 790.43 750.91 863.55 846.27 846.27 829.35 58262 883.18 839.02 964.87 945.58 945.58 926.67 58263 947.77 900.38 1,035.44 1,014.73 1,014.73 994.43 58267 1,010.18 959.67 1,103.62 1,081.55 1,081.55 1,059.92 58270 844.28 802.07 922.38 903.93 903.93 885.86 58275 942.94 895.79 1,030.16 1,009.55 1,009.55 989.36 58280 1,005.04 954.79 1,098.01 1,076.04 1,076.04 1,054.53 58285 1,285.03 1,220.78 1,403.90 1,375.81 1,375.81 1,348.29 58290 1,103.22 1,048.06 1,205.27 1,181.17 1,181.17 1,157.54 58291 1,191.70 1,132.12 1,301.94 1,275.90 1,275.90 1,250.38 58292 1,258.65 1,195.72 1,375.08 1,347.58 1,347.58 1,320.63 58293 1,308.17 1,242.76 1,429.17 1,400.59 1,400.59 1,372.57 58294 1,169.64 1,111.16 1,277.83 1,252.28 1,252.28 1,227.23 58301 89.08 84.63 97.32 95.38 95.38 93.47 # 58301 65.35 62.08 71.39 69.97 69.97 68.56 58321 71.66 68.08 78.29 76.73 76.73 75.20 # 58321 47.31 44.94 51.68 50.65 50.65 49.63 58322 80.24 76.23 87.66 85.92 85.92 84.20 # 58322 56.51 53.68 61.73 60.50 60.50 59.29 58323 14.42 13.70 15.76 15.44 15.44 15.13 # 58323 11.61 11.03 12.68 12.43 12.43 12.18 58340 108.66 103.23 118.71 116.35 116.35 114.02

Page 136: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 136Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 58340 55.58 52.80 60.72 59.50 59.50 58.32 58345 260.80 247.76 284.92 279.22 279.22 273.63 58346 430.29 408.78 470.10 460.69 460.69 451.48 58350 89.14 84.68 97.38 95.44 95.44 93.53 # 58350 73.84 70.15 80.67 79.06 79.06 77.49 58353 900.44 855.42 983.73 964.06 964.06 944.77 # 58353 208.89 198.45 228.22 223.65 223.65 219.18 58356 1,683.21 1,599.05 1,838.91 1,802.13 1,802.13 1,766.09 # 58356 333.20 316.54 364.02 356.74 356.74 349.61 58400 420.28 399.27 459.16 449.97 449.97 440.97 58410 782.32 743.20 854.68 837.59 837.59 820.84 58520 810.18 769.67 885.12 867.42 867.42 850.07 58540 868.07 824.67 948.37 929.41 929.41 910.82 58541 686.12 651.81 749.58 734.59 734.59 719.89 58542 785.06 745.81 857.68 840.52 840.52 823.71 58543 794.31 754.59 867.78 850.43 850.43 833.42 58544 865.99 822.69 946.09 927.18 927.18 908.64 58545 866.03 822.73 946.14 927.22 927.22 908.67 58546 1,076.84 1,023.00 1,176.45 1,152.92 1,152.92 1,129.86 58548 1,831.03 1,739.48 2,000.40 1,960.39 1,960.39 1,921.19 58550 844.07 801.87 922.15 903.70 903.70 885.63 58552 947.09 899.74 1,034.70 1,014.01 1,014.01 993.74 58553 1,090.83 1,036.29 1,191.73 1,167.89 1,167.89 1,144.54 58554 1,275.70 1,211.92 1,393.71 1,365.83 1,365.83 1,338.52 58555 288.91 274.46 315.63 309.32 309.32 303.13 # 58555 181.82 172.73 198.64 194.67 194.67 190.77 58558 377.27 358.41 412.17 403.93 403.93 395.85 # 58558 256.13 243.32 279.82 274.22 274.22 268.73 58559 328.39 311.97 358.77 351.59 351.59 344.56 58560 370.71 352.17 405.00 396.90 396.90 388.96 58561 525.78 499.49 574.41 562.93 562.93 551.67 58562 391.44 371.87 427.65 419.09 419.09 410.71 # 58562 278.42 264.50 304.18 298.09 298.09 292.13 58563 1,493.93 1,419.23 1,632.11 1,599.48 1,599.48 1,567.48 # 58563 328.13 311.72 358.48 351.31 351.31 344.29 58565 1,672.25 1,588.64 1,826.94 1,790.40 1,790.40 1,754.59 # 58565 412.78 392.14 450.96 441.95 441.95 433.10 58570 745.96 708.66 814.96 798.66 798.66 782.69 58571 860.27 817.26 939.85 921.05 921.05 902.62 58572 978.66 929.73 1,069.19 1,047.81 1,047.81 1,026.86 58573 1,166.57 1,108.24 1,274.48 1,248.99 1,248.99 1,224.01 58600 346.48 329.16 378.53 370.97 370.97 363.55 58605 313.53 297.85 342.53 335.67 335.67 328.96 58611 74.55 70.82 81.44 79.81 79.81 78.21 58615 231.59 220.01 253.01 247.95 247.95 243.00 58660 646.00 613.70 705.76 691.64 691.64 677.81 58661 624.18 592.97 681.92 668.28 668.28 654.91 58662 679.90 645.91 742.80 727.94 727.94 713.38 58670 347.93 330.53 380.11 372.51 372.51 365.06

Page 137: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 137Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

58671 347.33 329.96 379.45 371.86 371.86 364.42 58672 703.16 668.00 768.20 752.84 752.84 737.78 58673 764.41 726.19 835.12 818.42 818.42 802.06 58700 747.92 710.52 817.10 800.76 800.76 784.74 58720 705.47 670.20 770.73 755.32 755.32 740.21 58740 846.36 804.04 924.65 906.15 906.15 888.03 58750 928.50 882.08 1,014.39 994.11 994.11 974.22 58752 885.93 841.63 967.87 948.52 948.52 929.55 58760 785.78 746.49 858.46 841.29 841.29 824.47 58770 879.82 835.83 961.20 941.98 941.98 923.14 58800 299.74 284.75 327.46 320.92 320.92 314.50 # 58800 282.88 268.74 309.05 302.88 302.88 296.82 58805 383.90 364.71 419.42 411.03 411.03 402.81 58820 295.40 280.63 322.72 316.27 316.27 309.95 58822 715.89 680.10 782.12 766.48 766.48 751.15 58825 666.30 632.99 727.94 713.38 713.38 699.11 58900 432.34 410.72 472.33 462.89 462.89 453.63 58920 727.90 691.51 795.24 779.33 779.33 763.75 58925 715.13 679.37 781.28 765.65 765.65 750.33 58940 501.99 476.89 548.42 537.45 537.45 526.70 58943 1,131.33 1,074.76 1,235.97 1,211.25 1,211.25 1,187.02 58950 1,084.97 1,030.72 1,185.33 1,161.63 1,161.63 1,138.40 58951 1,398.81 1,328.87 1,528.20 1,497.63 1,497.63 1,467.68 58952 1,581.50 1,502.43 1,727.79 1,693.24 1,693.24 1,659.37 58953 1,958.09 1,860.19 2,139.22 2,096.44 2,096.44 2,054.51 58954 2,128.20 2,021.79 2,325.06 2,278.55 2,278.55 2,232.98 58956 1,327.95 1,261.55 1,450.78 1,421.77 1,421.77 1,393.33 58957 1,528.19 1,451.78 1,669.55 1,636.15 1,636.15 1,603.43 58958 1,681.08 1,597.03 1,836.58 1,799.85 1,799.85 1,763.86 58960 934.91 888.16 1,021.38 1,000.96 1,000.96 980.94 58970 211.67 201.09 231.25 226.63 226.63 222.10 # 58970 192.31 182.69 210.09 205.90 205.90 201.78 58976 240.55 228.52 262.80 257.54 257.54 252.39 # 58976 210.27 199.76 229.72 225.12 225.12 220.62 59000 117.44 111.57 128.31 125.74 125.74 123.22 # 59000 78.11 74.20 85.33 83.63 83.63 81.96 59001 174.26 165.55 190.38 186.58 186.58 182.85 59012 196.89 187.05 215.11 210.81 210.81 206.59 59015 148.41 140.99 162.14 158.90 158.90 155.72 # 59015 127.80 121.41 139.62 136.83 136.83 134.09 59020 65.96 62.66 72.06 70.62 70.62 69.21 59020 TC 29.94 28.44 32.71 32.05 32.05 31.41 59020 26 36.02 34.22 39.35 38.57 38.57 37.80 59025 45.16 42.90 49.34 48.35 48.35 47.38 59025 TC 16.21 15.40 17.71 17.35 17.35 17.01 59025 26 28.95 27.50 31.63 30.99 30.99 30.37 59030 99.25 94.29 108.43 106.26 106.26 104.13 59050 49.34 46.87 53.90 52.82 52.82 51.76 59051 40.96 38.91 44.75 43.85 43.85 42.98

Page 138: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 138Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

59070 378.52 359.59 413.53 405.26 405.26 397.15 # 59070 293.91 279.21 321.09 314.67 314.67 308.38 59072 461.18 438.12 503.84 493.76 493.76 483.89 59074 363.76 345.57 397.41 389.46 389.46 381.67 # 59074 291.63 277.05 318.61 312.24 312.24 305.99 59076 461.18 438.12 503.84 493.76 493.76 483.89 59100 769.45 730.98 840.63 823.81 823.81 807.33 59120 764.13 725.92 834.81 818.11 818.11 801.75 59121 766.47 728.15 837.37 820.63 820.63 804.22 59130 896.34 851.52 979.25 959.66 959.66 940.47 59135 811.25 770.69 886.29 868.57 868.57 851.20 59136 820.79 779.75 896.71 878.78 878.78 861.21 59140 383.51 364.33 418.98 410.60 410.60 402.39 59150 741.92 704.82 810.54 794.33 794.33 778.45 59151 720.51 684.48 787.15 771.41 771.41 755.98 59160 193.65 183.97 211.57 207.33 207.33 203.18 # 59160 166.80 158.46 182.23 178.58 178.58 175.01 59200 67.10 63.75 73.31 71.85 71.85 70.41 # 59200 43.37 41.20 47.38 46.44 46.44 45.51 59300 182.61 173.48 199.50 195.51 195.51 191.60 # 59300 143.59 136.41 156.87 153.73 153.73 150.66 59320 147.32 139.95 160.94 157.72 157.72 154.57 59325 235.20 223.44 256.96 251.82 251.82 246.78 59350 259.65 246.67 283.67 278.00 278.00 272.45 59400 2,004.53 1,904.30 2,189.95 2,146.14 2,146.14 2,103.22 59409 791.64 752.06 864.87 847.57 847.57 830.62 59410 1,008.44 958.02 1,101.72 1,079.69 1,079.69 1,058.09 59412 100.29 95.28 109.57 107.38 107.38 105.23 59414 89.27 84.81 97.53 95.58 95.58 93.67 59425 432.28 410.67 472.27 462.83 462.83 453.57 # 59425 345.79 328.50 377.78 370.22 370.22 362.81 59426 772.51 733.88 843.96 827.08 827.08 810.54 # 59426 610.16 579.65 666.60 653.27 653.27 640.21 59430 174.91 166.16 191.08 187.27 187.27 183.52 # 59430 135.26 128.50 147.78 144.82 144.82 141.92 59510 2,223.44 2,112.27 2,429.11 2,380.52 2,380.52 2,332.91 59514 891.48 846.91 973.95 954.47 954.47 935.38 59515 1,222.95 1,161.80 1,336.07 1,309.34 1,309.34 1,283.16 59525 470.06 446.56 513.54 503.27 503.27 493.21 59610 2,107.78 2,002.39 2,302.75 2,256.69 2,256.69 2,211.55 59612 891.82 847.23 974.31 954.83 954.83 935.73 59614 1,107.91 1,052.51 1,210.39 1,186.18 1,186.18 1,162.45 59618 2,253.60 2,140.92 2,462.06 2,412.82 2,412.82 2,364.56 59620 915.11 869.35 999.75 979.75 979.75 960.16 59622 1,256.25 1,193.44 1,372.46 1,345.01 1,345.01 1,318.11 59812 302.91 287.76 330.92 324.30 324.30 317.81 # 59812 283.24 269.08 309.44 303.26 303.26 297.19 59820 358.76 340.82 391.94 384.10 384.10 376.42 # 59820 338.78 321.84 370.12 362.71 362.71 355.45

Page 139: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 139Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

59821 362.87 344.73 396.44 388.52 388.52 380.74 # 59821 341.01 323.96 372.55 365.10 365.10 357.80 59830 418.59 397.66 457.31 448.17 448.17 439.21 59840 206.78 196.44 225.91 221.39 221.39 216.96 # 59840 198.97 189.02 217.37 213.03 213.03 208.77 59841 365.93 347.63 399.77 391.78 391.78 383.95 # 59841 347.20 329.84 379.32 371.73 371.73 364.30 59850 338.38 321.46 369.68 362.28 362.28 355.04 59851 357.52 339.64 390.59 382.78 382.78 375.12 59852 488.15 463.74 533.30 522.64 522.64 512.19 59855 398.92 378.97 435.82 427.10 427.10 418.55 59856 470.07 446.57 513.56 503.29 503.29 493.22 59857 505.46 480.19 552.22 541.18 541.18 530.36 59866 212.00 201.40 231.61 226.98 226.98 222.43 59870 450.03 427.53 491.66 481.83 481.83 472.19 59871 128.79 122.35 140.70 137.89 137.89 135.13 59899 472.93 449.28 516.67 506.33 506.33 496.20 60000 160.85 152.81 175.73 172.21 172.21 168.77 # 60000 145.55 138.27 159.01 155.83 155.83 152.71 60100 107.27 101.91 117.20 114.85 114.85 112.55 # 60100 77.92 74.02 85.12 83.42 83.42 81.75 60200 636.18 604.37 695.03 681.12 681.12 667.49 60210 684.13 649.92 747.41 732.46 732.46 717.81 60212 975.27 926.51 1,065.49 1,044.18 1,044.18 1,023.29 60220 684.31 650.09 747.60 732.65 732.65 718.00 60225 901.54 856.46 984.93 965.23 965.23 945.92 60240 891.54 846.96 974.00 954.52 954.52 935.43 60252 1,283.18 1,219.02 1,401.87 1,373.84 1,373.84 1,346.36 60254 1,629.27 1,547.81 1,779.98 1,744.38 1,744.38 1,709.49 60260 1,062.41 1,009.29 1,160.68 1,137.47 1,137.47 1,114.72 60270 1,329.61 1,263.13 1,452.60 1,423.55 1,423.55 1,395.08 60271 1,027.54 976.16 1,122.58 1,100.14 1,100.14 1,078.14 60280 425.53 404.25 464.89 455.60 455.60 446.49 60281 567.00 538.65 619.45 607.06 607.06 594.92 60300 109.67 104.19 119.82 117.43 117.43 115.08 # 60300 49.10 46.65 53.65 52.58 52.58 51.53 60500 934.26 887.55 1,020.68 1,000.27 1,000.27 980.26 60502 1,247.29 1,184.93 1,362.67 1,335.41 1,335.41 1,308.71 60505 1,344.89 1,277.65 1,469.30 1,439.92 1,439.92 1,411.12 60512 238.55 226.62 260.61 255.40 255.40 250.30 60520 1,011.03 960.48 1,104.55 1,082.46 1,082.46 1,060.81 60521 1,093.02 1,038.37 1,194.13 1,170.24 1,170.24 1,146.84 60522 1,323.29 1,257.13 1,445.70 1,416.79 1,416.79 1,388.45 60540 1,029.72 978.23 1,124.96 1,102.47 1,102.47 1,080.43 60545 1,182.30 1,123.19 1,291.67 1,265.84 1,265.84 1,240.53 60600 1,364.83 1,296.59 1,491.08 1,461.26 1,461.26 1,432.04 60605 1,690.23 1,605.72 1,846.58 1,809.65 1,809.65 1,773.46 60650 1,161.30 1,103.24 1,268.73 1,243.36 1,243.36 1,218.49 61000 110.64 105.11 120.88 118.46 118.46 116.09

Page 140: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 140Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

61001 82.77 78.63 90.42 88.62 88.62 86.85 61020 97.53 92.65 106.55 104.42 104.42 102.33 61026 100.07 95.07 109.33 107.15 107.15 105.01 61050 83.60 79.42 91.33 89.50 89.50 87.71 61055 117.62 111.74 128.50 125.94 125.94 123.42 61070 55.78 52.99 60.94 59.72 59.72 58.52 61105 435.23 413.47 475.49 465.98 465.98 456.67 61107 308.34 292.92 336.86 330.12 330.12 323.52 61108 870.81 827.27 951.36 932.33 932.33 913.69 61120 715.35 679.58 781.52 765.89 765.89 750.57 61140 1,219.70 1,158.72 1,332.53 1,305.88 1,305.88 1,279.77 61150 1,294.19 1,229.48 1,413.90 1,385.62 1,385.62 1,357.91 61151 962.05 913.95 1,051.04 1,030.02 1,030.02 1,009.42 61154 1,223.59 1,162.41 1,336.77 1,310.03 1,310.03 1,283.84 61156 1,202.90 1,142.76 1,314.17 1,287.89 1,287.89 1,262.13 61210 361.09 343.04 394.50 386.61 386.61 378.88 61215 483.21 459.05 527.91 517.35 517.35 507.00 61250 782.73 743.59 855.13 838.03 838.03 821.27 61253 795.77 755.98 869.38 851.99 851.99 834.95 61304 1,591.46 1,511.89 1,738.67 1,703.90 1,703.90 1,669.82 61305 1,939.69 1,842.71 2,119.12 2,076.74 2,076.74 2,035.20 61312 2,016.17 1,915.36 2,202.66 2,158.61 2,158.61 2,115.44 61313 1,920.26 1,824.25 2,097.89 2,055.94 2,055.94 2,014.81 61314 1,763.59 1,675.41 1,926.72 1,888.19 1,888.19 1,850.42 61315 2,002.39 1,902.27 2,187.61 2,143.85 2,143.85 2,100.98 61316 85.97 81.67 93.92 92.05 92.05 90.21 61320 1,842.11 1,750.00 2,012.50 1,972.25 1,972.25 1,932.81 61321 2,034.75 1,933.01 2,222.96 2,178.50 2,178.50 2,134.93 61322 2,303.62 2,188.44 2,516.71 2,466.37 2,466.37 2,417.05 61323 2,332.65 2,216.02 2,548.42 2,497.46 2,497.46 2,447.51 61330 1,568.42 1,490.00 1,713.50 1,679.23 1,679.23 1,645.65 61332 1,729.78 1,643.29 1,889.78 1,851.98 1,851.98 1,814.94 61333 1,781.50 1,692.43 1,946.29 1,907.37 1,907.37 1,869.22 61340 1,379.16 1,310.20 1,506.73 1,476.60 1,476.60 1,447.07 61343 2,127.07 2,020.72 2,323.83 2,277.36 2,277.36 2,231.81 61345 1,969.82 1,871.33 2,152.03 2,108.99 2,108.99 2,066.80 61450 1,862.65 1,769.52 2,034.95 1,994.25 1,994.25 1,954.37 61458 1,942.93 1,845.78 2,122.65 2,080.19 2,080.19 2,038.58 61460 2,046.44 1,944.12 2,235.74 2,191.03 2,191.03 2,147.21 61480 1,577.88 1,498.99 1,723.84 1,689.36 1,689.36 1,655.57 61500 1,276.20 1,212.39 1,394.25 1,366.36 1,366.36 1,339.04 61501 1,112.12 1,056.51 1,214.99 1,190.69 1,190.69 1,166.87 61510 2,112.22 2,006.61 2,307.60 2,261.45 2,261.45 2,216.22 61512 2,469.05 2,345.60 2,697.44 2,643.49 2,643.49 2,590.63 61514 1,837.96 1,746.06 2,007.97 1,967.81 1,967.81 1,928.46 61516 1,794.28 1,704.57 1,960.26 1,921.05 1,921.05 1,882.63 61517 85.93 81.63 93.87 92.00 92.00 90.16 61518 2,669.07 2,535.62 2,915.96 2,857.65 2,857.65 2,800.49 61519 2,841.83 2,699.74 3,104.70 3,042.61 3,042.61 2,981.77

Page 141: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 141Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

61520 3,659.99 3,476.99 3,998.54 3,918.57 3,918.57 3,840.20 61521 3,057.27 2,904.41 3,340.07 3,273.27 3,273.27 3,207.80 61522 2,101.33 1,996.26 2,295.70 2,249.78 2,249.78 2,204.78 61524 2,004.72 1,904.48 2,190.15 2,146.35 2,146.35 2,103.42 61526 3,559.17 3,381.21 3,888.39 3,810.63 3,810.63 3,734.42 61530 2,999.80 2,849.81 3,277.28 3,211.73 3,211.73 3,147.49 61531 1,172.61 1,113.98 1,281.08 1,255.46 1,255.46 1,230.35 61533 1,469.67 1,396.19 1,605.62 1,573.51 1,573.51 1,542.04 61534 1,571.61 1,493.03 1,716.98 1,682.65 1,682.65 1,649.00 61535 957.66 909.78 1,046.25 1,025.32 1,025.32 1,004.81 61536 2,512.03 2,386.43 2,744.39 2,689.51 2,689.51 2,635.72 61537 2,388.10 2,268.70 2,609.01 2,556.83 2,556.83 2,505.69 61538 2,596.62 2,466.79 2,836.81 2,780.07 2,780.07 2,724.47 61539 2,275.69 2,161.91 2,486.20 2,436.47 2,436.47 2,387.75 61540 2,123.26 2,017.10 2,319.67 2,273.27 2,273.27 2,227.80 61541 2,089.75 1,985.26 2,283.05 2,237.38 2,237.38 2,192.64 61543 2,054.82 1,952.08 2,244.89 2,200.00 2,200.00 2,156.00 61544 1,849.85 1,757.36 2,020.96 1,980.54 1,980.54 1,940.94 61545 3,100.52 2,945.49 3,387.31 3,319.57 3,319.57 3,253.18 61546 2,245.39 2,133.12 2,453.09 2,404.03 2,404.03 2,355.95 61548 1,522.97 1,446.82 1,663.84 1,630.56 1,630.56 1,597.95 61550 936.63 889.80 1,023.27 1,002.80 1,002.80 982.74 61552 1,133.59 1,076.91 1,238.45 1,213.68 1,213.68 1,189.40 61556 1,531.11 1,454.55 1,672.73 1,639.28 1,639.28 1,606.49 61557 1,549.01 1,471.56 1,692.29 1,658.45 1,658.45 1,625.28 61558 1,823.17 1,732.01 1,991.81 1,951.98 1,951.98 1,912.93 61559 2,050.54 1,948.01 2,240.21 2,195.41 2,195.41 2,151.50 61563 1,851.13 1,758.57 2,022.36 1,981.91 1,981.91 1,942.27 61564 2,241.65 2,129.57 2,449.01 2,400.03 2,400.03 2,352.03 61566 2,176.45 2,067.63 2,377.77 2,330.22 2,330.22 2,283.61 61567 2,493.01 2,368.36 2,723.61 2,669.14 2,669.14 2,615.76 61570 1,805.03 1,714.78 1,972.00 1,932.55 1,932.55 1,893.90 61571 1,924.12 1,827.91 2,102.10 2,060.05 2,060.05 2,018.85 61575 2,095.80 1,991.01 2,289.66 2,243.87 2,243.87 2,199.00 61576 3,511.76 3,336.17 3,836.60 3,759.87 3,759.87 3,684.67 61580 2,409.88 2,289.39 2,632.80 2,580.14 2,580.14 2,528.54 61581 2,569.13 2,440.67 2,806.77 2,750.64 2,750.64 2,695.62 61582 2,769.38 2,630.91 3,025.55 2,965.03 2,965.03 2,905.73 61583 2,781.25 2,642.19 3,038.52 2,977.75 2,977.75 2,918.19 61584 2,744.17 2,606.96 2,998.00 2,938.04 2,938.04 2,879.28 61585 3,105.04 2,949.79 3,392.26 3,324.41 3,324.41 3,257.92 61586 2,294.66 2,179.93 2,506.92 2,456.78 2,456.78 2,407.64 61590 2,952.15 2,804.54 3,225.22 3,160.72 3,160.72 3,097.50 61591 3,004.41 2,854.19 3,282.32 3,216.68 3,216.68 3,152.35 61592 3,056.80 2,903.96 3,339.55 3,272.76 3,272.76 3,207.30 61595 2,278.57 2,164.64 2,489.34 2,439.55 2,439.55 2,390.76 61596 2,370.46 2,251.94 2,589.73 2,537.94 2,537.94 2,487.17 61597 2,723.07 2,586.92 2,974.96 2,915.46 2,915.46 2,857.15 61598 2,725.15 2,588.89 2,977.22 2,917.68 2,917.68 2,859.33

Page 142: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 142Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

61600 2,059.00 1,956.05 2,249.46 2,204.47 2,204.47 2,160.38 61601 2,320.29 2,204.28 2,534.92 2,484.22 2,484.22 2,434.54 61605 2,103.78 1,998.59 2,298.38 2,252.41 2,252.41 2,207.37 61606 2,878.79 2,734.85 3,145.08 3,082.17 3,082.17 3,020.53 61607 2,630.35 2,498.83 2,873.65 2,816.18 2,816.18 2,759.85 61608 3,136.36 2,979.54 3,426.47 3,357.94 3,357.94 3,290.78 61610 1,529.28 1,452.82 1,670.74 1,637.32 1,637.32 1,604.57 61611 382.42 363.30 417.80 409.43 409.43 401.25 61612 1,437.12 1,365.26 1,570.05 1,538.64 1,538.64 1,507.87 61613 3,113.96 2,958.26 3,402.00 3,333.95 3,333.95 3,267.28 61615 2,209.97 2,099.47 2,414.39 2,366.10 2,366.10 2,318.78 61616 3,217.29 3,056.43 3,514.89 3,444.60 3,444.60 3,375.70 61618 1,253.99 1,191.29 1,369.98 1,342.58 1,342.58 1,315.73 61619 1,400.42 1,330.40 1,529.96 1,499.36 1,499.36 1,469.37 61623 555.73 527.94 607.13 594.99 594.99 583.08 61624 1,116.75 1,060.91 1,220.05 1,195.64 1,195.64 1,171.74 61626 849.66 807.18 928.26 909.70 909.70 891.50 61630 1,294.18 1,229.47 1,413.89 1,385.61 1,385.61 1,357.90 61635 1,393.01 1,323.36 1,521.86 1,491.42 1,491.42 1,461.59 61645 765.65 727.37 836.48 819.74 819.74 803.34 61650 511.35 485.78 558.65 547.47 547.47 536.52 61651 217.17 206.31 237.26 232.51 232.51 227.86 61680 2,171.63 2,063.05 2,372.51 2,325.06 2,325.06 2,278.55 61682 4,046.28 3,843.97 4,420.57 4,332.15 4,332.15 4,245.51 61684 2,770.59 2,632.06 3,026.87 2,966.33 2,966.33 2,907.00 61686 4,359.90 4,141.91 4,763.20 4,667.93 4,667.93 4,574.57 61690 2,099.49 1,994.52 2,293.70 2,247.82 2,247.82 2,202.87 61692 3,542.97 3,365.82 3,870.69 3,793.28 3,793.28 3,717.41 61697 4,106.42 3,901.10 4,486.27 4,396.54 4,396.54 4,308.61 61698 4,503.12 4,277.96 4,919.65 4,821.26 4,821.26 4,724.83 61700 3,301.80 3,136.71 3,607.22 3,535.08 3,535.08 3,464.38 61702 3,900.16 3,705.15 4,260.92 4,175.71 4,175.71 4,092.19 61703 1,317.15 1,251.29 1,438.98 1,410.20 1,410.20 1,381.99 61705 2,492.69 2,368.06 2,723.27 2,668.81 2,668.81 2,615.43 61708 2,072.16 1,968.55 2,263.83 2,218.56 2,218.56 2,174.19 61710 2,094.38 1,989.66 2,288.11 2,242.35 2,242.35 2,197.50 61711 2,516.62 2,390.79 2,749.41 2,694.42 2,694.42 2,640.53 61720 1,231.32 1,169.75 1,345.21 1,318.31 1,318.31 1,291.94 61735 1,524.82 1,448.58 1,665.87 1,632.55 1,632.55 1,599.90 61750 1,360.41 1,292.39 1,486.25 1,456.52 1,456.52 1,427.39 61751 1,334.07 1,267.37 1,457.48 1,428.32 1,428.32 1,399.76 61760 1,534.93 1,458.18 1,676.91 1,643.37 1,643.37 1,610.51 61770 1,568.35 1,489.93 1,713.42 1,679.15 1,679.15 1,645.57 61781 230.43 218.91 251.75 246.71 246.71 241.78 61782 172.76 164.12 188.74 184.97 184.97 181.26 61783 227.39 216.02 248.42 243.46 243.46 238.59 61790 848.59 806.16 927.08 908.55 908.55 890.38 61791 1,034.97 983.22 1,130.70 1,108.09 1,108.09 1,085.93 61796 980.71 931.67 1,071.42 1,050.00 1,050.00 1,029.00

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 143Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

61797 216.17 205.36 236.16 231.44 231.44 226.81 61798 1,341.21 1,274.15 1,465.27 1,435.97 1,435.97 1,407.26 61799 297.92 283.02 325.47 318.96 318.96 312.58 61800 150.14 142.63 164.02 160.75 160.75 157.53 61850 949.69 902.21 1,037.54 1,016.80 1,016.80 996.46 61860 1,520.11 1,444.10 1,660.72 1,627.50 1,627.50 1,594.96 61863 1,450.46 1,377.94 1,584.63 1,552.94 1,552.94 1,521.88 61864 278.70 264.77 304.49 298.39 298.39 292.42 61867 2,208.70 2,098.27 2,413.01 2,364.75 2,364.75 2,317.45 61868 488.91 464.46 534.13 523.45 523.45 512.98 61870 1,109.67 1,054.19 1,212.32 1,188.08 1,188.08 1,164.32 61880 546.24 518.93 596.77 584.83 584.83 573.14 61885 491.66 467.08 537.14 526.40 526.40 515.88 61886 806.13 765.82 880.69 863.08 863.08 845.81 61888 380.77 361.73 415.99 407.68 407.68 399.52 62000 996.35 946.53 1,088.51 1,066.74 1,066.74 1,045.41 62005 1,201.25 1,141.19 1,312.37 1,286.13 1,286.13 1,260.40 62010 1,478.08 1,404.18 1,614.81 1,582.52 1,582.52 1,550.87 62100 1,545.97 1,468.67 1,688.97 1,655.20 1,655.20 1,622.09 62115 1,277.47 1,213.60 1,395.64 1,367.73 1,367.73 1,340.37 62117 1,595.38 1,515.61 1,742.95 1,708.10 1,708.10 1,673.93 62120 1,611.31 1,530.74 1,760.35 1,725.15 1,725.15 1,690.65 62121 1,541.83 1,464.74 1,684.45 1,650.77 1,650.77 1,617.75 62140 996.79 946.95 1,088.99 1,067.21 1,067.21 1,045.87 62141 1,097.98 1,043.08 1,199.54 1,175.55 1,175.55 1,152.05 62142 853.12 810.46 932.03 913.39 913.39 895.13 62143 1,000.24 950.23 1,092.76 1,070.91 1,070.91 1,049.50 62145 1,363.69 1,295.51 1,489.84 1,460.04 1,460.04 1,430.84 62146 1,199.92 1,139.92 1,310.91 1,284.69 1,284.69 1,259.00 62147 1,371.92 1,303.32 1,498.82 1,468.84 1,468.84 1,439.47 62148 124.58 118.35 136.10 133.38 133.38 130.71 62160 186.42 177.10 203.67 199.59 199.59 195.60 62161 1,469.72 1,396.23 1,605.66 1,573.56 1,573.56 1,542.08 62162 1,827.36 1,735.99 1,996.39 1,956.46 1,956.46 1,917.33 62163 1,079.38 1,025.41 1,179.22 1,155.64 1,155.64 1,132.52 62164 2,010.54 1,910.01 2,196.51 2,152.58 2,152.58 2,109.53 62165 1,497.93 1,423.03 1,636.48 1,603.76 1,603.76 1,571.68 62180 1,544.29 1,467.08 1,687.14 1,653.40 1,653.40 1,620.34 62190 850.74 808.20 929.43 910.85 910.85 892.63 62192 940.43 893.41 1,027.42 1,006.87 1,006.87 986.73 62194 443.08 420.93 484.07 474.39 474.39 464.90 62200 1,331.01 1,264.46 1,454.13 1,425.05 1,425.05 1,396.55 62201 1,162.91 1,104.76 1,270.47 1,245.06 1,245.06 1,220.16 62220 992.26 942.65 1,084.05 1,062.37 1,062.37 1,041.12 62223 1,009.02 958.57 1,102.36 1,080.31 1,080.31 1,058.70 62225 500.95 475.90 547.29 536.34 536.34 525.61 62230 811.59 771.01 886.66 868.93 868.93 851.55 62252 79.71 75.72 87.08 85.34 85.34 83.64 62252 TC 34.32 32.60 37.49 36.74 36.74 36.01

Page 144: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 144Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

62252 26 45.39 43.12 49.59 48.60 48.60 47.62 62256 572.35 543.73 625.29 612.79 612.79 600.53 62258 1,086.50 1,032.18 1,187.01 1,163.27 1,163.27 1,140.01 62263 602.84 572.70 658.61 645.44 645.44 632.53 # 62263 327.16 310.80 357.42 350.27 350.27 343.26 62264 395.74 375.95 432.34 423.69 423.69 415.22 # 62264 234.01 222.31 255.66 250.54 250.54 245.53 62267 234.99 223.24 256.73 251.60 251.60 246.56 # 62267 156.93 149.08 171.44 168.02 168.02 164.66 62268 253.94 241.24 277.43 271.88 271.88 266.44 62269 265.51 252.23 290.06 284.27 284.27 278.59 62270 147.50 140.13 161.15 157.93 157.93 154.77 # 62270 76.00 72.20 83.03 81.37 81.37 79.74 62272 185.19 175.93 202.32 198.27 198.27 194.30 # 62272 80.92 76.87 88.40 86.63 86.63 84.89 62273 163.88 155.69 179.04 175.47 175.47 171.96 # 62273 111.74 106.15 122.07 119.63 119.63 117.24 62280 283.71 269.52 309.95 303.75 303.75 297.68 # 62280 156.32 148.50 170.78 167.36 167.36 164.01 62281 226.06 214.76 246.97 242.03 242.03 237.19 # 62281 152.69 145.06 166.82 163.48 163.48 160.22 62282 270.89 257.35 295.95 290.03 290.03 284.23 # 62282 140.70 133.67 153.72 150.65 150.65 147.64 62284 168.97 160.52 184.60 180.91 180.91 177.28 # 62284 84.05 79.85 91.83 89.99 89.99 88.19 62287 549.69 522.21 600.54 588.54 588.54 576.76 62290 310.49 294.97 339.22 332.43 332.43 325.78 # 62290 168.43 160.01 184.01 180.33 180.33 176.72 62291 307.38 292.01 335.81 329.10 329.10 322.52 # 62291 166.57 158.24 181.98 178.34 178.34 174.78 62292 563.89 535.70 616.06 603.74 603.74 591.66 62294 763.36 725.19 833.97 817.29 817.29 800.95 62302 224.72 213.48 245.50 240.59 240.59 235.78 # 62302 120.44 114.42 131.58 128.95 128.95 126.37 62303 233.15 221.49 254.71 249.62 249.62 244.63 # 62303 122.31 116.19 133.62 130.95 130.95 128.33 62304 222.35 211.23 242.91 238.06 238.06 233.30 # 62304 118.70 112.77 129.69 127.09 127.09 124.55 62305 241.85 229.76 264.22 258.93 258.93 253.76 # 62305 123.84 117.65 135.30 132.60 132.60 129.94 62310 222.18 211.07 242.73 237.88 237.88 233.12 # 62310 106.04 100.74 115.85 113.54 113.54 111.27 62311 203.99 193.79 222.86 218.40 218.40 214.03 # 62311 87.22 82.86 95.29 93.38 93.38 91.52 62318 213.72 203.03 233.48 228.82 228.82 224.24 # 62318 98.20 93.29 107.28 105.13 105.13 103.03 62319 157.68 149.80 172.27 168.82 168.82 165.44 # 62319 94.30 89.59 103.03 100.97 100.97 98.95 62350 387.38 368.01 423.21 414.75 414.75 406.46

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 145Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

62351 833.38 791.71 910.47 892.26 892.26 874.41 62355 257.73 244.84 281.57 275.93 275.93 270.41 62360 299.44 284.47 327.14 320.60 320.60 314.18 62361 345.47 328.20 377.43 369.89 369.89 362.49 62362 372.58 353.95 407.04 398.90 398.90 390.92 62365 284.26 270.05 310.56 304.35 304.35 298.26 62367 38.90 36.96 42.50 41.65 41.65 40.83 # 62367 24.85 23.61 27.15 26.61 26.61 26.08 62368 53.46 50.79 58.41 57.24 57.24 56.09 # 62368 34.72 32.98 37.93 37.17 37.17 36.42 62369 109.97 104.47 120.14 117.74 117.74 115.38 # 62369 35.04 33.29 38.28 37.51 37.51 36.77 62370 116.59 110.76 127.37 124.82 124.82 122.33 # 62370 46.03 43.73 50.29 49.29 49.29 48.30 63001 1,197.67 1,137.79 1,308.46 1,282.28 1,282.28 1,256.64 63003 1,192.85 1,133.21 1,303.19 1,277.13 1,277.13 1,251.59 63005 1,136.71 1,079.87 1,241.85 1,217.01 1,217.01 1,192.67 63011 1,054.75 1,002.01 1,152.31 1,129.27 1,129.27 1,106.68 63012 1,146.66 1,089.33 1,252.73 1,227.67 1,227.67 1,203.12 63015 1,431.15 1,359.59 1,563.53 1,532.26 1,532.26 1,501.61 63016 1,466.51 1,393.18 1,602.16 1,570.12 1,570.12 1,538.71 63017 1,205.97 1,145.67 1,317.52 1,291.17 1,291.17 1,265.35 63020 1,116.36 1,060.54 1,219.62 1,195.23 1,195.23 1,171.32 63030 929.28 882.82 1,015.24 994.93 994.93 975.04 63035 187.00 177.65 204.30 200.22 200.22 196.21 63040 1,343.19 1,276.03 1,467.43 1,438.09 1,438.09 1,409.33 63042 1,248.42 1,186.00 1,363.90 1,336.62 1,336.62 1,309.88 63043 293.84 279.15 321.02 314.61 314.61 308.32 63044 293.84 279.15 321.02 314.61 314.61 308.32 63045 1,241.00 1,178.95 1,355.79 1,328.68 1,328.68 1,302.10 63046 1,175.57 1,116.79 1,284.31 1,258.62 1,258.62 1,233.44 63047 1,060.43 1,007.41 1,158.52 1,135.35 1,135.35 1,112.64 63048 206.55 196.22 225.65 221.15 221.15 216.72 63050 1,439.07 1,367.12 1,572.19 1,540.75 1,540.75 1,509.93 63051 1,653.17 1,570.51 1,806.09 1,769.97 1,769.97 1,734.57 63055 1,572.64 1,494.01 1,718.11 1,683.75 1,683.75 1,650.08 63056 1,431.59 1,360.01 1,564.01 1,532.73 1,532.73 1,502.07 63057 312.51 296.88 341.41 334.58 334.58 327.89 63064 1,710.26 1,624.75 1,868.46 1,831.10 1,831.10 1,794.47 63066 202.89 192.75 221.66 217.24 217.24 212.89 63075 1,307.71 1,242.32 1,428.67 1,400.09 1,400.09 1,372.09 63076 241.00 228.95 263.29 258.03 258.03 252.86 63077 1,451.57 1,378.99 1,585.84 1,554.12 1,554.12 1,523.04 63078 189.51 180.03 207.03 202.89 202.89 198.84 63081 1,699.06 1,614.11 1,856.23 1,819.10 1,819.10 1,782.72 63082 260.07 247.07 284.13 278.45 278.45 272.88 63085 1,850.71 1,758.17 2,021.90 1,981.46 1,981.46 1,941.83 63086 185.93 176.63 203.12 199.07 199.07 195.09 63087 2,332.95 2,216.30 2,548.75 2,497.77 2,497.77 2,447.81

Page 146: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 146Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

