FLORIDA WORKERS’ COMPENSATION HEALTH CARE PROVIDER FEE FOR SERVICE REIMBURSEMENT MANUAL
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FLORIDA WORKERS’ COMPENSATION HEALTH CARE PROVIDER FEE FOR SERVICE REIMBURSEMENT MANUAL 2001 EDITION Department of Labor and Employment Security Division of Workers’ Compensation Bureau of Rehabilitation and Medical Services 2728 Centerview Drive Suite 101 Forrest Building Tallahassee, Florida 32399-0664 (850) 488-3431 (850) 410-4622 38F-7.020 Florida Workers' Compensation Health Care Provider Fee for Service Reimbursement Manual. (1) The Florida Workers' Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition, is adopted by reference as part of this rule. The manual contains reimbursement policies and maximum reimbursement allowances for physician services, nonphysician services, pharmaceutical and medical supplies, as well as basic instructions and information for all providers and insurance carriers in the preparation and reimbursement of bills for medical services. The Florida Workers' Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition, is available for inspection during normal business hours at the Division of Workers' Compensation, Bureau of Rehabilitation and Medical Services, 101 Forrest Building, 2728 Centerview Drive, Tallahassee, Florida 32399-0664, or via the Division's home page at http://www2.myflorida.com/les/wc/. (2) The Physicians' Current Procedural Terminology (CPTTM), 4th Edition, copyright 1999, American Medical Association (cover states “Current Procedural Terminology CPTTM , 2000 Standard Edition”); the Current Dental Terminology (CDT-3), 3rd Edition, copyright 1999, American Dental Association (cover states “Current Dental Terminology (CDT-3), Version 2000”); and 2000 HCPCS (HCPCS), 11th Edition, copyright 1999, Ingenix, are adopted by reference as part of this rule. When a procedure or service is performed, which is not listed in the Florida Workers' Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition, the provider must use a code contained in either the CPTTM, CDT-3 or HCPCS. Specific Authority 440.13(7), 440.13(8), 440.13(11), 440.13(12), 440.13(13), 440.13(14), 440.591 F.S. Law Implemented 440.13(6), 440.13(7), 440.13(8), 440.13(11), 440.13(12), 440.13(13), 440.13(14) F.S. History--New 10-1-82, Amended 3-16-83, 11-6-83, 5-21-85, Formerly 38F-7.20, Amended 4-1-88, 7-20-88, 6-1-91, 4-29-92, 2-18-96, 9-1-97, 12-15-97, 9-17-98, 9-30-01. i FLORIDA WORKERS’ COMPENSATION HEALTH CARE PROVIDER FEE FOR SERVICE REIMBURSEMENT MANUAL 2001 EDITION Rule 38F-7.020, Florida Administrative Code In accordance with Section 440.13, Florida Statutes (F.S.), this manual provides reimbursement policies and a schedule of maximum reimbursement allowances for physicians and other licensed health care providers rendering medical services to Florida’s injured workers. The maximum reimbursement allowances and procedure codes are listed in Section X. NOTICES AND DISCLAIMERS The 2001 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual provides five-digit numeric codes and modifiers for reporting medical services and procedures that were selected from the following references by the State of Florida, Department of Labor and Employment Security, Division of Workers’ Compensation, and the Agency for Health Care Administration for inclusion in this publication. When a service or procedure is performed that does not have a procedure code listed in the 2001 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, the physician or health care provider must use a code listed in the following materials: Physician’s Current Procedural Terminology (CPTTM), Fourth Edition, Copyright 1999, American Medical Association. Current Dental Terminology (CDT-3), Third Edition, Copyright 1999, American Dental Association. 2000 HCPCS (HCPCS), Eleventh Edition, Copyright 1999, Ingenix. The CPT and CDT-3 contain listings of descriptive terms and identifying codes used for reporting medical and dental services and procedures by physicians and dentists. HCPCS includes a listing of injection medications and numeric codes used for reporting subcutaneous, intramuscular and intravenous injections administered by physicians. HCPCS also contains a listing of descriptive terms and numeric codes used for reporting dental services and procedures performed by dentists. It is expressly understood and agreed that the American Medical Association’s rights include, but not limited to, common law and statutory rights of literary property in the CPT and in any update thereto, including all descriptive terms and identifying codes and modifiers for reporting procedures and medical services and/or any other information or materials contained in the CPT and in any update thereto are not assigned or released as a result of the agreement between the American Medical Association and the State of Florida, but are at all times reserved and retained by the American Medical Association. CPT codes, descriptions and material only are copyright 1999 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The American Medical Association assumes no liability for the data contained or not contained herein. -ii- This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. -iii- CONTENTS SECTION I: ADMINISTRATIVE PURPOSE OF MANUAL .................................................1 SECTION II: BASIC PROGRAM REQUIREMENTS Authorization ........................................................................................................1 Billing ...................................................................................................................1 Certification ..........................................................................................................1 Materials Adopted for Reference..........................................................................1 Medical Records ...................................................................................................2 Reimbursement Information .................................................................................4 SECTION III: DENTAL SERVICES Workers’ Compensation Billing Requirements ....................................................6 General Dental Services..................................................................................6 Oral and Maxillofacial Surgical Services .......................................................6 Temporomandibular Joint Services ................................................................6 SECTION IV: DISPENSING OF MEDICATION Medicinal Drugs....................................................................................................7 Patent, Proprietary or Over-the-Counter Drugs ....................................................8 SECTION V: MEDICAL SUPPLIER SERVICES .....................................................................9 SECTION VI: MEDICAL SERVICES Biofeedback Services............................................................................................9 Evaluation and Management Services ................................................................10 Impairment Rating ..............................................................................................10 Independent Medical Examination .....................................................................10 Injections.............................................................................................................10 Neurology and Neuromuscular Services ............................................................12 Ophthalmological Services .................................................................................14 Psychiatric and Psychological Services ..............................................................14 Radiology............................................................................................................15 Supplies...............................................................................................................15 Thermography.....................................................................................................16 Transcutaneous Neurostimulator ........................................................................16 SECTION VII: PHYSICAL MEDICINE AND REHABILITATION SERVICES General Information............................................................................................17 Level I: Physical Medicine Services ..............................................................18 Evaluation .........................................................................................18 Modalities and Therapeutic Procedures............................................19 Manipulative Treatment....................................................................20 Acupuncture......................................................................................21 Level II: Physical Reconditioning Services.....................................................21 Physical Reconditioning Assessment ...............................................22 Physical Reconditioning Program.....................................................22 Level III: Multidisciplinary Services .................................................................24 Functional Capacity Evaluation........................................................24 Work Hardening Program.................................................................25 Interdisciplinary Pain Program. ........................................................25 iv SECTION VIII. SURGICAL SERVICES Surgical Package (Global Reimbursement) ........................................................26 Surgical Assistants ..............................................................................................26 Multiple Procedures ............................................................................................27 Bilateral Procedures ............................................................................................28 SECTION IX. ANESTHESIA SERVICES Anesthesia Definitions ........................................................................................28 Anesthesia Variables………………………………………………………….……..28 Reimbursement Methodology……………………………………………………...30 Medical Direction by Anesthesiologist...............................................................31 Local Anesthesia.................................................................................................32 Regional and General Anesthesia .......................................................................32 SECTION X. SCHEDULE OF MAXIMUM REIMBURSEMENT ALLOWANCES Anesthesia ...........................................................................................................34 Surgery................................................................................................................36 Radiology............................................................................................................69 Pathology ............................................................................................................82 Medicine ...........................................................................................................104 Dental................................................................................................................112 Injections...........................................................................................................116 APPENDIX. APPENDIX A. DEFINITIONS ..........................................................................................119 APPENDIX B. DIRECTORY OF REFERENCES ............................................................122 APPENDIX C. MODIFIERS..............................................................................................125 APPENDIX D. WORKERS’ COMPENSATION UNIQUE PROCEDURE CODES ......128 INDEX .........................................................................................................................................130 v Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition SECTION I: ADMINISTRATIVE PURPOSE OF MANUAL. The administrative purpose of the Florida Workers’ Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition, is to provide reimbursement policies and a schedule of maximum reimbursement allowances for physicians and other licensed health care providers, rendering medical services to Florida’s injured workers. Federal facilities are exempt from the reimbursement policies and maximum reimbursement allowances provided in this manual. All health care providers who participate in a workers’ compensation managed care arrangement may enter into contractual agreements for reimbursement. The agreements are made with workers’ compensation insurance carriers or entities authorized to do business in Florida. The policies and schedule of maximum reimbursement allowances contained in this manual are not required to be adopted or used in managed care contracts. SECTION II: BASIC PROGRAM REQUIREMENTS. A. Authorization. Florida health care providers, out-of-state providers and federal facilities must be authorized by the employer’s workers’ compensation carrier or a self-insured employer prior to rendering service. Documented emergency care, defined in section 395.002, Florida Statutes (F.S.), is the only exception to this provision. B. Billing. Health care providers, including out-of-state providers and federal facilities, must report medical services rendered and must bill in accordance with rule 38F-7.602, Florida Administrative Code (F.A.C.). C. Certification. Florida health care providers, in order to qualify for reimbursement for rendering medical services to injured employees, must comply with provider eligibility requirements in section 440.13, F.S. D. Materials Adopted for Reference. 1. The following publications are adopted for reference to the listings of descriptive terms and identifying codes for reporting medical services and procedures provided to injured employees by physicians and other health care providers: a. Physicians’ Current Procedural Terminology (CPT ), Fourth Edition, Copyright 1999, American Medical Association. TM b. Current Dental Terminology (CDT-3), Third Edition, Copyright 1999, American Dental Association. c. 2000 HCPCS (HCPCS), Eleventh Edition, Copyright 1999, Ingenix. 1 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition 2. Physicians and providers shall use the procedure codes and descriptions, modifiers, guidelines, definitions and instructions of the referenced CPT, CDT-3 and HCPCS, in part for injections and dental, when billing workers’ compensation carriers for medical services rendered to injured employees. The procedure code descriptors, guidelines, definitions, and instructions of these references are not provided in this manual. Any modification to a procedure code descriptor by the workers’ compensation program shall be specified and shall take precedence over any referenced descriptor. E. Medical Records. 1. Required documentation. Unless instructed otherwise, it is the responsibility of all health care providers to furnish with the medical bill, without charge, the following documentation to the carrier, and to the Division or Agency, if requested. a. A complete report of the patient’s symptoms, findings and plan of treatment within fifteen (15) days after the service or specific evaluation is rendered unless otherwise specified by law. b. An operative report when a surgical procedure is performed. c. A narrative report when a consultation or an independent medical examination is rendered. d. A narrative report, computerized report or other explanatory report form when a report is listed as part of a procedure code’s descriptor, when a report is provided as an explanation of the results of the testing procedures or when anesthesia, pathology, or radiology services are performed. 2. Additional written documentation. If requested, additional written documentation must be provided by a health care provider to a carrier, without charge, when the medical necessity of medical care must be substantiated in more detail than the information contained in the medical record. Failure to forward the following information, when requested by the carrier, may result in the billed service being disallowed and not reimbursed. a. Objective findings that support the need for medical care, as well as continuing treatment. b. The estimated period of time and number of services required for treatment. c. The anticipated benefits of the treatment to the patient. 2 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition 3. Special requests. a. Carriers may request physicians to complete information on forms not required by the Division or Agency or to prepare special narrative reports. These requests may include reports on the following: (1) Medical evaluation of a proposed job description for an injured employee and the appropriateness of the physical requirements of the job considering the employee’s injury and activity limitations. (2) A determination of the kind, type and amount of future medical care and projected cost over a defined period of time. b. Reimbursement for special requests shall be agreed upon by the carrier and provider prior to the provider’s provision of the service. Reimbursement for special requests, reported under procedure code 99080, shall be made by the carrier at the agreed upon reimbursement amount. 