63088 253.38 240.71 276.82 271.29 271.29 265.86 63090 1,894.72 1,799.98 2,069.98 2,028.58 2,028.58 1,988.01 63091 173.06 164.41 189.07 185.29 185.29 181.59 63101 2,236.75 2,124.91 2,443.65 2,394.77 2,394.77 2,346.87 63102 2,196.51 2,086.68 2,399.68 2,351.69 2,351.69 2,304.66 63103 286.28 271.97 312.77 306.51 306.51 300.38 63170 1,544.91 1,467.66 1,687.81 1,654.06 1,654.06 1,620.97 63172 1,340.17 1,273.16 1,464.13 1,434.86 1,434.86 1,406.16 63173 1,656.53 1,573.70 1,809.76 1,773.56 1,773.56 1,738.10 63180 1,440.17 1,368.16 1,573.38 1,541.92 1,541.92 1,511.08 63182 1,352.96 1,285.31 1,478.11 1,448.54 1,448.54 1,419.57 63185 1,093.58 1,038.90 1,194.74 1,170.84 1,170.84 1,147.42 63190 1,216.88 1,156.04 1,329.45 1,302.86 1,302.86 1,276.80 63191 1,308.60 1,243.17 1,429.65 1,401.06 1,401.06 1,373.03 63194 1,548.60 1,471.17 1,691.85 1,658.01 1,658.01 1,624.86 63195 1,492.07 1,417.47 1,630.09 1,597.49 1,597.49 1,565.54 63196 1,381.98 1,312.88 1,509.81 1,479.61 1,479.61 1,450.02 63197 1,661.23 1,578.17 1,814.90 1,778.60 1,778.60 1,743.03 63198 1,628.13 1,546.72 1,778.73 1,743.16 1,743.16 1,708.29 63199 1,709.05 1,623.60 1,867.14 1,829.80 1,829.80 1,793.21 63200 1,480.01 1,406.01 1,616.91 1,584.57 1,584.57 1,552.88 63250 2,732.54 2,595.91 2,985.30 2,925.59 2,925.59 2,867.08 63251 2,949.04 2,801.59 3,221.83 3,157.39 3,157.39 3,094.25 63252 2,945.75 2,798.46 3,218.23 3,153.86 3,153.86 3,090.79 63265 1,612.80 1,532.16 1,761.98 1,726.75 1,726.75 1,692.21 63266 1,658.97 1,576.02 1,812.42 1,776.18 1,776.18 1,740.65 63267 1,320.37 1,254.35 1,442.50 1,413.65 1,413.65 1,385.37 63268 1,383.59 1,314.41 1,511.57 1,481.34 1,481.34 1,451.71 63270 2,015.02 1,914.27 2,201.41 2,157.38 2,157.38 2,114.23 63271 1,999.20 1,899.24 2,184.13 2,140.45 2,140.45 2,097.63 63272 1,825.37 1,734.10 1,994.22 1,954.33 1,954.33 1,915.24 63273 1,802.69 1,712.56 1,969.44 1,930.06 1,930.06 1,891.45 63275 1,737.62 1,650.74 1,898.35 1,860.39 1,860.39 1,823.19 63276 1,724.51 1,638.28 1,884.02 1,846.34 1,846.34 1,809.41 63277 1,496.58 1,421.75 1,635.01 1,602.32 1,602.32 1,570.27 63278 1,540.86 1,463.82 1,683.39 1,649.72 1,649.72 1,616.73 63280 2,043.36 1,941.19 2,232.37 2,187.73 2,187.73 2,143.97 63281 2,018.49 1,917.57 2,205.21 2,161.10 2,161.10 2,117.89 63282 1,899.77 1,804.78 2,075.50 2,033.98 2,033.98 1,993.31 63283 1,825.97 1,734.67 1,994.87 1,954.98 1,954.98 1,915.88 63285 2,540.95 2,413.90 2,775.99 2,720.46 2,720.46 2,666.06 63286 2,503.35 2,378.18 2,734.91 2,680.21 2,680.21 2,626.61 63287 2,673.75 2,540.06 2,921.07 2,862.65 2,862.65 2,805.39 63290 2,675.89 2,542.10 2,923.42 2,864.95 2,864.95 2,807.64 63295 325.66 309.38 355.79 348.67 348.67 341.70 63300 1,776.09 1,687.29 1,940.38 1,901.57 1,901.57 1,863.54 63301 2,134.80 2,028.06 2,332.27 2,285.63 2,285.63 2,239.91 63302 2,102.47 1,997.35 2,296.95 2,251.01 2,251.01 2,205.99 63303 2,238.02 2,126.12 2,445.04 2,396.14 2,396.14 2,348.22

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 147Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

63304 2,260.19 2,147.18 2,469.26 2,419.88 2,419.88 2,371.48 63305 2,353.19 2,235.53 2,570.86 2,519.44 2,519.44 2,469.05 63306 2,240.45 2,128.43 2,447.69 2,398.74 2,398.74 2,350.76 63307 2,239.94 2,127.94 2,447.13 2,398.19 2,398.19 2,350.22 63308 316.48 300.66 345.76 338.85 338.85 332.07 63600 882.96 838.81 964.63 945.33 945.33 926.43 63610 423.36 402.19 462.52 453.27 453.27 444.21 63615 953.91 906.21 1,042.14 1,021.30 1,021.30 1,000.88 63620 1,080.66 1,026.63 1,180.62 1,157.02 1,157.02 1,133.88 63621 248.57 236.14 271.56 266.13 266.13 260.81 63650 1,213.59 1,152.91 1,325.85 1,299.33 1,299.33 1,273.34 # 63650 403.39 383.22 440.70 431.89 431.89 423.26 63655 791.79 752.20 865.03 847.73 847.73 830.78 63661 538.89 511.95 588.74 576.97 576.97 565.43 # 63661 311.29 295.73 340.09 333.29 333.29 326.62 63662 798.66 758.73 872.54 855.09 855.09 837.99 63663 739.72 702.73 808.14 791.98 791.98 776.15 # 63663 441.56 419.48 482.40 472.75 472.75 463.30 63664 823.87 782.68 900.08 882.08 882.08 864.44 63685 352.84 335.20 385.48 377.78 377.78 370.22 63688 355.87 338.08 388.79 381.02 381.02 373.39 63700 1,125.23 1,068.97 1,229.32 1,204.73 1,204.73 1,180.64 63702 1,229.72 1,168.23 1,343.46 1,316.60 1,316.60 1,290.27 63704 1,596.25 1,516.44 1,743.91 1,709.03 1,709.03 1,674.85 63706 1,639.49 1,557.52 1,791.15 1,755.33 1,755.33 1,720.22 63707 882.88 838.74 964.55 945.27 945.27 926.36 63709 1,060.04 1,007.04 1,158.10 1,134.94 1,134.94 1,112.23 63710 1,043.50 991.33 1,140.03 1,117.23 1,117.23 1,094.88 63740 906.38 861.06 990.22 970.42 970.42 951.00 63741 649.56 617.08 709.64 695.45 695.45 681.55 63744 645.51 613.23 705.21 691.12 691.12 677.29 63746 575.93 547.13 629.20 616.62 616.62 604.29 64400 117.81 111.92 128.71 126.13 126.13 123.61 # 64400 68.17 64.76 74.47 72.98 72.98 71.52 64402 120.84 114.80 132.02 129.38 129.38 126.79 # 64402 75.57 71.79 82.56 80.90 80.90 79.28 64405 93.70 89.02 102.37 100.33 100.33 98.33 # 64405 60.61 57.58 66.22 64.89 64.89 63.60 64408 96.99 92.14 105.96 103.85 103.85 101.76 # 64408 72.94 69.29 79.68 78.09 78.09 76.52 64410 114.90 109.16 125.53 123.03 123.03 120.57 # 64410 68.69 65.26 75.05 73.54 73.54 72.07 64413 118.60 112.67 129.57 126.98 126.98 124.44 # 64413 78.64 74.71 85.92 84.20 84.20 82.52 64415 111.36 105.79 121.66 119.22 119.22 116.84 # 64415 64.84 61.60 70.84 69.43 69.43 68.03 64416 78.47 74.55 85.73 84.02 84.02 82.34 64417 121.14 115.08 132.34 129.70 129.70 127.10 # 64417 69.93 66.43 76.39 74.87 74.87 73.37

Page 148: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 148Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

64418 134.92 128.17 147.40 144.45 144.45 141.57 # 64418 74.04 70.34 80.89 79.27 79.27 77.68 64420 105.01 99.76 114.72 112.42 112.42 110.17 # 64420 66.30 62.99 72.44 70.99 70.99 69.58 64421 141.25 134.19 154.32 151.24 151.24 148.21 # 64421 89.74 85.25 98.04 96.08 96.08 94.16 64425 124.92 118.67 136.47 133.75 133.75 131.07 # 64425 91.20 86.64 99.64 97.65 97.65 95.69 64430 129.29 122.83 141.25 138.43 138.43 135.65 # 64430 79.96 75.96 87.35 85.61 85.61 83.89 64435 127.00 120.65 138.75 135.98 135.98 133.26 # 64435 80.80 76.76 88.27 86.50 86.50 84.78 64445 127.17 120.81 138.93 136.15 136.15 133.42 # 64445 71.28 67.72 77.88 76.33 76.33 74.80 64446 78.78 74.84 86.07 84.34 84.34 82.65 64447 113.01 107.36 123.46 120.99 120.99 118.58 # 64447 65.86 62.57 71.96 70.52 70.52 69.10 64448 70.80 67.26 77.35 75.80 75.80 74.28 64449 83.07 78.92 90.76 88.94 88.94 87.16 64450 74.12 70.41 80.97 79.35 79.35 77.76 # 64450 44.14 41.93 48.22 47.25 47.25 46.31 64455 45.73 43.44 49.96 48.96 48.96 47.98 # 64455 34.49 32.77 37.69 36.93 36.93 36.19 64461 139.33 132.36 152.21 149.17 149.17 146.19 # 64461 85.32 81.05 93.21 91.34 91.34 89.52 64462 79.38 75.41 86.72 84.99 84.99 83.28 # 64462 53.78 51.09 58.75 57.58 57.58 56.43 64463 151.22 143.66 165.21 161.91 161.91 158.67 # 64463 83.15 78.99 90.84 89.02 89.02 87.24 64479 219.75 208.76 240.07 235.27 235.27 230.56 # 64479 128.90 122.46 140.83 138.01 138.01 135.25 64480 105.73 100.44 115.51 113.19 113.19 110.93 # 64480 62.02 58.92 67.76 66.40 66.40 65.08 64483 203.71 193.52 222.55 218.10 218.10 213.74 # 64483 109.74 104.25 119.89 117.50 117.50 115.15 64484 82.42 78.30 90.05 88.24 88.24 86.48 # 64484 51.19 48.63 55.92 54.81 54.81 53.72 64486 116.01 110.21 126.74 124.21 124.21 121.73 # 64486 62.31 59.19 68.07 66.71 66.71 65.38 64487 142.49 135.37 155.68 152.56 152.56 149.51 # 64487 72.87 69.23 79.61 78.03 78.03 76.46 64488 143.33 136.16 156.58 153.46 153.46 150.39 # 64488 78.70 74.77 85.99 84.26 84.26 82.57 64489 197.58 187.70 215.86 211.54 211.54 207.31 # 64489 88.62 84.19 96.82 94.89 94.89 92.99 64490 177.43 168.56 193.84 189.97 189.97 186.17 # 64490 103.75 98.56 113.34 111.08 111.08 108.86 64491 88.71 84.27 96.91 94.97 94.97 93.07 # 64491 59.37 56.40 64.86 63.56 63.56 62.28

Page 149: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 149Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

64492 89.03 84.58 97.27 95.32 95.32 93.41 # 64492 59.99 56.99 65.54 64.23 64.23 62.94 64493 160.50 152.48 175.35 171.84 171.84 168.41 # 64493 88.69 84.26 96.90 94.96 94.96 93.06 64494 81.45 77.38 88.99 87.20 87.20 85.46 # 64494 51.17 48.61 55.90 54.79 54.79 53.69 64495 81.76 77.67 89.32 87.54 87.54 85.79 # 64495 51.79 49.20 56.58 55.45 55.45 54.35 64505 98.86 93.92 108.01 105.85 105.85 103.73 # 64505 83.87 79.68 91.63 89.80 89.80 88.01 64508 60.32 57.30 65.90 64.57 64.57 63.28 # 64508 70.62 67.09 77.15 75.61 75.61 74.11 64510 118.34 112.42 129.28 126.70 126.70 124.17 # 64510 71.50 67.93 78.12 76.56 76.56 75.03 64517 171.65 163.07 187.53 183.78 183.78 180.10 # 64517 119.51 113.53 130.56 127.95 127.95 125.38 64520 171.33 162.76 187.17 183.43 183.43 179.76 # 64520 78.60 74.67 85.87 84.16 84.16 82.48 64530 176.41 167.59 192.73 188.88 188.88 185.10 # 64530 89.62 85.14 97.91 95.96 95.96 94.04 64550 14.85 14.11 16.23 15.90 15.90 15.58 # 64550 8.60 8.17 9.40 9.21 9.21 9.03 64553 196.00 186.20 214.13 209.85 209.85 205.65 # 64553 150.11 142.60 163.99 160.71 160.71 157.50 64555 197.61 187.73 215.89 211.58 211.58 207.35 # 64555 147.34 139.97 160.97 157.75 157.75 154.59 64561 748.18 710.77 817.39 801.03 801.03 785.01 # 64561 294.54 279.81 321.78 315.34 315.34 309.04 64565 175.94 167.14 192.21 188.37 188.37 184.60 # 64565 125.68 119.40 137.31 134.56 134.56 131.87 64566 114.95 109.20 125.58 123.07 123.07 120.61 # 64566 30.03 28.53 32.81 32.15 32.15 31.51 64568 629.69 598.21 687.94 674.19 674.19 660.71 64569 752.76 715.12 822.39 805.94 805.94 789.82 64570 624.49 593.27 682.26 668.61 668.61 655.24 64575 304.81 289.57 333.01 326.35 326.35 319.82 64580 288.70 274.27 315.41 309.10 309.10 302.91 64581 646.74 614.40 706.56 692.43 692.43 678.58 64585 226.25 214.94 247.18 242.24 242.24 237.39 # 64585 137.27 130.41 149.97 146.97 146.97 144.03 64590 245.47 233.20 268.18 262.82 262.82 257.57 # 64590 154.30 146.59 168.58 165.21 165.21 161.91 64595 225.45 214.18 246.31 241.39 241.39 236.56 # 64595 120.86 114.82 132.04 129.40 129.40 126.81 64600 362.06 343.96 395.55 387.64 387.64 379.89 # 64600 211.58 201.00 231.15 226.53 226.53 222.00 64605 689.30 654.84 753.07 738.00 738.00 723.25 # 64605 392.69 373.06 429.02 420.44 420.44 412.03 64610 692.87 658.23 756.96 741.83 741.83 727.00

Page 150: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 150Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 64610 470.58 447.05 514.11 503.83 503.83 493.75 64611 108.24 102.83 118.25 115.89 115.89 113.56 # 64611 95.44 90.67 104.27 102.19 102.19 100.14 64612 123.31 117.14 134.71 132.02 132.02 129.38 # 64612 110.82 105.28 121.07 118.65 118.65 116.28 64615 136.03 129.23 148.61 145.65 145.65 142.74 # 64615 119.17 113.21 130.19 127.59 127.59 125.04 64616 118.63 112.70 129.61 127.02 127.02 124.48 # 64616 103.95 98.75 113.56 111.30 111.30 109.07 64617 182.23 173.12 199.09 195.11 195.11 191.21 # 64617 119.17 113.21 130.19 127.59 127.59 125.04 64620 194.29 184.58 212.27 208.02 208.02 203.86 # 64620 166.50 158.18 181.91 178.27 178.27 174.71 64630 220.02 209.02 240.37 235.57 235.57 230.85 # 64630 185.99 176.69 203.19 199.13 199.13 195.16 64632 81.28 77.22 88.80 87.03 87.03 85.30 # 64632 66.92 63.57 73.11 71.65 71.65 70.21 64633 393.27 373.61 429.65 421.06 421.06 412.64 # 64633 220.93 209.88 241.36 236.53 236.53 231.81 64634 174.97 166.22 191.15 187.34 187.34 183.59 # 64634 67.56 64.18 73.81 72.34 72.34 70.89 64635 388.65 369.22 424.60 416.12 416.12 407.79 # 64635 217.87 206.98 238.03 233.27 233.27 228.60 64636 158.99 151.04 173.70 170.22 170.22 166.82 # 64636 59.08 56.13 64.55 63.26 63.26 62.00 64640 123.69 117.51 135.14 132.43 132.43 129.79 # 64640 88.72 84.28 96.92 94.98 94.98 93.08 64642 132.96 126.31 145.26 142.35 142.35 139.50 # 64642 104.24 99.03 113.88 111.61 111.61 109.38 64643 87.92 83.52 96.05 94.13 94.13 92.24 # 64643 70.44 66.92 76.96 75.42 75.42 73.91 64644 152.39 144.77 166.49 163.15 163.15 159.88 # 64644 114.30 108.59 124.88 122.38 122.38 119.93 64645 107.58 102.20 117.53 115.18 115.18 112.88 # 64645 80.73 76.69 88.19 86.43 86.43 84.71 64646 141.32 134.25 154.39 151.31 151.31 148.28 # 64646 112.59 106.96 123.00 120.54 120.54 118.13 64647 166.87 158.53 182.31 178.66 178.66 175.09 # 64647 131.59 125.01 143.76 140.89 140.89 138.07 64650 71.54 67.96 78.15 76.59 76.59 75.06 # 64650 40.63 38.60 44.39 43.50 43.50 42.63 64653 89.51 85.03 97.78 95.83 95.83 93.91 # 64653 52.36 49.74 57.20 56.06 56.06 54.95 64680 286.89 272.55 313.43 307.17 307.17 301.02 # 64680 160.76 152.72 175.63 172.12 172.12 168.68 64681 321.22 305.16 350.93 343.92 343.92 337.04 # 64681 187.28 177.92 204.61 200.51 200.51 196.50 64702 472.49 448.87 516.20 505.87 505.87 495.75 64704 304.85 289.61 333.05 326.39 326.39 319.86

Page 151: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 151Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

64708 471.34 447.77 514.94 504.63 504.63 494.53 64712 548.20 520.79 598.91 586.93 586.93 575.18 64713 698.61 663.68 763.23 747.97 747.97 733.01 64714 619.45 588.48 676.75 663.22 663.22 649.96 64716 511.46 485.89 558.77 547.60 547.60 536.65 64718 559.36 531.39 611.10 598.87 598.87 586.89 64719 378.50 359.58 413.52 405.25 405.25 397.14 64721 404.30 384.09 441.70 432.87 432.87 424.21 # 64721 401.80 381.71 438.97 430.19 430.19 421.59 64722 351.04 333.49 383.51 375.84 375.84 368.32 64726 264.23 251.02 288.67 282.90 282.90 277.24 64727 178.82 169.88 195.36 191.45 191.45 187.62 64732 356.21 338.40 389.16 381.37 381.37 373.75 64734 394.06 374.36 430.51 421.90 421.90 413.46 64736 378.46 359.54 413.47 405.20 405.20 397.10 64738 406.94 386.59 444.58 435.69 435.69 426.97 64740 437.21 415.35 477.65 468.10 468.10 458.74 64742 464.96 441.71 507.97 497.81 497.81 487.85 64744 465.66 442.38 508.74 498.56 498.56 488.59 64746 430.63 409.10 470.47 461.06 461.06 451.84 64755 891.84 847.25 974.34 954.86 954.86 935.76 64760 485.16 460.90 530.04 519.43 519.43 509.05 64763 486.01 461.71 530.97 520.35 520.35 509.94 64766 580.04 551.04 633.70 621.02 621.02 608.60 64771 570.70 542.17 623.50 611.03 611.03 598.81 64772 535.38 508.61 584.90 573.21 573.21 561.74 64774 397.64 377.76 434.42 425.73 425.73 417.22 64776 374.62 355.89 409.27 401.09 401.09 393.06 64778 142.54 135.41 155.72 152.61 152.61 149.56 64782 434.81 413.07 475.03 465.53 465.53 456.22 64783 214.57 203.84 234.42 229.72 229.72 225.12 64784 699.65 664.67 764.37 749.09 749.09 734.10 64786 1,031.34 979.77 1,126.74 1,104.20 1,104.20 1,082.12 64787 236.99 225.14 258.91 253.74 253.74 248.66 64788 379.58 360.60 414.69 406.40 406.40 398.27 64790 804.02 763.82 878.39 860.82 860.82 843.61 64792 1,146.38 1,089.06 1,252.42 1,227.37 1,227.37 1,202.82 64795 185.83 176.54 203.02 198.96 198.96 194.98 64802 643.19 611.03 702.68 688.63 688.63 674.85 64804 964.39 916.17 1,053.60 1,032.53 1,032.53 1,011.87 64809 975.60 926.82 1,065.84 1,044.52 1,044.52 1,023.63 64818 600.18 570.17 655.70 642.59 642.59 629.73 64820 694.56 659.83 758.80 743.62 743.62 728.76 64821 655.56 622.78 716.20 701.87 701.87 687.83 64822 655.56 622.78 716.20 701.87 701.87 687.83 64823 747.43 710.06 816.57 800.24 800.24 784.23 64831 652.15 619.54 712.47 698.22 698.22 684.26 64832 327.83 311.44 358.16 350.99 350.99 343.98 64834 709.60 674.12 775.24 759.74 759.74 744.54

Page 152: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 152Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

64835 773.23 734.57 844.76 827.86 827.86 811.30 64836 775.67 736.89 847.42 830.47 830.47 813.87 64837 361.52 343.44 394.96 387.06 387.06 379.32 64840 968.41 919.99 1,057.99 1,036.83 1,036.83 1,016.09 64856 973.68 925.00 1,063.75 1,042.48 1,042.48 1,021.63 64857 1,013.21 962.55 1,106.93 1,084.80 1,084.80 1,063.09 64858 1,092.76 1,038.12 1,193.84 1,169.96 1,169.96 1,146.56 64859 245.83 233.54 268.57 263.20 263.20 257.93 64861 1,278.22 1,214.31 1,396.46 1,368.52 1,368.52 1,341.15 64862 1,474.26 1,400.55 1,610.63 1,578.42 1,578.42 1,546.85 64864 848.46 806.04 926.95 908.41 908.41 890.24 64865 1,083.79 1,029.60 1,184.04 1,160.36 1,160.36 1,137.15 64866 1,109.17 1,053.71 1,211.77 1,187.54 1,187.54 1,163.79 64868 977.72 928.83 1,068.15 1,046.79 1,046.79 1,025.86 64872 117.46 111.59 128.33 125.76 125.76 123.25 64874 167.34 158.97 182.82 179.16 179.16 175.57 64876 174.03 165.33 190.13 186.32 186.32 182.60 64885 1,109.24 1,053.78 1,211.85 1,187.61 1,187.61 1,163.86 64886 1,262.87 1,199.73 1,379.69 1,352.10 1,352.10 1,325.06 64890 1,048.30 995.89 1,145.27 1,122.37 1,122.37 1,099.92 64891 1,120.36 1,064.34 1,223.99 1,199.51 1,199.51 1,175.52 64892 1,004.19 953.98 1,097.08 1,075.14 1,075.14 1,053.63 64893 1,090.40 1,035.88 1,191.26 1,167.43 1,167.43 1,144.09 64895 1,286.83 1,222.49 1,405.86 1,377.75 1,377.75 1,350.19 64896 1,383.84 1,314.65 1,511.85 1,481.61 1,481.61 1,451.98 64897 1,199.99 1,139.99 1,310.99 1,284.77 1,284.77 1,259.08 64898 1,314.86 1,249.12 1,436.49 1,407.76 1,407.76 1,379.61 64901 548.22 520.81 598.93 586.95 586.95 575.21 64902 644.61 612.38 704.24 690.15 690.15 676.35 64905 986.89 937.55 1,078.18 1,056.62 1,056.62 1,035.48 64907 1,317.52 1,251.64 1,439.39 1,410.60 1,410.60 1,382.39 64910 787.12 747.76 859.92 842.72 842.72 825.86 64911 968.87 920.43 1,058.49 1,037.32 1,037.32 1,016.58 65091 592.23 562.62 647.01 634.08 634.08 621.39 65093 584.98 555.73 639.09 626.31 626.31 613.79 65101 687.32 652.95 750.89 735.87 735.87 721.15 65103 718.44 682.52 784.90 769.20 769.20 753.81 65105 792.81 753.17 866.15 848.83 848.83 831.85 65110 1,148.76 1,091.32 1,255.02 1,229.91 1,229.91 1,205.32 65112 1,336.17 1,269.36 1,459.76 1,430.57 1,430.57 1,401.95 65114 1,404.24 1,334.03 1,534.13 1,503.45 1,503.45 1,473.38 65125 417.31 396.44 455.91 446.79 446.79 437.85 # 65125 272.75 259.11 297.98 292.02 292.02 286.18 65130 682.56 648.43 745.69 730.78 730.78 716.16 65135 693.01 658.36 757.11 741.97 741.97 727.13 65140 753.92 716.22 823.65 807.19 807.19 791.04 65150 533.39 506.72 582.73 571.08 571.08 559.66 65155 790.75 751.21 863.89 846.62 846.62 829.69 65175 612.49 581.87 669.15 655.76 655.76 642.65

Page 153: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 153Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

65205 52.47 49.85 57.33 56.18 56.18 55.05 # 65205 42.17 40.06 46.07 45.15 45.15 44.24 65210 64.28 61.07 70.23 68.83 68.83 67.45 # 65210 50.86 48.32 55.57 54.45 54.45 53.36 65220 54.24 51.53 59.26 58.08 58.08 56.91 # 65220 40.50 38.48 44.25 43.37 43.37 42.50 65222 62.41 59.29 68.18 66.82 66.82 65.48 # 65222 49.92 47.42 54.53 53.44 53.44 52.37 65235 668.27 634.86 730.09 715.48 715.48 701.18 65260 903.87 858.68 987.48 967.74 967.74 948.38 65265 1,019.45 968.48 1,113.75 1,091.48 1,091.48 1,069.65 65270 243.62 231.44 266.16 260.83 260.83 255.61 # 65270 132.78 126.14 145.06 142.16 142.16 139.32 65272 463.27 440.11 506.13 496.01 496.01 486.08 # 65272 330.89 314.35 361.50 354.27 354.27 347.19 65273 359.79 341.80 393.07 385.20 385.20 377.50 65275 537.72 510.83 587.45 575.70 575.70 564.19 # 65275 436.56 414.73 476.94 467.41 467.41 458.06 65280 633.72 602.03 692.33 678.49 678.49 664.92 65285 1,047.97 995.57 1,144.91 1,122.01 1,122.01 1,099.57 65286 650.05 617.55 710.18 695.98 695.98 682.07 # 65286 467.72 444.33 510.98 500.76 500.76 490.74 65290 460.99 437.94 503.63 493.56 493.56 483.69 65400 632.93 601.28 691.47 677.64 677.64 664.09 # 65400 566.43 538.11 618.83 606.45 606.45 594.32 65410 132.57 125.94 144.83 141.93 141.93 139.09 # 65410 98.85 93.91 108.00 105.83 105.83 103.72 65420 474.31 450.59 518.18 507.82 507.82 497.66 # 65420 353.17 335.51 385.84 378.12 378.12 370.55 65426 601.61 571.53 657.26 644.12 644.12 631.24 # 65426 449.88 427.39 491.50 481.67 481.67 472.03 65430 107.31 101.94 117.23 114.89 114.89 112.59 # 65430 97.94 93.04 107.00 104.86 104.86 102.76 65435 74.30 70.59 81.18 79.56 79.56 77.97 # 65435 65.56 62.28 71.62 70.18 70.18 68.78 65436 363.62 345.44 397.26 389.31 389.31 381.52 # 65436 350.20 332.69 382.59 374.95 374.95 367.45 65450 302.11 287.00 330.05 323.45 323.45 316.97 # 65450 299.61 284.63 327.32 320.78 320.78 314.36 65600 366.54 348.21 400.44 392.44 392.44 384.59 # 65600 322.83 306.69 352.69 345.64 345.64 338.73 65710 1,041.49 989.42 1,137.83 1,115.07 1,115.07 1,092.78 65730 1,156.59 1,098.76 1,263.57 1,238.30 1,238.30 1,213.53 65750 1,164.93 1,106.68 1,272.68 1,247.23 1,247.23 1,222.29 65755 1,158.53 1,100.60 1,265.69 1,240.38 1,240.38 1,215.57 65756 1,121.89 1,065.80 1,225.67 1,201.15 1,201.15 1,177.13 65757 130.09 123.59 142.13 139.29 139.29 136.51 65770 1,328.51 1,262.08 1,451.39 1,422.37 1,422.37 1,393.92 65772 420.69 399.66 459.61 450.42 450.42 441.42

Page 154: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 154Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 65772 381.98 362.88 417.31 408.96 408.96 400.79 65775 517.97 492.07 565.88 554.56 554.56 543.48 65778 1,270.10 1,206.60 1,387.59 1,359.84 1,359.84 1,332.64 # 65778 56.22 53.41 61.42 60.19 60.19 58.98 65779 1,071.86 1,018.27 1,171.01 1,147.59 1,147.59 1,124.63 # 65779 145.84 138.55 159.33 156.15 156.15 153.02 65780 669.89 636.40 731.86 717.22 717.22 702.88 65781 1,258.73 1,195.79 1,375.16 1,347.65 1,347.65 1,320.69 65782 1,084.79 1,030.55 1,185.13 1,161.43 1,161.43 1,138.20 65785 1,891.88 1,797.29 2,066.88 2,025.54 2,025.54 1,985.03 # 65785 367.03 348.68 400.98 392.97 392.97 385.11 65800 111.92 106.32 122.27 119.82 119.82 117.43 # 65800 87.88 83.49 96.01 94.09 94.09 92.21 65810 436.98 415.13 477.40 467.85 467.85 458.49 65815 588.89 559.45 643.37 630.50 630.50 617.88 # 65815 448.71 426.27 490.21 480.40 480.40 470.80 65820 700.93 665.88 765.76 750.44 750.44 735.44 65850 792.36 752.74 865.65 848.34 848.34 831.38 65855 253.01 240.36 276.41 270.88 270.88 265.47 # 65855 224.28 213.07 245.03 240.13 240.13 235.32 65860 288.30 273.89 314.97 308.67 308.67 302.50 # 65860 239.91 227.91 262.10 256.85 256.85 251.71 65865 443.34 421.17 484.35 474.66 474.66 465.18 65870 554.71 526.97 606.02 593.89 593.89 582.02 65875 591.21 561.65 645.90 632.98 632.98 620.32 65880 621.07 590.02 678.52 664.95 664.95 651.66 65900 903.45 858.28 987.02 967.28 967.28 947.93 65920 740.94 703.89 809.47 793.28 793.28 777.41 65930 600.31 570.29 655.83 642.71 642.71 629.86 66020 171.72 163.13 187.60 183.85 183.85 180.17 # 66020 123.64 117.46 135.08 132.38 132.38 129.73 66030 151.80 144.21 165.84 162.53 162.53 159.28 # 66030 103.72 98.53 113.31 111.04 111.04 108.82 66130 648.10 615.70 708.06 693.90 693.90 680.02 # 66130 537.26 510.40 586.96 575.22 575.22 563.72 66150 820.74 779.70 896.66 878.73 878.73 861.15 66155 820.07 779.07 895.93 878.01 878.01 860.45 66160 927.25 880.89 1,013.02 992.76 992.76 972.90 66170 907.35 861.98 991.28 971.45 971.45 952.03 66172 1,137.20 1,080.34 1,242.39 1,217.54 1,217.54 1,193.19 66174 893.97 849.27 976.66 957.12 957.12 937.97 66175 937.23 890.37 1,023.93 1,003.44 1,003.44 983.38 66179 1,013.91 963.21 1,107.69 1,085.54 1,085.54 1,063.83 66180 1,071.38 1,017.81 1,170.48 1,147.07 1,147.07 1,124.13 66183 968.58 920.15 1,058.17 1,037.01 1,037.01 1,016.28 66184 735.71 698.92 803.76 787.68 787.68 771.93 66185 793.49 753.82 866.89 849.55 849.55 832.57 66220 700.07 665.07 764.83 749.54 749.54 734.54 66225 878.60 834.67 959.87 940.68 940.68 921.86

Page 155: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 155Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

66250 691.75 657.16 755.73 740.62 740.62 725.81 # 66250 524.09 497.89 572.57 561.12 561.12 549.90 66500 329.31 312.84 359.77 352.57 352.57 345.52 66505 361.30 343.24 394.73 386.84 386.84 379.10 66600 779.26 740.30 851.35 834.31 834.31 817.63 66605 996.45 946.63 1,088.62 1,066.86 1,066.86 1,045.52 66625 402.87 382.73 440.14 431.34 431.34 422.72 66630 535.19 508.43 584.69 573.00 573.00 561.53 66635 540.57 513.54 590.57 578.76 578.76 567.18 66680 485.69 461.41 530.62 520.01 520.01 509.61 66682 595.34 565.57 650.41 637.40 637.40 624.65 66700 419.98 398.98 458.83 449.65 449.65 440.66 # 66700 370.34 351.82 404.59 396.50 396.50 388.56 66710 410.93 390.38 448.94 439.96 439.96 431.16 # 66710 370.03 351.53 404.26 396.18 396.18 388.25 66711 602.38 572.26 658.10 644.93 644.93 632.03 66720 440.55 418.52 481.30 471.67 471.67 462.24 # 66720 396.52 376.69 433.19 424.53 424.53 416.05 66740 408.74 388.30 446.55 437.61 437.61 428.86 # 66740 370.34 351.82 404.59 396.50 396.50 388.56 66761 274.78 261.04 300.20 294.19 294.19 288.31 # 66761 222.01 210.91 242.55 237.69 237.69 232.94 66762 442.88 420.74 483.85 474.18 474.18 464.69 # 66762 400.73 380.69 437.79 429.04 429.04 420.46 66770 492.68 468.05 538.26 527.49 527.49 516.95 # 66770 454.59 431.86 496.64 486.70 486.70 476.97 66820 364.76 346.52 398.50 390.53 390.53 382.72 66821 306.28 290.97 334.62 327.92 327.92 321.37 # 66821 290.04 275.54 316.87 310.53 310.53 304.32 66825 711.04 675.49 776.81 761.28 761.28 746.05 66830 670.95 637.40 733.01 718.35 718.35 703.98 66840 656.22 623.41 716.92 702.58 702.58 688.53 66850 747.15 709.79 816.26 799.93 799.93 783.93 66852 796.82 756.98 870.53 853.12 853.12 836.05 66920 711.27 675.71 777.07 761.53 761.53 746.30 66930 808.61 768.18 883.41 865.74 865.74 848.42 66940 737.30 700.44 805.51 789.39 789.39 773.61 66982 751.68 714.10 821.22 804.79 804.79 788.69 66983 699.55 664.57 764.26 748.97 748.97 733.99 66984 602.78 572.64 658.54 645.37 645.37 632.47 66985 724.69 688.46 791.73 775.89 775.89 760.38 66986 857.06 814.21 936.34 917.62 917.62 899.27 66990 86.86 82.52 94.90 93.00 93.00 91.14 67005 443.86 421.67 484.92 475.23 475.23 465.73 67010 510.79 485.25 558.04 546.88 546.88 535.95 67015 543.94 516.74 594.25 582.37 582.37 570.72 67025 676.52 642.69 739.09 724.32 724.32 709.83 # 67025 595.03 565.28 650.07 637.07 637.07 624.32 67027 804.91 764.66 879.36 861.78 861.78 844.54

Page 156: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 156Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

67028 96.53 91.70 105.46 103.35 103.35 101.28 # 67028 94.96 90.21 103.74 101.67 101.67 99.64 67030 496.95 472.10 542.92 532.06 532.06 521.42 67031 362.70 344.57 396.26 388.33 388.33 380.57 # 67031 335.22 318.46 366.23 358.90 358.90 351.73 67036 850.53 808.00 929.20 910.62 910.62 892.40 67039 911.75 866.16 996.08 976.17 976.17 956.64 67040 986.43 937.11 1,077.68 1,056.13 1,056.13 1,035.00 67041 1,091.25 1,036.69 1,192.19 1,168.35 1,168.35 1,144.99 67042 1,091.56 1,036.98 1,192.53 1,168.68 1,168.68 1,145.31 67043 1,153.07 1,095.42 1,259.73 1,234.54 1,234.54 1,209.85 67101 730.43 693.91 798.00 782.03 782.03 766.39 # 67101 634.58 602.85 693.28 679.41 679.41 665.82 67105 672.43 638.81 734.63 719.93 719.93 705.54 # 67105 606.86 576.52 663.00 649.74 649.74 636.74 67107 961.40 913.33 1,050.33 1,029.32 1,029.32 1,008.73 67108 1,213.94 1,153.24 1,326.23 1,299.71 1,299.71 1,273.72 67110 707.97 672.57 773.46 757.99 757.99 742.83 # 67110 652.40 619.78 712.75 698.49 698.49 684.51 67113 1,330.54 1,264.01 1,453.61 1,424.54 1,424.54 1,396.05 67115 468.54 445.11 511.88 501.64 501.64 491.61 67120 610.89 580.35 667.40 654.05 654.05 640.98 # 67120 524.71 498.47 573.24 561.78 561.78 550.54 67121 857.01 814.16 936.28 917.56 917.56 899.21 67141 489.64 465.16 534.93 524.24 524.24 513.75 # 67141 458.42 435.50 500.83 490.81 490.81 480.99 67145 493.21 468.55 538.83 528.06 528.06 517.50 # 67145 468.23 444.82 511.54 501.31 501.31 491.28 67208 563.03 534.88 615.11 602.81 602.81 590.76 # 67208 545.23 517.97 595.67 583.75 583.75 572.08 67210 485.58 461.30 530.50 519.88 519.88 509.48 # 67210 470.29 446.78 513.80 503.52 503.52 493.44 67218 1,313.42 1,247.75 1,434.91 1,406.22 1,406.22 1,378.09 67220 499.63 474.65 545.85 534.93 534.93 524.24 # 67220 470.29 446.78 513.80 503.52 503.52 493.44 67221 268.33 254.91 293.15 287.28 287.28 281.53 # 67221 204.32 194.10 223.22 218.75 218.75 214.38 67225 28.30 26.89 30.92 30.30 30.30 29.69 # 67225 26.74 25.40 29.21 28.62 28.62 28.05 67227 271.05 257.50 296.13 290.20 290.20 284.40 # 67227 242.64 230.51 265.09 259.79 259.79 254.59 67228 320.21 304.20 349.83 342.84 342.84 335.98 # 67228 291.17 276.61 318.10 311.74 311.74 305.51 67229 1,058.81 1,005.87 1,156.75 1,133.61 1,133.61 1,110.95 67250 732.10 695.50 799.83 783.83 783.83 768.15 67255 640.54 608.51 699.79 685.79 685.79 672.07 67311 562.93 534.78 615.00 602.69 602.69 590.64 67312 672.05 638.45 734.22 719.53 719.53 705.15 67314 633.91 602.21 692.54 678.70 678.70 665.13

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 157Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

67316 756.61 718.78 826.60 810.06 810.06 793.86 67318 662.53 629.40 723.81 709.33 709.33 695.14 67320 309.94 294.44 338.61 331.83 331.83 325.20 67331 294.09 279.39 321.30 314.87 314.87 308.57 67332 319.08 303.13 348.60 341.63 341.63 334.80 67334 290.00 275.50 316.83 310.49 310.49 304.28 67335 142.67 135.54 155.87 152.75 152.75 149.70 67340 344.74 327.50 376.63 369.09 369.09 361.71 67343 615.30 584.54 672.22 658.78 658.78 645.60 67345 227.75 216.36 248.81 243.83 243.83 238.96 # 67345 206.52 196.19 225.62 221.11 221.11 216.68 67346 184.21 175.00 201.25 197.23 197.23 193.28 67400 870.42 826.90 950.94 931.91 931.91 913.27 67405 742.18 705.07 810.83 794.62 794.62 778.72 67412 796.84 757.00 870.55 853.14 853.14 836.07 67413 800.79 760.75 874.86 857.37 857.37 840.22 67414 1,250.07 1,187.57 1,365.71 1,338.39 1,338.39 1,311.62 67415 100.43 95.41 109.72 107.53 107.53 105.37 67420 1,526.21 1,449.90 1,667.39 1,634.04 1,634.04 1,601.35 67430 1,162.27 1,104.16 1,269.78 1,244.39 1,244.39 1,219.51 67440 1,128.19 1,071.78 1,232.55 1,207.89 1,207.89 1,183.73 67445 1,322.87 1,256.73 1,445.24 1,416.34 1,416.34 1,388.02 67450 1,175.94 1,117.14 1,284.71 1,259.02 1,259.02 1,233.84 67500 75.61 71.83 82.60 80.95 80.95 79.33 # 67500 70.30 66.79 76.81 75.27 75.27 73.76 67505 84.25 80.04 92.05 90.21 90.21 88.40 # 67505 77.69 73.81 84.88 83.18 83.18 81.51 67515 91.69 87.11 100.18 98.18 98.18 96.21 # 67515 85.13 80.87 93.00 91.14 91.14 89.32 67550 903.46 858.29 987.03 967.29 967.29 947.95 67560 926.43 880.11 1,012.13 991.89 991.89 972.05 67570 1,089.41 1,034.94 1,190.18 1,166.38 1,166.38 1,143.05 67700 242.15 230.04 264.55 259.26 259.26 254.07 # 67700 109.14 103.68 119.23 116.85 116.85 114.52 67710 201.38 191.31 220.01 215.60 215.60 211.29 # 67710 90.85 86.31 99.26 97.27 97.27 95.32 67715 215.30 204.54 235.22 230.52 230.52 225.91 # 67715 101.65 96.57 111.06 108.84 108.84 106.66 67800 118.27 112.36 129.21 126.63 126.63 124.10 # 67800 97.66 92.78 106.70 104.56 104.56 102.47 67801 151.36 143.79 165.36 162.05 162.05 158.80 # 67801 126.70 120.37 138.43 135.65 135.65 132.94 67805 187.90 178.51 205.29 201.18 201.18 197.16 # 67805 155.74 147.95 170.14 166.74 166.74 163.40 67808 346.66 329.33 378.73 371.15 371.15 363.73 67810 156.73 148.89 171.22 167.80 167.80 164.44 # 67810 69.00 65.55 75.38 73.88 73.88 72.40 67820 47.17 44.81 51.53 50.50 50.50 49.48 # 67820 50.29 47.78 54.95 53.84 53.84 52.76

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 158Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

67825 119.61 113.63 130.67 128.06 128.06 125.50 # 67825 113.68 108.00 124.20 121.72 121.72 119.28 67830 242.11 230.00 264.50 259.21 259.21 254.02 # 67830 130.02 123.52 142.05 139.21 139.21 136.42 67835 412.42 391.80 450.57 441.55 441.55 432.72 67840 251.41 238.84 274.67 269.17 269.17 263.79 # 67840 149.32 141.85 163.13 159.86 159.86 156.66 67850 196.65 186.82 214.84 210.54 210.54 206.33 # 67850 128.28 121.87 140.15 137.34 137.34 134.60 67875 157.00 149.15 171.52 168.10 168.10 164.74 # 67875 92.05 87.45 100.57 98.56 98.56 96.59 67880 424.43 403.21 463.69 454.42 454.42 445.34 # 67880 346.07 328.77 378.09 370.52 370.52 363.11 67882 523.39 497.22 571.80 560.37 560.37 549.16 # 67882 444.09 421.89 485.17 475.47 475.47 465.96 67900 594.40 564.68 649.38 636.40 636.40 623.67 # 67900 480.75 456.71 525.22 514.72 514.72 504.42 67901 700.02 665.02 764.77 749.48 749.48 734.49 # 67901 543.60 516.42 593.88 582.00 582.00 570.37 67902 682.81 648.67 745.97 731.06 731.06 716.44 67903 551.67 524.09 602.70 590.65 590.65 578.84 # 67903 456.45 433.63 498.67 488.70 488.70 478.93 67904 680.45 646.43 743.39 728.53 728.53 713.95 # 67904 563.37 535.20 615.48 603.18 603.18 591.11 67906 478.95 455.00 523.25 512.79 512.79 502.53 67908 458.44 435.52 500.85 490.83 490.83 481.01 # 67908 398.81 378.87 435.70 426.98 426.98 418.44 67909 496.67 471.84 542.62 531.76 531.76 521.12 # 67909 412.37 391.75 450.51 441.51 441.51 432.68 67911 530.44 503.92 579.51 567.92 567.92 556.55 67912 805.13 764.87 879.60 862.01 862.01 844.77 # 67912 462.32 439.20 505.08 494.98 494.98 485.08 67914 429.76 408.27 469.51 460.12 460.12 450.92 # 67914 306.12 290.81 334.43 327.74 327.74 321.18 67915 266.47 253.15 291.12 285.30 285.30 279.60 # 67915 184.04 174.84 201.07 197.04 197.04 193.10 67916 545.61 518.33 596.08 584.15 584.15 572.47 # 67916 405.43 385.16 442.93 434.08 434.08 425.40 67917 556.98 529.13 608.50 596.33 596.33 584.41 # 67917 431.47 409.90 471.39 461.96 461.96 452.72 67921 420.44 399.42 459.33 450.14 450.14 441.14 # 67921 289.93 275.43 316.74 310.41 310.41 304.20 67922 264.28 251.07 288.73 282.96 282.96 277.30 # 67922 183.73 174.54 200.72 196.71 196.71 192.77 67923 545.07 517.82 595.49 583.58 583.58 571.91 # 67923 405.20 384.94 442.68 433.83 433.83 425.16 67924 581.36 552.29 635.13 622.43 622.43 609.98 # 67924 431.50 409.93 471.42 461.99 461.99 452.76 67930 336.60 319.77 367.74 360.38 360.38 353.17

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 159Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 67930 228.57 217.14 249.71 244.72 244.72 239.82 67935 551.47 523.90 602.49 590.43 590.43 578.62 # 67935 419.72 398.73 458.54 449.37 449.37 440.38 67938 219.01 208.06 239.27 234.49 234.49 229.79 # 67938 108.48 103.06 118.52 116.15 116.15 113.83 67950 530.92 504.37 580.03 568.42 568.42 557.05 # 67950 436.32 414.50 476.68 467.14 467.14 457.80 67961 532.03 505.43 581.24 569.62 569.62 558.22 # 67961 428.06 406.66 467.66 458.31 458.31 449.14 67966 717.28 681.42 783.63 767.96 767.96 752.59 # 67966 621.12 590.06 678.57 665.00 665.00 651.69 67971 684.10 649.90 747.39 732.44 732.44 717.78 67973 881.04 836.99 962.54 943.29 943.29 924.43 67974 879.34 835.37 960.68 941.46 941.46 922.63 67975 646.53 614.20 706.33 692.21 692.21 678.36 68020 111.76 106.17 122.10 119.66 119.66 117.27 # 68020 103.95 98.75 113.56 111.30 111.30 109.07 68040 59.02 56.07 64.48 63.19 63.19 61.93 # 68040 48.72 46.28 53.22 52.15 52.15 51.11 68100 155.46 147.69 169.84 166.45 166.45 163.13 # 68100 92.08 87.48 100.60 98.59 98.59 96.62 68110 206.55 196.22 225.65 221.15 221.15 216.72 # 68110 139.42 132.45 152.32 149.27 149.27 146.28 68115 284.98 270.73 311.34 305.12 305.12 299.01 # 68115 173.52 164.84 189.57 185.77 185.77 182.06 68130 496.92 472.07 542.88 532.02 532.02 521.39 # 68130 387.02 367.67 422.82 414.37 414.37 406.08 68135 146.59 139.26 160.15 156.94 156.94 153.80 # 68135 141.90 134.81 155.03 151.93 151.93 148.89 68200 38.66 36.73 42.24 41.40 41.40 40.57 # 68200 33.04 31.39 36.10 35.37 35.37 34.66 68320 667.53 634.15 729.27 714.69 714.69 700.40 # 68320 506.11 480.80 552.92 541.86 541.86 531.02 68325 620.58 589.55 677.98 664.42 664.42 651.13 68326 608.20 577.79 664.46 651.16 651.16 638.15 68328 667.91 634.51 729.69 715.09 715.09 700.79 68330 557.94 530.04 609.55 597.36 597.36 585.41 # 68330 433.37 411.70 473.46 463.99 463.99 454.71 68335 609.97 579.47 666.39 653.06 653.06 640.00 68340 501.94 476.84 548.37 537.40 537.40 526.64 # 68340 375.18 356.42 409.88 401.68 401.68 393.65 68360 491.51 466.93 536.97 526.23 526.23 515.71 # 68360 387.54 368.16 423.38 414.92 414.92 406.62 68362 618.44 587.52 675.65 662.14 662.14 648.89 68371 387.60 368.22 423.45 414.99 414.99 406.69 68400 257.39 244.52 281.20 275.57 275.57 270.07 # 68400 124.38 118.16 135.88 133.17 133.17 130.50 68420 293.42 278.75 320.56 314.16 314.16 307.88 # 68420 159.48 151.51 174.24 170.75 170.75 167.34

Page 160: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 160Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

68440 94.57 89.84 103.32 101.25 101.25 99.22 # 68440 92.08 87.48 100.60 98.59 98.59 96.62 68500 918.29 872.38 1,003.24 983.17 983.17 963.50 68505 912.59 866.96 997.00 977.06 977.06 957.52 68510 412.88 392.24 451.08 442.06 442.06 433.22 # 68510 279.25 265.29 305.08 298.98 298.98 293.00 68520 646.76 614.42 706.58 692.45 692.45 678.60 68525 253.14 240.48 276.55 271.02 271.02 265.60 68530 393.03 373.38 429.39 420.80 420.80 412.38 # 68530 244.41 232.19 267.02 261.68 261.68 256.45 68540 876.25 832.44 957.31 938.16 938.16 919.39 68550 1,044.43 992.21 1,141.04 1,118.23 1,118.23 1,095.86 68700 568.64 540.21 621.24 608.82 608.82 596.64 68705 217.48 206.61 237.60 232.85 232.85 228.19 # 68705 156.59 148.76 171.07 167.65 167.65 164.29 68720 712.62 676.99 778.54 762.97 762.97 747.71 68745 715.27 679.51 781.44 765.81 765.81 750.49 68750 739.75 702.76 808.17 792.01 792.01 776.17 68760 185.14 175.88 202.26 198.21 198.21 194.25 # 68760 137.06 130.21 149.74 146.75 146.75 143.82 68761 136.41 129.59 149.03 146.05 146.05 143.13 # 68761 111.43 105.86 121.74 119.30 119.30 116.92 68770 592.39 562.77 647.19 634.24 634.24 621.55 68801 92.29 87.68 100.83 98.82 98.82 96.84 # 68801 80.42 76.40 87.86 86.10 86.10 84.38 68810 178.78 169.84 195.32 191.41 191.41 187.58 # 68810 141.01 133.96 154.05 150.97 150.97 147.95 68811 154.98 147.23 169.31 165.93 165.93 162.61 68815 361.79 343.70 395.26 387.35 387.35 379.60 # 68815 208.18 197.77 227.44 222.88 222.88 218.42 68816 577.10 548.25 630.49 617.88 617.88 605.52 # 68816 188.08 178.68 205.48 201.38 201.38 197.35 68840 118.42 112.50 129.38 126.79 126.79 124.26 # 68840 109.05 103.60 119.14 116.76 116.76 114.43 68850 57.49 54.62 62.81 61.56 61.56 60.33 # 68850 53.12 50.46 58.03 56.87 56.87 55.73 69000 173.38 164.71 189.42 185.63 185.63 181.92 # 69000 113.13 107.47 123.59 121.12 121.12 118.69 69005 201.37 191.30 220.00 215.59 215.59 211.28 # 69005 150.48 142.96 164.40 161.12 161.12 157.90 69020 214.65 203.92 234.51 229.82 229.82 225.22 # 69020 134.41 127.69 146.84 143.91 143.91 141.04 69100 92.39 87.77 100.94 98.91 98.91 96.93 # 69100 47.43 45.06 51.82 50.78 50.78 49.77 69105 129.07 122.62 141.01 138.20 138.20 135.44 # 69105 61.01 57.96 66.65 65.32 65.32 64.01 69110 423.95 402.75 463.16 453.91 453.91 444.83 # 69110 305.93 290.63 334.22 327.54 327.54 320.99 69120 382.07 362.97 417.42 409.07 409.07 400.89

Page 161: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 161Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

69140 823.98 782.78 900.20 882.19 882.19 864.55 69145 367.22 348.86 401.19 393.16 393.16 385.30 # 69145 236.40 224.58 258.27 253.10 253.10 248.04 69150 1,000.18 950.17 1,092.70 1,070.85 1,070.85 1,049.43 69155 1,602.14 1,522.03 1,750.33 1,715.33 1,715.33 1,681.02 69200 91.61 87.03 100.08 98.08 98.08 96.12 # 69200 45.71 43.42 49.93 48.93 48.93 47.96 69205 96.56 91.73 105.49 103.39 103.39 101.32 69209 11.21 10.65 12.25 12.01 12.01 11.76 69210 46.31 43.99 50.59 49.58 49.58 48.59 # 69210 31.95 30.35 34.90 34.20 34.20 33.52 69220 102.44 97.32 111.92 109.68 109.68 107.48 # 69220 50.31 47.79 54.96 53.85 53.85 52.77 69222 202.76 192.62 221.51 217.09 217.09 212.74 # 69222 129.39 122.92 141.36 138.53 138.53 135.76 69300 687.21 652.85 750.78 735.76 735.76 721.04 # 69300 458.35 435.43 500.74 490.73 490.73 480.92 69310 1,029.82 978.33 1,125.08 1,102.57 1,102.57 1,080.52 69320 1,465.10 1,391.85 1,600.63 1,568.61 1,568.61 1,537.24 69420 177.49 168.62 193.91 190.04 190.04 186.24 # 69420 114.42 108.70 125.01 122.51 122.51 120.06 69421 141.69 134.61 154.80 151.71 151.71 148.67 69424 117.83 111.94 128.73 126.16 126.16 123.64 # 69424 59.76 56.77 65.29 63.97 63.97 62.70 69433 187.96 178.56 205.34 201.24 201.24 197.21 # 69433 126.14 119.83 137.80 135.04 135.04 132.34 69436 152.97 145.32 167.12 163.77 163.77 160.49 69440 654.18 621.47 714.69 700.40 700.40 686.39 69450 515.21 489.45 562.87 551.61 551.61 540.58 69501 700.38 665.36 765.16 749.86 749.86 734.86 69502 929.78 883.29 1,015.78 995.46 995.46 975.56 69505 1,140.03 1,083.03 1,245.48 1,220.58 1,220.58 1,196.16 69511 1,165.74 1,107.45 1,273.57 1,248.10 1,248.10 1,223.13 69530 1,579.15 1,500.19 1,725.22 1,690.72 1,690.72 1,656.91 69535 2,578.26 2,449.35 2,816.75 2,760.41 2,760.41 2,705.20 69540 192.56 182.93 210.37 206.16 206.16 202.03 # 69540 119.81 113.82 130.89 128.27 128.27 125.71 69550 986.14 936.83 1,077.35 1,055.80 1,055.80 1,034.69 69552 1,493.80 1,419.11 1,631.98 1,599.34 1,599.34 1,567.36 69554 2,348.40 2,230.98 2,565.63 2,514.31 2,514.31 2,464.02 69601 1,000.43 950.41 1,092.97 1,071.11 1,071.11 1,049.69 69602 1,039.49 987.52 1,135.65 1,112.94 1,112.94 1,090.67 69603 1,207.67 1,147.29 1,319.38 1,292.99 1,292.99 1,267.13 69604 1,063.19 1,010.03 1,161.53 1,138.30 1,138.30 1,115.53 69605 1,486.61 1,412.28 1,624.12 1,591.63 1,591.63 1,559.80 69610 363.72 345.53 397.36 389.41 389.41 381.63 # 69610 281.29 267.23 307.31 301.17 301.17 295.15 69620 649.01 616.56 709.04 694.86 694.86 680.97 # 69620 466.68 443.35 509.85 499.65 499.65 489.66

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 162Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

69631 839.74 797.75 917.41 899.07 899.07 881.08 69632 1,025.54 974.26 1,120.40 1,097.99 1,097.99 1,076.02 69633 994.28 944.57 1,086.26 1,064.53 1,064.53 1,043.25 69635 1,171.75 1,113.16 1,280.13 1,254.54 1,254.54 1,229.44 69636 1,311.89 1,246.30 1,433.25 1,404.58 1,404.58 1,376.48 69637 1,304.54 1,239.31 1,425.21 1,396.70 1,396.70 1,368.76 69641 993.71 944.02 1,085.62 1,063.91 1,063.91 1,042.64 69642 1,276.83 1,212.99 1,394.94 1,367.04 1,367.04 1,339.70 69643 1,170.09 1,111.59 1,278.33 1,252.76 1,252.76 1,227.71 69644 1,405.90 1,335.61 1,535.95 1,505.24 1,505.24 1,475.13 69645 1,381.75 1,312.66 1,509.56 1,479.37 1,479.37 1,449.78 69646 1,470.58 1,397.05 1,606.61 1,574.48 1,574.48 1,542.99 69650 768.20 729.79 839.26 822.47 822.47 806.02 69660 887.35 842.98 969.43 950.04 950.04 931.04 69661 1,157.72 1,099.83 1,264.80 1,239.50 1,239.50 1,214.71 69662 1,111.35 1,055.78 1,214.15 1,189.86 1,189.86 1,166.07 69666 771.03 732.48 842.35 825.50 825.50 808.99 69667 771.38 732.81 842.73 825.87 825.87 809.36 69670 904.11 858.90 987.74 967.98 967.98 948.62 69676 790.17 750.66 863.26 846.00 846.00 829.08 69700 653.52 620.84 713.97 699.68 699.68 685.69 69711 824.42 783.20 900.68 882.67 882.67 865.02 69714 1,033.52 981.84 1,129.12 1,106.53 1,106.53 1,084.40 69715 1,279.49 1,215.52 1,397.85 1,369.89 1,369.89 1,342.50 69717 1,086.41 1,032.09 1,186.90 1,163.17 1,163.17 1,139.90 69718 1,292.73 1,228.09 1,412.30 1,384.06 1,384.06 1,356.38 69720 1,159.24 1,101.28 1,266.47 1,241.14 1,241.14 1,216.32 69725 1,814.11 1,723.40 1,981.91 1,942.27 1,942.27 1,903.42 69740 1,122.12 1,066.01 1,225.91 1,201.39 1,201.39 1,177.37 69745 1,325.45 1,259.18 1,448.06 1,419.10 1,419.10 1,390.72 69801 184.39 175.17 201.45 197.42 197.42 193.48 # 69801 122.26 116.15 133.57 130.90 130.90 128.28 69805 1,013.51 962.83 1,107.25 1,085.11 1,085.11 1,063.41 69806 906.46 861.14 990.31 970.51 970.51 951.10 69820 817.37 776.50 892.98 875.12 875.12 857.61 69840 858.54 815.61 937.95 919.20 919.20 900.81 69905 875.10 831.35 956.05 936.93 936.93 918.19 69910 976.74 927.90 1,067.09 1,045.74 1,045.74 1,024.82 69915 1,485.26 1,411.00 1,622.65 1,590.20 1,590.20 1,558.39 69930 1,180.34 1,121.32 1,289.52 1,263.72 1,263.72 1,238.45 69950 1,726.34 1,640.02 1,886.02 1,848.30 1,848.30 1,811.34 69955 1,925.02 1,828.77 2,103.09 2,061.02 2,061.02 2,019.80 69960 1,857.05 1,764.20 2,028.83 1,988.26 1,988.26 1,948.49 69970 2,072.84 1,969.20 2,264.58 2,219.29 2,219.29 2,174.90 69990 213.46 202.79 233.21 228.54 228.54 223.97 70010 59.82 56.83 65.35 64.04 64.04 62.77 70015 139.94 132.94 152.88 149.82 149.82 146.82 70015 TC 79.59 75.61 86.95 85.22 85.22 83.51 70015 26 60.36 57.34 65.94 64.62 64.62 63.33

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 163Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

70030 25.08 23.83 27.40 26.85 26.85 26.31 70030 TC 16.83 15.99 18.39 18.02 18.02 17.66 70030 26 8.24 7.83 9.00 8.82 8.82 8.65 70100 29.49 28.02 32.22 31.58 31.58 30.95 70100 TC 20.58 19.55 22.48 22.03 22.03 21.60 70100 26 8.91 8.46 9.73 9.53 9.53 9.34 70110 34.19 32.48 37.35 36.60 36.60 35.87 70110 TC 21.83 20.74 23.85 23.38 23.38 22.91 70110 26 12.36 11.74 13.50 13.24 13.24 12.97 70120 30.43 28.91 33.25 32.58 32.58 31.92 70120 TC 21.52 20.44 23.51 23.03 23.03 22.57 70120 26 8.91 8.46 9.73 9.53 9.53 9.34 70130 49.24 46.78 53.80 52.72 52.72 51.66 70130 TC 32.44 30.82 35.44 34.73 34.73 34.04 70130 26 16.80 15.96 18.35 17.99 17.99 17.63 70134 46.46 44.14 50.76 49.75 49.75 48.75 70134 TC 29.32 27.85 32.03 31.38 31.38 30.75 70134 26 17.14 16.28 18.72 18.34 18.34 17.97 70140 26.73 25.39 29.20 28.61 28.61 28.04 70140 TC 16.52 15.69 18.04 17.69 17.69 17.33 70140 26 10.21 9.70 11.16 10.94 10.94 10.72 70150 37.35 35.48 40.80 39.99 39.99 39.18 70150 TC 24.33 23.11 26.58 26.05 26.05 25.53 70150 26 13.03 12.38 14.24 13.95 13.95 13.67 70160 29.14 27.68 31.83 31.20 31.20 30.58 70160 TC 20.58 19.55 22.48 22.03 22.03 21.60 70160 26 8.56 8.13 9.35 9.17 9.17 8.98 70170 50.10 47.60 54.74 53.65 53.65 52.58 70170 TC 35.36 33.59 38.63 37.86 37.86 37.10 70170 26 14.74 14.00 16.10 15.78 15.78 15.47 70190 32.13 30.52 35.10 34.40 34.40 33.71 70190 TC 21.20 20.14 23.16 22.70 22.70 22.25 70190 26 10.93 10.38 11.94 11.70 11.70 11.47 70200 38.07 36.17 41.60 40.77 40.77 39.95 70200 TC 24.33 23.11 26.58 26.05 26.05 25.53 70200 26 13.74 13.05 15.01 14.71 14.71 14.41 70210 26.64 25.31 29.11 28.52 28.52 27.95 70210 TC 18.08 17.18 19.76 19.37 19.37 18.98 70210 26 8.56 8.13 9.35 9.17 9.17 8.98 70220 33.87 32.18 37.01 36.27 36.27 35.55 70220 TC 21.52 20.44 23.51 23.03 23.03 22.57 70220 26 12.36 11.74 13.50 13.24 13.24 12.97 70240 27.04 25.69 29.54 28.96 28.96 28.38 70240 TC 17.46 16.59 19.08 18.70 18.70 18.32 70240 26 9.59 9.11 10.48 10.27 10.27 10.06 70250 32.58 30.95 35.59 34.88 34.88 34.18 70250 TC 20.27 19.26 22.15 21.70 21.70 21.26 70250 26 12.31 11.69 13.44 13.18 13.18 12.91 70260 41.44 39.37 45.28 44.37 44.37 43.48

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 164Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

70260 TC 24.33 23.11 26.58 26.05 26.05 25.53 70260 26 17.11 16.25 18.69 18.32 18.32 17.95 70300 13.52 12.84 14.77 14.47 14.47 14.18 70300 TC 7.78 7.39 8.50 8.33 8.33 8.17 70300 26 5.74 5.45 6.27 6.14 6.14 6.01 70310 32.84 31.20 35.88 35.17 35.17 34.47 70310 TC 24.95 23.70 27.26 26.71 26.71 26.19 70310 26 7.89 7.50 8.63 8.45 8.45 8.28 70320 46.85 44.51 51.19 50.16 50.16 49.16 70320 TC 35.25 33.49 38.51 37.74 37.74 36.98 70320 26 11.60 11.02 12.67 12.42 12.42 12.17 70328 27.62 26.24 30.18 29.58 29.58 28.99 70328 TC 18.71 17.77 20.44 20.02 20.02 19.62 70328 26 8.91 8.46 9.73 9.53 9.53 9.34 70330 42.26 40.15 46.17 45.25 45.25 44.34 70330 TC 29.94 28.44 32.71 32.05 32.05 31.41 70330 26 12.31 11.69 13.44 13.18 13.18 12.91 70332 73.52 69.84 80.32 78.71 78.71 77.13 70332 TC 43.37 41.20 47.38 46.44 46.44 45.51 70332 26 30.15 28.64 32.94 32.28 32.28 31.64 70336 288.12 273.71 314.77 308.48 308.48 302.31 70336 TC 216.00 205.20 235.98 231.27 231.27 226.64 70336 26 72.13 68.52 78.80 77.22 77.22 75.68 70350 18.18 17.27 19.86 19.46 19.46 19.07 70350 TC 8.40 7.98 9.18 8.99 8.99 8.81 70350 26 9.78 9.29 10.68 10.47 10.47 10.26 70355 18.94 17.99 20.69 20.27 20.27 19.87 70355 TC 8.09 7.69 8.84 8.67 8.67 8.50 70355 26 10.85 10.31 11.86 11.62 11.62 11.39 70360 25.39 24.12 27.74 27.19 27.19 26.65 70360 TC 17.14 16.28 18.72 18.34 18.34 17.97 70360 26 8.24 7.83 9.00 8.82 8.82 8.65 C 70370 68.51 65.08 74.84 73.35 73.35 71.88 C 70370 TC 52.74 50.10 57.62 56.47 56.47 55.34 70370 26 15.77 14.98 17.23 16.88 16.88 16.55 70371 83.92 79.72 91.68 89.85 89.85 88.06 70371 TC 42.12 40.01 46.01 45.09 45.09 44.19 70371 26 41.80 39.71 45.67 44.76 44.76 43.86 70380 32.26 30.65 35.25 34.55 34.55 33.86 70380 TC 23.39 22.22 25.55 25.05 25.05 24.54 70380 26 8.87 8.43 9.69 9.50 9.50 9.30 70390 84.08 79.88 91.86 90.02 90.02 88.22 70390 TC 65.54 62.26 71.60 70.16 70.16 68.76 70390 26 18.55 17.62 20.26 19.86 19.86 19.46 70450 105.82 100.53 115.61 113.30 113.30 111.03 70450 TC 63.98 60.78 69.90 68.49 68.49 67.13 70450 26 41.85 39.76 45.72 44.80 44.80 43.91 70460 147.04 139.69 160.64 157.44 157.44 154.28 70460 TC 91.76 87.17 100.25 98.24 98.24 96.28

Page 165: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 165Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

70460 26 55.28 52.52 60.40 59.19 59.19 58.01 70470 174.20 165.49 190.31 186.51 186.51 182.78 70470 TC 111.74 106.15 122.07 119.63 119.63 117.24 70470 26 62.45 59.33 68.23 66.86 66.86 65.53 C 70480 160.82 152.78 175.70 172.18 172.18 168.74 C 70480 TC 98.01 93.11 107.08 104.94 104.94 102.84 70480 26 62.81 59.67 68.62 67.25 67.25 65.91 70481 248.67 236.24 271.68 266.25 266.25 260.92 70481 TC 181.06 172.01 197.81 193.86 193.86 189.98 70481 26 67.61 64.23 73.86 72.39 72.39 70.94 70482 271.13 257.57 296.21 290.28 290.28 284.48 70482 TC 200.39 190.37 218.93 214.54 214.54 210.25 70482 26 70.74 67.20 77.28 75.74 75.74 74.22 70486 126.74 120.40 138.46 135.69 135.69 132.97 70486 TC 84.89 80.65 92.75 90.90 90.90 89.08 70486 26 41.85 39.76 45.72 44.80 44.80 43.91 70487 152.97 145.32 167.12 163.77 163.77 160.49 70487 TC 97.70 92.82 106.74 104.60 104.60 102.51 70487 26 55.28 52.52 60.40 59.19 59.19 58.01 70488 185.75 176.46 202.93 198.87 198.87 194.89 70488 TC 123.61 117.43 135.04 132.34 132.34 129.70 70488 26 62.14 59.03 67.88 66.53 66.53 65.19 C 70490 160.82 152.78 175.70 172.18 172.18 168.74 C 70490 TC 98.01 93.11 107.08 104.94 104.94 102.84 70490 26 62.81 59.67 68.62 67.25 67.25 65.91 70491 213.07 202.42 232.78 228.13 228.13 223.56 70491 TC 145.15 137.89 158.57 155.40 155.40 152.29 70491 26 67.92 64.52 74.20 72.71 72.71 71.27 70492 250.55 238.02 273.72 268.25 268.25 262.88 70492 TC 179.50 170.53 196.11 192.19 192.19 188.35 70492 26 71.05 67.50 77.63 76.07 76.07 74.55 70496 266.20 252.89 290.82 285.00 285.00 279.30 70496 TC 180.72 171.68 197.43 193.49 193.49 189.62 70496 26 85.49 81.22 93.40 91.54 91.54 89.71 70498 265.27 252.01 289.81 284.02 284.02 278.33 70498 TC 179.78 170.79 196.41 192.48 192.48 188.62 70498 26 85.49 81.22 93.40 91.54 91.54 89.71 C 70540 303.76 288.57 331.86 325.22 325.22 318.71 C 70540 TC 237.85 225.96 259.85 254.66 254.66 249.56 70540 26 65.91 62.61 72.00 70.56 70.56 69.15 70542 359.92 341.92 393.21 385.34 385.34 377.64 70542 TC 280.62 266.59 306.58 300.45 300.45 294.43 70542 26 79.30 75.34 86.64 84.90 84.90 83.20 70543 441.26 419.20 482.08 472.44 472.44 462.99 70543 TC 336.20 319.39 367.30 359.95 359.95 352.75 70543 26 105.06 99.81 114.78 112.48 112.48 110.23 C 70544 296.86 282.02 324.32 317.84 317.84 311.48 C 70544 TC 237.85 225.96 259.85 254.66 254.66 249.56 70544 26 59.01 56.06 64.47 63.18 63.18 61.92

Page 166: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 166Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

70545 344.94 327.69 376.84 369.31 369.31 361.93 70545 TC 286.24 271.93 312.72 306.46 306.46 300.33 70545 26 58.70 55.77 64.14 62.85 62.85 61.59 C 70546 483.11 458.95 527.79 517.24 517.24 506.89 C 70546 TC 394.89 375.15 431.42 422.80 422.80 414.35 70546 26 88.21 83.80 96.37 94.44 94.44 92.55 C 70547 296.86 282.02 324.32 317.84 317.84 311.48 C 70547 TC 237.85 225.96 259.85 254.66 254.66 249.56 70547 26 59.01 56.06 64.47 63.18 63.18 61.92 70548 367.73 349.34 401.74 393.70 393.70 385.83 70548 TC 308.72 293.28 337.27 330.52 330.52 323.91 70548 26 59.01 56.06 64.47 63.18 63.18 61.92 C 70549 483.11 458.95 527.79 517.24 517.24 506.89 C 70549 TC 394.89 375.15 431.42 422.80 422.80 414.35 70549 26 88.21 83.80 96.37 94.44 94.44 92.55 70551 208.85 198.41 228.17 223.61 223.61 219.13 70551 TC 136.41 129.59 149.03 146.05 146.05 143.13 70551 26 72.44 68.82 79.14 77.56 77.56 76.00 70552 288.51 274.08 315.19 308.89 308.89 302.71 70552 TC 201.32 191.25 219.94 215.54 215.54 211.23 70552 26 87.18 82.82 95.24 93.33 93.33 91.47 70553 341.65 324.57 373.26 365.79 365.79 358.48 70553 TC 229.42 217.95 250.64 245.63 245.63 240.72 70553 26 112.23 106.62 122.61 120.16 120.16 117.76 70554 405.12 384.86 442.59 433.73 433.73 425.06 70554 TC 301.20 286.14 329.06 322.48 322.48 316.03 70554 26 103.91 98.71 113.52 111.25 111.25 109.03 70555 584.25 555.04 638.30 625.53 625.53 613.02 70555 TC 460.60 437.57 503.21 493.14 493.14 483.28 70555 26 123.65 117.47 135.09 132.39 132.39 129.74 70557 26 142.70 135.57 155.91 152.79 152.79 149.73 70558 26 157.16 149.30 171.70 168.26 168.26 164.89 70559 26 158.33 150.41 172.97 169.51 169.51 166.12 71010 20.44 19.42 22.33 21.88 21.88 21.45 71010 TC 11.52 10.94 12.58 12.33 12.33 12.09 71010 26 8.91 8.46 9.73 9.53 9.53 9.34 71015 25.26 24.00 27.60 27.05 27.05 26.51 71015 TC 14.65 13.92 16.01 15.69 15.69 15.38 71015 26 10.61 10.08 11.59 11.36 11.36 11.13 71020 25.31 24.04 27.65 27.09 27.09 26.55 71020 TC 14.65 13.92 16.01 15.69 15.69 15.38 71020 26 10.66 10.13 11.65 11.42 11.42 11.19 71021 30.84 29.30 33.70 33.02 33.02 32.36 71021 TC 17.46 16.59 19.08 18.70 18.70 18.32 71021 26 13.39 12.72 14.63 14.34 14.34 14.05 71022 37.89 36.00 41.40 40.57 40.57 39.76 71022 TC 21.83 20.74 23.85 23.38 23.38 22.91 71022 26 16.07 15.27 17.56 17.20 17.20 16.86 71023 57.23 54.37 62.53 61.27 61.27 60.04

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 167Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

71023 TC 38.69 36.76 42.27 41.42 41.42 40.60 71023 26 18.55 17.62 20.26 19.86 19.86 19.46 71030 37.87 35.98 41.38 40.55 40.55 39.73 71030 TC 22.45 21.33 24.53 24.04 24.04 23.55 71030 26 15.42 14.65 16.85 16.51 16.51 16.18 71034 75.03 71.28 81.97 80.33 80.33 78.72 71034 TC 52.11 49.50 56.93 55.79 55.79 54.67 71034 26 22.92 21.77 25.04 24.53 24.53 24.04 71035 29.49 28.02 32.22 31.58 31.58 30.95 71035 TC 20.58 19.55 22.48 22.03 22.03 21.60 71035 26 8.91 8.46 9.73 9.53 9.53 9.34 71100 29.68 28.20 32.43 31.79 31.79 31.15 71100 TC 18.71 17.77 20.44 20.02 20.02 19.62 71100 26 10.97 10.42 11.98 11.74 11.74 11.51 71101 33.00 31.35 36.05 35.33 35.33 34.63 71101 TC 19.64 18.66 21.46 21.03 21.03 20.61 71101 26 13.36 12.69 14.59 14.31 14.31 14.02 71110 33.96 32.26 37.10 36.35 36.35 35.63 71110 TC 20.58 19.55 22.48 22.03 22.03 21.60 71110 26 13.39 12.72 14.63 14.34 14.34 14.05 71111 43.22 41.06 47.22 46.28 46.28 45.36 71111 TC 27.14 25.78 29.65 29.05 29.05 28.46 71111 26 16.09 15.29 17.58 17.23 17.23 16.88 71120 26.78 25.44 29.26 28.67 28.67 28.09 71120 TC 16.83 15.99 18.39 18.02 18.02 17.66 71120 26 9.94 9.44 10.86 10.64 10.64 10.43 71130 32.49 30.87 35.50 34.79 34.79 34.10 71130 TC 21.52 20.44 23.51 23.03 23.03 22.57 71130 26 10.97 10.42 11.98 11.74 11.74 11.51 C 71250 148.10 140.70 161.81 158.57 158.57 155.40 C 71250 TC 98.01 93.11 107.08 104.94 104.94 102.84 71250 26 50.09 47.59 54.73 53.64 53.64 52.57 71260 206.84 196.50 225.98 221.46 221.46 217.03 71260 TC 145.78 138.49 159.26 156.08 156.08 152.96 71260 26 61.06 58.01 66.71 65.38 65.38 64.07 71270 247.73 235.34 270.64 265.22 265.22 259.92 71270 TC 180.12 171.11 196.78 192.84 192.84 188.99 71270 26 67.61 64.23 73.86 72.39 72.39 70.94 71275 271.21 257.65 296.30 290.38 290.38 284.57 71275 TC 182.28 173.17 199.15 195.17 195.17 191.27 71275 26 88.93 84.48 97.15 95.21 95.21 93.30 C 71550 309.26 293.80 337.87 331.11 331.11 324.48 C 71550 TC 237.85 225.96 259.85 254.66 254.66 249.56 71550 26 71.41 67.84 78.02 76.45 76.45 74.92 71551 409.73 389.24 447.63 438.68 438.68 429.90 71551 TC 325.27 309.01 355.36 348.25 348.25 341.29 71551 26 84.46 80.24 92.28 90.44 90.44 88.63 C 71552 505.71 480.42 552.48 541.43 541.43 530.60 C 71552 TC 394.87 375.13 431.40 422.77 422.77 414.32

Page 168: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 168Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

71552 26 110.84 105.30 121.10 118.67 118.67 116.30 71555 356.73 338.89 389.72 381.93 381.93 374.29 71555 TC 269.07 255.62 293.96 288.09 288.09 282.33 71555 26 87.66 83.28 95.77 93.85 93.85 91.98 72020 19.99 18.99 21.84 21.40 21.40 20.98 72020 TC 12.46 11.84 13.62 13.34 13.34 13.08 72020 26 7.53 7.15 8.22 8.06 8.06 7.90 72040 29.99 28.49 32.76 32.11 32.11 31.46 72040 TC 19.02 18.07 20.78 20.37 20.37 19.96 72040 26 10.97 10.42 11.98 11.74 11.74 11.51 72050 40.68 38.65 44.45 43.56 43.56 42.69 72050 TC 25.26 24.00 27.60 27.05 27.05 26.51 72050 26 15.42 14.65 16.85 16.51 16.51 16.18 72052 50.90 48.36 55.61 54.50 54.50 53.41 72052 TC 33.07 31.42 36.13 35.41 35.41 34.70 72052 26 17.83 16.94 19.48 19.09 19.09 18.71 72070 30.61 29.08 33.44 32.78 32.78 32.12 72070 TC 19.64 18.66 21.46 21.03 21.03 20.61 72070 26 10.97 10.42 11.98 11.74 11.74 11.51 72072 31.24 29.68 34.13 33.45 33.45 32.79 72072 TC 20.58 19.55 22.48 22.03 22.03 21.60 72072 26 10.66 10.13 11.65 11.42 11.42 11.19 72074 35.30 33.54 38.57 37.80 37.80 37.04 72074 TC 24.64 23.41 26.92 26.38 26.38 25.85 72074 26 10.66 10.13 11.65 11.42 11.42 11.19 72080 27.80 26.41 30.37 29.76 29.76 29.16 72080 TC 17.14 16.28 18.72 18.34 18.34 17.97 72080 26 10.66 10.13 11.65 11.42 11.42 11.19 72081 35.14 33.38 38.39 37.62 37.62 36.87 72081 TC 22.14 21.03 24.18 23.70 23.70 23.23 72081 26 13.00 12.35 14.20 13.92 13.92 13.64 72082 55.98 53.18 61.16 59.94 59.94 58.74 72082 TC 40.25 38.24 43.98 43.10 43.10 42.24 72082 26 15.73 14.94 17.18 16.84 16.84 16.50 72083 60.84 57.80 66.47 65.14 65.14 63.84 72083 TC 43.68 41.50 47.73 46.77 46.77 45.84 72083 26 17.16 16.30 18.75 18.37 18.37 18.00 72084 72.67 69.04 79.40 77.81 77.81 76.26 72084 TC 52.74 50.10 57.62 56.47 56.47 55.34 72084 26 19.93 18.93 21.77 21.33 21.33 20.91 72100 31.55 29.97 34.47 33.78 33.78 33.10 72100 TC 20.58 19.55 22.48 22.03 22.03 21.60 72100 26 10.97 10.42 11.98 11.74 11.74 11.51 72110 44.11 41.90 48.19 47.22 47.22 46.28 72110 TC 28.70 27.27 31.36 30.73 30.73 30.12 72110 26 15.42 14.65 16.85 16.51 16.51 16.18 72114 56.02 53.22 61.20 59.98 59.98 58.79 72114 TC 39.94 37.94 43.63 42.76 42.76 41.91 72114 26 16.09 15.29 17.58 17.23 17.23 16.88

Page 169: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 169Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

72120 36.23 34.42 39.58 38.79 38.79 38.02 72120 TC 25.26 24.00 27.60 27.05 27.05 26.51 72120 26 10.97 10.42 11.98 11.74 11.74 11.51 C 72125 150.51 142.98 164.43 161.14 161.14 157.92 C 72125 TC 98.01 93.11 107.08 104.94 104.94 102.84 72125 26 52.51 49.88 57.36 56.21 56.21 55.09 72126 206.44 196.12 225.54 221.03 221.03 216.61 72126 TC 146.71 139.37 160.28 157.07 157.07 153.93 72126 26 59.72 56.73 65.24 63.94 63.94 62.66 72127 243.51 231.33 266.03 260.71 260.71 255.50 72127 TC 181.37 172.30 198.15 194.18 194.18 190.29 72127 26 62.14 59.03 67.88 66.53 66.53 65.19 C 72128 147.07 139.72 160.68 157.47 157.47 154.32 C 72128 TC 98.01 93.11 107.08 104.94 104.94 102.84 72128 26 49.06 46.61 53.60 52.53 52.53 51.49 72129 206.75 196.41 225.87 221.35 221.35 216.92 72129 TC 147.02 139.67 160.62 157.41 157.41 154.26 72129 26 59.72 56.73 65.24 63.94 63.94 62.66 72130 245.07 232.82 267.74 262.38 262.38 257.14 72130 TC 182.93 173.78 199.85 195.85 195.85 191.92 72130 26 62.14 59.03 67.88 66.53 66.53 65.19 C 72131 147.07 139.72 160.68 157.47 157.47 154.32 C 72131 TC 98.01 93.11 107.08 104.94 104.94 102.84 72131 26 49.06 46.61 53.60 52.53 52.53 51.49 72132 206.12 195.81 225.18 220.67 220.67 216.26 72132 TC 146.40 139.08 159.94 156.75 156.75 153.61 72132 26 59.72 56.73 65.24 63.94 63.94 62.66 72133 243.17 231.01 265.66 260.35 260.35 255.14 72133 TC 181.06 172.01 197.81 193.86 193.86 189.98 72133 26 62.11 59.00 67.85 66.49 66.49 65.16 72141 203.20 193.04 222.00 217.56 217.56 213.21 72141 TC 130.48 123.96 142.55 139.70 139.70 136.91 72141 26 72.72 69.08 79.44 77.86 77.86 76.30 72142 293.16 278.50 320.28 313.87 313.87 307.59 72142 TC 205.38 195.11 224.38 219.89 219.89 215.50 72142 26 87.78 83.39 95.90 93.98 93.98 92.10 72146 203.20 193.04 222.00 217.56 217.56 213.21 72146 TC 130.48 123.96 142.55 139.70 139.70 136.91 72146 26 72.72 69.08 79.44 77.86 77.86 76.30 72147 290.07 275.57 316.91 310.57 310.57 304.36 72147 TC 202.88 192.74 221.65 217.22 217.22 212.88 72147 26 87.18 82.82 95.24 93.33 93.33 91.47 72148 202.26 192.15 220.97 216.56 216.56 212.22 72148 TC 129.54 123.06 141.52 138.69 138.69 135.92 72148 26 72.72 69.08 79.44 77.86 77.86 76.30 72149 289.73 275.24 316.53 310.20 310.20 304.00 72149 TC 201.95 191.85 220.63 216.21 216.21 211.89 72149 26 87.78 83.39 95.90 93.98 93.98 92.10 72156 343.21 326.05 374.96 367.46 367.46 360.11

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 170Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

72156 TC 230.98 219.43 252.34 247.30 247.30 242.35 72156 26 112.23 106.62 122.61 120.16 120.16 117.76 72157 343.84 326.65 375.65 368.14 368.14 360.78 72157 TC 231.61 220.03 253.03 247.97 247.97 243.02 72157 26 112.23 106.62 122.61 120.16 120.16 117.76 72158 342.59 325.46 374.28 366.79 366.79 359.46 72158 TC 230.36 218.84 251.67 246.63 246.63 241.70 72158 26 112.23 106.62 122.61 120.16 120.16 117.76 72159 373.83 355.14 408.41 400.25 400.25 392.24 72159 TC 285.31 271.04 311.70 305.46 305.46 299.36 72159 26 88.52 84.09 96.70 94.77 94.77 92.87 72170 28.51 27.08 31.14 30.52 30.52 29.91 72170 TC 19.95 18.95 21.79 21.36 21.36 20.93 72170 26 8.56 8.13 9.35 9.17 9.17 8.98 72190 34.31 32.59 37.48 36.73 36.73 36.00 72190 TC 23.70 22.52 25.90 25.38 25.38 24.87 72190 26 10.61 10.08 11.59 11.36 11.36 11.13 72191 276.13 262.32 301.67 295.63 295.63 289.72 72191 TC 187.59 178.21 204.94 200.85 200.85 196.83 72191 26 88.54 84.11 96.73 94.79 94.79 92.90 72192 133.12 126.46 145.43 142.52 142.52 139.67 72192 TC 79.59 75.61 86.95 85.22 85.22 83.51 72192 26 53.54 50.86 58.49 57.32 57.32 56.17 72193 203.66 193.48 222.50 218.05 218.05 213.69 72193 TC 146.71 139.37 160.28 157.07 157.07 153.93 72193 26 56.95 54.10 62.22 60.97 60.97 59.75 72194 234.22 222.51 255.89 250.77 250.77 245.76 72194 TC 174.50 165.78 190.65 186.83 186.83 183.09 72194 26 59.72 56.73 65.24 63.94 63.94 62.66 C 72195 309.57 294.09 338.20 331.44 331.44 324.82 C 72195 TC 237.85 225.96 259.85 254.66 254.66 249.56 72195 26 71.72 68.13 78.35 76.79 76.79 75.24 72196 368.83 350.39 402.95 394.89 394.89 386.99 72196 TC 283.75 269.56 309.99 303.80 303.80 297.72 72196 26 85.08 80.83 92.95 91.09 91.09 89.27 72197 453.91 431.21 495.89 485.98 485.98 476.26 72197 TC 343.07 325.92 374.81 367.31 367.31 359.96 72197 26 110.84 105.30 121.10 118.67 118.67 116.30 72198 359.78 341.79 393.06 385.19 385.19 377.49 72198 TC 272.20 258.59 297.38 291.43 291.43 285.60 72198 26 87.59 83.21 95.69 93.78 93.78 91.91 72200 25.70 24.42 28.08 27.52 27.52 26.97 72200 TC 17.14 16.28 18.72 18.34 18.34 17.97 72200 26 8.56 8.13 9.35 9.17 9.17 8.98 72202 29.54 28.06 32.27 31.63 31.63 30.99 72202 TC 20.27 19.26 22.15 21.70 21.70 21.26 72202 26 9.27 8.81 10.13 9.92 9.92 9.73 72220 25.39 24.12 27.74 27.19 27.19 26.65 72220 TC 16.83 15.99 18.39 18.02 18.02 17.66