4. Copies of medical records. a. A health care provider, when requested, shall provide a copy of the injured employee’s medical records to a carrier or carrier’s representative, attorney or rehabilitation staff. Reimbursement shall be made to a health care provider for medical records by the carrier as follows: (1) Up to $1.00 per page for providing copies of requested medical records, or for furnishing duplicates of required documentation, additional written documentation or other records previously submitted to the carrier. (2) An additional fee up to $1.00 per year for each year of records, when a year or more of medical records are requested by a carrier. b. A health care provider, when requested, shall furnish an injured employee or the employee’s attorney a copy of the employee’s medical chart, records and reports. Reimbursement for medical records shall be made to a health care provider by the employee or employee’s representative at $.50 per page. c. A health care provider, when requested, shall furnish the injured employee’s nonpaper medical records to an injured employee and a carrier or any of their representatives. Reimbursement shall be made to a health care provider by the requesting party at the provider’s actual cost for x-rays, microfilm, or other non-paper records. d. A health care provider, when requested, shall provide medical records to the Division or Agency without charge. Failure to forward the requested information shall result in administrative action pursuant to the provisions in section 440.13, F.S. 3 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition F. Reimbursement Information. 1. Provider payment. a. Federal facilities. Federal facilities are exempt from the reimbursement provisions and allowances in this reimbursement manual. Reimbursement shall be made to a federal facility at its usual and customary charge by a carrier. b. Florida health care providers. Reimbursement shall be made to a Florida health care provider at the provider’s usual and customary charge or this manual’s maximum reimbursement allowance, whichever is less. c. Out-of-state providers. (1) Prior to the delivery of medical services, a carrier may mutually agree with an outof-state provider upon the amount of reimbursement to be made by the carrier for the services to be provided. Reimbursement shall be made by the carrier at the reimbursement amount agreed upon by the provider and carrier. (2) If a reimbursement agreement is not made, the carrier shall reimburse the provider the greater of the applicable maximum reimbursement allowance for the service in this manual, or the maximum reimbursement allowance under the workers’ compensation program in the state where the service is provided. 2. Reimbursement guidelines. a. Procedure codes paid by maximum reimbursement allowances (MRAs). Reimbursement for procedure codes, billed by a provider that are listed in this manual with assigned MRAs, shall be made by the carrier at the maximum allowance after the application of any reimbursement policies contained in this manual. b. Procedure codes paid by report (BR). (1) Reimbursement by the carrier for procedure codes paid by report (BR) shall be based on a provider’s documentation submitted to the carrier in a special report containing information on medical necessity, prevailing charges, fees and reimbursement for similar procedures or cost of the services or supplies. (2) The information, furnished by the provider in a special report to satisfy the BR requirement for reimbursement purposes, shall be in addition to the requirements in Section II. E. Reimbursement by the carrier shall be determined by report (BR) for the following procedure codes: 4 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition (a) Procedure codes that are listed in this manual that do not have an assigned MRA but a BR in the MRA column for specific procedures, services or supplies. (b) Procedure codes that are listed in this manual with BR in the MRA column for non-referenced medical procedures billed for the appropriate anatomical area with a generic code ending in “ 99 ”. (c) Valid procedure codes that are listed in the materials adopted for reference in Section II, D. but not listed in this manual. c. Procedure codes not covered (NC). Reimbursement shall not be made for services or supplies that are not covered (NC) under Florida’s workers’ compensation program. Reimbursement shall not be made for procedure codes listed in this manual with NC in the MRA column. d. Reimbursement exclusions. (1) Reimbursement shall not be made for failed appointments. This exclusion does not apply to the statutory provisions for independent medical examinations contained in section 440.13, F.S. (2) Reimbursement shall not be made for services or supplies that are provided solely for the purpose of maintaining or promoting the injured employee’s health beyond pre-injury health status. 3. Carrier reimbursement responsibilities. a. Carriers shall use the procedure codes and descriptions, guidelines, definitions and instructions of the referenced CPT, CDT-3 and HCPCS in part for injections and dental when reviewing bills before making reimbursement decisions. b. Carriers shall have a methodology, available upon request by the Division or Agency, for determining reimbursement for procedure codes that have no established MRAs, including unlisted procedure codes and procedure codes that are paid BR. (1) Carriers shall utilize the expertise of physicians for concerns regarding the appropriateness and cost of the medical services reported; billing and coding issues; and reimbursement determinations. (2) Carriers shall make reimbursement decisions based on all the provider documentation; the carrier medical claims data; relative value studies; prevailing charges and reimbursement for procedures, services and supplies; and carrier medical consultant recommendations. c. Carriers shall provide an explanation of bill review, which shall comply with the instructions and requirements in rule 38F-7.602, F.A.C. 5 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition SECTION III: DENTAL SERVICES. A. All dental services shall be authorized by a carrier before the services are initiated. Reimbursement to a dentist or oral surgeon shall only be made by a carrier for authorized services. B. Workers’ compensation billing requirements. Dental services shall be billed by dentists and oral surgeons, pursuant to the following requirements and to the billing instructions in rule 38F-7.602, F.A.C., for LES Forms DWC9 (HCFA-1500) and DWC-11 (J588). 