Page 171: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 171Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

72220 26 8.56 8.13 9.35 9.17 9.17 8.98 72240 89.86 85.37 98.18 96.21 96.21 94.29 72240 TC 45.24 42.98 49.43 48.44 48.44 47.47 72240 26 44.62 42.39 48.75 47.77 47.77 46.82 72255 89.52 85.04 97.80 95.84 95.84 93.92 72255 TC 44.31 42.09 48.40 47.44 47.44 46.49 72255 26 45.22 42.96 49.40 48.42 48.42 47.45 72265 84.50 80.28 92.32 90.47 90.47 88.67 72265 TC 43.68 41.50 47.73 46.77 46.77 45.84 72265 26 40.82 38.78 44.60 43.70 43.70 42.83 72270 117.62 111.74 128.50 125.94 125.94 123.42 72270 TC 52.11 49.50 56.93 55.79 55.79 54.67 72270 26 65.51 62.23 71.56 70.14 70.14 68.74 72275 104.81 99.57 114.51 112.22 112.22 109.97 72275 TC 66.47 63.15 72.62 71.17 71.17 69.75 72275 26 38.34 36.42 41.88 41.04 41.04 40.23 72285 105.32 100.05 115.06 112.76 112.76 110.50 72285 TC 46.18 43.87 50.45 49.44 49.44 48.45 72285 26 59.14 56.18 64.61 63.32 63.32 62.05 72295 90.41 85.89 98.77 96.80 96.80 94.86 72295 TC 48.05 45.65 52.50 51.45 51.45 50.43 72295 26 42.35 40.23 46.26 45.34 45.34 44.44 73000 24.72 23.48 27.00 26.46 26.46 25.93 73000 TC 16.52 15.69 18.04 17.69 17.69 17.33 73000 26 8.20 7.79 8.96 8.77 8.77 8.60 73010 26.95 25.60 29.44 28.85 28.85 28.28 73010 TC 18.08 17.18 19.76 19.37 19.37 18.98 73010 26 8.87 8.43 9.69 9.50 9.50 9.30 73020 20.61 19.58 22.52 22.07 22.07 21.63 73020 TC 13.09 12.44 14.31 14.02 14.02 13.74 73020 26 7.53 7.15 8.22 8.06 8.06 7.90 73030 26.06 24.76 28.47 27.90 27.90 27.34 73030 TC 16.83 15.99 18.39 18.02 18.02 17.66 73030 26 9.23 8.77 10.09 9.88 9.88 9.68 73040 90.10 85.60 98.44 96.47 96.47 94.54 73040 TC 63.35 60.18 69.21 67.83 67.83 66.47 73040 26 26.74 25.40 29.21 28.62 28.62 28.05 73050 31.77 30.18 34.71 34.02 34.02 33.34 73050 TC 21.52 20.44 23.51 23.03 23.03 22.57 73050 26 10.26 9.75 11.21 10.99 10.99 10.78 73060 25.97 24.67 28.37 27.81 27.81 27.26 73060 TC 17.77 16.88 19.41 19.02 19.02 18.64 73060 26 8.20 7.79 8.96 8.77 8.77 8.60 73070 24.36 23.14 26.61 26.08 26.08 25.56 73070 TC 16.52 15.69 18.04 17.69 17.69 17.33 73070 26 7.84 7.45 8.57 8.40 8.40 8.22 73080 27.89 26.50 30.48 29.87 29.87 29.27 73080 TC 19.33 18.36 21.11 20.69 20.69 20.27 73080 26 8.56 8.13 9.35 9.17 9.17 8.98

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 172Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

73085 87.57 83.19 95.67 93.76 93.76 91.89 73085 TC 59.61 56.63 65.12 63.83 63.83 62.55 73085 26 27.97 26.57 30.56 29.95 29.95 29.35 73090 23.16 22.00 25.30 24.79 24.79 24.30 73090 TC 14.96 14.21 16.34 16.02 16.02 15.70 73090 26 8.20 7.79 8.96 8.77 8.77 8.60 73092 24.41 23.19 26.67 26.14 26.14 25.62 73092 TC 16.52 15.69 18.04 17.69 17.69 17.33 73092 26 7.89 7.50 8.63 8.45 8.45 8.28 73100 25.97 24.67 28.37 27.81 27.81 27.26 73100 TC 17.77 16.88 19.41 19.02 19.02 18.64 73100 26 8.20 7.79 8.96 8.77 8.77 8.60 73110 31.63 30.05 34.56 33.87 33.87 33.19 73110 TC 23.08 21.93 25.22 24.71 24.71 24.22 73110 26 8.56 8.13 9.35 9.17 9.17 8.98 73115 96.00 91.20 104.88 102.79 102.79 100.73 73115 TC 68.35 64.93 74.67 73.17 73.17 71.71 73115 26 27.65 26.27 30.21 29.60 29.60 29.01 73120 23.47 22.30 25.65 25.13 25.13 24.62 73120 TC 15.27 14.51 16.69 16.35 16.35 16.03 73120 26 8.20 7.79 8.96 8.77 8.77 8.60 73130 27.57 26.19 30.12 29.52 29.52 28.93 73130 TC 19.02 18.07 20.78 20.37 20.37 19.96 73130 26 8.56 8.13 9.35 9.17 9.17 8.98 73140 28.02 26.62 30.61 30.00 30.00 29.41 73140 TC 21.20 20.14 23.16 22.70 22.70 22.25 73140 26 6.81 6.47 7.44 7.29 7.29 7.14 C 73200 147.07 139.72 160.68 157.47 157.47 154.32 C 73200 TC 98.01 93.11 107.08 104.94 104.94 102.84 73200 26 49.06 46.61 53.60 52.53 52.53 51.49 73201 200.85 190.81 219.43 215.04 215.04 210.74 73201 TC 143.90 136.71 157.22 154.08 154.08 151.00 73201 26 56.95 54.10 62.22 60.97 60.97 59.75 73202 249.21 236.75 272.26 266.82 266.82 261.49 73202 TC 189.49 180.02 207.02 202.88 202.88 198.82 73202 26 59.72 56.73 65.24 63.94 63.94 62.66 C 73206 293.95 279.25 321.14 314.72 314.72 308.43 C 73206 TC 206.01 195.71 225.07 220.57 220.57 216.15 73206 26 87.95 83.55 96.08 94.16 94.16 92.28 C 73218 304.08 288.88 332.21 325.57 325.57 319.06 C 73218 TC 237.85 225.96 259.85 254.66 254.66 249.56 73218 26 66.22 62.91 72.35 70.90 70.90 69.48 73219 362.11 344.00 395.60 387.69 387.69 379.94 73219 TC 282.50 268.38 308.64 302.46 302.46 296.41 73219 26 79.61 75.63 86.97 85.24 85.24 83.54 73220 448.13 425.72 489.58 479.79 479.79 470.20 73220 TC 342.76 325.62 374.46 366.98 366.98 359.64 73220 26 105.37 100.10 115.12 112.82 112.82 110.56 73221 213.22 202.56 232.94 228.29 228.29 223.72

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 173Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

73221 TC 146.69 139.36 160.26 157.06 157.06 153.92 73221 26 66.54 63.21 72.69 71.24 71.24 69.82 73222 339.00 322.05 370.36 362.95 362.95 355.70 73222 TC 259.39 246.42 283.38 277.71 277.71 272.16 73222 26 79.61 75.63 86.97 85.24 85.24 83.54 73223 420.96 399.91 459.90 450.70 450.70 441.68 73223 TC 315.59 299.81 344.78 337.88 337.88 331.12 73223 26 105.37 100.10 115.12 112.82 112.82 110.56 73225 363.21 345.05 396.81 388.87 388.87 381.10 73225 TC 279.38 265.41 305.22 299.12 299.12 293.14 73225 26 83.83 79.64 91.59 89.76 89.76 87.96 73501 26.68 25.35 29.15 28.57 28.57 27.99 73501 TC 17.46 16.59 19.08 18.70 18.70 18.32 73501 26 9.23 8.77 10.09 9.88 9.88 9.68 73502 37.17 35.31 40.61 39.79 39.79 39.00 73502 TC 26.20 24.89 28.62 28.05 28.05 27.49 73502 26 10.97 10.42 11.98 11.74 11.74 11.51 73503 46.43 44.11 50.73 49.71 49.71 48.73 73503 TC 32.44 30.82 35.44 34.73 34.73 34.04 73503 26 13.98 13.28 15.27 14.96 14.96 14.66 73521 35.61 33.83 38.90 38.12 38.12 37.36 73521 TC 24.33 23.11 26.58 26.05 26.05 25.53 73521 26 11.28 10.72 12.33 12.09 12.09 11.85 73522 44.02 41.82 48.09 47.13 47.13 46.18 73522 TC 29.32 27.85 32.03 31.38 31.38 30.75 73522 26 14.70 13.97 16.07 15.74 15.74 15.43 73523 50.98 48.43 55.69 54.58 54.58 53.49 73523 TC 35.25 33.49 38.51 37.74 37.74 36.98 73523 26 15.73 14.94 17.18 16.84 16.84 16.50 73525 91.32 86.75 99.76 97.77 97.77 95.82 73525 TC 63.35 60.18 69.21 67.83 67.83 66.47 73525 26 27.97 26.57 30.56 29.95 29.95 29.35 73551 25.03 23.78 27.35 26.80 26.80 26.25 73551 TC 16.83 15.99 18.39 18.02 18.02 17.66 73551 26 8.20 7.79 8.96 8.77 8.77 8.60 73552 29.18 27.72 31.88 31.25 31.25 30.62 73552 TC 19.95 18.95 21.79 21.36 21.36 20.93 73552 26 9.23 8.77 10.09 9.88 9.88 9.68 73560 27.84 26.45 30.42 29.81 29.81 29.21 73560 TC 19.64 18.66 21.46 21.03 21.03 20.61 73560 26 8.20 7.79 8.96 8.77 8.77 8.60 73562 31.99 30.39 34.95 34.25 34.25 33.56 73562 TC 22.76 21.62 24.86 24.37 24.37 23.89 73562 26 9.23 8.77 10.09 9.88 9.88 9.68 73564 35.30 33.54 38.57 37.80 37.80 37.04 73564 TC 24.33 23.11 26.58 26.05 26.05 25.53 73564 26 10.97 10.42 11.98 11.74 11.74 11.51 73565 31.90 30.31 34.86 34.16 34.16 33.48 73565 TC 23.39 22.22 25.55 25.05 25.05 24.54

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 174Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

73565 26 8.51 8.08 9.29 9.11 9.11 8.92 73580 103.49 98.32 113.07 110.80 110.80 108.58 73580 TC 75.84 72.05 82.86 81.20 81.20 79.58 73580 26 27.65 26.27 30.21 29.60 29.60 29.01 73590 25.66 24.38 28.04 27.47 27.47 26.92 73590 TC 17.46 16.59 19.08 18.70 18.70 18.32 73590 26 8.20 7.79 8.96 8.77 8.77 8.60 73592 25.03 23.78 27.35 26.80 26.80 26.25 73592 TC 17.14 16.28 18.72 18.34 18.34 17.97 73592 26 7.89 7.50 8.63 8.45 8.45 8.28 73600 26.90 25.56 29.39 28.81 28.81 28.23 73600 TC 18.71 17.77 20.44 20.02 20.02 19.62 73600 26 8.20 7.79 8.96 8.77 8.77 8.60 73610 27.89 26.50 30.48 29.87 29.87 29.27 73610 TC 19.33 18.36 21.11 20.69 20.69 20.27 73610 26 8.56 8.13 9.35 9.17 9.17 8.98 73615 94.16 89.45 102.87 100.81 100.81 98.80 73615 TC 66.16 62.85 72.28 70.83 70.83 69.41 73615 26 27.99 26.59 30.58 29.97 29.97 29.37 73620 23.47 22.30 25.65 25.13 25.13 24.62 73620 TC 15.90 15.11 17.38 17.03 17.03 16.69 73620 26 7.57 7.19 8.27 8.11 8.11 7.95 73630 26.01 24.71 28.42 27.85 27.85 27.30 73630 TC 17.77 16.88 19.41 19.02 19.02 18.64 73630 26 8.24 7.83 9.00 8.82 8.82 8.65 73650 24.41 23.19 26.67 26.14 26.14 25.62 73650 TC 16.52 15.69 18.04 17.69 17.69 17.33 73650 26 7.89 7.50 8.63 8.45 8.45 8.28 73660 25.21 23.95 27.54 26.99 26.99 26.45 73660 TC 18.71 17.77 20.44 20.02 20.02 19.62 73660 26 6.50 6.18 7.11 6.97 6.97 6.83 C 73700 147.07 139.72 160.68 157.47 157.47 154.32 C 73700 TC 98.01 93.11 107.08 104.94 104.94 102.84 73700 26 49.06 46.61 53.60 52.53 52.53 51.49 73701 203.66 193.48 222.50 218.05 218.05 213.69 73701 TC 146.71 139.37 160.28 157.07 157.07 153.93 73701 26 56.95 54.10 62.22 60.97 60.97 59.75 73702 246.40 234.08 269.19 263.81 263.81 258.53 73702 TC 186.99 177.64 204.29 200.20 200.20 196.20 73702 26 59.41 56.44 64.91 63.61 63.61 62.33 C 73706 298.68 283.75 326.31 319.79 319.79 313.40 C 73706 TC 205.98 195.68 225.03 220.54 220.54 216.12 73706 26 92.70 88.07 101.28 99.26 99.26 97.27 C 73718 304.08 288.88 332.21 325.57 325.57 319.06 C 73718 TC 237.85 225.96 259.85 254.66 254.66 249.56 73718 26 66.22 62.91 72.35 70.90 70.90 69.48 73719 361.80 343.71 395.27 387.37 387.37 379.62 73719 TC 282.50 268.38 308.64 302.46 302.46 296.41 73719 26 79.30 75.34 86.64 84.90 84.90 83.20

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 175Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

73720 450.63 428.10 492.32 482.47 482.47 472.82 73720 TC 345.25 327.99 377.19 369.64 369.64 362.25 73720 26 105.37 100.10 115.12 112.82 112.82 110.56 73721 213.53 202.85 233.28 228.61 228.61 224.03 73721 TC 147.00 139.65 160.60 157.39 157.39 154.24 73721 26 66.54 63.21 72.69 71.24 71.24 69.82 73722 342.13 325.02 373.77 366.30 366.30 358.97 73722 TC 262.52 249.39 286.80 281.06 281.06 275.44 73722 26 79.61 75.63 86.97 85.24 85.24 83.54 73723 422.53 401.40 461.61 452.38 452.38 443.33 73723 TC 317.15 301.29 346.48 339.55 339.55 332.75 73723 26 105.37 100.10 115.12 112.82 112.82 110.56 73725 360.50 342.48 393.85 385.97 385.97 378.26 73725 TC 272.20 258.59 297.38 291.43 291.43 285.60 73725 26 88.30 83.89 96.47 94.54 94.54 92.66 74000 21.38 20.31 23.36 22.89 22.89 22.43 74000 TC 12.46 11.84 13.62 13.34 13.34 13.08 74000 26 8.91 8.46 9.73 9.53 9.53 9.34 74010 31.91 30.31 34.86 34.16 34.16 33.48 74010 TC 20.58 19.55 22.48 22.03 22.03 21.60 74010 26 11.33 10.76 12.37 12.12 12.12 11.88 74020 33.94 32.24 37.08 36.34 36.34 35.62 74020 TC 20.58 19.55 22.48 22.03 22.03 21.60 74020 26 13.36 12.69 14.59 14.31 14.31 14.02 74022 40.41 38.39 44.15 43.26 43.26 42.40 74022 TC 24.64 23.41 26.92 26.38 26.38 25.85 74022 26 15.77 14.98 17.23 16.88 16.88 16.55 74150 136.68 129.85 149.33 146.34 146.34 143.42 74150 TC 78.34 74.42 85.58 83.87 83.87 82.19 74150 26 58.34 55.42 63.73 62.46 62.46 61.20 74160 208.23 197.82 227.49 222.94 222.94 218.48 74160 TC 145.78 138.49 159.26 156.08 156.08 152.96 74160 26 62.45 59.33 68.23 66.86 66.86 65.53 74170 236.58 224.75 258.46 253.30 253.30 248.23 74170 TC 167.94 159.54 183.47 179.80 179.80 176.20 74170 26 68.64 65.21 74.99 73.50 73.50 72.02 74174 350.92 333.37 383.38 375.71 375.71 368.20 74174 TC 243.78 231.59 266.33 261.00 261.00 255.78 74174 26 107.13 101.77 117.04 114.69 114.69 112.40 74175 277.45 263.58 303.12 297.06 297.06 291.11 74175 TC 188.83 179.39 206.30 202.17 202.17 198.12 74175 26 88.62 84.19 96.82 94.89 94.89 92.99 74176 183.76 174.57 200.76 196.74 196.74 192.81 74176 TC 98.32 93.40 107.41 105.26 105.26 103.16 74176 26 85.44 81.17 93.35 91.48 91.48 89.65 74177 281.22 267.16 307.23 301.09 301.09 295.07 74177 TC 191.98 182.38 209.74 205.54 205.54 201.43 74177 26 89.24 84.78 97.50 95.54 95.54 93.63 74178 318.88 302.94 348.38 341.41 341.41 334.58

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 176Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

74178 TC 220.37 209.35 240.75 235.93 235.93 231.22 74178 26 98.51 93.58 107.62 105.47 105.47 103.36 74181 298.96 284.01 326.61 320.08 320.08 313.67 74181 TC 227.55 216.17 248.60 243.63 243.63 238.75 74181 26 71.41 67.84 78.02 76.45 76.45 74.92 74182 405.98 385.68 443.53 434.67 434.67 425.97 74182 TC 321.21 305.15 350.92 343.91 343.91 337.03 74182 26 84.77 80.53 92.61 90.76 90.76 88.94 74183 454.54 431.81 496.58 486.65 486.65 476.92 74183 TC 343.69 326.51 375.49 367.98 367.98 360.62 74183 26 110.84 105.30 121.10 118.67 118.67 116.30 74185 361.66 343.58 395.12 387.22 387.22 379.48 74185 TC 274.07 260.37 299.43 293.43 293.43 287.57 74185 26 87.59 83.21 95.69 93.78 93.78 91.91 74190 71.35 67.78 77.95 76.38 76.38 74.85 74190 TC 48.31 45.89 52.77 51.72 51.72 50.68 74190 26 23.04 21.89 25.17 24.67 24.67 24.17 74210 69.63 66.15 76.07 74.55 74.55 73.06 74210 TC 52.11 49.50 56.93 55.79 55.79 54.67 74210 26 17.52 16.64 19.14 18.76 18.76 18.38 74220 79.74 75.75 87.11 85.38 85.38 83.67 74220 TC 57.11 54.25 62.39 61.15 61.15 59.93 74220 26 22.63 21.50 24.73 24.23 24.23 23.75 C 74230 113.47 107.80 123.97 121.49 121.49 119.06 C 74230 TC 87.39 83.02 95.47 93.56 93.56 91.69 74230 26 26.07 24.77 28.49 27.91 27.91 27.35 74235 26 60.05 57.05 65.61 64.30 64.30 63.01 74240 102.31 97.19 111.77 109.54 109.54 107.35 74240 TC 68.35 64.93 74.67 73.17 73.17 71.71 74240 26 33.96 32.26 37.10 36.35 36.35 35.63 74241 106.37 101.05 116.21 113.88 113.88 111.61 74241 TC 72.41 68.79 79.11 77.52 77.52 75.97 74241 26 33.96 32.26 37.10 36.35 36.35 35.63 74245 154.49 146.77 168.79 165.40 165.40 162.09 74245 TC 109.87 104.38 120.04 117.63 117.63 115.28 74245 26 44.62 42.39 48.75 47.77 47.77 46.82 74246 114.80 109.06 125.42 122.91 122.91 120.45 74246 TC 80.84 76.80 88.32 86.55 86.55 84.81 74246 26 33.96 32.26 37.10 36.35 36.35 35.63 C 74247 121.67 115.59 132.93 130.27 130.27 127.66 C 74247 TC 87.70 83.32 95.82 93.90 93.90 92.02 74247 26 33.96 32.26 37.10 36.35 36.35 35.63 74249 165.42 157.15 180.72 177.11 177.11 173.57 74249 TC 120.80 114.76 131.97 129.33 129.33 126.74 74249 26 44.62 42.39 48.75 47.77 47.77 46.82 74250 93.21 88.55 101.83 99.80 99.80 97.80 74250 TC 70.22 66.71 76.72 75.19 75.19 73.68 74250 26 22.99 21.84 25.12 24.61 24.61 24.12 C 74251 200.97 190.92 219.56 215.17 215.17 210.86

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 177Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

C 74251 TC 167.01 158.66 182.46 178.81 178.81 175.24 74251 26 33.96 32.26 37.10 36.35 36.35 35.63 C 74260 191.69 182.11 209.43 205.24 205.24 201.14 C 74260 TC 167.01 158.66 182.46 178.81 178.81 175.24 74260 26 24.69 23.46 26.98 26.44 26.44 25.91 C 74261 216.02 205.22 236.00 231.29 231.29 226.67 C 74261 TC 98.01 93.11 107.08 104.94 104.94 102.84 74261 26 118.01 112.11 128.93 126.35 126.35 123.82 C 74262 328.25 311.84 358.62 351.44 351.44 344.41 C 74262 TC 205.72 195.43 224.74 220.25 220.25 215.84 74262 26 122.53 116.40 133.86 131.18 131.18 128.56 C 74270 121.67 115.59 132.93 130.27 130.27 127.66 C 74270 TC 87.70 83.32 95.82 93.90 93.90 92.02 74270 26 33.96 32.26 37.10 36.35 36.35 35.63 74280 191.05 181.50 208.73 204.55 204.55 200.46 74280 TC 142.34 135.22 155.50 152.40 152.40 149.35 74280 26 48.71 46.27 53.21 52.14 52.14 51.09 74283 189.36 179.89 206.87 202.73 202.73 198.67 74283 TC 89.58 85.10 97.87 95.91 95.91 93.99 74283 26 99.78 94.79 109.01 106.82 106.82 104.68 74290 62.89 59.75 68.71 67.34 67.34 66.00 74290 TC 47.12 44.76 51.47 50.44 50.44 49.43 74290 26 15.77 14.98 17.23 16.88 16.88 16.55 74300 26 17.80 16.91 19.45 19.06 19.06 18.68 74301 26 10.27 9.76 11.22 10.99 10.99 10.78 74328 151.23 143.67 165.22 161.92 161.92 158.68 74328 TC 116.60 110.77 127.39 124.83 124.83 122.34 74328 26 34.63 32.90 37.84 37.08 37.08 36.34 74329 26 34.94 33.19 38.17 37.41 37.41 36.66 74330 161.17 153.11 176.08 172.56 172.56 169.11 74330 TC 116.60 110.77 127.39 124.83 124.83 122.34 74330 26 44.57 42.34 48.69 47.71 47.71 46.76 74340 123.43 117.26 134.85 132.15 132.15 129.50 74340 TC 97.00 92.15 105.97 103.86 103.86 101.78 74340 26 26.43 25.11 28.88 28.30 28.30 27.74 74355 134.63 127.90 147.09 144.14 144.14 141.25 74355 TC 97.00 92.15 105.97 103.86 103.86 101.78 74355 26 37.63 35.75 41.11 40.30 40.30 39.49 74360 143.91 136.71 157.22 154.08 154.08 151.00 74360 TC 116.60 110.77 127.39 124.83 124.83 122.34 74360 26 27.31 25.94 29.83 29.23 29.23 28.65 74363 26 41.99 39.89 45.87 44.95 44.95 44.06 74400 98.61 93.68 107.73 105.58 105.58 103.47 74400 TC 74.59 70.86 81.49 79.86 79.86 78.26 74400 26 24.02 22.82 26.24 25.71 25.71 25.20 74410 97.05 92.20 106.03 103.91 103.91 101.83 74410 TC 73.34 69.67 80.12 78.52 78.52 76.95 74410 26 23.71 22.52 25.90 25.38 25.38 24.87 74415 122.03 115.93 133.32 130.65 130.65 128.04

Page 178: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 178Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

74415 TC 98.01 93.11 107.08 104.94 104.94 102.84 74415 26 24.02 22.82 26.24 25.71 25.71 25.20 74420 114.23 108.52 124.80 122.30 122.30 119.85 74420 TC 97.00 92.15 105.97 103.86 103.86 101.78 74420 26 17.23 16.37 18.83 18.45 18.45 18.08 74425 65.52 62.24 71.58 70.15 70.15 68.75 74425 TC 48.31 45.89 52.77 51.72 51.72 50.68 74425 26 17.21 16.35 18.80 18.42 18.42 18.06 74430 34.48 32.76 37.67 36.92 36.92 36.18 74430 TC 18.71 17.77 20.44 20.02 20.02 19.62 74430 26 15.77 14.98 17.23 16.88 16.88 16.55 74440 72.87 69.23 79.61 78.03 78.03 76.46 74440 TC 54.92 52.17 60.00 58.80 58.80 57.63 74440 26 17.95 17.05 19.61 19.22 19.22 18.84 74445 94.89 90.15 103.67 101.60 101.60 99.57 74445 TC 41.67 39.59 45.53 44.62 44.62 43.72 74445 26 53.22 50.56 58.14 56.98 56.98 55.84 74450 70.06 66.56 76.54 75.01 75.01 73.52 74450 TC 53.93 51.23 58.91 57.74 57.74 56.59 74450 26 16.13 15.32 17.62 17.26 17.26 16.92 74455 72.93 69.28 79.67 78.07 78.07 76.51 74455 TC 56.80 53.96 62.05 60.81 60.81 59.59 74455 26 16.13 15.32 17.62 17.26 17.26 16.92 74470 72.03 68.43 78.69 77.12 77.12 75.58 74470 TC 46.22 43.91 50.50 49.48 49.48 48.50 74470 26 25.81 24.52 28.20 27.63 27.63 27.08 74485 83.26 79.10 90.97 89.15 89.15 87.37 74485 TC 57.73 54.84 63.07 61.80 61.80 60.57 74485 26 25.52 24.24 27.88 27.32 27.32 26.77 74710 33.63 31.95 36.74 36.01 36.01 35.28 74710 TC 16.83 15.99 18.39 18.02 18.02 17.66 74710 26 16.80 15.96 18.35 17.99 17.99 17.63 C 74712 385.07 365.82 420.69 412.28 412.28 404.03 C 74712 TC 237.85 225.96 259.85 254.66 254.66 249.56 74712 26 147.22 139.86 160.84 157.62 157.62 154.47 74713 211.42 200.85 230.98 226.35 226.35 221.82 74713 TC 123.92 117.72 135.38 132.68 132.68 130.02 74713 26 87.50 83.13 95.60 93.69 93.69 91.82 74740 67.22 63.86 73.44 71.97 71.97 70.53 74740 TC 48.68 46.25 53.19 52.13 52.13 51.08 74740 26 18.55 17.62 20.26 19.86 19.86 19.46 74742 26 28.91 27.46 31.58 30.95 30.95 30.33 74775 84.45 80.23 92.26 90.42 90.42 88.62 74775 TC 53.93 51.23 58.91 57.74 57.74 56.59 74775 26 30.52 28.99 33.34 32.67 32.67 32.02 75557 289.87 275.38 316.69 310.35 310.35 304.14 75557 TC 176.69 167.86 193.04 189.18 189.18 185.39 75557 26 113.18 107.52 123.65 121.18 121.18 118.75 75559 395.96 376.16 432.58 423.94 423.94 415.46

Page 179: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 179Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

75559 TC 255.68 242.90 279.34 273.75 273.75 268.27 75559 26 140.29 133.28 153.27 150.20 150.20 147.20 75561 383.06 363.91 418.50 410.12 410.12 401.93 75561 TC 257.83 244.94 281.68 276.05 276.05 270.53 75561 26 125.23 118.97 136.82 134.08 134.08 131.40 75563 453.90 431.21 495.89 485.98 485.98 476.26 75563 TC 310.29 294.78 339.00 332.21 332.21 325.57 75563 26 143.61 136.43 156.89 153.76 153.76 150.68 75565 49.20 46.74 53.75 52.68 52.68 51.62 75565 TC 37.15 35.29 40.58 39.77 39.77 38.97 75565 26 12.05 11.45 13.17 12.90 12.90 12.65 C 75571 39.39 37.42 43.03 42.17 42.17 41.33 C 75571 TC 11.21 10.65 12.25 12.01 12.01 11.76 75571 26 28.18 26.77 30.79 30.16 30.16 29.57 75572 257.18 244.32 280.97 275.34 275.34 269.84 75572 TC 172.29 163.68 188.23 184.47 184.47 180.78 75572 26 84.89 80.65 92.75 90.90 90.90 89.08 C 75573 329.42 312.95 359.89 352.69 352.69 345.64 C 75573 TC 206.01 195.71 225.07 220.57 220.57 216.15 75573 26 123.41 117.24 134.83 132.14 132.14 129.49 C 75574 321.58 305.50 351.33 344.30 344.30 337.41 C 75574 TC 205.69 195.41 224.72 220.23 220.23 215.82 75574 26 115.88 110.09 126.60 124.07 124.07 121.59 75600 175.98 167.18 192.26 188.42 188.42 184.64 75600 TC 152.33 144.71 166.42 163.09 163.09 159.83 75600 26 23.65 22.47 25.84 25.32 25.32 24.82 75605 127.31 120.94 139.08 136.30 136.30 133.57 75605 TC 72.72 69.08 79.44 77.86 77.86 76.30 75605 26 54.59 51.86 59.64 58.44 58.44 57.27 75625 126.91 120.56 138.64 135.87 135.87 133.16 75625 TC 72.41 68.79 79.11 77.52 77.52 75.97 75625 26 54.51 51.78 59.55 58.35 58.35 57.19 75630 158.48 150.56 173.14 169.68 169.68 166.29 75630 TC 72.41 68.79 79.11 77.52 77.52 75.97 75630 26 86.07 81.77 94.04 92.15 92.15 90.31 C 75635 322.74 306.60 352.59 345.54 345.54 338.63 C 75635 TC 205.98 195.68 225.03 220.54 220.54 216.12 75635 26 116.77 110.93 127.57 125.02 125.02 122.52 75658 153.21 145.55 167.38 164.04 164.04 160.76 75658 TC 90.80 86.26 99.20 97.21 97.21 95.27 75658 26 62.41 59.29 68.18 66.82 66.82 65.48 75705 224.56 213.33 245.33 240.42 240.42 235.61 75705 TC 113.59 107.91 124.10 121.61 121.61 119.19 75705 26 110.97 105.42 121.23 118.81 118.81 116.43 75710 149.37 141.90 163.19 159.92 159.92 156.72 75710 TC 94.23 89.52 102.95 100.89 100.89 98.88 75710 26 55.13 52.37 60.23 59.02 59.02 57.83 75716 171.32 162.75 187.16 183.43 183.43 179.76 75716 TC 108.26 102.85 118.28 115.91 115.91 113.59

Page 180: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 180Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

75716 26 63.06 59.91 68.90 67.52 67.52 66.17 75726 137.04 130.19 149.72 146.73 146.73 143.80 75726 TC 82.71 78.57 90.36 88.55 88.55 86.78 75726 26 54.33 51.61 59.35 58.17 58.17 57.01 75731 157.05 149.20 171.58 168.15 168.15 164.80 75731 TC 101.10 96.05 110.46 108.25 108.25 106.09 75731 26 55.95 53.15 61.12 59.90 59.90 58.71 75733 168.13 159.72 183.68 180.01 180.01 176.41 75733 TC 105.76 100.47 115.54 113.23 113.23 110.96 75733 26 62.38 59.26 68.15 66.78 66.78 65.45 75736 146.95 139.60 160.54 157.33 157.33 154.18 75736 TC 92.67 88.04 101.25 99.22 99.22 97.23 75736 26 54.28 51.57 59.31 58.12 58.12 56.96 75741 139.38 132.41 152.27 149.22 149.22 146.23 75741 TC 77.09 73.24 84.23 82.55 82.55 80.89 75741 26 62.29 59.18 68.06 66.70 66.70 65.37 75743 157.14 149.28 171.67 168.23 168.23 164.86 75743 TC 78.03 74.13 85.25 83.55 83.55 81.88 75743 26 79.11 75.15 86.42 84.70 84.70 83.01 75746 139.23 132.27 152.11 149.06 149.06 146.08 75746 TC 84.24 80.03 92.03 90.19 90.19 88.39 75746 26 54.99 52.24 60.08 58.88 58.88 57.71 75756 152.46 144.84 166.57 163.23 163.23 159.97 75756 TC 97.67 92.79 106.71 104.57 104.57 102.48 75756 26 54.79 52.05 59.86 58.66 58.66 57.49 75774 78.97 75.02 86.27 84.55 84.55 82.86 75774 TC 61.79 58.70 67.51 66.16 66.16 64.84 75774 26 17.18 16.32 18.77 18.39 18.39 18.02 75791 293.76 279.07 320.93 314.51 314.51 308.22 75791 TC 209.78 199.29 229.18 224.60 224.60 220.10 75791 26 83.98 79.78 91.75 89.91 89.91 88.11 C 75801 209.59 199.11 228.98 224.40 224.40 219.91 C 75801 TC 166.69 158.36 182.11 178.47 178.47 174.90 75801 26 42.89 40.75 46.86 45.93 45.93 45.01 75803 257.63 244.75 281.46 275.84 275.84 270.32 75803 TC 200.29 190.28 218.82 214.44 214.44 210.15 75803 26 57.34 54.47 62.64 61.39 61.39 60.16 75805 265.64 252.36 290.21 284.41 284.41 278.71 75805 TC 225.85 214.56 246.74 241.81 241.81 236.97 75805 26 39.79 37.80 43.47 42.60 42.60 41.75 75807 26 57.62 54.74 62.95 61.70 61.70 60.47 75809 89.46 84.99 97.74 95.78 95.78 93.86 75809 TC 66.16 62.85 72.28 70.83 70.83 69.41 75809 26 23.30 22.14 25.46 24.96 24.96 24.46 75810 521.57 495.49 569.81 558.42 558.42 547.25 75810 TC 465.34 442.07 508.38 498.21 498.21 488.26 75810 26 56.23 53.42 61.43 60.20 60.20 59.00 75820 104.80 99.56 114.49 112.21 112.21 109.96 75820 TC 70.84 67.30 77.40 75.84 75.84 74.32

Page 181: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 181Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

75820 26 33.95 32.25 37.09 36.35 36.35 35.63 75822 126.03 119.73 137.69 134.94 134.94 132.24 75822 TC 74.90 71.16 81.83 80.20 80.20 78.60 75822 26 51.13 48.57 55.86 54.74 54.74 53.65 75825 125.35 119.08 136.94 134.21 134.21 131.53 75825 TC 70.22 66.71 76.72 75.19 75.19 73.68 75825 26 55.13 52.37 60.23 59.02 59.02 57.83 75827 127.51 121.13 139.30 136.52 136.52 133.79 75827 TC 72.41 68.79 79.11 77.52 77.52 75.97 75827 26 55.10 52.35 60.20 59.00 59.00 57.81 75831 129.49 123.02 141.47 138.64 138.64 135.87 75831 TC 75.22 71.46 82.18 80.53 80.53 78.92 75831 26 54.28 51.57 59.31 58.12 58.12 56.96 75833 151.77 144.18 165.81 162.50 162.50 159.24 75833 TC 81.12 77.06 88.62 86.85 86.85 85.11 75833 26 70.65 67.12 77.19 75.65 75.65 74.13 75840 136.16 129.35 148.75 145.77 145.77 142.85 75840 TC 80.21 76.20 87.63 85.88 85.88 84.17 75840 26 55.95 53.15 61.12 59.90 59.90 58.71 75842 165.78 157.49 181.11 177.49 177.49 173.94 75842 TC 92.98 88.33 101.58 99.54 99.54 97.55 75842 26 72.80 69.16 79.53 77.95 77.95 76.38 75860 131.40 124.83 143.55 140.68 140.68 137.86 75860 TC 76.78 72.94 83.88 82.20 82.20 80.56 75860 26 54.62 51.89 59.67 58.48 58.48 57.30 75870 135.54 128.76 148.07 145.11 145.11 142.21 75870 TC 79.59 75.61 86.95 85.22 85.22 83.51 75870 26 55.95 53.15 61.12 59.90 59.90 58.71 75872 128.93 122.48 140.85 138.03 138.03 135.27 75872 TC 76.46 72.64 83.54 81.87 81.87 80.24 75872 26 52.46 49.84 57.32 56.17 56.17 55.04 75880 128.89 122.45 140.82 138.00 138.00 135.24 75880 TC 93.64 88.96 102.30 100.26 100.26 98.26 75880 26 35.26 33.50 38.53 37.75 37.75 37.00 75885 146.20 138.89 159.72 156.53 156.53 153.40 75885 TC 78.03 74.13 85.25 83.55 83.55 81.88 75885 26 68.17 64.76 74.47 72.98 72.98 71.52 75887 147.16 139.80 160.77 157.55 157.55 154.40 75887 TC 78.65 74.72 85.93 84.21 84.21 82.54 75887 26 68.51 65.08 74.84 73.35 73.35 71.88 75889 132.39 125.77 144.64 141.74 141.74 138.91 75889 TC 78.34 74.42 85.58 83.87 83.87 82.19 75889 26 54.05 51.35 59.05 57.87 57.87 56.71 75891 133.32 126.65 145.65 142.74 142.74 139.89 75891 TC 78.65 74.72 85.93 84.21 84.21 82.54 75891 26 54.67 51.94 59.73 58.54 58.54 57.36 75893 106.96 101.61 116.85 114.52 114.52 112.23 75893 TC 80.52 76.49 87.96 86.20 86.20 84.48 75893 26 26.43 25.11 28.88 28.30 28.30 27.74

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 182Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

75894 956.45 908.63 1,044.92 1,024.03 1,024.03 1,003.55 75894 TC 891.82 847.23 974.31 954.83 954.83 935.73 75894 26 64.63 61.40 70.61 69.20 69.20 67.82 75898 120.87 114.83 132.05 129.41 129.41 126.82 75898 TC 38.87 36.93 42.47 41.62 41.62 40.79 75898 26 82.00 77.90 89.59 87.79 87.79 86.03 75901 158.24 150.33 172.88 169.42 169.42 166.03 75901 TC 134.85 128.11 147.33 144.38 144.38 141.50 75901 26 23.39 22.22 25.55 25.05 25.05 24.54 75902 65.06 61.81 71.08 69.66 69.66 68.26 75902 TC 46.49 44.17 50.80 49.78 49.78 48.78 75902 26 18.56 17.63 20.27 19.87 19.87 19.47 75952 241.40 229.33 263.73 258.45 258.45 253.29 75952 26 218.27 207.36 238.46 233.69 233.69 229.02 75953 97.54 92.66 106.56 104.43 104.43 102.34 75953 26 66.14 62.83 72.25 70.81 70.81 69.39 75954 26 110.31 104.79 120.51 118.09 118.09 115.74 75956 26 340.54 323.51 372.04 364.60 364.60 357.31 75957 26 292.37 277.75 319.41 313.03 313.03 306.77 75958 26 194.31 184.59 212.28 208.04 208.04 203.87 75959 26 169.76 161.27 185.46 181.75 181.75 178.11 75962 126.20 119.89 137.87 135.11 135.11 132.41 75962 TC 100.17 95.16 109.43 107.25 107.25 105.10 75962 26 26.04 24.74 28.45 27.89 27.89 27.34 75964 79.54 75.56 86.89 85.16 85.16 83.46 75964 TC 62.10 59.00 67.85 66.49 66.49 65.16 75964 26 17.43 16.56 19.04 18.66 18.66 18.30 75966 156.70 148.87 171.20 167.77 167.77 164.42 75966 TC 93.92 89.22 102.60 100.56 100.56 98.54 75966 26 62.78 59.64 68.59 67.22 67.22 65.87 75968 78.66 74.73 85.94 84.23 84.23 82.55 75968 TC 61.17 58.11 66.83 65.49 65.49 64.18 75968 26 17.49 16.62 19.11 18.73 18.73 18.35 75970 465.70 442.42 508.78 498.61 498.61 488.64 75970 TC 426.13 404.82 465.54 456.23 456.23 447.11 75970 26 39.57 37.59 43.23 42.37 42.37 41.52 75978 124.64 118.41 136.17 133.45 133.45 130.78 75978 TC 98.60 93.67 107.72 105.57 105.57 103.45 75978 26 26.04 24.74 28.45 27.89 27.89 27.34 75984 96.83 91.99 105.79 103.67 103.67 101.60 75984 TC 62.42 59.30 68.20 66.83 66.83 65.49 75984 26 34.41 32.69 37.59 36.85 36.85 36.11 75989 111.70 106.12 122.04 119.60 119.60 117.21 75989 TC 54.30 51.59 59.33 58.14 58.14 56.98 75989 26 57.40 54.53 62.71 61.46 61.46 60.23 76000 42.22 40.11 46.13 45.21 45.21 44.30 76000 TC 33.69 32.01 36.81 36.08 36.08 35.35 76000 26 8.53 8.10 9.32 9.13 9.13 8.95 76001 131.70 125.12 143.89 141.01 141.01 138.20

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 183Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76001 TC 97.00 92.15 105.97 103.86 103.86 101.78 76001 26 34.70 32.97 37.92 37.16 37.16 36.41 76010 23.56 22.38 25.74 25.22 25.22 24.71 76010 TC 14.65 13.92 16.01 15.69 15.69 15.38 76010 26 8.91 8.46 9.73 9.53 9.53 9.34 76080 51.07 48.52 55.80 54.68 54.68 53.59 76080 TC 25.26 24.00 27.60 27.05 27.05 26.51 76080 26 25.81 24.52 28.20 27.63 27.63 27.08 76098 15.35 14.58 16.77 16.43 16.43 16.10 76098 TC 7.47 7.10 8.17 8.00 8.00 7.84 76098 26 7.89 7.50 8.63 8.45 8.45 8.28 76100 83.67 79.49 91.41 89.59 89.59 87.79 76100 TC 53.05 50.40 57.96 56.80 56.80 55.66 76100 26 30.62 29.09 33.45 32.79 32.79 32.13 76101 118.07 112.17 129.00 126.42 126.42 123.89 76101 TC 85.52 81.24 93.43 91.56 91.56 89.73 76101 26 32.55 30.92 35.56 34.85 34.85 34.14 76102 155.48 147.71 169.87 166.47 166.47 163.14 76102 TC 122.64 116.51 133.99 131.31 131.31 128.69 76102 26 32.83 31.19 35.87 35.16 35.16 34.45 76120 75.03 71.28 81.97 80.33 80.33 78.72 76120 TC 56.17 53.36 61.36 60.13 60.13 58.93 76120 26 18.86 17.92 20.61 20.19 20.19 19.79 76125 43.01 40.86 46.99 46.05 46.05 45.13 76125 TC 29.05 27.60 31.74 31.11 31.11 30.49 76125 26 13.96 13.26 15.25 14.94 14.94 14.64 76376 21.16 20.10 23.12 22.66 22.66 22.21 76376 TC 11.52 10.94 12.58 12.33 12.33 12.09 76376 26 9.63 9.15 10.52 10.32 10.32 10.11 76377 66.21 62.90 72.34 70.89 70.89 69.47 76377 TC 27.45 26.08 29.99 29.39 29.39 28.81 76377 26 38.76 36.82 42.34 41.49 41.49 40.66 C 76380 101.08 96.03 110.43 108.23 108.23 106.06 C 76380 TC 53.05 50.40 57.96 56.80 56.80 55.66 76380 26 48.04 45.64 52.49 51.44 51.44 50.42 76506 107.63 102.25 117.59 115.24 115.24 112.94 76506 TC 76.15 72.34 83.19 81.52 81.52 79.89 76506 26 31.47 29.90 34.39 33.70 33.70 33.02 76510 157.20 149.34 171.74 168.30 168.30 164.93 76510 TC 71.47 67.90 78.09 76.52 76.52 74.99 76510 26 85.73 81.44 93.66 91.78 91.78 89.94 76511 93.55 88.87 102.20 100.15 100.15 98.15 76511 TC 42.43 40.31 46.36 45.43 45.43 44.52 76511 26 51.11 48.55 55.83 54.72 54.72 53.62 76512 86.05 81.75 94.01 92.14 92.14 90.30 76512 TC 34.94 33.19 38.17 37.41 37.41 36.66 76512 26 51.11 48.55 55.83 54.72 54.72 53.62 76513 86.96 82.61 95.00 93.10 93.10 91.24 76513 TC 52.42 49.80 57.27 56.12 56.12 54.99

Page 184: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 184Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76513 26 34.53 32.80 37.72 36.96 36.96 36.23 76514 14.15 13.44 15.46 15.15 15.15 14.85 76514 TC 4.66 4.43 5.09 4.99 4.99 4.89 76514 26 9.49 9.02 10.37 10.17 10.17 9.96 76516 71.73 68.14 78.36 76.80 76.80 75.26 76516 TC 41.81 39.72 45.68 44.77 44.77 43.87 76516 26 29.92 28.42 32.68 32.03 32.03 31.38 76519 76.41 72.59 83.48 81.81 81.81 80.18 76519 TC 46.49 44.17 50.80 49.78 49.78 48.78 76519 26 29.92 28.42 32.68 32.03 32.03 31.38 76529 72.49 68.87 79.20 77.61 77.61 76.06 76529 TC 41.18 39.12 44.99 44.09 44.09 43.21 76529 26 31.31 29.74 34.20 33.52 33.52 32.86 76536 105.17 99.91 114.90 112.60 112.60 110.34 76536 TC 77.71 73.82 84.89 83.19 83.19 81.52 76536 26 27.46 26.09 30.00 29.41 29.41 28.82 76604 80.15 76.14 87.56 85.81 85.81 84.10 76604 TC 53.67 50.99 58.64 57.47 57.47 56.32 76604 26 26.48 25.16 28.93 28.36 28.36 27.80 76641 98.12 93.21 107.19 105.05 105.05 102.95 76641 TC 62.42 59.30 68.20 66.83 66.83 65.49 76641 26 35.71 33.92 39.01 38.23 38.23 37.47 76642 81.03 76.98 88.53 86.76 86.76 85.02 76642 TC 47.74 45.35 52.15 51.11 51.11 50.08 76642 26 33.29 31.63 36.37 35.65 35.65 34.94 76700 111.91 106.31 122.26 119.81 119.81 117.42 76700 TC 72.41 68.79 79.11 77.52 77.52 75.97 76700 26 39.51 37.53 43.16 42.30 42.30 41.45 76705 83.46 79.29 91.18 89.36 89.36 87.57 76705 TC 54.61 51.88 59.66 58.47 58.47 57.29 76705 26 28.85 27.41 31.52 30.89 30.89 30.27 76770 103.47 98.30 113.05 110.78 110.78 108.56 76770 TC 67.41 64.04 73.65 72.17 72.17 70.73 76770 26 36.06 34.26 39.40 38.61 38.61 37.84 76775 53.75 51.06 58.72 57.55 57.55 56.40 76775 TC 25.57 24.29 27.93 27.37 27.37 26.82 76775 26 28.18 26.77 30.79 30.16 30.16 29.57 76776 141.97 134.87 155.10 152.00 152.00 148.96 76776 TC 104.88 99.64 114.59 112.30 112.30 110.06 76776 26 37.09 35.24 40.53 39.72 39.72 38.93 76800 129.60 123.12 141.59 138.76 138.76 135.99 76800 TC 71.16 67.60 77.74 76.19 76.19 74.67 76800 26 58.44 55.52 63.85 62.57 62.57 61.32 76801 113.31 107.64 123.79 121.31 121.31 118.89 76801 TC 64.29 61.08 70.24 68.84 68.84 67.46 76801 26 49.02 46.57 53.56 52.49 52.49 51.44 76802 61.09 58.04 66.75 65.41 65.41 64.10 76802 TC 19.67 18.69 21.49 21.07 21.07 20.64 76802 26 41.42 39.35 45.25 44.34 44.34 43.46

Page 185: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 185Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76805 130.14 123.63 142.17 139.33 139.33 136.55 76805 TC 80.84 76.80 88.32 86.55 86.55 84.81 76805 26 49.30 46.84 53.87 52.79 52.79 51.73 76810 87.03 82.68 95.08 93.18 93.18 91.32 76810 TC 38.09 36.19 41.62 40.79 40.79 39.97 76810 26 48.94 46.49 53.46 52.39 52.39 51.35 76811 169.63 161.15 185.32 181.62 181.62 177.99 76811 TC 73.94 70.24 80.78 79.17 79.17 77.58 76811 26 95.69 90.91 104.55 102.45 102.45 100.41 76812 190.99 181.44 208.66 204.48 204.48 200.39 76812 TC 101.13 96.07 110.48 108.27 108.27 106.11 76812 26 89.86 85.37 98.18 96.21 96.21 94.29 76813 112.51 106.88 122.91 120.45 120.45 118.05 76813 TC 53.05 50.40 57.96 56.80 56.80 55.66 76813 26 59.46 56.49 64.96 63.66 63.66 62.39 76814 76.38 72.56 83.44 81.78 81.78 80.14 76814 TC 26.20 24.89 28.62 28.05 28.05 27.49 76814 26 50.18 47.67 54.82 53.73 53.73 52.66 76815 77.46 73.59 84.63 82.94 82.94 81.28 76815 TC 45.56 43.28 49.77 48.77 48.77 47.79 76815 26 31.90 30.31 34.86 34.16 34.16 33.48 76816 105.77 100.48 115.55 113.24 113.24 110.98 76816 TC 63.04 59.89 68.87 67.49 67.49 66.15 76816 26 42.73 40.59 46.68 45.75 45.75 44.83 76817 89.44 84.97 97.72 95.76 95.76 93.84 76817 TC 52.11 49.50 56.93 55.79 55.79 54.67 76817 26 37.33 35.46 40.78 39.96 39.96 39.17 76818 112.53 106.90 122.94 120.47 120.47 118.06 76818 TC 59.58 56.60 65.09 63.79 63.79 62.51 76818 26 52.96 50.31 57.86 56.70 56.70 55.56 76819 82.01 77.91 89.60 87.80 87.80 86.04 76819 TC 43.37 41.20 47.38 46.44 46.44 45.51 76819 26 38.64 36.71 42.22 41.38 41.38 40.55 76820 43.99 41.79 48.06 47.09 47.09 46.15 76820 TC 19.02 18.07 20.78 20.37 20.37 19.96 76820 26 24.97 23.72 27.28 26.74 26.74 26.21 76821 85.44 81.17 93.35 91.48 91.48 89.65 76821 TC 50.24 47.73 54.89 53.80 53.80 52.72 76821 26 35.20 33.44 38.46 37.69 37.69 36.93 76825 252.10 239.50 275.43 269.92 269.92 264.52 76825 TC 170.10 161.60 185.84 182.13 182.13 178.48 76825 26 82.00 77.90 89.59 87.79 87.79 86.03 76826 148.22 140.81 161.93 158.69 158.69 155.51 76826 TC 107.69 102.31 117.66 115.30 115.30 112.99 76826 26 40.53 38.50 44.28 43.39 43.39 42.53 76827 69.67 66.19 76.12 74.60 74.60 73.11 76827 TC 41.50 39.43 45.34 44.44 44.44 43.55 76827 26 28.18 26.77 30.79 30.16 30.16 29.57 76828 49.89 47.40 54.51 53.42 53.42 52.35

Page 186: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 186Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76828 TC 22.14 21.03 24.18 23.70 23.70 23.23 76828 26 27.75 26.36 30.31 29.70 29.70 29.11 76830 111.05 105.50 121.33 118.90 118.90 116.52 76830 TC 77.09 73.24 84.23 82.55 82.55 80.89 76830 26 33.96 32.26 37.10 36.35 36.35 35.63 76831 108.04 102.64 118.04 115.68 115.68 113.37 76831 TC 72.09 68.49 78.76 77.19 77.19 75.65 76831 26 35.94 34.14 39.26 38.48 38.48 37.71 76856 100.12 95.11 109.38 107.19 107.19 105.05 76856 TC 66.47 63.15 72.62 71.17 71.17 69.75 76856 26 33.65 31.97 36.77 36.03 36.03 35.31 76857 44.33 42.11 48.43 47.46 47.46 46.51 76857 TC 19.95 18.95 21.79 21.36 21.36 20.93 76857 26 24.38 23.16 26.63 26.11 26.11 25.59 76870 62.43 59.31 68.21 66.84 66.84 65.50 76870 TC 31.19 29.63 34.07 33.40 33.40 32.73 76870 26 31.23 29.67 34.12 33.44 33.44 32.78 76872 86.13 81.82 94.09 92.21 92.21 90.37 76872 TC 53.36 50.69 58.29 57.13 57.13 55.99 76872 26 32.77 31.13 35.80 35.09 35.09 34.39 76873 155.21 147.45 169.57 166.18 166.18 162.85 76873 TC 79.27 75.31 86.61 84.87 84.87 83.17 76873 26 75.94 72.14 82.96 81.31 81.31 79.68 76881 103.93 98.73 113.54 111.27 111.27 109.04 76881 TC 73.34 69.67 80.12 78.52 78.52 76.95 76881 26 30.59 29.06 33.42 32.75 32.75 32.10 76882 33.98 32.28 37.12 36.37 36.37 35.65 76882 TC 9.96 9.46 10.88 10.66 10.66 10.44 76882 26 24.02 22.82 26.24 25.71 25.71 25.20 C 76885 116.59 110.76 127.37 124.82 124.82 122.33 C 76885 TC 80.21 76.20 87.63 85.88 85.88 84.17 76885 26 36.38 34.56 39.74 38.95 38.95 38.17 76886 96.40 91.58 105.32 103.21 103.21 101.15 76886 TC 66.47 63.15 72.62 71.17 71.17 69.75 76886 26 29.92 28.42 32.68 32.03 32.03 31.38 76930 26 32.02 30.42 34.98 34.28 34.28 33.59 76932 88.75 84.31 96.96 95.01 95.01 93.12 76932 TC 56.73 53.89 61.97 60.73 60.73 59.51 76932 26 32.02 30.42 34.98 34.28 34.28 33.59 76936 249.06 236.61 272.10 266.66 266.66 261.33 76936 TC 152.93 145.28 167.07 163.73 163.73 160.45 76936 26 96.14 91.33 105.03 102.93 102.93 100.87 76937 29.11 27.65 31.80 31.17 31.17 30.54 76937 TC 14.99 14.24 16.38 16.05 16.05 15.73 76937 26 14.12 13.41 15.42 15.11 15.11 14.81 76940 163.80 155.61 178.95 175.38 175.38 171.87 76940 TC 63.53 60.35 69.40 68.01 68.01 66.65 76940 26 100.27 95.26 109.55 107.35 107.35 105.20 76941 123.03 116.88 134.41 131.72 131.72 129.09

Page 187: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 187Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76941 TC 56.37 53.55 61.58 60.35 60.35 59.14 76941 26 66.66 63.33 72.83 71.37 71.37 69.94 76942 56.63 53.80 61.87 60.63 60.63 59.42 76942 TC 24.01 22.81 26.23 25.70 25.70 25.19 76942 26 32.62 30.99 35.64 34.93 34.93 34.22 76945 90.18 85.67 98.52 96.55 96.55 94.62 76945 TC 56.37 53.55 61.58 60.35 60.35 59.14 76945 26 33.81 32.12 36.94 36.20 36.20 35.48 76946 30.67 29.14 33.51 32.84 32.84 32.19 76946 TC 11.52 10.94 12.58 12.33 12.33 12.09 76946 26 19.14 18.18 20.91 20.49 20.49 20.08 76948 64.41 61.19 70.37 68.97 68.97 67.59 76948 TC 34.63 32.90 37.84 37.08 37.08 36.34 76948 26 29.78 28.29 32.53 31.88 31.88 31.25 76965 85.62 81.34 93.54 91.67 91.67 89.84 76965 TC 20.89 19.85 22.83 22.37 22.37 21.92 76965 26 64.73 61.49 70.71 69.30 69.30 67.91 76970 83.86 79.67 91.62 89.79 89.79 88.00 76970 TC 64.91 61.66 70.91 69.49 69.49 68.10 76970 26 18.95 18.00 20.70 20.29 20.29 19.88 76975 97.67 92.79 106.71 104.57 104.57 102.48 76975 TC 56.37 53.55 61.58 60.35 60.35 59.14 76975 26 41.30 39.24 45.13 44.23 44.23 43.34 76977 6.42 6.10 7.02 6.88 6.88 6.74 76977 TC 3.72 3.53 4.06 3.98 3.98 3.90 76977 26 2.70 2.57 2.96 2.90 2.90 2.84 76998 158.40 150.48 173.05 169.59 169.59 166.20 76998 TC 97.00 92.15 105.97 103.86 103.86 101.78 76998 26 61.40 58.33 67.08 65.73 65.73 64.42 77001 63.48 60.31 69.36 67.97 67.97 66.61 77001 TC 44.96 42.71 49.12 48.14 48.14 47.17 77001 26 18.52 17.59 20.23 19.83 19.83 19.44 77002 84.14 79.93 91.92 90.08 90.08 88.27 77002 TC 56.80 53.96 62.05 60.81 60.81 59.59 77002 26 27.34 25.97 29.87 29.27 29.27 28.68 77003 77.88 73.99 85.09 83.39 83.39 81.72 77003 TC 48.37 45.95 52.84 51.78 51.78 50.75 77003 26 29.52 28.04 32.25 31.60 31.60 30.97 77011 201.39 191.32 220.02 215.61 215.61 211.30 77011 TC 140.47 133.45 153.47 150.40 150.40 147.38 77011 26 60.93 57.88 66.56 65.23 65.23 63.93 77012 114.99 109.24 125.63 123.12 123.12 120.66 77012 TC 58.67 55.74 64.10 62.82 62.82 61.57 77012 26 56.33 53.51 61.54 60.31 60.31 59.10 77013 533.04 506.39 582.35 570.70 570.70 559.28 77013 TC 341.80 324.71 373.42 365.95 365.95 358.64 77013 26 191.24 181.68 208.93 204.76 204.76 200.66 77014 107.41 102.04 117.35 115.00 115.00 112.70 77014 TC 64.91 61.66 70.91 69.49 69.49 68.10

Page 188: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 188Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

77014 26 42.50 40.38 46.44 45.51 45.51 44.60 77021 360.96 342.91 394.35 386.46 386.46 378.73 77021 TC 287.52 273.14 314.11 307.83 307.83 301.68 77021 26 73.44 69.77 80.24 78.63 78.63 77.05 77022 656.21 623.40 716.91 702.57 702.57 688.52 77022 TC 448.92 426.47 490.44 480.63 480.63 471.02 77022 26 207.29 196.93 226.47 221.94 221.94 217.50 77051 7.46 7.09 8.15 7.99 7.99 7.83 77051 TC 4.68 4.45 5.12 5.01 5.01 4.91 77051 26 2.77 2.63 3.02 2.97 2.97 2.91 77052 7.46 7.09 8.15 7.99 7.99 7.83 77052 TC 4.68 4.45 5.12 5.01 5.01 4.91 77052 26 2.77 2.63 3.02 2.97 2.97 2.91 77053 52.77 50.13 57.65 56.50 56.50 55.37 77053 TC 35.25 33.49 38.51 37.74 37.74 36.98 77053 26 17.52 16.64 19.14 18.76 18.76 18.38 77054 69.39 65.92 75.81 74.29 74.29 72.81 77054 TC 47.12 44.76 51.47 50.44 50.44 49.43 77054 26 22.27 21.16 24.33 23.85 23.85 23.38 77055 81.75 77.66 89.31 87.53 87.53 85.78 77055 TC 47.43 45.06 51.82 50.78 50.78 49.77 77055 26 34.32 32.60 37.49 36.74 36.74 36.01 77056 104.98 99.73 114.69 112.40 112.40 110.16 77056 TC 62.42 59.30 68.20 66.83 66.83 65.49 77056 26 42.56 40.43 46.49 45.56 45.56 44.65 77057 75.19 71.43 82.14 80.50 80.50 78.89 77057 TC 40.87 38.83 44.65 43.76 43.76 42.88 77057 26 34.32 32.60 37.49 36.74 36.74 36.01 C 77058 474.52 450.79 518.41 508.04 508.04 497.87 C 77058 TC 394.87 375.13 431.40 422.77 422.77 414.32 77058 26 79.66 75.68 87.03 85.30 85.30 83.59 C 77059 474.52 450.79 518.41 508.04 508.04 497.87 C 77059 TC 394.87 375.13 431.40 422.77 422.77 414.32 77059 26 79.66 75.68 87.03 85.30 85.30 83.59 77063 51.37 48.80 56.12 54.99 54.99 53.89 77063 TC 22.17 21.06 24.22 23.74 23.74 23.26 77063 26 29.21 27.75 31.91 31.28 31.28 30.66 77071 44.15 41.94 48.23 47.27 47.27 46.32 77072 21.11 20.05 23.06 22.60 22.60 22.15 77072 TC 11.84 11.25 12.94 12.68 12.68 12.43 77072 26 9.27 8.81 10.13 9.92 9.92 9.73 77073 32.69 31.06 35.72 35.01 35.01 34.30 77073 TC 18.71 17.77 20.44 20.02 20.02 19.62 77073 26 13.98 13.28 15.27 14.96 14.96 14.66 77074 58.46 55.54 63.87 62.59 62.59 61.34 77074 TC 36.19 34.38 39.54 38.74 38.74 37.97 77074 26 22.27 21.16 24.33 23.85 23.85 23.38 77075 79.17 75.21 86.49 84.77 84.77 83.08 77075 TC 52.74 50.10 57.62 56.47 56.47 55.34

Page 189: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 189Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

77075 26 26.43 25.11 28.88 28.30 28.30 27.74 77076 87.37 83.00 95.45 93.54 93.54 91.67 77076 TC 53.05 50.40 57.96 56.80 56.80 55.66 77076 26 34.32 32.60 37.49 36.74 36.74 36.01 77077 34.12 32.41 37.27 36.52 36.52 35.79 77077 TC 18.39 17.47 20.09 19.69 19.69 19.30 77077 26 15.73 14.94 17.18 16.84 16.84 16.50 C 77078 65.09 61.84 71.12 69.69 69.69 68.30 C 77078 TC 53.05 50.40 57.96 56.80 56.80 55.66 77078 26 12.05 11.45 13.17 12.90 12.90 12.65 77080 37.08 35.23 40.51 39.71 39.71 38.92 77080 TC 27.14 25.78 29.65 29.05 29.05 28.46 77080 26 9.94 9.44 10.86 10.64 10.64 10.43 77081 25.62 24.34 27.99 27.43 27.43 26.88 77081 TC 14.96 14.21 16.34 16.02 16.02 15.70 77081 26 10.66 10.13 11.65 11.42 11.42 11.19 C 77084 316.43 300.61 345.70 338.79 338.79 332.02 C 77084 TC 237.85 225.96 259.85 254.66 254.66 249.56 77084 26 78.58 74.65 85.85 84.13 84.13 82.46 77085 50.93 48.38 55.64 54.52 54.52 53.43 77085 TC 35.88 34.09 39.20 38.42 38.42 37.65 77085 26 15.06 14.31 16.46 16.12 16.12 15.80 77086 31.95 30.35 34.90 34.20 34.20 33.52 77086 TC 23.39 22.22 25.55 25.05 25.05 24.54 77086 26 8.56 8.13 9.35 9.17 9.17 8.98 77261 72.94 69.29 79.68 78.09 78.09 76.52 77262 109.16 103.70 119.26 116.87 116.87 114.54 77263 159.87 151.88 174.66 171.17 171.17 167.74 77280 243.81 231.62 266.36 261.04 261.04 255.82 77280 TC 208.84 198.40 228.16 223.59 223.59 219.12 77280 26 34.97 33.22 38.20 37.44 37.44 36.70 77285 384.30 365.09 419.85 411.46 411.46 403.22 77285 TC 331.54 314.96 362.20 354.96 354.96 347.86 77285 26 52.76 50.12 57.64 56.49 56.49 55.36 77290 460.89 437.85 503.53 493.45 493.45 483.59 77290 TC 382.43 363.31 417.81 409.45 409.45 401.26 77290 26 78.45 74.53 85.71 84.00 84.00 82.32 77293 419.74 398.75 458.56 449.40 449.40 440.40 77293 TC 319.34 303.37 348.88 341.90 341.90 335.05 77293 26 100.40 95.38 109.69 107.49 107.49 105.34 77295 451.44 428.87 493.20 483.33 483.33 473.66 77295 TC 236.83 224.99 258.74 253.56 253.56 248.49 77295 26 214.61 203.88 234.46 229.77 229.77 225.17 77300 61.43 58.36 67.11 65.77 65.77 64.46 77300 TC 30.26 28.75 33.06 32.41 32.41 31.76 77300 26 31.17 29.61 34.05 33.37 33.37 32.71 77301 1,757.16 1,669.30 1,919.70 1,881.30 1,881.30 1,843.67 77301 TC 1,357.13 1,289.27 1,482.66 1,453.00 1,453.00 1,423.94 77301 26 400.03 380.03 437.03 428.29 428.29 419.73

Page 190: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 190Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

77306 137.95 131.05 150.71 147.69 147.69 144.74 77306 TC 67.70 64.32 73.97 72.48 72.48 71.04 77306 26 70.25 66.74 76.75 75.22 75.22 73.72 77307 267.33 253.96 292.05 286.21 286.21 280.49 77307 TC 122.30 116.19 133.62 130.95 130.95 128.33 77307 26 145.03 137.78 158.45 155.27 155.27 152.17 77316 172.58 163.95 188.54 184.77 184.77 181.08 77316 TC 102.32 97.20 111.78 109.55 109.55 107.35 77316 26 70.25 66.74 76.75 75.22 75.22 73.72 77317 224.73 213.49 245.51 240.60 240.60 235.80 77317 TC 132.89 126.25 145.19 142.29 142.29 139.45 77317 26 91.84 87.25 100.34 98.34 98.34 96.37 77318 325.32 309.05 355.41 348.30 348.30 341.33 77318 TC 180.29 171.28 196.97 193.03 193.03 189.16 77318 26 145.03 137.78 158.45 155.27 155.27 152.17 77321 86.02 81.72 93.98 92.10 92.10 90.26 77321 TC 38.37 36.45 41.92 41.08 41.08 40.26 77321 26 47.64 45.26 52.05 51.00 51.00 49.98 77331 60.05 57.05 65.61 64.30 64.30 63.01 77331 TC 16.52 15.69 18.04 17.69 17.69 17.33 77331 26 43.53 41.35 47.55 46.60 46.60 45.67 77332 75.45 71.68 82.43 80.79 80.79 79.18 77332 TC 48.05 45.65 52.50 51.45 51.45 50.43 77332 26 27.40 26.03 29.93 29.34 29.34 28.75 77333 50.54 48.01 55.21 54.11 54.11 53.03 77333 TC 8.40 7.98 9.18 8.99 8.99 8.81 77333 26 42.14 40.03 46.03 45.11 45.11 44.22 77334 140.08 133.08 153.04 149.98 149.98 146.98 77334 TC 78.03 74.13 85.25 83.55 83.55 81.88 77334 26 62.06 58.96 67.80 66.45 66.45 65.11 77336 69.74 66.25 76.19 74.67 74.67 73.17 77338 466.71 443.37 509.88 499.68 499.68 489.68 77338 TC 252.10 239.50 275.43 269.92 269.92 264.52 77338 26 214.61 203.88 234.46 229.77 229.77 225.17 77370 107.07 101.72 116.98 114.64 114.64 112.36 77372 944.63 897.40 1,032.01 1,011.37 1,011.37 991.14 77373 1,200.85 1,140.81 1,311.93 1,285.69 1,285.69 1,259.97 77401 21.20 20.14 23.16 22.70 22.70 22.25 77417 9.65 9.17 10.55 10.34 10.34 10.13 77427 178.38 169.46 194.88 190.98 190.98 187.16 77431 97.85 92.96 106.90 104.77 104.77 102.67 77432 403.42 383.25 440.74 431.93 431.93 423.29 77435 608.08 577.68 664.33 651.05 651.05 638.03 77469 309.42 293.95 338.04 331.28 331.28 324.66 77470 146.96 139.61 160.55 157.34 157.34 154.19 77470 TC 42.41 40.29 46.33 45.40 45.40 44.49 77470 26 104.56 99.33 114.23 111.94 111.94 109.70 77600 377.73 358.84 412.67 404.41 404.41 396.32 77600 TC 298.37 283.45 325.97 319.45 319.45 313.05

Page 191: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 191Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

77600 26 79.36 75.39 86.70 84.96 84.96 83.26 77605 712.49 676.87 778.40 762.83 762.83 747.57 77605 TC 601.21 571.15 656.82 643.69 643.69 630.82 77605 26 111.28 105.72 121.58 119.15 119.15 116.77 77610 881.32 837.25 962.84 943.59 943.59 924.72 77610 TC 798.84 758.90 872.74 855.28 855.28 838.18 77610 26 82.47 78.35 90.10 88.30 88.30 86.53 77615 945.72 898.43 1,033.19 1,012.53 1,012.53 992.28 77615 TC 841.48 799.41 919.32 900.93 900.93 882.91 77615 26 104.24 99.03 113.88 111.61 111.61 109.38 77620 345.29 328.03 377.23 369.69 369.69 362.30 77620 TC 267.14 253.78 291.85 286.01 286.01 280.29 77620 26 78.14 74.23 85.36 83.66 83.66 82.00 77750 349.74 332.25 382.09 374.45 374.45 366.97 77750 TC 99.80 94.81 109.03 106.85 106.85 104.71 77750 26 249.94 237.44 273.06 267.59 267.59 262.25 77761 360.42 342.40 393.76 385.88 385.88 378.17 77761 TC 169.71 161.22 185.40 181.70 181.70 178.07 77761 26 190.71 181.17 208.35 204.18 204.18 200.10 77762 482.62 458.49 527.26 516.72 516.72 506.38 77762 TC 194.66 184.93 212.67 208.41 208.41 204.25 77762 26 287.97 273.57 314.61 308.32 308.32 302.15 77763 685.64 651.36 749.06 734.08 734.08 719.39 77763 TC 252.02 239.42 275.33 269.82 269.82 264.43 77763 26 433.62 411.94 473.73 464.26 464.26 454.97 77767 202.85 192.71 221.62 217.19 217.19 212.84 77767 TC 150.09 142.59 163.98 160.70 160.70 157.49 77767 26 52.76 50.12 57.64 56.49 56.49 55.36 77768 316.77 300.93 346.07 339.15 339.15 332.36 77768 TC 246.82 234.48 269.65 264.26 264.26 258.97 77768 26 69.94 66.44 76.41 74.88 74.88 73.38 77770 291.47 276.90 318.44 312.06 312.06 305.82 77770 TC 193.77 184.08 211.69 207.46 207.46 203.31 77770 26 97.70 92.82 106.74 104.60 104.60 102.51 77771 543.17 516.01 593.41 581.54 581.54 569.92 77771 TC 352.92 335.27 385.56 377.84 377.84 370.29 77771 26 190.25 180.74 207.85 203.70 203.70 199.63 77772 828.04 786.64 904.64 886.55 886.55 868.81 77772 TC 557.91 530.01 609.51 597.32 597.32 585.37 77772 26 270.14 256.63 295.12 289.23 289.23 283.44 77778 723.51 687.33 790.43 774.62 774.62 759.13 77778 TC 324.06 307.86 354.04 346.96 346.96 340.02 77778 26 399.45 379.48 436.40 427.67 427.67 419.12 77789 110.59 105.06 120.82 118.40 118.40 116.04 77789 TC 53.05 50.40 57.96 56.80 56.80 55.66 77789 26 57.54 54.66 62.86 61.61 61.61 60.38 77790 13.09 12.44 14.31 14.02 14.02 13.74 78012 72.60 68.97 79.32 77.73 77.73 76.18 78012 TC 63.32 60.15 69.17 67.79 67.79 66.44

Page 192: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 192Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78012 26 9.27 8.81 10.13 9.92 9.92 9.73 78013 175.15 166.39 191.35 187.52 187.52 183.77 78013 TC 157.27 149.41 171.82 168.38 168.38 165.01 78013 26 17.88 16.99 19.54 19.15 19.15 18.77 78014 221.92 210.82 242.44 237.59 237.59 232.84 78014 TC 197.86 187.97 216.17 211.84 211.84 207.61 78014 26 24.06 22.86 26.29 25.76 25.76 25.24 78015 203.03 192.88 221.81 217.37 217.37 213.03 78015 TC 171.01 162.46 186.83 183.09 183.09 179.43 78015 26 32.02 30.42 34.98 34.28 34.28 33.59 78016 257.45 244.58 281.27 275.64 275.64 270.14 78016 TC 223.43 212.26 244.10 239.21 239.21 234.43 78016 26 34.02 32.32 37.17 36.42 36.42 35.70 78018 288.15 273.74 314.80 308.51 308.51 302.34 78018 TC 247.48 235.11 270.38 264.97 264.97 259.67 78018 26 40.67 38.64 44.44 43.55 43.55 42.68 78020 78.51 74.58 85.77 84.05 84.05 82.37 78020 TC 51.15 48.59 55.88 54.76 54.76 53.67 78020 26 27.36 25.99 29.89 29.29 29.29 28.70 78070 276.04 262.24 301.58 295.55 295.55 289.64 78070 TC 237.82 225.93 259.82 254.62 254.62 249.53 78070 26 38.21 36.30 41.75 40.91 40.91 40.09 78071 330.86 314.32 361.47 354.23 354.23 347.15 78071 TC 273.39 259.72 298.68 292.71 292.71 286.86 78071 26 57.47 54.60 62.79 61.54 61.54 60.31 78072 382.93 363.78 418.35 409.98 409.98 401.78 78072 TC 307.73 292.34 336.19 329.46 329.46 322.87 78072 26 75.20 71.44 82.16 80.51 80.51 78.90 78075 392.19 372.58 428.47 419.90 419.90 411.50 78075 TC 357.66 339.78 390.75 382.93 382.93 375.27 78075 26 34.53 32.80 37.72 36.96 36.96 36.23 78102 156.59 148.76 171.07 167.65 167.65 164.29 78102 TC 130.42 123.90 142.49 139.63 139.63 136.84 78102 26 26.17 24.86 28.59 28.01 28.01 27.45 78103 205.56 195.28 224.57 220.08 220.08 215.67 78103 TC 170.07 161.57 185.81 182.09 182.09 178.45 78103 26 35.48 33.71 38.77 38.00 38.00 37.24 78104 226.39 215.07 247.33 242.39 242.39 237.53 78104 TC 188.81 179.37 206.28 202.15 202.15 198.10 78104 26 37.59 35.71 41.07 40.25 40.25 39.45 78110 85.99 81.69 93.94 92.07 92.07 90.23 78110 TC 76.72 72.88 83.81 82.13 82.13 80.49 78110 26 9.27 8.81 10.13 9.92 9.92 9.73 78111 88.32 83.90 96.49 94.55 94.55 92.67 78111 TC 77.66 73.78 84.85 83.15 83.15 81.48 78111 26 10.66 10.13 11.65 11.42 11.42 11.19 78120 86.18 81.87 94.15 92.26 92.26 90.42 78120 TC 74.85 71.11 81.78 80.14 80.14 78.55 78120 26 11.33 10.76 12.37 12.12 12.12 11.88

Page 193: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 193Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78121 94.06 89.36 102.76 100.71 100.71 98.69 78121 TC 78.28 74.37 85.53 83.81 83.81 82.13 78121 26 15.77 14.98 17.23 16.88 16.88 16.55 78122 90.59 86.06 98.97 96.99 96.99 95.05 78122 TC 69.54 66.06 75.97 74.45 74.45 72.97 78122 26 21.05 20.00 23.00 22.54 22.54 22.09 78130 155.30 147.54 169.67 166.28 166.28 162.96 78130 TC 125.71 119.42 137.33 134.58 134.58 131.89 78130 26 29.59 28.11 32.33 31.68 31.68 31.05 C 78135 320.26 304.25 349.89 342.90 342.90 336.04 C 78135 TC 289.00 274.55 315.73 309.42 309.42 303.23 78135 26 31.26 29.70 34.16 33.48 33.48 32.81 78140 126.58 120.25 138.29 135.53 135.53 132.81 78140 TC 96.70 91.87 105.65 103.53 103.53 101.46 78140 26 29.88 28.39 32.65 31.99 31.99 31.35 78185 194.33 184.61 212.30 208.06 208.06 203.90 78185 TC 174.76 166.02 190.92 187.11 187.11 183.37 78185 26 19.57 18.59 21.38 20.95 20.95 20.54 78190 361.66 343.58 395.12 387.22 387.22 379.48 78190 TC 308.67 293.24 337.23 330.49 330.49 323.87 78190 26 52.99 50.34 57.89 56.73 56.73 55.59 78191 155.30 147.54 169.67 166.28 166.28 162.96 78191 TC 125.71 119.42 137.33 134.58 134.58 131.89 78191 26 29.59 28.11 32.33 31.68 31.68 31.05 78195 328.96 312.51 359.39 352.20 352.20 345.15 78195 TC 271.20 257.64 296.29 290.36 290.36 284.56 78195 26 57.76 54.87 63.10 61.84 61.84 60.59 78201 172.66 164.03 188.63 184.86 184.86 181.17 78201 TC 151.97 144.37 166.03 162.70 162.70 159.45 78201 26 20.69 19.66 22.61 22.16 22.16 21.71 78202 185.78 176.49 202.96 198.90 198.90 194.93 78202 TC 162.27 154.16 177.28 173.74 173.74 170.27 78202 26 23.51 22.33 25.68 25.16 25.16 24.66 78205 195.41 185.64 213.49 209.22 209.22 205.03 78205 TC 162.27 154.16 177.28 173.74 173.74 170.27 78205 26 33.14 31.48 36.20 35.48 35.48 34.76 78206 315.74 299.95 344.94 338.04 338.04 331.28 78206 TC 269.95 256.45 294.92 289.02 289.02 283.23 78206 26 45.79 43.50 50.03 49.02 49.02 48.05 78215 179.11 170.15 195.67 191.76 191.76 187.93 78215 TC 155.40 147.63 169.77 166.38 166.38 163.06 78215 26 23.71 22.52 25.90 25.38 25.38 24.87 78216 116.72 110.88 127.51 124.96 124.96 122.46 78216 TC 89.83 85.34 98.14 96.17 96.17 94.25 78216 26 26.88 25.54 29.37 28.78 28.78 28.21 78226 305.08 289.83 333.30 326.63 326.63 320.10 78226 TC 269.33 255.86 294.24 288.35 288.35 282.59 78226 26 35.75 33.96 39.05 38.27 38.27 37.50 C 78227 332.64 316.01 363.41 356.14 356.14 349.03

Page 194: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 194Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

C 78227 TC 289.00 274.55 315.73 309.42 309.42 303.23 78227 26 43.64 41.46 47.68 46.72 46.72 45.79 78230 130.27 123.76 142.32 139.47 139.47 136.68 78230 TC 111.38 105.81 121.68 119.24 119.24 116.86 78230 26 18.89 17.95 20.64 20.23 20.23 19.83 78231 120.55 114.52 131.70 129.06 129.06 126.49 78231 TC 94.83 90.09 103.60 101.53 101.53 99.50 78231 26 25.72 24.43 28.09 27.53 27.53 26.98 78232 91.65 87.07 100.13 98.13 98.13 96.16 78232 TC 72.04 68.44 78.71 77.13 77.13 75.59 78232 26 19.61 18.63 21.42 21.00 21.00 20.57 78258 204.89 194.65 223.85 219.37 219.37 214.98 78258 TC 169.14 160.68 184.78 181.09 181.09 177.47 78258 26 35.75 33.96 39.05 38.27 38.27 37.50 78261 229.01 217.56 250.19 245.19 245.19 240.29 78261 TC 195.68 185.90 213.79 209.51 209.51 205.32 78261 26 33.34 31.67 36.42 35.70 35.70 34.98 78262 225.25 213.99 246.09 241.17 241.17 236.35 78262 TC 192.87 183.23 210.71 206.51 206.51 202.38 78262 26 32.38 30.76 35.37 34.66 34.66 33.97 78264 307.58 292.20 336.03 329.31 329.31 322.72 78264 TC 271.83 258.24 296.98 291.04 291.04 285.22 78264 26 35.75 33.96 39.05 38.27 38.27 37.50 C 78265 336.41 319.59 367.53 360.18 360.18 352.98 C 78265 TC 289.28 274.82 316.04 309.72 309.72 303.52 78265 26 47.13 44.77 51.49 50.45 50.45 49.44 78266 435.50 413.73 475.79 466.28 466.28 456.95 78266 TC 383.26 364.10 418.72 410.34 410.34 402.13 78266 26 52.24 49.63 57.07 55.94 55.94 54.82 78270 92.60 87.97 101.17 99.14 99.14 97.16 78270 TC 82.34 78.22 89.95 88.16 88.16 86.40 78270 26 10.26 9.75 11.21 10.99 10.99 10.78 78271 82.61 78.48 90.25 88.45 88.45 86.68 78271 TC 72.66 69.03 79.38 77.80 77.80 76.25 78271 26 9.94 9.44 10.86 10.64 10.64 10.43 78272 88.86 84.42 97.08 95.14 95.14 93.24 78272 TC 75.79 72.00 82.80 81.14 81.14 79.52 78272 26 13.07 12.42 14.28 14.00 14.00 13.72 78278 321.81 305.72 351.58 344.55 344.55 337.66 78278 TC 274.01 260.31 299.36 293.37 293.37 287.50 78278 26 47.80 45.41 52.22 51.18 51.18 50.15 78282 26 18.55 17.62 20.26 19.86 19.86 19.46 78290 306.68 291.35 335.05 328.35 328.35 321.78 78290 TC 273.70 260.02 299.02 293.04 293.04 287.18 78290 26 32.98 31.33 36.03 35.31 35.31 34.60 78291 233.00 221.35 254.55 249.46 249.46 244.47 78291 TC 191.62 182.04 209.35 205.16 205.16 201.05 78291 26 41.39 39.32 45.22 44.31 44.31 43.42 78300 167.18 158.82 182.64 178.99 178.99 175.41

Page 195: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 195Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78300 TC 136.67 129.84 149.32 146.33 146.33 143.41 78300 26 30.52 28.99 33.34 32.67 32.67 32.02 78305 213.70 203.02 233.47 228.80 228.80 224.23 78305 TC 173.51 164.83 189.55 185.76 185.76 182.05 78305 26 40.19 38.18 43.91 43.03 43.03 42.17 78306 233.20 221.54 254.77 249.68 249.68 244.69 78306 TC 191.62 182.04 209.35 205.16 205.16 201.05 78306 26 41.58 39.50 45.43 44.52 44.52 43.63 78315 320.07 304.07 349.68 342.69 342.69 335.83 78315 TC 270.89 257.35 295.95 290.03 290.03 284.23 78315 26 49.18 46.72 53.73 52.66 52.66 51.60 78320 211.86 201.27 231.46 226.83 226.83 222.30 78320 TC 162.58 154.45 177.62 174.06 174.06 170.58 78320 26 49.27 46.81 53.83 52.75 52.75 51.69 78414 88.43 84.01 96.61 94.68 94.68 92.78 78414 TC 66.75 63.41 72.92 71.46 71.46 70.04 78414 26 21.68 20.60 23.69 23.22 23.22 22.76 78428 167.32 158.95 182.79 179.14 179.14 175.55 78428 TC 130.42 123.90 142.49 139.63 139.63 136.84 78428 26 36.90 35.06 40.32 39.51 39.51 38.72 78445 161.34 153.27 176.26 172.73 172.73 169.28 78445 TC 138.54 131.61 151.35 148.33 148.33 145.36 78445 26 22.80 21.66 24.91 24.41 24.41 23.93 78451 316.39 300.57 345.66 338.74 338.74 331.97 78451 TC 250.60 238.07 273.78 268.31 268.31 262.94 78451 26 65.79 62.50 71.88 70.44 70.44 69.03 78452 436.98 415.13 477.40 467.85 467.85 458.49 78452 TC 359.82 341.83 393.10 385.24 385.24 377.53 78452 26 77.17 73.31 84.31 82.62 82.62 80.96 78453 280.96 266.91 306.95 300.81 300.81 294.79 78453 TC 232.80 221.16 254.33 249.25 249.25 244.27 78453 26 48.15 45.74 52.60 51.55 51.55 50.52 78454 403.57 383.39 440.90 432.08 432.08 423.44 78454 TC 338.30 321.39 369.60 362.20 362.20 354.96 78454 26 65.27 62.01 71.31 69.89 69.89 68.48 78456 291.60 277.02 318.57 312.20 312.20 305.96 78456 TC 244.04 231.84 266.62 261.28 261.28 256.06 78456 26 47.56 45.18 51.96 50.92 50.92 49.90 78457 174.35 165.63 190.47 186.67 186.67 182.93 78457 TC 136.98 130.13 149.65 146.66 146.66 143.73 78457 26 37.37 35.50 40.83 40.01 40.01 39.20 78458 156.03 148.23 170.46 167.06 167.06 163.71 78458 TC 118.25 112.34 129.19 126.60 126.60 124.07 78458 26 37.79 35.90 41.29 40.46 40.46 39.65 78459 840.59 798.56 918.34 899.98 899.98 881.98 78459 TC 771.13 732.57 842.46 825.61 825.61 809.09 78459 26 69.46 65.99 75.89 74.37 74.37 72.89 78466 176.28 167.47 192.59 188.74 188.74 184.97 78466 TC 142.29 135.18 155.46 152.35 152.35 149.30

Page 196: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 196Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78466 26 33.99 32.29 37.13 36.39 36.39 35.66 78468 183.34 174.17 200.30 196.29 196.29 192.37 78468 TC 145.10 137.85 158.53 155.35 155.35 152.25 78468 26 38.24 36.33 41.78 40.94 40.94 40.12 78469 209.77 199.28 229.17 224.58 224.58 220.09 78469 TC 165.39 157.12 180.69 177.08 177.08 173.54 78469 26 44.38 42.16 48.48 47.52 47.52 46.56 78472 212.83 202.19 232.52 227.87 227.87 223.32 78472 TC 166.01 157.71 181.37 177.74 177.74 174.19 78472 26 46.81 44.47 51.14 50.12 50.12 49.12 78473 269.03 255.58 293.92 288.04 288.04 282.28 78473 TC 199.39 189.42 217.83 213.47 213.47 209.21 78473 26 69.64 66.16 76.08 74.57 74.57 73.07 78481 162.62 154.49 177.66 174.11 174.11 170.63 78481 TC 116.09 110.29 126.83 124.29 124.29 121.81 78481 26 46.53 44.20 50.83 49.82 49.82 48.82 78483 225.66 214.38 246.54 241.60 241.60 236.77 78483 TC 156.02 148.22 170.45 167.05 167.05 163.70 78483 26 69.64 66.16 76.08 74.57 74.57 73.07 78491 841.22 799.16 919.03 900.66 900.66 882.65 78491 TC 771.13 732.57 842.46 825.61 825.61 809.09 78491 26 70.09 66.59 76.58 75.05 75.05 73.54 78492 858.81 815.87 938.25 919.48 919.48 901.09 78492 TC 771.13 732.57 842.46 825.61 825.61 809.09 78492 26 87.68 83.30 95.80 93.87 93.87 92.00 78494 209.42 198.95 228.79 224.22 224.22 219.73 78494 TC 152.59 144.96 166.70 163.37 163.37 160.10 78494 26 56.83 53.99 62.09 60.85 60.85 59.63 78496 42.17 40.06 46.07 45.15 45.15 44.24 78496 TC 18.39 17.47 20.09 19.69 19.69 19.30 78496 26 23.78 22.59 25.98 25.46 25.46 24.96 78579 171.95 163.35 187.85 184.09 184.09 180.41 78579 TC 148.84 141.40 162.61 159.36 159.36 156.17 78579 26 23.11 21.95 25.24 24.74 24.74 24.24 78580 221.12 210.06 241.57 236.74 236.74 232.00 78580 TC 185.37 176.10 202.52 198.47 198.47 194.50 78580 26 35.75 33.96 39.05 38.27 38.27 37.50 78582 309.66 294.18 338.31 331.55 331.55 324.91 78582 TC 258.09 245.19 281.97 276.33 276.33 270.80 78582 26 51.57 48.99 56.34 55.21 55.21 54.11 78597 187.17 177.81 204.48 200.39 200.39 196.39 78597 TC 152.28 144.67 166.37 163.05 163.05 159.78 78597 26 34.89 33.15 38.12 37.36 37.36 36.62 78598 283.11 268.95 309.29 303.11 303.11 297.05 78598 TC 242.48 230.36 264.91 259.61 259.61 254.43 78598 26 40.63 38.60 44.39 43.50 43.50 42.63 78600 170.45 161.93 186.22 182.49 182.49 178.85 78600 TC 148.53 141.10 162.27 159.02 159.02 155.84 78600 26 21.92 20.82 23.94 23.46 23.46 22.99

Page 197: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 197Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78601 196.68 186.85 214.88 210.58 210.58 206.37 78601 TC 172.26 163.65 188.20 184.44 184.44 180.75 78601 26 24.42 23.20 26.68 26.15 26.15 25.63 78605 183.35 174.18 200.31 196.31 196.31 192.38 78605 TC 157.27 149.41 171.82 168.38 168.38 165.01 78605 26 26.07 24.77 28.49 27.91 27.91 27.35 78606 304.03 288.83 332.15 325.51 325.51 319.00 78606 TC 273.39 259.72 298.68 292.71 292.71 286.86 78606 26 30.64 29.11 33.48 32.81 32.81 32.15 78607 324.44 308.22 354.45 347.37 347.37 340.42 78607 TC 266.52 253.19 291.17 285.35 285.35 279.65 78607 26 57.92 55.02 63.27 62.01 62.01 60.77 78608 1,000.48 950.46 1,093.03 1,071.17 1,071.17 1,049.74 78608 TC 930.11 883.60 1,016.14 995.82 995.82 975.90 78608 26 70.37 66.85 76.88 75.34 75.34 73.83 78610 160.47 152.45 175.32 171.81 171.81 168.37 78610 TC 145.72 138.43 159.19 156.01 156.01 152.89 78610 26 14.74 14.00 16.10 15.78 15.78 15.47 78630 311.05 295.50 339.83 333.03 333.03 326.37 78630 TC 278.07 264.17 303.80 297.72 297.72 291.77 78630 26 32.98 31.33 36.03 35.31 35.31 34.60 78635 311.07 295.52 339.85 333.05 333.05 326.39 78635 TC 281.19 267.13 307.20 301.06 301.06 295.03 78635 26 29.88 28.39 32.65 31.99 31.99 31.35 78645 296.21 281.40 323.61 317.14 317.14 310.79 78645 TC 269.02 255.57 293.91 288.03 288.03 282.27 78645 26 27.19 25.83 29.70 29.11 29.11 28.52 78647 322.33 306.21 352.14 345.10 345.10 338.20 78647 TC 278.38 264.46 304.13 298.05 298.05 292.09 78647 26 43.95 41.75 48.01 47.06 47.06 46.12 78650 302.33 287.21 330.29 323.69 323.69 317.22 78650 TC 273.08 259.43 298.34 292.38 292.38 286.53 78650 26 29.25 27.79 31.96 31.31 31.31 30.69 78660 166.18 157.87 181.55 177.92 177.92 174.36 78660 TC 140.10 133.10 153.07 150.01 150.01 147.00 78660 26 26.07 24.77 28.49 27.91 27.91 27.35 78700 158.34 150.42 172.98 169.52 169.52 166.13 78700 TC 136.67 129.84 149.32 146.33 146.33 143.41 78700 26 21.68 20.60 23.69 23.22 23.22 22.76 78701 193.81 184.12 211.74 207.51 207.51 203.35 78701 TC 170.70 162.17 186.50 182.77 182.77 179.11 78701 26 23.11 21.95 25.24 24.74 24.74 24.24 78707 215.55 204.77 235.49 230.77 230.77 226.16 78707 TC 169.76 161.27 185.46 181.75 181.75 178.11 78707 26 45.79 43.50 50.03 49.02 49.02 48.05 78708 163.25 155.09 178.35 174.79 174.79 171.29 78708 TC 105.42 100.15 115.17 112.87 112.87 110.62 78708 26 57.83 54.94 63.18 61.92 61.92 60.67 78709 336.79 319.95 367.94 360.58 360.58 353.37

Page 198: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 198Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78709 TC 269.64 256.16 294.58 288.70 288.70 282.92 78709 26 67.15 63.79 73.36 71.89 71.89 70.45 78710 184.88 175.64 201.99 197.95 197.95 193.99 78710 TC 154.78 147.04 169.10 165.72 165.72 162.40 78710 26 30.10 28.60 32.89 32.23 32.23 31.59 78725 100.26 95.25 109.54 107.35 107.35 105.20 78725 TC 82.34 78.22 89.95 88.16 88.16 86.40 78725 26 17.92 17.02 19.57 19.18 19.18 18.80 78730 69.94 66.44 76.41 74.88 74.88 73.38 78730 TC 62.42 59.30 68.20 66.83 66.83 65.49 78730 26 7.53 7.15 8.22 8.06 8.06 7.90 78740 200.73 190.69 219.29 214.91 214.91 210.61 78740 TC 173.82 165.13 189.90 186.10 186.10 182.38 78740 26 26.91 25.56 29.39 28.81 28.81 28.23 78761 192.89 183.25 210.74 206.53 206.53 202.40 78761 TC 157.90 150.01 172.51 169.06 169.06 165.68 78761 26 34.99 33.24 38.23 37.47 37.47 36.72 78800 176.68 167.85 193.03 189.16 189.16 185.38 78800 TC 143.85 136.66 157.16 154.02 154.02 150.94 78800 26 32.83 31.19 35.87 35.16 35.16 34.45 78801 240.63 228.60 262.89 257.63 257.63 252.48 78801 TC 201.61 191.53 220.26 215.86 215.86 211.54 78801 26 39.02 37.07 42.63 41.78 41.78 40.94 78802 299.39 284.42 327.08 320.54 320.54 314.13 78802 TC 258.40 245.48 282.30 276.66 276.66 271.12 78802 26 40.98 38.93 44.77 43.87 43.87 43.00 78803 314.15 298.44 343.21 336.34 336.34 329.61 78803 TC 263.09 249.94 287.43 281.68 281.68 276.05 78803 26 51.07 48.52 55.80 54.68 54.68 53.59 78804 520.66 494.63 568.82 557.45 557.45 546.31 78804 TC 469.69 446.21 513.14 502.88 502.88 492.82 78804 26 50.97 48.42 55.68 54.57 54.57 53.48 78805 168.94 160.49 184.56 180.87 180.87 177.25 78805 TC 133.86 127.17 146.25 143.32 143.32 140.46 78805 26 35.08 33.33 38.33 37.56 37.56 36.81 78806 306.88 291.54 335.27 328.57 328.57 322.00 78806 TC 265.90 252.61 290.50 284.69 284.69 279.00 78806 26 40.98 38.93 44.77 43.87 43.87 43.00 78807 314.15 298.44 343.21 336.34 336.34 329.61 78807 TC 263.40 250.23 287.76 282.01 282.01 276.38 78807 26 50.75 48.21 55.44 54.34 54.34 53.26 78808 41.64 39.56 45.49 44.59 44.59 43.69 C 78811 1,192.88 1,133.24 1,303.23 1,277.17 1,277.17 1,251.63 C 78811 TC 1,117.38 1,061.51 1,220.74 1,196.32 1,196.32 1,172.39 78811 26 75.50 71.73 82.49 80.85 80.85 79.22 C 78812 1,209.34 1,148.87 1,321.20 1,294.77 1,294.77 1,268.88 C 78812 TC 1,117.38 1,061.51 1,220.74 1,196.32 1,196.32 1,172.39 78812 26 91.96 87.36 100.46 98.45 98.45 96.49 C 78813 1,213.38 1,152.71 1,325.62 1,299.11 1,299.11 1,273.13

Page 199: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 199Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

C 78813 TC 1,117.38 1,061.51 1,220.74 1,196.32 1,196.32 1,172.39 78813 26 96.00 91.20 104.88 102.79 102.79 100.73 C 78814 1,223.33 1,162.16 1,336.48 1,309.76 1,309.76 1,283.56 C 78814 TC 1,117.38 1,061.51 1,220.74 1,196.32 1,196.32 1,172.39 78814 26 105.94 100.64 115.74 113.42 113.42 111.16 C 78815 1,234.39 1,172.67 1,348.57 1,321.60 1,321.60 1,295.18 C 78815 TC 1,117.38 1,061.51 1,220.74 1,196.32 1,196.32 1,172.39 78815 26 117.00 111.15 127.82 125.27 125.27 122.76 C 78816 1,235.60 1,173.82 1,349.89 1,322.89 1,322.89 1,296.43 C 78816 TC 1,117.38 1,061.51 1,220.74 1,196.32 1,196.32 1,172.39 78816 26 118.22 112.31 129.16 126.57 126.57 124.04 79005 129.42 122.95 141.39 138.56 138.56 135.79 79005 TC 43.34 41.17 47.35 46.40 46.40 45.47 79005 26 86.08 81.78 94.05 92.16 92.16 90.32 79101 135.49 128.72 148.03 145.07 145.07 142.17 79101 TC 42.12 40.01 46.01 45.09 45.09 44.19 79101 26 93.37 88.70 102.01 99.97 99.97 97.97 79200 150.59 143.06 164.52 161.23 161.23 158.01 79200 TC 51.46 48.89 56.22 55.10 55.10 53.99 79200 26 99.13 94.17 108.30 106.13 106.13 104.01 79300 26 77.76 73.87 84.95 83.25 83.25 81.58 79403 181.05 172.00 197.80 193.84 193.84 189.97 79403 TC 72.66 69.03 79.38 77.80 77.80 76.25 79403 26 108.38 102.96 118.40 116.04 116.04 113.71 79440 137.53 130.65 150.25 147.25 147.25 144.30 79440 TC 44.31 42.09 48.40 47.44 47.44 46.49 79440 26 93.22 88.56 101.84 99.81 99.81 97.81 79445 26 113.07 107.42 123.53 121.06 121.06 118.63 80500 21.00 19.95 22.94 22.48 22.48 22.03 # 80500 18.81 17.87 20.55 20.14 20.14 19.73 80502 69.00 65.55 75.38 73.88 73.88 72.40 # 80502 66.81 63.47 72.99 71.53 71.53 70.10 83020 26 17.90 17.01 19.56 19.17 19.17 18.79 84165 26 17.90 17.01 19.56 19.17 19.17 18.79 84166 26 17.90 17.01 19.56 19.17 19.17 18.79 84181 26 17.90 17.01 19.56 19.17 19.17 18.79 84182 26 17.90 17.01 19.56 19.17 19.17 18.79 85060 24.17 22.96 26.40 25.88 25.88 25.36 85097 83.47 79.30 91.20 89.37 89.37 87.58 # 85097 48.50 46.08 52.99 51.93 51.93 50.90 85390 26 17.90 17.01 19.56 19.17 19.17 18.79 85396 20.06 19.06 21.92 21.48 21.48 21.06 85576 26 17.90 17.01 19.56 19.17 19.17 18.79 86077 54.12 51.41 59.12 57.94 57.94 56.78 # 86077 50.38 47.86 55.04 53.94 53.94 52.85 86078 53.81 51.12 58.79 57.62 57.62 56.47 # 86078 50.38 47.86 55.04 53.94 53.94 52.85 86079 53.19 50.53 58.11 56.95 56.95 55.81 # 86079 49.75 47.26 54.35 53.26 53.26 52.19

Page 200: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 200Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

86153 26 33.39 31.72 36.48 35.75 35.75 35.04 86255 26 17.90 17.01 19.56 19.17 19.17 18.79 86256 26 17.90 17.01 19.56 19.17 19.17 18.79 86320 26 17.90 17.01 19.56 19.17 19.17 18.79 86325 26 17.90 17.01 19.56 19.17 19.17 18.79 86327 26 20.32 19.30 22.20 21.75 21.75 21.31 86334 26 17.90 17.01 19.56 19.17 19.17 18.79 86335 26 17.90 17.01 19.56 19.17 19.17 18.79 86485 40.98 38.93 44.77 43.87 43.87 43.00 86486 4.34 4.12 4.74 4.65 4.65 4.55 86490 61.48 58.41 67.17 65.83 65.83 64.52 86510 5.28 5.02 5.77 5.66 5.66 5.54 86580 6.84 6.50 7.48 7.33 7.33 7.18 87164 26 17.90 17.01 19.56 19.17 19.17 18.79 87207 26 17.90 17.01 19.56 19.17 19.17 18.79 88104 69.33 65.86 75.74 74.22 74.22 72.74 88104 TC 40.56 38.53 44.31 43.42 43.42 42.55 88104 26 28.76 27.32 31.42 30.79 30.79 30.16 88106 67.52 64.14 73.76 72.29 72.29 70.84 88106 TC 48.05 45.65 52.50 51.45 51.45 50.43 88106 26 19.46 18.49 21.26 20.84 20.84 20.42 88108 65.65 62.37 71.73 70.29 70.29 68.89 88108 TC 43.06 40.91 47.05 46.10 46.10 45.18 88108 26 22.60 21.47 24.69 24.20 24.20 23.71 88112 65.58 62.30 71.65 70.21 70.21 68.80 88112 TC 37.75 35.86 41.24 40.41 40.41 39.61 88112 26 27.83 26.44 30.41 29.80 29.80 29.20 88120 563.29 535.13 615.40 603.09 603.09 591.03 88120 TC 505.42 480.15 552.17 541.13 541.13 530.31 88120 26 57.87 54.98 63.23 61.96 61.96 60.72 88121 491.55 466.97 537.02 526.27 526.27 515.75 88121 TC 441.75 419.66 482.61 472.96 472.96 463.50 88121 26 49.80 47.31 54.41 53.31 53.31 52.24 88125 21.71 20.62 23.71 23.24 23.24 22.78 88125 TC 8.40 7.98 9.18 8.99 8.99 8.81 88125 26 13.31 12.64 14.54 14.25 14.25 13.96 88141 30.59 29.06 33.42 32.75 32.75 32.10 88160 65.93 62.63 72.02 70.59 70.59 69.17 88160 TC 39.94 37.94 43.63 42.76 42.76 41.91 88160 26 25.99 24.69 28.39 27.83 27.83 27.28 88161 59.37 56.40 64.86 63.56 63.56 62.28 88161 TC 34.32 32.60 37.49 36.74 36.74 36.01 88161 26 25.06 23.81 27.38 26.83 26.83 26.29 88162 95.48 90.71 104.32 102.24 102.24 100.19 88162 TC 56.14 53.33 61.33 60.10 60.10 58.89 88162 26 39.33 37.36 42.96 42.10 42.10 41.26 88172 53.66 50.98 58.63 57.45 57.45 56.30 88172 TC 17.46 16.59 19.08 18.70 18.70 18.32 88172 26 36.20 34.39 39.55 38.76 38.76 37.98

Page 201: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 201Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

88173 141.73 134.64 154.84 151.74 151.74 148.71 88173 TC 70.82 67.28 77.37 75.82 75.82 74.30 88173 26 70.92 67.37 77.48 75.92 75.92 74.41 88177 28.75 27.31 31.41 30.77 30.77 30.15 88177 TC 6.56 6.23 7.16 7.03 7.03 6.89 88177 26 22.19 21.08 24.24 23.76 23.76 23.29 88182 102.08 96.98 111.53 109.30 109.30 107.11 88182 TC 65.79 62.50 71.88 70.44 70.44 69.03 88182 26 36.28 34.47 39.64 38.85 38.85 38.07 88184 66.47 63.15 72.62 71.17 71.17 69.75 88185 40.59 38.56 44.34 43.46 43.46 42.58 88187 69.73 66.24 76.18 74.66 74.66 73.16 88188 88.67 84.24 96.88 94.94 94.94 93.05 88189 109.54 104.06 119.67 117.28 117.28 114.93 88291 30.43 28.91 33.25 32.58 32.58 31.92 88300 13.74 13.05 15.01 14.71 14.71 14.41 88300 TC 9.34 8.87 10.20 9.99 9.99 9.80 88300 26 4.40 4.18 4.81 4.72 4.72 4.62 88302 29.26 27.80 31.97 31.33 31.33 30.71 88302 TC 22.14 21.03 24.18 23.70 23.70 23.23 88302 26 7.12 6.76 7.77 7.61 7.61 7.46 88304 41.23 39.17 45.05 44.15 44.15 43.26 88304 TC 29.94 28.44 32.71 32.05 32.05 31.41 88304 26 11.28 10.72 12.33 12.09 12.09 11.85 88305 67.98 64.58 74.27 72.78 72.78 71.32 88305 TC 29.94 28.44 32.71 32.05 32.05 31.41 88305 26 38.04 36.14 41.56 40.73 40.73 39.92 88307 279.37 265.40 305.21 299.10 299.10 293.12 88307 TC 196.01 186.21 214.14 209.86 209.86 205.67 88307 26 83.36 79.19 91.07 89.25 89.25 87.47 88309 425.93 404.63 465.32 456.02 456.02 446.90 88309 TC 278.41 264.49 304.16 298.08 298.08 292.12 88309 26 147.52 140.14 161.16 157.94 157.94 154.78 88311 20.09 19.09 21.95 21.52 21.52 21.09 88311 TC 7.47 7.10 8.17 8.00 8.00 7.84 88311 26 12.62 11.99 13.79 13.51 13.51 13.25 88312 88.59 84.16 96.78 94.85 94.85 92.95 88312 TC 61.48 58.41 67.17 65.83 65.83 64.52 88312 26 27.11 25.75 29.61 29.03 29.03 28.45 88313 61.30 58.24 66.98 65.64 65.64 64.33 88313 TC 49.30 46.84 53.87 52.79 52.79 51.73 88313 26 12.00 11.40 13.11 12.85 12.85 12.59 88314 69.76 66.27 76.21 74.68 74.68 73.19 88314 TC 47.43 45.06 51.82 50.78 50.78 49.77 88314 26 22.33 21.21 24.39 23.91 23.91 23.43 88319 80.74 76.70 88.21 86.45 86.45 84.72 88319 TC 53.67 50.99 58.64 57.47 57.47 56.32 88319 26 27.07 25.72 29.58 28.99 28.99 28.42 88321 97.48 92.61 106.50 104.37 104.37 102.28

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 202Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 88321 83.74 79.55 91.48 89.65 89.65 87.86 88323 130.98 124.43 143.09 140.23 140.23 137.43 88323 TC 44.31 42.09 48.40 47.44 47.44 46.49 88323 26 86.67 82.34 94.69 92.79 92.79 90.94 88325 163.49 155.32 178.62 175.04 175.04 171.55 # 88325 131.64 125.06 143.82 140.94 140.94 138.13 88329 47.61 45.23 52.01 50.98 50.98 49.96 # 88329 36.05 34.25 39.39 38.61 38.61 37.84 88331 89.95 85.45 98.27 96.30 96.30 94.38 88331 TC 27.45 26.08 29.99 29.39 29.39 28.81 88331 26 62.51 59.38 68.29 66.92 66.92 65.58 88332 47.30 44.94 51.68 50.65 50.65 49.63 88332 TC 16.52 15.69 18.04 17.69 17.69 17.33 88332 26 30.78 29.24 33.63 32.96 32.96 32.30 88333 94.06 89.36 102.76 100.71 100.71 98.69 88333 TC 31.19 29.63 34.07 33.40 33.40 32.73 88333 26 62.86 59.72 68.68 67.31 67.31 65.96 88334 57.90 55.01 63.26 62.00 62.00 60.75 88334 TC 19.33 18.36 21.11 20.69 20.69 20.27 88334 26 38.57 36.64 42.14 41.30 41.30 40.47 88341 81.08 77.03 88.58 86.81 86.81 85.08 88341 TC 54.33 51.61 59.35 58.17 58.17 57.01 88341 26 26.75 25.41 29.22 28.64 28.64 28.06 88342 96.79 91.95 105.74 103.63 103.63 101.56 88342 TC 61.17 58.11 66.83 65.49 65.49 64.18 88342 26 35.62 33.84 38.92 38.13 38.13 37.38 88344 155.18 147.42 169.53 166.14 166.14 162.82 88344 TC 116.12 110.31 126.86 124.32 124.32 121.83 88344 26 39.07 37.12 42.69 41.84 41.84 41.00 88346 85.11 80.85 92.98 91.11 91.11 89.30 88346 TC 48.37 45.95 52.84 51.78 51.78 50.75 88346 26 36.74 34.90 40.14 39.33 39.33 38.55 88348 310.80 295.26 339.55 332.75 332.75 326.09 88348 TC 234.96 223.21 256.69 251.56 251.56 246.54 88348 26 75.84 72.05 82.86 81.20 81.20 79.58 88350 65.61 62.33 71.68 70.24 70.24 68.84 88350 TC 38.09 36.19 41.62 40.79 40.79 39.97 88350 26 27.52 26.14 30.06 29.46 29.46 28.88 88355 146.42 139.10 159.97 156.77 156.77 153.63 88355 TC 64.60 61.37 70.58 69.16 69.16 67.78 88355 26 81.82 77.73 89.39 87.61 87.61 85.86 88356 193.10 183.45 210.97 206.75 206.75 202.61 88356 TC 72.66 69.03 79.38 77.80 77.80 76.25 88356 26 120.44 114.42 131.58 128.95 128.95 126.37 88358 79.20 75.24 86.53 84.80 84.80 83.11 88358 TC 34.63 32.90 37.84 37.08 37.08 36.34 88358 26 44.57 42.34 48.69 47.71 47.71 46.76 88360 111.11 105.55 121.38 118.96 118.96 116.58 88360 TC 56.80 53.96 62.05 60.81 60.81 59.59

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 203Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

88360 26 54.32 51.60 59.34 58.16 58.16 56.99 88361 135.80 129.01 148.36 145.39 145.39 142.49 88361 TC 77.40 73.53 84.56 82.87 82.87 81.21 88361 26 58.40 55.48 63.80 62.53 62.53 61.27 88362 237.64 225.76 259.62 254.43 254.43 249.34 88362 TC 129.51 123.03 141.48 138.66 138.66 135.88 88362 26 108.13 102.72 118.13 115.77 115.77 113.46 88363 21.93 20.83 23.95 23.47 23.47 23.00 # 88363 19.12 18.16 20.88 20.47 20.47 20.06 88364 121.00 114.95 132.19 129.55 129.55 126.96 88364 TC 87.39 83.02 95.47 93.56 93.56 91.69 88364 26 33.61 31.93 36.72 35.98 35.98 35.26 88365 159.43 151.46 174.18 170.69 170.69 167.28 88365 TC 115.49 109.72 126.18 123.66 123.66 121.19 88365 26 43.94 41.74 48.00 47.05 47.05 46.10 88366 235.05 223.30 256.80 251.65 251.65 246.62 88366 TC 172.94 164.29 188.93 185.15 185.15 181.45 88366 26 62.11 59.00 67.85 66.49 66.49 65.16 88367 96.64 91.81 105.58 103.47 103.47 101.40 88367 TC 62.10 59.00 67.85 66.49 66.49 65.16 88367 26 34.54 32.81 37.73 36.97 36.97 36.24 88368 103.89 98.70 113.51 111.24 111.24 109.02 88368 TC 63.98 60.78 69.90 68.49 68.49 67.13 88368 26 39.91 37.91 43.60 42.72 42.72 41.87 88369 97.62 92.74 106.65 104.52 104.52 102.43 88369 TC 66.79 63.45 72.97 71.51 71.51 70.08 88369 26 30.83 29.29 33.68 33.01 33.01 32.35 88371 26 17.90 17.01 19.56 19.17 19.17 18.79 88372 26 17.90 17.01 19.56 19.17 19.17 18.79 88373 67.51 64.13 73.75 72.28 72.28 70.83 88373 TC 46.83 44.49 51.16 50.14 50.14 49.14 88373 26 20.68 19.65 22.60 22.15 22.15 21.70 88374 305.78 290.49 334.06 327.38 327.38 320.84 88374 TC 261.30 248.24 285.48 279.77 279.77 274.17 88374 26 44.48 42.26 48.60 47.62 47.62 46.67 88375 47.74 45.35 52.15 51.11 51.11 50.08 88377 365.66 347.38 399.49 391.49 391.49 383.66 88377 TC 301.23 286.17 329.10 322.52 322.52 316.07 88377 26 64.43 61.21 70.39 68.99 68.99 67.61 88380 132.16 125.55 144.38 141.50 141.50 138.67 88380 TC 75.81 72.02 82.82 81.17 81.17 79.55 88380 26 56.34 53.52 61.55 60.32 60.32 59.11 88381 105.38 100.11 115.13 112.83 112.83 110.57 88381 TC 80.50 76.48 87.95 86.19 86.19 84.47 88381 26 24.88 23.64 27.19 26.65 26.65 26.12 88387 39.91 37.91 43.60 42.72 42.72 41.87 88387 TC 8.09 7.69 8.84 8.67 8.67 8.50 88387 26 31.82 30.23 34.76 34.07 34.07 33.40 88388 32.60 30.97 35.62 34.90 34.90 34.20

Page 204: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 204Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

88388 TC 8.71 8.27 9.51 9.32 9.32 9.13 88388 26 23.89 22.70 26.11 25.59 25.59 25.08 89049 236.21 224.40 258.06 252.90 252.90 247.84 # 89049 64.18 60.97 70.12 68.71 68.71 67.34 89060 26 17.90 17.01 19.56 19.17 19.17 18.79 89220 14.33 13.61 15.65 15.34 15.34 15.03 89230 4.66 4.43 5.09 4.99 4.99 4.89 90460 22.92 21.77 25.04 24.53 24.53 24.04 90461 11.59 11.01 12.66 12.41 12.41 12.16 90471 22.92 21.77 25.04 24.53 24.53 24.04 90472 11.59 11.01 12.66 12.41 12.41 12.16 90473 22.92 21.77 25.04 24.53 24.53 24.04 90474 11.59 11.01 12.66 12.41 12.41 12.16 90785 13.66 12.98 14.93 14.63 14.63 14.34 90791 128.96 122.51 140.89 138.07 138.07 135.31 # 90791 125.22 118.96 136.80 134.07 134.07 131.39 90792 142.20 135.09 155.35 152.25 152.25 149.20 # 90792 138.46 131.54 151.27 148.25 148.25 145.28 90832 62.62 59.49 68.41 67.05 67.05 65.70 # 90832 62.31 59.19 68.07 66.71 66.71 65.38 90833 64.47 61.25 70.44 69.03 69.03 67.65 # 90833 63.84 60.65 69.75 68.36 68.36 66.99 90834 83.28 79.12 90.99 89.17 89.17 87.39 # 90834 82.97 78.82 90.64 88.83 88.83 87.06 90836 81.86 77.77 89.44 87.64 87.64 85.89 # 90836 81.23 77.17 88.75 86.97 86.97 85.24 90837 125.22 118.96 136.80 134.07 134.07 131.39 # 90837 124.28 118.07 135.78 133.07 133.07 130.41 90838 107.94 102.54 117.92 115.56 115.56 113.25 # 90838 107.32 101.95 117.24 114.90 114.90 112.60 90839 130.50 123.98 142.58 139.73 139.73 136.93 # 90839 129.87 123.38 141.89 139.05 139.05 136.26 90840 62.31 59.19 68.07 66.71 66.71 65.38 # 90840 62.00 58.90 67.74 66.38 66.38 65.06 90845 89.64 85.16 97.93 95.98 95.98 94.06 # 90845 89.33 84.86 97.59 95.63 95.63 93.73 90846 100.98 95.93 110.32 108.11 108.11 105.95 # 90846 100.36 95.34 109.64 107.44 107.44 105.29 90847 104.56 99.33 114.23 111.94 111.94 109.70 # 90847 103.94 98.74 113.55 111.29 111.29 109.05 90849 32.59 30.96 35.60 34.89 34.89 34.19 # 90849 29.47 28.00 32.20 31.56 31.56 30.92 90853 25.13 23.87 27.45 26.90 26.90 26.36 # 90853 24.82 23.58 27.12 26.58 26.58 26.05 90865 159.14 151.18 173.86 170.38 170.38 166.98 # 90865 126.05 119.75 137.71 134.96 134.96 132.26 90867 191.67 182.09 209.40 205.22 205.22 201.11 # 90867 116.05 110.25 126.79 124.26 124.26 121.77 90868 176.80 167.96 193.15 189.29 189.29 185.51

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 205Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 90868 24.14 22.93 26.37 25.84 25.84 25.32 90869 172.58 163.95 188.54 184.77 184.77 181.08 # 90869 96.95 92.10 105.92 103.80 103.80 101.72 90870 167.29 158.93 182.77 179.11 179.11 175.54 # 90870 108.59 103.16 118.63 116.27 116.27 113.94 90880 98.80 93.86 107.94 105.78 105.78 103.66 # 90880 92.24 87.63 100.77 98.76 98.76 96.78 90901 35.23 33.47 38.49 37.72 37.72 36.96 # 90901 19.31 18.34 21.09 20.67 20.67 20.25 90911 77.91 74.01 85.11 83.41 83.41 81.74 # 90911 43.25 41.09 47.25 46.31 46.31 45.38 90935 70.57 67.04 77.10 75.56 75.56 74.05 90937 101.13 96.07 110.48 108.27 108.27 106.11 90945 82.77 78.63 90.42 88.62 88.62 86.85 90947 120.72 114.68 131.88 129.25 129.25 126.66 90951 912.39 866.77 996.79 976.84 976.84 957.31 90954 789.51 750.03 862.53 845.28 845.28 828.38 90955 441.92 419.82 482.79 473.13 473.13 463.67 90956 307.30 291.94 335.73 329.02 329.02 322.44 90957 624.14 592.93 681.87 668.23 668.23 654.87 90958 421.52 400.44 460.51 451.29 451.29 442.27 90959 285.65 271.37 312.08 305.83 305.83 299.71 90960 273.31 259.64 298.59 292.62 292.62 286.76 90961 229.27 217.81 250.48 245.47 245.47 240.56 90962 176.29 167.48 192.60 188.75 188.75 184.98 90963 526.53 500.20 575.23 563.73 563.73 552.46 90964 459.96 436.96 502.50 492.45 492.45 482.61 90965 437.71 415.82 478.19 468.63 468.63 459.25 90966 228.67 217.24 249.83 244.84 244.84 239.94 90967 17.47 16.60 19.09 18.71 18.71 18.33 90968 15.06 14.31 16.46 16.12 16.12 15.80 90969 14.70 13.97 16.07 15.74 15.74 15.43 90970 7.48 7.11 8.18 8.02 8.02 7.85 90997 90.55 86.02 98.92 96.95 96.95 95.00 91010 160.79 152.75 175.66 172.16 172.16 168.72 91010 TC 95.51 90.73 104.34 102.26 102.26 100.21 91010 26 65.28 62.02 71.32 69.90 69.90 68.49 91013 21.09 20.04 23.05 22.59 22.59 22.14 91013 TC 11.86 11.27 12.96 12.70 12.70 12.44 91013 26 9.23 8.77 10.09 9.88 9.88 9.68 91020 212.41 201.79 232.06 227.41 227.41 222.87 91020 TC 139.19 132.23 152.06 149.03 149.03 146.05 91020 26 73.22 69.56 79.99 78.40 78.40 76.83 91022 153.77 146.08 167.99 164.63 164.63 161.35 91022 TC 80.84 76.80 88.32 86.55 86.55 84.81 91022 26 72.94 69.29 79.68 78.09 78.09 76.52 91030 123.92 117.72 135.38 132.68 132.68 130.02 91030 TC 78.03 74.13 85.25 83.55 83.55 81.88 91030 26 45.90 43.61 50.15 49.15 49.15 48.17

Page 206: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 206Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

91034 171.26 162.70 187.11 183.37 183.37 179.70 91034 TC 121.42 115.35 132.65 130.00 130.00 127.40 91034 26 49.84 47.35 54.45 53.36 53.36 52.29 91035 429.67 408.19 469.42 460.03 460.03 450.83 91035 TC 348.09 330.69 380.29 372.69 372.69 365.24 91035 26 81.58 77.50 89.13 87.34 87.34 85.59 91037 145.40 138.13 158.85 155.68 155.68 152.56 91037 TC 96.13 91.32 105.02 102.91 102.91 100.86 91037 26 49.27 46.81 53.83 52.75 52.75 51.69 91038 400.11 380.10 437.12 428.38 428.38 419.81 91038 TC 344.34 327.12 376.19 368.67 368.67 361.30 91038 26 55.77 52.98 60.93 59.71 59.71 58.51 91040 386.80 367.46 422.58 414.13 414.13 405.85 91040 TC 338.10 321.20 369.38 362.00 362.00 354.75 91040 26 48.70 46.27 53.21 52.14 52.14 51.09 91065 69.55 66.07 75.98 74.46 74.46 72.98 91065 TC 59.61 56.63 65.12 63.83 63.83 62.55 91065 26 9.94 9.44 10.86 10.64 10.64 10.43 91110 792.69 753.06 866.02 848.70 848.70 831.73 91110 TC 607.85 577.46 664.08 650.80 650.80 637.78 91110 26 184.84 175.60 201.94 197.90 197.90 193.95 91111 641.65 609.57 701.01 686.99 686.99 673.24 91111 TC 590.68 561.15 645.32 632.42 632.42 619.77 91111 26 50.96 48.41 55.67 54.56 54.56 53.46 91112 959.98 911.98 1,048.78 1,027.80 1,027.80 1,007.25 91112 TC 853.25 810.59 932.18 913.54 913.54 895.26 91112 26 106.73 101.39 116.60 114.26 114.26 111.98 91117 133.49 126.82 145.84 142.92 142.92 140.06 91120 378.26 359.35 413.25 404.98 404.98 396.89 91120 TC 329.36 312.89 359.82 352.62 352.62 345.58 91120 26 48.90 46.46 53.43 52.36 52.36 51.31 91122 207.83 197.44 227.06 222.51 222.51 218.06 91122 TC 119.83 113.84 130.92 128.29 128.29 125.73 91122 26 87.99 83.59 96.13 94.21 94.21 92.32 91132 138.29 131.38 151.09 148.06 148.06 145.11 91132 TC 111.12 105.56 121.39 118.97 118.97 116.59 91132 26 27.17 25.81 29.68 29.08 29.08 28.50 91133 154.34 146.62 168.61 165.24 165.24 161.94 91133 TC 120.80 114.76 131.97 129.33 129.33 126.74 91133 26 33.54 31.86 36.64 35.90 35.90 35.19 91200 28.97 27.52 31.65 31.02 31.02 30.39 91200 TC 16.21 15.40 17.71 17.35 17.35 17.01 91200 26 12.76 12.12 13.94 13.66 13.66 13.39 92002 75.13 71.37 82.08 80.43 80.43 78.82 # 92002 46.10 43.80 50.37 49.36 49.36 48.37 92004 138.65 131.72 151.48 148.45 148.45 145.49 # 92004 96.19 91.38 105.09 102.98 102.98 100.92 92012 79.04 75.09 86.35 84.63 84.63 82.94 # 92012 50.63 48.10 55.32 54.21 54.21 53.13

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 207Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92014 114.99 109.24 125.63 123.12 123.12 120.66 # 92014 76.90 73.06 84.02 82.34 82.34 80.70 92018 139.50 132.53 152.41 149.36 149.36 146.37 92019 69.25 65.79 75.66 74.14 74.14 72.66 92020 25.08 23.83 27.40 26.85 26.85 26.31 # 92020 20.09 19.09 21.95 21.52 21.52 21.09 92025 34.96 33.21 38.19 37.43 37.43 36.69 92025 TC 15.58 14.80 17.02 16.68 16.68 16.34 92025 26 19.37 18.40 21.16 20.73 20.73 20.32 92060 60.24 57.23 65.81 64.50 64.50 63.22 92060 TC 23.39 22.22 25.55 25.05 25.05 24.54 92060 26 36.85 35.01 40.26 39.46 39.46 38.66 92065 48.47 46.05 52.96 51.90 51.90 50.86 92065 TC 30.88 29.34 33.74 33.06 33.06 32.41 92065 26 17.59 16.71 19.22 18.84 18.84 18.46 92071 36.15 34.34 39.49 38.70 38.70 37.93 # 92071 32.40 30.78 35.40 34.68 34.68 33.99 92072 127.79 121.40 139.61 136.82 136.82 134.08 # 92072 100.00 95.00 109.25 107.07 107.07 104.93 92081 30.98 29.43 33.84 33.17 33.17 32.50 92081 TC 15.27 14.51 16.69 16.35 16.35 16.03 92081 26 15.71 14.92 17.16 16.81 16.81 16.48 92082 43.93 41.73 47.99 47.04 47.04 46.09 92082 TC 23.08 21.93 25.22 24.71 24.71 24.22 92082 26 20.85 19.81 22.78 22.32 22.32 21.87 92083 58.75 55.81 64.18 62.89 62.89 61.64 92083 TC 31.82 30.23 34.76 34.07 34.07 33.40 92083 26 26.93 25.58 29.42 28.83 28.83 28.26 92100 72.99 69.34 79.74 78.14 78.14 76.58 # 92100 32.71 31.07 35.73 35.02 35.02 34.32 92132 32.15 30.54 35.12 34.42 34.42 33.73 92132 TC 13.71 13.02 14.97 14.67 14.67 14.38 92132 26 18.44 17.52 20.15 19.75 19.75 19.35 92133 40.95 38.90 44.74 43.84 43.84 42.96 92133 TC 14.02 13.32 15.32 15.01 15.01 14.71 92133 26 26.93 25.58 29.42 28.83 28.83 28.26 92134 41.89 39.80 45.77 44.85 44.85 43.95 92134 TC 14.33 13.61 15.65 15.34 15.34 15.03 92134 26 27.55 26.17 30.10 29.50 29.50 28.91 92136 81.72 77.63 89.27 87.49 87.49 85.74 92136 TC 51.80 49.21 56.59 55.46 55.46 54.36 92136 26 29.92 28.42 32.68 32.03 32.03 31.38 92140 57.78 54.89 63.12 61.86 61.86 60.62 # 92140 25.94 24.64 28.34 27.77 27.77 27.22 92145 14.15 13.44 15.46 15.15 15.15 14.85 92145 TC 5.90 5.61 6.45 6.33 6.33 6.20 92145 26 8.24 7.83 9.00 8.82 8.82 8.65 92225 25.44 24.17 27.80 27.24 27.24 26.70 # 92225 20.45 19.43 22.34 21.90 21.90 21.46

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 208Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92226 23.34 22.17 25.50 24.99 24.99 24.50 # 92226 18.34 17.42 20.03 19.63 19.63 19.24 92227 12.77 12.13 13.95 13.67 13.67 13.40 92228 31.93 30.33 34.88 34.18 34.18 33.50 92228 TC 11.84 11.25 12.94 12.68 12.68 12.43 92228 26 20.09 19.09 21.95 21.52 21.52 21.09 92230 53.87 51.18 58.86 57.68 57.68 56.53 # 92230 32.33 30.71 35.32 34.62 34.62 33.93 92235 100.13 95.12 109.39 107.20 107.20 105.06 92235 TC 54.92 52.17 60.00 58.80 58.80 57.63 92235 26 45.21 42.95 49.39 48.40 48.40 47.44 92240 229.44 217.97 250.67 245.65 245.65 240.74 92240 TC 167.94 159.54 183.47 179.80 179.80 176.20 92240 26 61.50 58.43 67.19 65.85 65.85 64.53 92250 71.27 67.71 77.87 76.31 76.31 74.78 92250 TC 48.05 45.65 52.50 51.45 51.45 50.43 92250 26 23.22 22.06 25.37 24.86 24.86 24.37 92260 17.12 16.26 18.70 18.32 18.32 17.95 # 92260 10.57 10.04 11.55 11.32 11.32 11.09 92265 73.23 69.57 80.01 78.41 78.41 76.84 92265 TC 31.51 29.93 34.42 33.73 33.73 33.05 92265 26 41.72 39.63 45.57 44.67 44.67 43.77 92270 84.15 79.94 91.93 90.09 90.09 88.29 92270 TC 43.99 41.79 48.06 47.09 47.09 46.15 92270 26 40.16 38.15 43.87 43.00 43.00 42.14 92275 135.05 128.30 147.55 144.59 144.59 141.70 92275 TC 82.68 78.55 90.33 88.53 88.53 86.76 92275 26 52.37 49.75 57.21 56.07 56.07 54.95 92283 49.43 46.96 54.00 52.92 52.92 51.87 92283 TC 40.56 38.53 44.31 43.42 43.42 42.55 92283 26 8.87 8.43 9.69 9.50 9.50 9.30 92284 55.06 52.31 60.16 58.95 58.95 57.76 92284 TC 43.06 40.91 47.05 46.10 46.10 45.18 92284 26 12.00 11.40 13.11 12.85 12.85 12.59 92285 18.28 17.37 19.98 19.57 19.57 19.18 92285 TC 15.27 14.51 16.69 16.35 16.35 16.03 92285 26 3.01 2.86 3.29 3.22 3.22 3.15 92286 35.50 33.73 38.79 38.02 38.02 37.26 92286 TC 14.02 13.32 15.32 15.01 15.01 14.71 92286 26 21.48 20.41 23.47 23.00 23.00 22.54 C 92287 124.14 117.93 135.62 132.91 132.91 130.25 C 92287 TC 79.25 75.29 86.58 84.85 84.85 83.15 92287 26 44.90 42.66 49.06 48.08 48.08 47.12 92311 93.82 89.13 102.50 100.45 100.45 98.44 # 92311 54.17 51.46 59.18 57.99 57.99 56.83 92312 108.07 102.67 118.07 115.71 115.71 113.40 # 92312 61.86 58.77 67.59 66.23 66.23 64.91 92313 89.37 84.90 97.64 95.68 95.68 93.77 # 92313 45.97 43.67 50.22 49.22 49.22 48.23

Page 209: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 209Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92315 66.01 62.71 72.12 70.68 70.68 69.26 # 92315 21.36 20.29 23.33 22.86 22.86 22.40 92316 83.61 79.43 91.34 89.52 89.52 87.72 # 92316 32.10 30.50 35.08 34.37 34.37 33.68 92317 68.82 65.38 75.19 73.68 73.68 72.21 # 92317 21.68 20.60 23.69 23.22 23.22 22.76 92325 36.81 34.97 40.22 39.41 39.41 38.62 92326 30.88 29.34 33.74 33.06 33.06 32.41 92502 93.10 88.45 101.72 99.68 99.68 97.69 92504 27.34 25.97 29.87 29.27 29.27 28.68 # 92504 9.23 8.77 10.09 9.88 9.88 9.68 92507 75.44 71.67 82.42 80.78 80.78 79.17 92508 22.09 20.99 24.14 23.66 23.66 23.18 92511 101.97 96.87 111.40 109.17 109.17 106.98 # 92511 37.65 35.77 41.14 40.31 40.31 39.50 92512 56.11 53.30 61.30 60.06 60.06 58.87 # 92512 28.01 26.61 30.60 29.99 29.99 29.39 92516 64.02 60.82 69.94 68.54 68.54 67.17 # 92516 22.49 21.37 24.58 24.08 24.08 23.60 92520 70.09 66.59 76.58 75.05 75.05 73.54 # 92520 40.11 38.10 43.82 42.94 42.94 42.08 92521 105.52 100.24 115.28 112.98 112.98 110.72 92522 88.17 83.76 96.32 94.39 94.39 92.51 92523 184.17 174.96 201.20 197.18 197.18 193.23 92524 85.67 81.39 93.60 91.72 91.72 89.88 92526 81.87 77.78 89.45 87.65 87.65 85.91 92537 38.26 36.35 41.80 40.96 40.96 40.15 92537 TC 7.47 7.10 8.17 8.00 8.00 7.84 92537 26 30.79 29.25 33.64 32.97 32.97 32.32 92538 19.43 18.46 21.23 20.80 20.80 20.39 92538 TC 4.03 3.83 4.40 4.31 4.31 4.23 92538 26 15.40 14.63 16.82 16.49 16.49 16.16 92540 96.31 91.49 105.21 103.11 103.11 101.05 92540 TC 19.33 18.36 21.11 20.69 20.69 20.27 92540 26 76.98 73.13 84.10 82.42 82.42 80.78 92541 23.01 21.86 25.14 24.63 24.63 24.14 92541 TC 2.78 2.64 3.04 2.98 2.98 2.92 92541 26 20.23 19.22 22.10 21.67 21.67 21.23 92542 26.78 25.44 29.26 28.67 28.67 28.09 92542 TC 2.47 2.35 2.70 2.65 2.65 2.59 92542 26 24.31 23.09 26.55 26.02 26.02 25.51 92544 15.86 15.07 17.33 16.99 16.99 16.64 92544 TC 2.16 2.05 2.36 2.31 2.31 2.27 92544 26 13.70 13.02 14.97 14.67 14.67 14.38 92545 14.52 13.79 15.86 15.54 15.54 15.23 92545 TC 1.85 1.76 2.02 1.98 1.98 1.94 92545 26 12.67 12.04 13.85 13.57 13.57 13.29 92546 92.10 87.50 100.63 98.61 98.61 96.65 92546 TC 77.69 73.81 84.88 83.18 83.18 81.51

Page 210: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 210Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92546 26 14.41 13.69 15.74 15.43 15.43 15.12 92547 5.31 5.04 5.80 5.68 5.68 5.57 92548 92.44 87.82 100.99 98.97 98.97 96.99 92548 TC 67.10 63.75 73.31 71.85 71.85 70.41 92548 26 25.34 24.07 27.68 27.13 27.13 26.59 92550 20.28 19.27 22.16 21.71 21.71 21.28 92552 27.45 26.08 29.99 29.39 29.39 28.81 92553 32.75 31.11 35.78 35.06 35.06 34.36 92555 20.58 19.55 22.48 22.03 22.03 21.60 92556 32.75 31.11 35.78 35.06 35.06 34.36 92557 35.76 33.97 39.07 38.28 38.28 37.51 # 92557 31.70 30.12 34.64 33.95 33.95 33.27 92561 33.35 31.68 36.43 35.71 35.71 34.99 92562 40.87 38.83 44.65 43.76 43.76 42.88 92563 27.14 25.78 29.65 29.05 29.05 28.46 92564 24.64 23.41 26.92 26.38 26.38 25.85 92565 14.02 13.32 15.32 15.01 15.01 14.71 92567 13.69 13.01 14.96 14.66 14.66 14.38 # 92567 10.57 10.04 11.55 11.32 11.32 11.09 92568 15.32 14.55 16.73 16.40 16.40 16.07 # 92568 15.01 14.26 16.40 16.07 16.07 15.74 92570 30.85 29.31 33.71 33.03 33.03 32.37 # 92570 28.98 27.53 31.66 31.03 31.03 30.41 92571 24.01 22.81 26.23 25.70 25.70 25.19 92572 31.51 29.93 34.42 33.73 33.73 33.05 92575 63.64 60.46 69.53 68.14 68.14 66.78 92576 31.51 29.93 34.42 33.73 33.73 33.05 92577 14.65 13.92 16.01 15.69 15.69 15.38 92579 40.22 38.21 43.94 43.07 43.07 42.21 # 92579 36.16 34.35 39.50 38.71 38.71 37.94 92582 59.58 56.60 65.09 63.79 63.79 62.51 92583 46.18 43.87 50.45 49.44 49.44 48.45 92584 64.57 61.34 70.54 69.13 69.13 67.75 92585 121.76 115.67 133.02 130.36 130.36 127.75 92585 TC 95.79 91.00 104.65 102.56 102.56 100.51 92585 26 25.96 24.66 28.36 27.80 27.80 27.24 92586 75.19 71.43 82.14 80.50 80.50 78.89 92587 20.59 19.56 22.49 22.05 22.05 21.61 92587 TC 2.78 2.64 3.04 2.98 2.98 2.92 92587 26 17.81 16.92 19.46 19.07 19.07 18.69 92588 31.50 29.93 34.42 33.73 33.73 33.05 92588 TC 3.41 3.24 3.73 3.66 3.66 3.59 92588 26 28.09 26.69 30.69 30.08 30.08 29.49 92596 37.10 35.25 40.54 39.73 39.73 38.94 92597 69.27 65.81 75.68 74.16 74.16 72.68 92601 135.04 128.29 147.53 144.58 144.58 141.69 # 92601 116.31 110.49 127.06 124.52 124.52 122.03 92602 84.75 80.51 92.59 90.74 90.74 88.92 # 92602 66.96 63.61 73.15 71.69 71.69 70.25

Page 211: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 211Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92603 143.66 136.48 156.95 153.81 153.81 150.74 # 92603 118.37 112.45 129.32 126.73 126.73 124.20 92604 84.58 80.35 92.40 90.55 90.55 88.75 # 92604 65.54 62.26 71.60 70.16 70.16 68.76 92607 119.72 113.73 130.79 128.18 128.18 125.61 92608 49.65 47.17 54.25 53.16 53.16 52.11 92609 104.15 98.94 113.78 111.50 111.50 109.27 92610 81.04 76.99 88.54 86.77 86.77 85.03 # 92610 70.11 66.60 76.59 75.06 75.06 73.55 92611 82.70 78.57 90.36 88.55 88.55 86.78 92612 170.14 161.63 185.87 182.16 182.16 178.51 # 92612 66.17 62.86 72.29 70.84 70.84 69.43 92613 37.12 35.26 40.55 39.73 39.73 38.94 92614 134.54 127.81 146.98 144.04 144.04 141.16 # 92614 65.86 62.57 71.96 70.52 70.52 69.10 92615 32.75 31.11 35.78 35.06 35.06 34.36 # 92615 32.44 30.82 35.44 34.73 34.73 34.04 92616 192.49 182.87 210.30 206.09 206.09 201.97 # 92616 98.20 93.29 107.28 105.13 105.13 103.03 92617 40.64 38.61 44.40 43.52 43.52 42.64 92620 89.76 85.27 98.06 96.09 96.09 94.17 # 92620 79.77 75.78 87.15 85.40 85.40 83.69 92621 21.25 20.19 23.22 22.76 22.76 22.30 # 92621 18.44 17.52 20.15 19.75 19.75 19.35 92625 66.95 63.60 73.14 71.68 71.68 70.24 # 92625 60.39 57.37 65.98 64.65 64.65 63.37 92626 85.27 81.01 93.16 91.30 91.30 89.47 # 92626 73.72 70.03 80.53 78.92 78.92 77.35 92627 21.15 20.09 23.10 22.64 22.64 22.20 # 92627 17.41 16.54 19.02 18.64 18.64 18.27 92640 107.78 102.39 117.75 115.39 115.39 113.08 # 92640 92.80 88.16 101.38 99.36 99.36 97.37 92920 535.37 508.60 584.89 573.19 573.19 561.73 92924 635.86 604.07 694.68 680.79 680.79 667.17 92928 594.35 564.63 649.32 636.34 636.34 623.61 92933 664.85 631.61 726.35 711.83 711.83 697.59 92937 594.00 564.30 648.95 635.96 635.96 623.24 92941 666.16 632.85 727.78 713.22 713.22 698.96 92943 665.88 632.59 727.48 712.93 712.93 698.67 92950 286.16 271.85 312.63 306.37 306.37 300.24 # 92950 183.75 174.56 200.74 196.73 196.73 192.80 92953 10.99 10.44 12.01 11.76 11.76 11.53 92960 191.92 182.32 209.67 205.47 205.47 201.37 # 92960 118.55 112.62 129.51 126.93 126.93 124.38 92961 253.74 241.05 277.21 271.66 271.66 266.24 92970 183.39 174.22 200.35 196.35 196.35 192.43 92971 98.46 93.54 107.57 105.42 105.42 103.32 92973 173.75 165.06 189.82 186.02 186.02 182.30 92974 158.61 150.68 173.28 169.82 169.82 166.43

Page 212: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 212Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92975 382.99 363.84 418.42 410.04 410.04 401.84 92977 54.28 51.57 59.31 58.12 58.12 56.96 92978 262.47 249.35 286.75 281.01 281.01 275.39 92978 TC 168.42 160.00 184.00 180.32 180.32 176.71 92978 26 94.05 89.35 102.75 100.69 100.69 98.68 92979 160.19 152.18 175.01 171.51 171.51 168.08 92979 TC 85.08 80.83 92.95 91.09 91.09 89.27 92979 26 75.11 71.35 82.05 80.41 80.41 78.80 92986 1,298.80 1,233.86 1,418.94 1,390.56 1,390.56 1,362.75 92987 1,339.93 1,272.93 1,463.87 1,434.59 1,434.59 1,405.90 92990 1,055.51 1,002.73 1,153.14 1,130.08 1,130.08 1,107.48 92992 2,616.69 2,485.86 2,858.74 2,801.56 2,801.56 2,745.53 92993 2,616.69 2,485.86 2,858.74 2,801.56 2,801.56 2,745.53 92997 642.21 610.10 701.62 687.59 687.59 673.83 92998 316.90 301.06 346.22 339.30 339.30 332.51 93000 15.71 14.92 17.16 16.81 16.81 16.48 93005 7.47 7.10 8.17 8.00 8.00 7.84 93010 8.24 7.83 9.00 8.82 8.82 8.65 93015 70.45 66.93 76.97 75.43 75.43 73.92 93016 21.68 20.60 23.69 23.22 23.22 22.76 93017 34.63 32.90 37.84 37.08 37.08 36.34 93018 14.15 13.44 15.46 15.15 15.15 14.85 93024 103.86 98.67 113.47 111.21 111.21 108.99 93024 TC 48.03 45.63 52.47 51.43 51.43 50.40 93024 26 55.83 53.04 61.00 59.78 59.78 58.58 93025 143.82 136.63 157.12 153.99 153.99 150.90 93025 TC 108.00 102.60 117.99 115.63 115.63 113.32 93025 26 35.82 34.03 39.13 38.35 38.35 37.58 93040 11.87 11.28 12.97 12.71 12.71 12.45 93041 4.97 4.72 5.43 5.32 5.32 5.22 93042 6.90 6.56 7.54 7.39 7.39 7.25 93050 16.02 15.22 17.50 17.16 17.16 16.81 93050 TC 7.78 7.39 8.50 8.33 8.33 8.17 93050 26 8.24 7.83 9.00 8.82 8.82 8.65 93224 82.51 78.38 90.14 88.33 88.33 86.56 93225 23.39 22.22 25.55 25.05 25.05 24.54 93226 33.38 31.71 36.47 35.74 35.74 35.03 93227 25.74 24.45 28.12 27.55 27.55 27.00 93228 25.40 24.13 27.75 27.20 27.20 26.66 93229 639.87 607.88 699.06 685.08 685.08 671.38 93260 62.79 59.65 68.60 67.23 67.23 65.88 93260 TC 19.33 18.36 21.11 20.69 20.69 20.27 93260 26 43.46 41.29 47.48 46.53 46.53 45.60 93261 56.70 53.87 61.95 60.71 60.71 59.49 93261 TC 19.33 18.36 21.11 20.69 20.69 20.27 93261 26 37.37 35.50 40.83 40.01 40.01 39.20 93268 183.04 173.89 199.97 195.97 195.97 192.05 93270 8.09 7.69 8.84 8.67 8.67 8.50 93271 150.15 142.64 164.04 160.76 160.76 157.54

Page 213: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 213Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93272 24.81 23.57 27.11 26.57 26.57 26.04 93278 27.63 26.25 30.19 29.59 29.59 29.00 93278 TC 15.58 14.80 17.02 16.68 16.68 16.34 93278 26 12.05 11.45 13.17 12.90 12.90 12.65 93279 46.61 44.28 50.92 49.90 49.90 48.90 93279 TC 15.27 14.51 16.69 16.35 16.35 16.03 93279 26 31.34 29.77 34.24 33.55 33.55 32.88 93280 54.62 51.89 59.67 58.48 58.48 57.30 93280 TC 17.14 16.28 18.72 18.34 18.34 17.97 93280 26 37.48 35.61 40.95 40.14 40.14 39.33 93281 63.96 60.76 69.87 68.47 68.47 67.10 93281 TC 20.27 19.26 22.15 21.70 21.70 21.26 93281 26 43.69 41.51 47.74 46.78 46.78 45.85 93282 59.05 56.10 64.52 63.23 63.23 61.96 93282 TC 17.77 16.88 19.41 19.02 19.02 18.64 93282 26 41.28 39.22 45.10 44.21 44.21 43.32 93283 76.94 73.09 84.05 82.37 82.37 80.73 93283 TC 20.89 19.85 22.83 22.37 22.37 21.92 93283 26 56.05 53.25 61.24 60.02 60.02 58.82 93284 84.87 80.63 92.72 90.87 90.87 89.06 93284 TC 23.70 22.52 25.90 25.38 25.38 24.87 93284 26 61.16 58.10 66.82 65.48 65.48 64.17 93285 39.45 37.48 43.10 42.24 42.24 41.40 93285 TC 14.02 13.32 15.32 15.01 15.01 14.71 93285 26 25.43 24.16 27.78 27.23 27.23 26.69 93286 25.36 24.09 27.70 27.15 27.15 26.61 93286 TC 10.59 10.06 11.57 11.34 11.34 11.11 93286 26 14.77 14.03 16.13 15.81 15.81 15.50 93287 33.83 32.14 36.96 36.23 36.23 35.50 93287 TC 11.52 10.94 12.58 12.33 12.33 12.09 93287 26 22.30 21.19 24.37 23.89 23.89 23.40 93288 34.36 32.64 37.54 36.79 36.79 36.05 93288 TC 13.71 13.02 14.97 14.67 14.67 14.38 93288 26 20.65 19.62 22.56 22.11 22.11 21.68 93289 61.55 58.47 67.24 65.90 65.90 64.57 93289 TC 17.14 16.28 18.72 18.34 18.34 17.97 93289 26 44.41 42.19 48.52 47.55 47.55 46.60 93290 29.36 27.89 32.07 31.43 31.43 30.80 93290 TC 8.40 7.98 9.18 8.99 8.99 8.81 93290 26 20.96 19.91 22.90 22.44 22.44 21.99 93291 33.73 32.04 36.85 36.11 36.11 35.39 93291 TC 12.77 12.13 13.95 13.67 13.67 13.40 93291 26 20.96 19.91 22.90 22.44 22.44 21.99 93292 30.61 29.08 33.44 32.78 32.78 32.12 93292 TC 9.65 9.17 10.55 10.34 10.34 10.13 93292 26 20.96 19.91 22.90 22.44 22.44 21.99 93293 48.24 45.83 52.70 51.65 51.65 50.61 93293 TC 33.07 31.42 36.13 35.41 35.41 34.70 93293 26 15.18 14.42 16.58 16.25 16.25 15.93

Page 214: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 214Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93294 32.84 31.20 35.88 35.17 35.17 34.47 93295 65.30 62.04 71.35 69.92 69.92 68.52 93296 22.76 21.62 24.86 24.37 24.37 23.89 93297 25.72 24.43 28.09 27.53 27.53 26.98 93298 25.72 24.43 28.09 27.53 27.53 26.98 93299 28.97 27.52 31.65 31.02 31.02 30.39 93303 215.88 205.09 235.85 231.14 231.14 226.52 93303 TC 153.55 145.87 167.75 164.39 164.39 161.10 93303 26 62.33 59.21 68.09 66.73 66.73 65.40 93304 140.70 133.67 153.72 150.65 150.65 147.64 93304 TC 104.88 99.64 114.59 112.30 112.30 110.06 93304 26 35.82 34.03 39.13 38.35 38.35 37.58 93306 206.52 196.19 225.62 221.11 221.11 216.68 93306 TC 144.50 137.28 157.87 154.71 154.71 151.62 93306 26 62.02 58.92 67.76 66.40 66.40 65.08 93307 119.00 113.05 130.01 127.41 127.41 124.86 93307 TC 74.90 71.16 81.83 80.20 80.20 78.60 93307 26 44.10 41.90 48.19 47.22 47.22 46.28 93308 112.25 106.64 122.64 120.19 120.19 117.78 93308 TC 87.08 82.73 95.14 93.24 93.24 91.38 93308 26 25.17 23.91 27.50 26.94 26.94 26.40 93312 281.08 267.03 307.08 300.94 300.94 294.93 93312 TC 162.27 154.16 177.28 173.74 173.74 170.27 93312 26 118.81 112.87 129.80 127.20 127.20 124.66 93313 22.21 21.10 24.27 23.78 23.78 23.31 93314 273.49 259.82 298.79 292.81 292.81 286.96 93314 TC 172.26 163.65 188.20 184.44 184.44 180.75 93314 26 101.23 96.17 110.60 108.39 108.39 106.23 93315 26 138.63 131.70 151.46 148.43 148.43 145.46 93316 37.73 35.84 41.22 40.39 40.39 39.58 93317 238.64 226.71 260.72 255.51 255.51 250.40 93317 TC 135.95 129.15 148.52 145.56 145.56 142.65 93317 26 102.69 97.56 112.19 109.95 109.95 107.76 93318 26 113.87 108.18 124.41 121.92 121.92 119.49 93320 49.48 47.01 54.06 52.98 52.98 51.92 93320 TC 31.53 29.95 34.44 33.75 33.75 33.07 93320 26 17.95 17.05 19.61 19.22 19.22 18.84 93321 24.70 23.47 26.99 26.45 26.45 25.92 93321 TC 17.48 16.61 19.10 18.72 18.72 18.34 93321 26 7.22 6.86 7.89 7.73 7.73 7.58 93325 22.80 21.66 24.91 24.41 24.41 23.93 93325 TC 19.67 18.69 21.49 21.07 21.07 20.64 93325 26 3.13 2.97 3.42 3.35 3.35 3.28 93350 218.80 207.86 239.04 234.26 234.26 229.57 93350 TC 149.18 141.72 162.98 159.72 159.72 156.53 93350 26 69.62 66.14 76.06 74.54 74.54 73.05 93351 246.62 234.29 269.43 264.04 264.04 258.76 93351 TC 163.52 155.34 178.64 175.06 175.06 171.57 93351 26 83.10 78.95 90.79 88.98 88.98 87.19

Page 215: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 215Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93352 30.79 29.25 33.64 32.97 32.97 32.32 93355 221.23 210.17 241.70 236.87 236.87 232.13 93451 704.38 669.16 769.53 754.15 754.15 739.06 93451 TC 563.15 534.99 615.24 602.93 602.93 590.87 93451 26 141.23 134.17 154.30 151.21 151.21 148.19 93452 800.65 760.62 874.71 857.22 857.22 840.08 93452 TC 553.76 526.07 604.98 592.88 592.88 581.03 93452 26 246.89 234.55 269.73 264.34 264.34 259.05 93453 1,033.46 981.79 1,129.06 1,106.47 1,106.47 1,084.35 93453 TC 707.34 671.97 772.77 757.31 757.31 742.16 93453 26 326.13 309.82 356.29 349.16 349.16 342.18 93454 812.53 771.90 887.69 869.93 869.93 852.53 93454 TC 562.50 534.38 614.54 602.24 602.24 590.20 93454 26 250.03 237.53 273.16 267.70 267.70 262.34 93455 945.72 898.43 1,033.19 1,012.53 1,012.53 992.28 93455 TC 656.76 623.92 717.51 703.16 703.16 689.09 93455 26 288.96 274.51 315.69 309.37 309.37 303.19 93456 1,018.74 967.80 1,112.97 1,090.71 1,090.71 1,068.89 93456 TC 697.97 663.07 762.53 747.28 747.28 732.33 93456 26 320.77 304.73 350.44 343.44 343.44 336.57 93457 1,151.26 1,093.70 1,257.76 1,232.60 1,232.60 1,207.95 93457 TC 791.64 752.06 864.87 847.57 847.57 830.62 93457 26 359.63 341.65 392.90 385.04 385.04 377.34 93458 975.36 926.59 1,065.58 1,044.27 1,044.27 1,023.39 93458 TC 669.87 636.38 731.84 717.20 717.20 702.86 93458 26 305.49 290.22 333.75 327.08 327.08 320.54 93459 1,078.29 1,024.38 1,178.04 1,154.47 1,154.47 1,131.38 93459 TC 733.88 697.19 801.77 785.74 785.74 770.03 93459 26 344.41 327.19 376.27 368.75 368.75 361.38 93460 1,157.81 1,099.92 1,264.91 1,239.61 1,239.61 1,214.81 93460 TC 774.15 735.44 845.76 828.84 828.84 812.27 93460 26 383.65 364.47 419.14 410.76 410.76 402.55 93461 1,322.81 1,256.67 1,445.17 1,416.27 1,416.27 1,387.95 93461 TC 899.63 854.65 982.85 963.19 963.19 943.93 93461 26 423.18 402.02 462.32 453.08 453.08 444.02 93462 204.24 194.03 223.13 218.67 218.67 214.30 93463 96.54 91.71 105.47 103.36 103.36 101.29 93464 250.28 237.77 273.44 267.96 267.96 262.60 93464 TC 164.79 156.55 180.03 176.43 176.43 172.90 93464 26 85.49 81.22 93.40 91.54 91.54 89.71 93503 128.17 121.76 140.02 137.22 137.22 134.47 93505 693.49 658.82 757.64 742.49 742.49 727.64 93505 TC 465.74 442.45 508.82 498.64 498.64 488.67 93505 26 227.75 216.36 248.81 243.83 243.83 238.96 93530 846.68 804.35 925.00 906.50 906.50 888.36 93530 TC 630.39 598.87 688.70 674.92 674.92 661.42 93530 26 216.29 205.48 236.30 231.58 231.58 226.94 93531 2,225.98 2,114.68 2,431.88 2,383.25 2,383.25 2,335.58 93531 TC 1,802.55 1,712.42 1,969.28 1,929.90 1,929.90 1,891.30

Page 216: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 216Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93531 26 423.43 402.26 462.60 453.34 453.34 444.28 93532 26 522.13 496.02 570.42 559.02 559.02 547.84 93533 26 348.49 331.07 380.73 373.12 373.12 365.65 93561 45.28 43.02 49.47 48.48 48.48 47.52 93561 TC 20.33 19.31 22.21 21.76 21.76 21.32 93561 26 24.95 23.70 27.26 26.71 26.71 26.19 93562 20.50 19.48 22.40 21.95 21.95 21.52 93562 TC 12.61 11.98 13.78 13.50 13.50 13.24 93562 26 7.89 7.50 8.63 8.45 8.45 8.28 93563 57.58 54.70 62.91 61.65 61.65 60.42 93564 60.04 57.04 65.60 64.29 64.29 63.00 93565 45.00 42.75 49.16 48.19 48.19 47.22 93566 155.15 147.39 169.50 166.11 166.11 162.78 # 93566 45.25 42.99 49.44 48.45 48.45 47.48 93567 129.04 122.59 140.98 138.16 138.16 135.40 # 93567 51.30 48.74 56.05 54.94 54.94 53.83 93568 139.63 132.65 152.55 149.50 149.50 146.51 # 93568 46.28 43.97 50.57 49.55 49.55 48.56 93571 262.16 249.05 286.41 280.68 280.68 275.07 93571 TC 168.42 160.00 184.00 180.32 180.32 176.71 93571 26 93.74 89.05 102.41 100.36 100.36 98.35 93572 26 75.11 71.35 82.05 80.41 80.41 78.80 93580 958.15 910.24 1,046.78 1,025.85 1,025.85 1,005.33 93581 1,305.67 1,240.39 1,426.45 1,397.92 1,397.92 1,369.96 93582 656.33 623.51 717.04 702.70 702.70 688.64 93583 740.38 703.36 808.86 792.68 792.68 776.83 93600 188.51 179.08 205.94 201.83 201.83 197.79 93600 TC 73.20 69.54 79.97 78.37 78.37 76.81 93600 26 115.31 109.54 125.97 123.45 123.45 120.98 93602 154.46 146.74 168.75 165.38 165.38 162.07 93602 TC 41.31 39.24 45.13 44.23 44.23 43.34 93602 26 113.15 107.49 123.61 121.14 121.14 118.71 93603 175.84 167.05 192.11 188.27 188.27 184.51 93603 TC 62.69 59.56 68.49 67.13 67.13 65.78 93603 26 113.15 107.49 123.61 121.14 121.14 118.71 93609 371.74 353.15 406.12 398.00 398.00 390.05 93609 TC 101.57 96.49 110.96 108.74 108.74 106.57 93609 26 270.17 256.66 295.16 289.26 289.26 283.48 93610 211.60 201.02 231.17 226.55 226.55 222.02 93610 TC 50.80 48.26 55.50 54.38 54.38 53.29 93610 26 160.80 152.76 175.67 172.16 172.16 168.72 93612 219.84 208.85 240.18 235.37 235.37 230.67 93612 TC 60.26 57.25 65.84 64.53 64.53 63.24 93612 26 159.58 151.60 174.34 170.86 170.86 167.44 93613 387.55 368.17 423.40 414.93 414.93 406.63 93615 62.88 59.74 68.70 67.33 67.33 65.99 93615 TC 11.93 11.33 13.03 12.77 12.77 12.51 93615 26 50.95 48.40 55.66 54.54 54.54 53.45 93616 26 63.77 60.58 69.67 68.28 68.28 66.91

Page 217: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 217Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93618 378.10 359.20 413.08 404.82 404.82 396.73 93618 TC 147.44 140.07 161.08 157.86 157.86 154.70 93618 26 230.66 219.13 252.00 246.96 246.96 242.03 93619 680.90 646.86 743.89 729.01 729.01 714.43 93619 TC 286.81 272.47 313.34 307.07 307.07 300.93 93619 26 394.09 374.39 430.55 421.94 421.94 413.49 93620 942.73 895.59 1,029.93 1,009.33 1,009.33 989.15 93620 TC 317.62 301.74 347.00 340.07 340.07 333.27 93620 26 625.11 593.85 682.93 669.27 669.27 655.88 93621 26 113.97 108.27 124.51 122.02 122.02 119.58 93622 26 166.70 158.37 182.13 178.48 178.48 174.92 93623 26 154.77 147.03 169.08 165.70 165.70 162.39 93624 26 256.27 243.46 279.98 274.38 274.38 268.89 93631 26 390.41 370.89 426.52 417.99 417.99 409.63 93640 378.23 359.32 413.22 404.95 404.95 396.85 93640 TC 190.54 181.01 208.16 204.00 204.00 199.92 93640 26 187.69 178.31 205.06 200.95 200.95 196.94 93641 585.36 556.09 639.50 626.72 626.72 614.18 93641 TC 266.50 253.18 291.16 285.34 285.34 279.63 93641 26 318.86 302.92 348.36 341.39 341.39 334.56 93642 398.52 378.59 435.38 426.67 426.67 418.14 93642 TC 134.14 127.43 146.54 143.61 143.61 140.74 93642 26 264.38 251.16 288.83 283.06 283.06 277.40 93644 260.77 247.73 284.89 279.20 279.20 273.61 93644 TC 92.67 88.04 101.25 99.22 99.22 97.23 93644 26 168.10 159.70 183.66 179.99 179.99 176.39 93650 587.75 558.36 642.11 629.27 629.27 616.69 93653 827.82 786.43 904.39 886.31 886.31 868.58 93654 1,102.90 1,047.76 1,204.92 1,180.82 1,180.82 1,157.20 93655 413.91 393.21 452.19 443.15 443.15 434.29 93656 1,103.62 1,048.44 1,205.71 1,181.59 1,181.59 1,157.96 93657 413.88 393.19 452.17 443.13 443.13 434.26 93660 147.66 140.28 161.32 158.09 158.09 154.93 93660 TC 55.83 53.04 61.00 59.78 59.78 58.58 93660 26 91.83 87.24 100.33 98.33 98.33 96.36 93662 284.53 270.30 310.85 304.62 304.62 298.53 93662 TC 145.53 138.25 158.99 155.81 155.81 152.70 93662 26 139.00 132.05 151.86 148.82 148.82 145.84 93701 21.20 20.14 23.16 22.70 22.70 22.25 93702 95.20 90.44 104.01 101.92 101.92 99.89 93724 261.00 247.95 285.14 279.44 279.44 273.85 93724 TC 24.64 23.41 26.92 26.38 26.38 25.85 93724 26 236.36 224.54 258.22 253.06 253.06 248.00 93750 53.27 50.61 58.20 57.04 57.04 55.90 # 93750 45.15 42.89 49.32 48.33 48.33 47.37 93784 49.12 46.66 53.66 52.59 52.59 51.54 93786 26.20 24.89 28.62 28.05 28.05 27.49 93788 4.66 4.43 5.09 4.99 4.99 4.89 93790 18.26 17.35 19.95 19.55 19.55 19.16

Page 218: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 218Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93797 15.16 14.40 16.56 16.23 16.23 15.90 # 93797 8.60 8.17 9.40 9.21 9.21 9.03 93798 23.40 22.23 25.56 25.06 25.06 24.55 # 93798 13.72 13.03 14.98 14.69 14.69 14.39 C 93880 172.64 164.01 188.61 184.84 184.84 181.15 C 93880 TC 133.57 126.89 145.92 143.00 143.00 140.14 93880 26 39.07 37.12 42.69 41.84 41.84 41.00 93882 116.97 111.12 127.79 125.24 125.24 122.73 93882 TC 92.39 87.77 100.94 98.91 98.91 96.93 93882 26 24.58 23.35 26.85 26.31 26.31 25.78 C 93886 179.41 170.44 196.01 192.08 192.08 188.24 C 93886 TC 133.29 126.63 145.62 142.72 142.72 139.86 93886 26 46.13 43.82 50.39 49.38 49.38 48.39 93888 133.28 126.62 145.61 142.70 142.70 139.85 93888 TC 108.31 102.89 118.32 115.95 115.95 113.63 93888 26 24.97 23.72 27.28 26.74 26.74 26.21 C 93890 183.91 174.71 200.92 196.90 196.90 192.97 C 93890 TC 133.60 126.92 145.96 143.04 143.04 140.17 93890 26 50.31 47.79 54.96 53.85 53.85 52.77 C 93892 139.50 132.53 152.41 149.36 149.36 146.37 C 93892 TC 80.21 76.20 87.63 85.88 85.88 84.17 93892 26 59.29 56.33 64.78 63.48 63.48 62.22 C 93893 138.34 131.42 151.13 148.11 148.11 145.14 C 93893 TC 80.21 76.20 87.63 85.88 85.88 84.17 93893 26 58.13 55.22 63.50 62.24 62.24 61.00 93922 80.03 76.03 87.43 85.69 85.69 83.97 93922 TC 67.72 64.33 73.98 72.50 72.50 71.05 93922 26 12.30 11.69 13.44 13.18 13.18 12.91 93923 124.88 118.64 136.44 133.71 133.71 131.03 93923 TC 102.98 97.83 112.50 110.25 110.25 108.04 93923 26 21.91 20.81 23.93 23.45 23.45 22.98 93924 156.33 148.51 170.79 167.37 167.37 164.02 93924 TC 132.01 125.41 144.22 141.34 141.34 138.51 93924 26 24.32 23.10 26.57 26.04 26.04 25.52 C 93925 171.76 163.17 187.65 183.90 183.90 180.22 C 93925 TC 133.29 126.63 145.62 142.72 142.72 139.86 93925 26 38.47 36.55 42.03 41.19 41.19 40.37 93926 138.22 131.31 151.01 147.98 147.98 145.03 93926 TC 114.53 108.80 125.12 122.61 122.61 120.16 93926 26 23.70 22.52 25.90 25.38 25.38 24.87 C 93930 172.61 163.98 188.58 184.81 184.81 181.11 C 93930 TC 133.57 126.89 145.92 143.00 143.00 140.14 93930 26 39.04 37.09 42.65 41.80 41.80 40.96 93931 117.02 111.17 127.85 125.29 125.29 122.79 93931 TC 92.70 88.07 101.28 99.26 99.26 97.27 93931 26 24.32 23.10 26.57 26.04 26.04 25.52 93965 107.96 102.56 117.94 115.59 115.59 113.28 93965 TC 90.83 86.29 99.23 97.24 97.24 95.30 93965 26 17.13 16.27 18.71 18.33 18.33 17.96

Page 219: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 219Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

C 93970 167.52 159.14 183.01 179.35 179.35 175.77 C 93970 TC 133.57 126.89 145.92 143.00 143.00 140.14 93970 26 33.95 32.25 37.09 36.35 36.35 35.63 93971 109.01 103.56 119.09 116.71 116.71 114.38 93971 TC 87.08 82.73 95.14 93.24 93.24 91.38 93971 26 21.93 20.83 23.95 23.47 23.47 23.00 C 93975 189.84 180.35 207.40 203.25 203.25 199.19 C 93975 TC 133.29 126.63 145.62 142.72 142.72 139.86 93975 26 56.56 53.73 61.79 60.56 60.56 59.35 93976 148.37 140.95 162.09 158.85 158.85 155.68 93976 TC 109.25 103.79 119.36 116.97 116.97 114.63 93976 26 39.12 37.16 42.73 41.88 41.88 41.04 C 93978 172.58 163.95 188.54 184.77 184.77 181.08 C 93978 TC 133.57 126.89 145.92 143.00 143.00 140.14 93978 26 39.01 37.06 42.62 41.77 41.77 40.93 93979 108.88 103.44 118.96 116.58 116.58 114.24 93979 TC 84.58 80.35 92.40 90.55 90.55 88.75 93979 26 24.29 23.08 26.54 26.01 26.01 25.50 93980 112.34 106.72 122.73 120.28 120.28 117.88 93980 TC 52.42 49.80 57.27 56.12 56.12 54.99 93980 26 59.92 56.92 65.46 64.15 64.15 62.86 93981 66.79 63.45 72.97 71.51 71.51 70.08 93981 TC 45.24 42.98 49.43 48.44 48.44 47.47 93981 26 21.55 20.47 23.54 23.07 23.07 22.61 93982 39.35 37.38 42.99 42.12 42.12 41.29 C 93990 104.14 98.93 113.77 111.49 111.49 109.26 C 93990 TC 79.90 75.91 87.30 85.55 85.55 83.84 93990 26 24.24 23.03 26.48 25.96 25.96 25.44 94002 91.10 86.55 99.53 97.54 97.54 95.59 94003 65.30 62.04 71.35 69.92 69.92 68.52 94004 47.79 45.40 52.21 51.16 51.16 50.14 94010 32.57 30.94 35.58 34.87 34.87 34.17 94010 TC 24.33 23.11 26.58 26.05 26.05 25.53 94010 26 8.24 7.83 9.00 8.82 8.82 8.65 94011 99.66 94.68 108.88 106.71 106.71 104.57 94012 152.70 145.07 166.83 163.50 163.50 160.23 94013 33.32 31.65 36.40 35.67 35.67 34.96 94014 51.94 49.34 56.74 55.60 55.60 54.49 94015 27.14 25.78 29.65 29.05 29.05 28.46 94016 24.81 23.57 27.11 26.57 26.57 26.04 94060 54.88 52.14 59.96 58.77 58.77 57.59 94060 TC 42.12 40.01 46.01 45.09 45.09 44.19 94060 26 12.76 12.12 13.94 13.66 13.66 13.39 94070 55.40 52.63 60.52 59.32 59.32 58.13 94070 TC 27.14 25.78 29.65 29.05 29.05 28.46 94070 26 28.27 26.86 30.89 30.27 30.27 29.66 94200 22.62 21.49 24.71 24.22 24.22 23.74 94200 TC 17.14 16.28 18.72 18.34 18.34 17.97 94200 26 5.47 5.20 5.98 5.87 5.87 5.75

Page 220: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 220Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

94250 23.55 22.37 25.73 25.21 25.21 24.70 94250 TC 18.39 17.47 20.09 19.69 19.69 19.30 94250 26 5.16 4.90 5.64 5.52 5.52 5.41 94375 36.02 34.22 39.35 38.57 38.57 37.80 94375 TC 21.52 20.44 23.51 23.03 23.03 22.57 94375 26 14.51 13.78 15.85 15.53 15.53 15.21 94400 51.08 48.53 55.81 54.69 54.69 53.60 94400 TC 31.82 30.23 34.76 34.07 34.07 33.40 94400 26 19.26 18.30 21.05 20.62 20.62 20.21 94450 62.01 58.91 67.75 66.39 66.39 65.07 94450 TC 42.43 40.31 46.36 45.43 45.43 44.52 94450 26 19.57 18.59 21.38 20.95 20.95 20.54 94452 52.26 49.65 57.10 55.96 55.96 54.84 94452 TC 38.06 36.16 41.58 40.76 40.76 39.94 94452 26 14.19 13.48 15.50 15.19 15.19 14.89 94453 72.31 68.69 78.99 77.42 77.42 75.87 94453 TC 53.67 50.99 58.64 57.47 57.47 56.32 94453 26 18.64 17.71 20.37 19.96 19.96 19.56 94610 57.89 55.00 63.25 61.99 61.99 60.74 94620 52.46 49.84 57.32 56.17 56.17 55.04 94620 TC 22.45 21.33 24.53 24.04 24.04 23.55 94620 26 30.01 28.51 32.79 32.13 32.13 31.49 94621 150.53 143.00 164.45 161.16 161.16 157.94 94621 TC 82.99 78.84 90.67 88.85 88.85 87.07 94621 26 67.54 64.16 73.78 72.31 72.31 70.86 94640 16.21 15.40 17.71 17.35 17.35 17.01 94644 38.69 36.76 42.27 41.42 41.42 40.60 94645 12.46 11.84 13.62 13.34 13.34 13.08 94660 59.20 56.24 64.68 63.39 63.39 62.12 # 94660 37.04 35.19 40.47 39.66 39.66 38.87 94662 36.38 34.56 39.74 38.95 38.95 38.17 94664 15.27 14.51 16.69 16.35 16.35 16.03 94667 23.05 21.90 25.19 24.68 24.68 24.18 94668 25.55 24.27 27.91 27.35 27.35 26.80 94669 28.98 27.53 31.66 31.03 31.03 30.41 94680 51.72 49.13 56.50 55.37 55.37 54.27 94680 TC 39.31 37.34 42.94 42.08 42.08 41.24 94680 26 12.40 11.78 13.55 13.27 13.27 13.01 94681 47.38 45.01 51.76 50.73 50.73 49.71 94681 TC 37.75 35.86 41.24 40.41 40.41 39.61 94681 26 9.63 9.15 10.52 10.32 10.32 10.11 94690 44.29 42.08 48.39 47.43 47.43 46.48 94690 TC 40.56 38.53 44.31 43.42 43.42 42.55 94690 26 3.73 3.54 4.07 3.99 3.99 3.91 94726 47.66 45.28 52.07 51.03 51.03 50.00 94726 TC 35.56 33.78 38.85 38.07 38.07 37.31 94726 26 12.09 11.49 13.21 12.95 12.95 12.68 94727 38.29 36.38 41.84 41.00 41.00 40.18 94727 TC 26.20 24.89 28.62 28.05 28.05 27.49

Page 221: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 221Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

94727 26 12.09 11.49 13.21 12.95 12.95 12.68 94728 36.73 34.89 40.12 39.32 39.32 38.54 94728 TC 24.33 23.11 26.58 26.05 26.05 25.53 94728 26 12.40 11.78 13.55 13.27 13.27 13.01 94729 48.90 46.46 53.43 52.36 52.36 51.31 94729 TC 39.94 37.94 43.63 42.76 42.76 41.91 94729 26 8.96 8.51 9.79 9.59 9.59 9.40 94750 72.18 68.57 78.86 77.28 77.28 75.74 94750 TC 61.17 58.11 66.83 65.49 65.49 64.18 94750 26 11.02 10.47 12.04 11.80 11.80 11.56 94760 2.78 2.64 3.04 2.98 2.98 2.92 94761 4.34 4.12 4.74 4.65 4.65 4.55 94762 21.52 20.44 23.51 23.03 23.03 22.57 94770 7.22 6.86 7.89 7.73 7.73 7.58 94780 51.73 49.14 56.51 55.38 55.38 54.28 # 94780 22.38 21.26 24.45 23.95 23.95 23.47 94781 21.05 20.00 23.00 22.54 22.54 22.09 # 94781 8.24 7.83 9.00 8.82 8.82 8.65 95004 5.95 5.65 6.50 6.37 6.37 6.24 95012 16.83 15.99 18.39 18.02 18.02 17.66 95017 7.16 6.80 7.82 7.66 7.66 7.51 # 95017 3.42 3.25 3.74 3.67 3.67 3.60 95018 18.72 17.78 20.45 20.03 20.03 19.63 # 95018 6.86 6.52 7.50 7.35 7.35 7.20 95024 6.89 6.55 7.53 7.38 7.38 7.23 # 95024 0.95 0.90 1.04 1.01 1.01 0.99 95027 4.08 3.88 4.46 4.37 4.37 4.28 95028 11.84 11.25 12.94 12.68 12.68 12.43 95044 4.97 4.72 5.43 5.32 5.32 5.22 95052 5.90 5.61 6.45 6.33 6.33 6.20 95056 38.97 37.02 42.57 41.72 41.72 40.88 95060 30.88 29.34 33.74 33.06 33.06 32.41 95065 22.45 21.33 24.53 24.04 24.04 23.55 95070 26.80 25.46 29.28 28.69 28.69 28.12 95071 30.85 29.31 33.71 33.03 33.03 32.37 95076 109.43 103.96 119.55 117.16 117.16 114.82 # 95076 71.65 68.07 78.28 76.72 76.72 75.19 95079 79.24 75.28 86.57 84.84 84.84 83.13 # 95079 65.51 62.23 71.56 70.14 70.14 68.74 95115 7.78 7.39 8.50 8.33 8.33 8.17 95117 9.03 8.58 9.87 9.67 9.67 9.48 95144 11.17 10.61 12.20 11.96 11.96 11.72 # 95144 3.06 2.91 3.35 3.28 3.28 3.21 95145 19.29 18.33 21.08 20.65 20.65 20.24 # 95145 3.06 2.91 3.35 3.28 3.28 3.21 95146 34.59 32.86 37.79 37.03 37.03 36.29 # 95146 3.06 2.91 3.35 3.28 3.28 3.21 95147 31.16 29.60 34.04 33.36 33.36 32.69 # 95147 3.06 2.91 3.35 3.28 3.28 3.21

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 222Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95148 46.14 43.83 50.40 49.39 49.39 48.40 # 95148 3.06 2.91 3.35 3.28 3.28 3.21 95149 62.07 58.97 67.82 66.46 66.46 65.12 # 95149 3.06 2.91 3.35 3.28 3.28 3.21 95165 11.49 10.92 12.56 12.31 12.31 12.06 # 95165 3.06 2.91 3.35 3.28 3.28 3.21 95170 8.68 8.25 9.49 9.30 9.30 9.12 # 95170 3.06 2.91 3.35 3.28 3.28 3.21 95180 127.01 120.66 138.76 135.99 135.99 133.27 # 95180 98.60 93.67 107.72 105.57 105.57 103.45 95250 139.14 132.18 152.01 148.97 148.97 145.99 95251 42.16 40.05 46.06 45.14 45.14 44.24 95782 917.78 871.89 1,002.67 982.62 982.62 962.96 95782 TC 793.80 754.11 867.23 849.88 849.88 832.89 95782 26 123.98 117.78 135.45 132.73 132.73 130.08 95783 962.60 914.47 1,051.64 1,030.61 1,030.61 1,010.00 95783 TC 825.93 784.63 902.32 884.28 884.28 866.59 95783 26 136.67 129.84 149.32 146.33 146.33 143.41 95800 162.03 153.93 177.02 173.48 173.48 170.00 95800 TC 111.43 105.86 121.74 119.30 119.30 116.92 95800 26 50.60 48.07 55.28 54.18 54.18 53.10 95801 84.34 80.12 92.14 90.30 90.30 88.49 95801 TC 36.19 34.38 39.54 38.74 38.74 37.97 95801 26 48.15 45.74 52.60 51.55 51.55 50.52 95803 128.87 122.43 140.79 137.98 137.98 135.22 95803 TC 86.14 81.83 94.10 92.22 92.22 90.38 95803 26 42.73 40.59 46.68 45.75 45.75 44.83 95805 382.63 363.50 418.03 409.66 409.66 401.48 95805 TC 324.82 308.58 354.87 347.77 347.77 340.81 95805 26 57.81 54.92 63.16 61.89 61.89 60.65 95806 154.18 146.47 168.44 165.07 165.07 161.77 95806 TC 94.57 89.84 103.32 101.25 101.25 99.22 95806 26 59.60 56.62 65.11 63.81 63.81 62.54 95807 427.93 406.53 467.51 458.16 458.16 448.99 95807 TC 366.97 348.62 400.91 392.90 392.90 385.04 95807 26 60.96 57.91 66.60 65.26 65.26 63.96 95808 564.52 536.29 616.73 604.39 604.39 592.31 95808 TC 478.71 454.77 522.99 512.52 512.52 502.27 95808 26 85.81 81.52 93.75 91.87 91.87 90.03 95810 561.34 533.27 613.26 600.99 600.99 588.97 95810 TC 442.16 420.05 483.06 473.40 473.40 463.93 95810 26 119.18 113.22 130.20 127.60 127.60 125.05 95811 589.84 560.35 644.40 631.51 631.51 618.88 95811 TC 465.86 442.57 508.96 498.78 498.78 488.81 95811 26 123.98 117.78 135.45 132.73 132.73 130.08 95812 312.54 296.91 341.45 334.62 334.62 327.92 95812 TC 256.56 243.73 280.29 274.69 274.69 269.19 95812 26 55.99 53.19 61.17 59.95 59.95 58.75 95813 380.69 361.66 415.91 407.59 407.59 399.44

Page 223: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 223Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95813 TC 291.21 276.65 318.15 311.79 311.79 305.56 95813 26 89.48 85.01 97.76 95.81 95.81 93.89 95816 324.41 308.19 354.42 347.33 347.33 340.39 95816 TC 268.42 255.00 293.25 287.39 287.39 281.64 95816 26 55.99 53.19 61.17 59.95 59.95 58.75 95819 370.28 351.77 404.54 396.44 396.44 388.52 95819 TC 314.29 298.58 343.37 336.50 336.50 329.77 95819 26 55.99 53.19 61.17 59.95 59.95 58.75 95822 334.09 317.39 365.00 357.70 357.70 350.54 95822 TC 278.10 264.20 303.83 297.76 297.76 291.80 95822 26 55.99 53.19 61.17 59.95 59.95 58.75 95824 54.06 51.36 59.06 57.88 57.88 56.72 95824 TC 15.81 15.02 17.27 16.93 16.93 16.59 95824 26 38.25 36.34 41.79 40.95 40.95 40.14 95827 620.48 589.46 677.88 664.32 664.32 651.04 95827 TC 564.80 536.56 617.04 604.70 604.70 592.61 95827 26 55.67 52.89 60.82 59.60 59.60 58.41 95829 1,689.35 1,604.88 1,845.61 1,808.70 1,808.70 1,772.52 95829 TC 1,362.96 1,294.81 1,489.03 1,459.25 1,459.25 1,430.06 95829 26 326.39 310.07 356.58 349.45 349.45 342.46 95830 224.39 213.17 245.15 240.25 240.25 235.44 # 95830 89.20 84.74 97.45 95.51 95.51 93.60 95831 28.05 26.65 30.65 30.04 30.04 29.44 # 95831 14.63 13.90 15.99 15.66 15.66 15.35 95832 27.13 25.77 29.64 29.04 29.04 28.46 # 95832 15.27 14.51 16.69 16.35 16.35 16.03 95833 34.88 33.14 38.11 37.35 37.35 36.60 # 95833 21.14 20.08 23.09 22.63 22.63 22.18 95834 47.91 45.51 52.34 51.29 51.29 50.27 # 95834 30.43 28.91 33.25 32.58 32.58 31.92 95851 16.94 16.09 18.50 18.14 18.14 17.77 # 95851 7.57 7.19 8.27 8.11 8.11 7.95 95852 14.84 14.10 16.22 15.89 15.89 15.57 # 95852 5.78 5.49 6.31 6.19 6.19 6.06 95857 50.09 47.59 54.73 53.64 53.64 52.57 # 95857 28.54 27.11 31.18 30.56 30.56 29.95 95860 111.98 106.38 122.34 119.89 119.89 117.50 95860 TC 61.79 58.70 67.51 66.16 66.16 64.84 95860 26 50.18 47.67 54.82 53.73 53.73 52.66 95861 158.21 150.30 172.85 169.38 169.38 165.99 95861 TC 77.71 73.82 84.89 83.19 83.19 81.52 95861 26 80.49 76.47 87.94 86.18 86.18 84.46 95863 196.25 186.44 214.41 210.12 210.12 205.92 95863 TC 99.26 94.30 108.45 106.27 106.27 104.14 95863 26 96.99 92.14 105.96 103.85 103.85 101.76 95864 221.01 209.96 241.45 236.62 236.62 231.89 95864 TC 116.12 110.31 126.86 124.32 124.32 121.83 95864 26 104.90 99.66 114.61 112.32 112.32 110.08 95865 134.25 127.54 146.67 143.74 143.74 140.86

Page 224: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 224Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95865 TC 52.11 49.50 56.93 55.79 55.79 54.67 95865 26 82.14 78.03 89.73 87.94 87.94 86.18 95866 123.58 117.40 135.01 132.31 132.31 129.66 95866 TC 58.36 55.44 63.76 62.48 62.48 61.23 95866 26 65.22 61.96 71.25 69.83 69.83 68.44 95867 86.84 82.50 94.88 92.98 92.98 91.11 95867 TC 46.18 43.87 50.45 49.44 49.44 48.45 95867 26 40.66 38.63 44.42 43.54 43.54 42.67 95868 122.27 116.16 133.58 130.92 130.92 128.29 95868 TC 60.85 57.81 66.48 65.15 65.15 63.85 95868 26 61.41 58.34 67.09 65.75 65.75 64.43 95869 83.73 79.54 91.47 89.64 89.64 87.85 95869 TC 64.29 61.08 70.24 68.84 68.84 67.46 95869 26 19.44 18.47 21.24 20.82 20.82 20.40 95870 83.73 79.54 91.47 89.64 89.64 87.85 95870 TC 64.60 61.37 70.58 69.16 69.16 67.78 95870 26 19.12 18.16 20.88 20.47 20.47 20.06 95872 186.01 176.71 203.22 199.16 199.16 195.18 95872 TC 36.81 34.97 40.22 39.41 39.41 38.62 95872 26 149.20 141.74 163.00 159.75 159.75 156.55 95873 66.61 63.28 72.77 71.31 71.31 69.89 95873 TC 47.14 44.78 51.50 50.46 50.46 49.45 95873 26 19.46 18.49 21.26 20.84 20.84 20.42 95874 66.27 62.96 72.40 70.96 70.96 69.54 95874 TC 46.83 44.49 51.16 50.14 50.14 49.14 95874 26 19.44 18.47 21.24 20.82 20.82 20.40 95875 115.03 109.28 125.67 123.15 123.15 120.69 95875 TC 57.73 54.84 63.07 61.80 61.80 60.57 95875 26 57.30 54.44 62.61 61.35 61.35 60.12 95885 53.38 50.71 58.32 57.16 57.16 56.02 95885 TC 34.97 33.22 38.20 37.44 37.44 36.70 95885 26 18.41 17.49 20.11 19.71 19.71 19.32 95886 84.38 80.16 92.18 90.34 90.34 88.54 95886 TC 39.34 37.37 42.98 42.11 42.11 41.27 95886 26 45.04 42.79 49.21 48.22 48.22 47.25 95887 74.64 70.91 81.55 79.91 79.91 78.32 95887 TC 37.78 35.89 41.27 40.45 40.45 39.64 95887 26 36.86 35.02 40.27 39.47 39.47 38.67 95905 61.99 58.89 67.72 66.37 66.37 65.04 95905 TC 59.29 56.33 64.78 63.48 63.48 62.22 95905 26 2.70 2.57 2.96 2.90 2.90 2.84 95907 88.72 84.28 96.92 94.98 94.98 93.08 95907 TC 36.81 34.97 40.22 39.41 39.41 38.62 95907 26 51.90 49.31 56.71 55.57 55.57 54.45 95908 110.13 104.62 120.31 117.91 117.91 115.55 95908 TC 45.24 42.98 49.43 48.44 48.44 47.47 95908 26 64.88 61.64 70.89 69.47 69.47 68.08 95909 134.04 127.34 146.44 143.51 143.51 140.63 95909 TC 56.17 53.36 61.36 60.13 60.13 58.93

Page 225: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 225Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95909 26 77.87 73.98 85.08 83.38 83.38 81.71 95910 178.71 169.77 195.24 191.33 191.33 187.50 95910 TC 74.59 70.86 81.49 79.86 79.86 78.26 95910 26 104.12 98.91 113.75 111.47 111.47 109.24 95911 216.22 205.41 236.22 231.50 231.50 226.86 95911 TC 86.14 81.83 94.10 92.22 92.22 90.38 95911 26 130.08 123.58 142.12 139.28 139.28 136.49 95912 242.78 230.64 265.24 259.93 259.93 254.74 95912 TC 88.33 83.91 96.50 94.56 94.56 92.68 95912 26 154.46 146.74 168.75 165.38 165.38 162.07 95913 278.36 264.44 304.11 298.02 298.02 292.07 95913 TC 95.51 90.73 104.34 102.26 102.26 100.21 95913 26 182.85 173.71 199.77 195.78 195.78 191.87 95921 80.17 76.16 87.58 85.84 85.84 84.12 95921 TC 35.88 34.09 39.20 38.42 38.42 37.65 95921 26 44.29 42.08 48.39 47.43 47.43 46.48 95922 93.24 88.58 101.87 99.83 99.83 97.83 95922 TC 45.87 43.58 50.12 49.12 49.12 48.14 95922 26 47.37 45.00 51.75 50.72 50.72 49.70 95923 148.80 141.36 162.56 159.31 159.31 156.12 95923 TC 103.63 98.45 113.22 110.95 110.95 108.73 95923 26 45.17 42.91 49.35 48.36 48.36 47.39 95924 139.04 132.09 151.90 148.87 148.87 145.89 95924 TC 52.11 49.50 56.93 55.79 55.79 54.67 95924 26 86.93 82.58 94.97 93.07 93.07 91.21 95925 139.71 132.72 152.63 149.58 149.58 146.59 95925 TC 112.34 106.72 122.73 120.28 120.28 117.88 95925 26 27.37 26.00 29.90 29.30 29.30 28.72 95926 123.79 117.60 135.24 132.54 132.54 129.89 95926 TC 97.04 92.19 106.02 103.90 103.90 101.82 95926 26 26.74 25.40 29.21 28.62 28.62 28.05 95927 127.82 121.43 139.64 136.85 136.85 134.11 95927 TC 101.07 96.02 110.42 108.22 108.22 106.05 95927 26 26.74 25.40 29.21 28.62 28.62 28.05 95928 204.88 194.64 223.84 219.36 219.36 214.98 95928 TC 127.04 120.69 138.79 136.02 136.02 133.30 95928 26 77.84 73.95 85.04 83.34 83.34 81.67 95929 206.39 196.07 225.48 220.97 220.97 216.56 95929 TC 127.98 121.58 139.82 137.02 137.02 134.29 95929 26 78.41 74.49 85.66 83.95 83.95 82.27 95930 115.79 110.00 126.50 123.97 123.97 121.49 95930 TC 97.67 92.79 106.71 104.57 104.57 102.48 95930 26 18.12 17.21 19.79 19.40 19.40 19.01 95933 68.78 65.34 75.14 73.63 73.63 72.16 95933 TC 38.37 36.45 41.92 41.08 41.08 40.26 95933 26 30.41 28.89 33.22 32.56 32.56 31.90 95937 74.68 70.95 81.59 79.96 79.96 78.36 95937 TC 41.18 39.12 44.99 44.09 44.09 43.21 95937 26 33.49 31.82 36.59 35.86 35.86 35.14

Page 226: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 226Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95938 305.32 290.05 333.56 326.89 326.89 320.36 95938 TC 260.62 247.59 284.73 279.04 279.04 273.46 95938 26 44.70 42.47 48.84 47.86 47.86 46.91 95939 451.96 429.36 493.76 483.89 483.89 474.20 95939 TC 335.52 318.74 366.55 359.23 359.23 352.04 95939 26 116.45 110.63 127.22 124.68 124.68 122.19 95940 31.65 30.07 34.58 33.89 33.89 33.21 95943 140.19 133.18 153.16 150.10 150.10 147.10 95943 TC 51.39 48.82 56.14 55.02 55.02 53.91 95943 26 88.80 84.36 97.01 95.07 95.07 93.17 95950 298.85 283.91 326.50 319.96 319.96 313.57 95950 TC 220.96 209.91 241.40 236.57 236.57 231.84 95950 26 77.88 73.99 85.09 83.39 83.39 81.72 95951 1,508.43 1,433.01 1,647.96 1,615.00 1,615.00 1,582.70 95951 TC 1,197.77 1,137.88 1,308.56 1,282.39 1,282.39 1,256.74 95951 26 310.66 295.13 339.40 332.61 332.61 325.97 95953 386.32 367.00 422.05 413.61 413.61 405.34 95953 TC 226.90 215.56 247.89 242.94 242.94 238.08 95953 26 159.42 151.45 174.17 170.68 170.68 167.27 95954 408.80 388.36 446.61 437.68 437.68 428.93 95954 TC 287.10 272.75 313.66 307.40 307.40 301.24 95954 26 121.71 115.62 132.96 130.31 130.31 127.70 95955 195.51 185.73 213.59 209.32 209.32 205.14 95955 TC 142.97 135.82 156.19 153.07 153.07 150.01 95955 26 52.54 49.91 57.40 56.25 56.25 55.12 95956 1,465.70 1,392.42 1,601.28 1,569.26 1,569.26 1,537.87 95956 TC 1,279.55 1,215.57 1,397.91 1,369.95 1,369.95 1,342.54 95956 26 186.15 176.84 203.37 199.30 199.30 195.30 95957 286.90 272.56 313.44 307.18 307.18 301.04 95957 TC 184.78 175.54 201.87 197.83 197.83 193.88 95957 26 102.12 97.01 111.56 109.33 109.33 107.15 95958 524.23 498.02 572.72 561.27 561.27 550.05 95958 TC 304.55 289.32 332.72 326.06 326.06 319.54 95958 26 219.67 208.69 239.99 235.20 235.20 230.49 95961 272.86 259.22 298.10 292.15 292.15 286.30 95961 TC 115.80 110.01 126.51 123.98 123.98 121.50 95961 26 157.05 149.20 171.58 168.15 168.15 164.80 95962 245.71 233.42 268.43 263.06 263.06 257.81 95962 TC 77.40 73.53 84.56 82.87 82.87 81.21 95962 26 168.31 159.89 183.87 180.19 180.19 176.59 95965 26 408.87 388.43 446.69 437.76 437.76 429.01 95966 26 206.88 196.54 226.02 221.50 221.50 217.07 95967 26 180.32 171.30 197.00 193.05 193.05 189.19 95970 61.90 58.81 67.63 66.27 66.27 64.95 # 95970 23.18 22.02 25.32 24.82 24.82 24.32 95971 47.72 45.33 52.13 51.08 51.08 50.06 # 95971 39.60 37.62 43.26 42.40 42.40 41.55 95972 54.96 52.21 60.04 58.85 58.85 57.67 # 95972 40.60 38.57 44.36 43.47 43.47 42.60

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 227Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95974 196.84 187.00 215.05 210.75 210.75 206.53 # 95974 158.44 150.52 173.10 169.64 169.64 166.24 95975 106.35 101.03 116.18 113.86 113.86 111.58 # 95975 89.80 85.31 98.11 96.14 96.14 94.22 95978 235.78 223.99 257.59 252.44 252.44 247.39 # 95978 186.45 177.13 203.70 199.63 199.63 195.64 95979 102.95 97.80 112.47 110.22 110.22 108.01 # 95979 86.72 82.38 94.74 92.84 92.84 90.99 95980 44.41 42.19 48.52 47.55 47.55 46.60 95981 29.36 27.89 32.07 31.43 31.43 30.80 # 95981 17.19 16.33 18.78 18.40 18.40 18.03 95982 49.25 46.79 53.81 52.73 52.73 51.67 # 95982 35.20 33.44 38.46 37.69 37.69 36.93 95990 80.78 76.74 88.25 86.49 86.49 84.77 95991 110.45 104.93 120.67 118.25 118.25 115.89 # 95991 38.64 36.71 42.22 41.38 41.38 40.55 95992 41.42 39.35 45.25 44.34 44.34 43.46 # 95992 36.42 34.60 39.79 39.00 39.00 38.21 96000 92.22 87.61 100.75 98.74 98.74 96.76 96001 104.16 98.95 113.79 111.52 111.52 109.28 96002 21.15 20.09 23.10 22.64 22.64 22.20 96003 16.97 16.12 18.54 18.17 18.17 17.80 96004 113.02 107.37 123.48 121.00 121.00 118.59 96020 26 160.46 152.44 175.31 171.80 171.80 168.36 96101 78.58 74.65 85.85 84.13 84.13 82.46 # 96101 78.27 74.36 85.51 83.80 83.80 82.12 96102 58.09 55.19 63.47 62.20 62.20 60.96 # 96102 22.81 21.67 24.92 24.43 24.43 23.94 96103 26.58 25.25 29.04 28.46 28.46 27.90 # 96103 25.96 24.66 28.36 27.80 27.80 27.24 96105 102.40 97.28 111.87 109.63 109.63 107.43 96111 125.52 119.24 137.13 134.39 134.39 131.70 # 96111 119.90 113.91 131.00 128.37 128.37 125.81 96116 90.05 85.55 98.38 96.42 96.42 94.48 # 96116 85.05 80.80 92.92 91.06 91.06 89.24 96118 94.50 89.78 103.25 101.18 101.18 99.15 # 96118 77.64 73.76 84.82 83.12 83.12 81.45 96119 73.03 69.38 79.79 78.19 78.19 76.62 # 96119 23.38 22.21 25.54 25.04 25.04 24.53 96120 44.69 42.46 48.83 47.85 47.85 46.90 # 96120 25.33 24.06 27.67 27.12 27.12 26.58 96125 110.94 105.39 121.20 118.77 118.77 116.39 96127 4.66 4.43 5.09 4.99 4.99 4.89 96150 21.28 20.22 23.25 22.79 22.79 22.33 # 96150 20.97 19.92 22.91 22.45 22.45 22.00 96151 20.25 19.24 22.13 21.69 21.69 21.25 # 96151 19.94 18.94 21.78 21.34 21.34 20.92 96152 19.54 18.56 21.34 20.92 20.92 20.50 # 96152 19.22 18.26 21.00 20.57 20.57 20.16

Page 228: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 228Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

96153 4.49 4.27 4.91 4.81 4.81 4.72 96154 19.18 18.22 20.95 20.54 20.54 20.13 # 96154 18.87 17.93 20.62 20.21 20.21 19.80 96360 50.96 48.41 55.67 54.56 54.56 53.46 96361 13.81 13.12 15.09 14.79 14.79 14.49 96365 61.73 58.64 67.44 66.09 66.09 64.77 96366 17.34 16.47 18.94 18.56 18.56 18.19 96367 27.67 26.29 30.23 29.62 29.62 29.03 96368 18.86 17.92 20.61 20.19 20.19 19.79 96369 170.10 161.60 185.84 182.13 182.13 178.48 96370 13.91 13.21 15.19 14.89 14.89 14.59 96371 64.00 60.80 69.92 68.52 68.52 67.15 96372 22.92 21.77 25.04 24.53 24.53 24.04 96373 17.92 17.02 19.57 19.18 19.18 18.80 96374 50.67 48.14 55.36 54.26 54.26 53.18 96375 20.10 19.10 21.97 21.53 21.53 21.10 96401 66.39 63.07 72.53 71.08 71.08 69.66 96402 29.23 27.77 31.94 31.29 31.29 30.67 96405 74.42 70.70 81.31 79.68 79.68 78.09 # 96405 28.84 27.40 31.51 30.88 30.88 30.26 96406 106.25 100.94 116.08 113.76 113.76 111.48 # 96406 44.74 42.50 48.88 47.90 47.90 46.94 96409 98.32 93.40 107.41 105.26 105.26 103.16 96411 55.44 52.67 60.57 59.36 59.36 58.18 96413 120.02 114.02 131.12 128.50 128.50 125.94 96415 25.79 24.50 28.18 27.61 27.61 27.06 96416 124.38 118.16 135.88 133.17 133.17 130.50 96417 55.80 53.01 60.96 59.74 59.74 58.55 96420 93.31 88.64 101.94 99.90 99.90 97.90 96422 149.74 142.25 163.59 160.32 160.32 157.11 96423 69.64 66.16 76.08 74.57 74.57 73.07 96425 159.99 151.99 174.79 171.29 171.29 167.87 96440 754.88 717.14 824.71 808.22 808.22 792.05 # 96440 134.52 127.79 146.96 144.01 144.01 141.14 96446 177.66 168.78 194.10 190.21 190.21 186.40 # 96446 26.55 25.22 29.00 28.43 28.43 27.86 96450 167.16 158.80 182.62 178.96 178.96 175.39 # 96450 78.49 74.57 85.76 84.04 84.04 82.36 96521 122.22 116.11 133.53 130.86 130.86 128.24 96522 100.34 95.32 109.62 107.42 107.42 105.27 96523 22.01 20.91 24.05 23.56 23.56 23.09 96542 110.05 104.55 120.23 117.83 117.83 115.47 # 96542 40.74 38.70 44.51 43.62 43.62 42.75 96549 0.01 0.01 0.01 0.01 0.01 0.01 96567 118.90 112.96 129.90 127.31 127.31 124.76 96570 56.01 53.21 61.19 59.97 59.97 58.78 96571 26.42 25.10 28.87 28.29 28.29 27.73 96900 18.08 17.18 19.76 19.37 19.37 18.98 96904 55.21 52.45 60.32 59.11 59.11 57.93

Page 229: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 229Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

96910 62.73 59.59 68.53 67.16 67.16 65.81 96912 80.21 76.20 87.63 85.88 85.88 84.17 96913 115.12 109.36 125.76 123.25 123.25 120.78 96920 142.17 135.06 155.32 152.21 152.21 149.17 # 96920 64.43 61.21 70.39 68.99 68.99 67.61 96921 156.59 148.76 171.07 167.65 167.65 164.29 # 96921 72.92 69.27 79.66 78.06 78.06 76.50 96922 218.50 207.58 238.72 233.94 233.94 229.26 # 96922 117.66 111.78 128.55 125.97 125.97 123.45 97001 71.55 67.97 78.17 76.60 76.60 75.07 97002 39.54 37.56 43.19 42.33 42.33 41.48 97003 79.98 75.98 87.38 85.63 85.63 83.92 97004 48.90 46.46 53.43 52.36 52.36 51.31 97012 15.17 14.41 16.57 16.24 16.24 15.92 97016 17.66 16.78 19.30 18.91 18.91 18.53 97018 9.93 9.43 10.84 10.63 10.63 10.42 97022 21.36 20.29 23.33 22.86 22.86 22.40 97024 5.87 5.58 6.42 6.29 6.29 6.16 97026 5.56 5.28 6.07 5.95 5.95 5.83 97028 6.90 6.56 7.54 7.39 7.39 7.25 97032 17.98 17.08 19.64 19.25 19.25 18.87 97033 24.27 23.06 26.52 25.99 25.99 25.47 97034 16.86 16.02 18.42 18.06 18.06 17.70 97035 12.17 11.56 13.29 13.03 13.03 12.77 97036 30.29 28.78 33.10 32.43 32.43 31.79 97110 30.42 28.90 33.24 32.57 32.57 31.91 97112 31.67 30.09 34.60 33.91 33.91 33.24 97113 39.77 37.78 43.45 42.57 42.57 41.72 97116 26.78 25.44 29.26 28.67 28.67 28.09 97124 24.68 23.45 26.97 26.43 26.43 25.90 97140 28.17 26.76 30.77 30.15 30.15 29.56 97150 16.60 15.77 18.14 17.77 17.77 17.41 97530 32.59 30.96 35.60 34.89 34.89 34.19 97532 25.40 24.13 27.75 27.20 27.20 26.66 97533 27.59 26.21 30.14 29.54 29.54 28.96 97535 32.92 31.27 35.96 35.24 35.24 34.53 97537 28.55 27.12 31.19 30.57 30.57 29.96 97542 29.17 27.71 31.87 31.23 31.23 30.61 97597 68.47 65.05 74.81 73.31 73.31 71.85 # 97597 22.89 21.75 25.01 24.52 24.52 24.02 97598 22.62 21.49 24.71 24.22 24.22 23.74 # 97598 10.75 10.21 11.74 11.51 11.51 11.28 97605 38.68 36.75 42.26 41.42 41.42 40.60 # 97605 24.63 23.40 26.91 26.37 26.37 25.84 97606 45.47 43.20 49.68 48.69 48.69 47.71 # 97606 26.74 25.40 29.21 28.62 28.62 28.05 97607 42.07 39.97 45.97 45.05 45.05 44.15 # 97607 27.53 26.15 30.07 29.47 29.47 28.89 97608 49.66 47.18 54.26 53.18 53.18 52.12

Page 230: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 230Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 97608 30.31 28.79 33.11 32.44 32.44 31.80 97610 106.79 101.45 116.67 114.33 114.33 112.04 # 97610 15.63 14.85 17.08 16.73 16.73 16.40 97750 31.04 29.49 33.91 33.24 33.24 32.57 97755 34.32 32.60 37.49 36.74 36.74 36.01 97760 35.41 33.64 38.69 37.92 37.92 37.16 97761 31.04 29.49 33.91 33.24 33.24 32.57 97762 42.95 40.80 46.92 45.98 45.98 45.06 97802 32.97 31.32 36.02 35.29 35.29 34.59 # 97802 31.10 29.55 33.98 33.30 33.30 32.64 97803 28.55 27.12 31.19 30.57 30.57 29.96 # 97803 26.36 25.04 28.80 28.22 28.22 27.66 97804 15.17 14.41 16.57 16.24 16.24 15.92 # 97804 14.54 13.81 15.88 15.56 15.56 15.25 98925 29.81 28.32 32.57 31.91 31.91 31.28 # 98925 22.94 21.79 25.06 24.55 24.55 24.06 98926 43.42 41.25 47.44 46.49 46.49 45.56 # 98926 34.99 33.24 38.23 37.47 37.47 36.72 98927 56.40 53.58 61.62 60.39 60.39 59.18 # 98927 46.10 43.80 50.37 49.36 49.36 48.37 98928 69.38 65.91 75.80 74.28 74.28 72.80 # 98928 58.14 55.23 63.51 62.25 62.25 61.01 98929 82.99 78.84 90.67 88.85 88.85 87.07 # 98929 69.88 66.39 76.35 74.82 74.82 73.32 98940 27.03 25.68 29.53 28.95 28.95 28.37 # 98940 22.03 20.93 24.07 23.59 23.59 23.12 98941 39.10 37.15 42.72 41.87 41.87 41.03 # 98941 33.80 32.11 36.93 36.19 36.19 35.47 98942 51.15 48.59 55.88 54.76 54.76 53.67 # 98942 45.53 43.25 49.74 48.75 48.75 47.77 99143 36.29 34.48 39.65 38.86 38.86 38.08 # 99143 31.08 29.53 33.96 33.28 33.28 32.61 99144 36.29 34.48 39.65 38.86 38.86 38.08 # 99144 31.08 29.53 33.96 33.28 33.28 32.61 99145 15.57 14.79 17.01 16.66 16.66 16.33 99148 53.68 51.00 58.65 57.48 57.48 56.33 99149 53.68 51.00 58.65 57.48 57.48 56.33 99150 15.57 14.79 17.01 16.66 16.66 16.33 99170 160.70 152.67 175.57 172.06 172.06 168.62 # 99170 86.71 82.37 94.73 92.83 92.83 90.98 99175 14.96 14.21 16.34 16.02 16.02 15.70 99183 106.70 101.37 116.58 114.24 114.24 111.95 99184 222.51 211.38 243.09 238.22 238.22 233.46 99195 87.88 83.49 96.01 94.09 94.09 92.21 99201 40.46 38.44 44.21 43.32 43.32 42.46 # 99201 25.48 24.21 27.84 27.29 27.29 26.75 99202 69.61 66.13 76.05 74.53 74.53 73.04 # 99202 48.38 45.96 52.85 51.80 51.80 50.76 99203 101.01 95.96 110.35 108.15 108.15 105.98

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 231Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 99203 73.84 70.15 80.67 79.06 79.06 77.49 99204 155.40 147.63 169.77 166.38 166.38 163.06 # 99204 125.11 118.85 136.68 133.94 133.94 131.26 99205 195.44 185.67 213.52 209.25 209.25 205.07 # 99205 162.65 154.52 177.70 174.14 174.14 170.66 99211 18.28 17.37 19.98 19.57 19.57 19.18 # 99211 8.91 8.46 9.73 9.53 9.53 9.34 99212 40.18 38.17 43.90 43.02 43.02 42.16 # 99212 24.26 23.05 26.51 25.98 25.98 25.46 99213 68.26 64.85 74.58 73.08 73.08 71.62 # 99213 49.21 46.75 53.76 52.69 52.69 51.64 99214 100.89 95.85 110.23 108.02 108.02 105.86 # 99214 75.60 71.82 82.59 80.94 80.94 79.32 99215 136.33 129.51 148.94 145.96 145.96 143.04 # 99215 106.98 101.63 116.87 114.54 114.54 112.25 99217 69.62 66.14 76.06 74.54 74.54 73.05 99218 96.12 91.31 105.01 102.90 102.90 100.84 99219 130.68 124.15 142.77 139.92 139.92 137.13 99220 178.63 169.70 195.16 191.26 191.26 187.43 99221 97.57 92.69 106.59 104.47 104.47 102.37 99222 131.90 125.31 144.11 141.22 141.22 138.39 99223 195.16 185.40 213.21 208.94 208.94 204.77 99224 38.29 36.38 41.84 41.00 41.00 40.18 99225 70.13 66.62 76.61 75.08 75.08 73.58 99226 101.22 96.16 110.58 108.38 108.38 106.21 99231 37.97 36.07 41.48 40.65 40.65 39.84 99232 69.50 66.03 75.93 74.42 74.42 72.93 99233 100.26 95.25 109.54 107.35 107.35 105.20 99234 128.89 122.45 140.82 138.00 138.00 135.24 99235 162.83 154.69 177.89 174.34 174.34 170.86 99236 209.84 199.35 229.25 224.66 224.66 220.17 99238 69.34 65.87 75.75 74.23 74.23 72.75 99239 102.67 97.54 112.17 109.93 109.93 107.73 99281 20.68 19.65 22.60 22.15 22.15 21.70 99282 40.34 38.32 44.07 43.18 43.18 42.32 99283 60.45 57.43 66.04 64.72 64.72 63.42 99284 114.75 109.01 125.36 122.85 122.85 120.39 99285 169.43 160.96 185.10 181.40 181.40 177.78 99291 261.51 248.43 285.69 279.98 279.98 274.38 # 99291 216.55 205.72 236.58 231.85 231.85 227.22 99292 117.81 111.92 128.71 126.13 126.13 123.61 # 99292 108.45 103.03 118.48 116.12 116.12 113.79 99304 87.76 83.37 95.88 93.96 93.96 92.08 99305 124.94 118.69 136.49 133.77 133.77 131.09 99306 159.62 151.64 174.39 170.90 170.90 167.49 99307 42.68 40.55 46.63 45.70 45.70 44.79 99308 65.98 62.68 72.08 70.64 70.64 69.23 99309 87.07 82.72 95.13 93.23 93.23 91.37 99310 129.59 123.11 141.58 138.75 138.75 135.98

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CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 232Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

99315 69.96 66.46 76.43 74.90 74.90 73.40 99316 101.39 96.32 110.77 108.55 108.55 106.38 99318 91.83 87.24 100.33 98.33 98.33 96.36 99324 53.14 50.48 58.05 56.89 56.89 55.75 99325 77.56 73.68 84.73 83.04 83.04 81.39 99326 133.97 127.27 146.36 143.43 143.43 140.56 99327 178.54 169.61 195.05 191.15 191.15 187.34 99328 208.79 198.35 228.10 223.54 223.54 219.06 99334 57.79 54.90 63.14 61.87 61.87 60.63 99335 91.25 86.69 99.69 97.70 97.70 95.75 99336 129.16 122.70 141.11 138.29 138.29 135.53 99337 185.28 176.02 202.42 198.38 198.38 194.41 99341 52.83 50.19 57.72 56.57 56.57 55.44 99342 76.31 72.49 83.36 81.70 81.70 80.06 99343 125.40 119.13 137.00 134.26 134.26 131.58 99344 175.02 166.27 191.21 187.38 187.38 183.63 99345 212.14 201.53 231.76 227.13 227.13 222.58 99347 53.10 50.45 58.02 56.86 56.86 55.72 99348 80.84 76.80 88.32 86.55 86.55 84.81 99349 122.95 116.80 134.32 131.63 131.63 129.00 99350 170.82 162.28 186.62 182.88 182.88 179.23 99354 95.80 91.01 104.66 102.57 102.57 100.52 # 99354 89.55 85.07 97.83 95.88 95.88 93.96 99355 93.33 88.66 101.96 99.92 99.92 97.92 # 99355 87.08 82.73 95.14 93.24 93.24 91.38 99356 88.40 83.98 96.58 94.65 94.65 92.75 99357 87.77 83.38 95.89 93.97 93.97 92.09 99406 13.53 12.85 14.78 14.48 14.48 14.19 # 99406 11.97 11.37 13.08 12.81 12.81 12.56 99407 26.53 25.20 28.98 28.41 28.41 27.84 # 99407 24.97 23.72 27.28 26.74 26.74 26.21 99415 7.78 7.39 8.50 8.33 8.33 8.17 99416 4.34 4.12 4.74 4.65 4.65 4.55 99460 93.39 88.72 102.03 99.99 99.99 97.99 99461 86.11 81.80 94.07 92.18 92.18 90.34 # 99461 61.13 58.07 66.78 65.45 65.45 64.14 99462 40.55 38.52 44.30 43.41 43.41 42.55 99463 114.28 108.57 124.86 122.36 122.36 119.91 99464 69.64 66.16 76.08 74.57 74.57 73.07 99465 147.47 140.10 161.12 157.90 157.90 154.73 99466 223.95 212.75 244.66 239.78 239.78 234.98 99467 113.36 107.69 123.84 121.37 121.37 118.94 99468 912.40 866.78 996.80 976.86 976.86 957.32 99469 386.14 366.83 421.85 413.41 413.41 405.15 99471 841.36 799.29 919.18 900.80 900.80 882.77 99472 395.85 376.06 432.47 423.82 423.82 415.35 99475 557.16 529.30 608.70 596.52 596.52 584.59 99476 335.13 318.37 366.13 358.80 358.80 351.62 99477 345.97 328.67 377.97 370.42 370.42 363.01

Page 233: KENTUCKY PART B - CGS Medicare...2016/10/01  · payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by

CGS PART B Kentucky - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 233Originated November 18, 2015 | Revised October 1, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

99478 132.62 125.99 144.89 141.99 141.99 139.15 99479 120.92 114.87 132.10 129.46 129.46 126.87 99480 115.80 110.01 126.51 123.98 123.98 121.50 99490 38.28 36.37 41.83 40.99 40.99 40.17 # 99490 30.16 28.65 32.95 32.29 32.29 31.65 99495 153.55 145.87 167.75 164.39 164.39 161.10 # 99495 106.41 101.09 116.25 113.93 113.93 111.65 99496 216.71 205.87 236.75 232.01 232.01 227.38 # 99496 153.95 146.25 168.19 164.83 164.83 161.53 99497 81.53 77.45 89.07 87.29 87.29 85.54 # 99497 75.91 72.11 82.93 81.27 81.27 79.65 99498 71.39 67.82 77.99 76.43 76.43 74.90 # 99498 71.08 67.53 77.66 76.11 76.11 74.59

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