1. General dental services. a. General dental services shall be billed by dentists on LES Form DWC-11. b. The dental guidelines and the American Dental Association’s dental procedure codes and descriptors shall be used from either the referenced CDT-3 or HCPCS. 2. Oral and maxillofacial surgical services. a. Oral and maxillofacial surgical services shall be billed by oral surgeons on LES Form DWC-9. b. The surgical guidelines and the American Medical Association’s procedure codes, descriptors and modifiers shall be used from the referenced CPT. Surgeons shall refer to the surgical services section of this manual for information on multiple surgical procedures, as well as other surgical reimbursement guidelines. 3. Temporomandibular joint services. a. Non-surgical treatment of temporomandibular joint disorders shall be billed by dentists on LES Form DWC-11. b. The appropriate guidelines and procedure codes and descriptors shall be used from either the referenced CPT, CDT-3 or HCPCS. A combination of CPT and dental procedure codes may be used. Dentists shall refer to the physical medicine section of this manual for information on physical therapy reimbursement guidelines. C. Reimbursement. 1. Reimbursement to a dentist for a dental procedure shall be the provider’s charge or the listed MRA, whichever is less. 2. Reimbursement to a surgeon for an oral and maxillofacial consultation shall be limited to one consultative visit per date of accident. 6 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition SECTION IV: DISPENSING OF MEDICATION. A. Medicinal drugs. 1. Medicinal drugs, commonly known as legend or prescription drugs, shall be ordered for an injured employee by a licensed physician, authorized by state law to prescribe such drugs and authorized by the carrier to treat the employee. 2. Medicinal drugs are dispensed, stored and sold only by a pharmacist licensed under Chapter 465, F.S., or a dispensing practitioner, according to the provisions in section 465.0276, F.S. 3. Medicinal drugs may be compounded by a pharmacist or physician when the drug formulation prescribed is not available commercially. 4. Federal regulations. a. The Food and Drug Administration requires drug manufacturers to register and list manufactured drug products. The National Drug Code (NDC) is assigned by the manufacturer and placed on all prescription stock packages. b. The NDC must be shown on all pharmaceutical billing unless otherwise defined in rule 38F-7.602, F.A.C. c. The Food and Drug Administration considers the “compounding of drugs” to be the practice of pharmacy/medicine. A compounded drug does not have a NDC. 5. Workers’ compensation billing requirements. a. Medicinal drugs shall be billed by a pharmacist on the LES Form DWC-10, pursuant to the billing instructions in rule 38F-7.602, F.A.C. b. Medicinal drugs shall be billed by a dispensing physician on the LES Form DWC-9, pursuant to the billing instructions in rule 38F-7.602, F.A.C. A dispensing physician shall also enter the following information on the LES Form DWC-9: (1) The workers’ compensation unique procedure code 96370 in element 24D under the area marked CPT/HCPCS in the first section of this block. (2) The whole numeric quantity dispensed in element 24G. (3) The NDC or the word “COMPOUND” in capital letters in element 24D under the area designated for a two digit modifier and continuing on in the same line in the second section of this block. 6. Reimbursement limitations. a. A pharmacist or physician shall be reimbursed for dispensing medication. Medicinal drugs shall be reimbursed the lesser of: 7 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition (1) The pharmaceutical reimbursement formula: Average Wholesale Price (AWP) x 1.2 + $4.18 = Reimbursement (2) The contracted reimbursement amount determined in accordance with the contractual arrangement between the provider and carrier. b. A pharmacist or physician shall be reimbursed for a professional service for compounding drugs whose formulations are not commercially available. The amount of reimbursement to be made by the carrier shall be mutually agreed upon by the provider and carrier prior to the compounding. B. Patent, proprietary or over-the-counter drugs: 1. Proprietary drugs may be dispensed to an injured employee by a physician during an office visit. a. Billing requirements. (1) Proprietary drugs shall be billed by a physician on LES Form DWC-9 under procedure code 99070. (2) An invoice indicating the cost of the proprietary drug shall be submitted to the carrier with the LES Form DWC-9 and shall include the name of the preparation, dosage and package size. b. Reimbursement. (1) Reimbursement shall be made at the provider’s charge or no greater than 20 percent above the actual cost of the item. (2) Reimbursement shall not be made for oral vitamins, nutrient preparations and other dietary supplements. 2. Patent, proprietary or over-the-counter drugs may be dispensed by a pharmacist. a. Billing requirements. Over-the-counter drugs shall be billed by a pharmacist on LES Form DWC-10 in accordance with the billing instructions in rule 38F-7.602, F.A.C. b. Reimbursement. Reimbursement shall be made at the pharmacist’s usual charge for the drug. 8 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition SECTION V: MEDICAL SUPPLIER SERVICES. A. Medical supplies, durable medical equipment (DME), appliances, devices, ocular and hearing aids, prosthetics or orthotics, shall be prescribed by a physician and may be provided to an injured employee by a medical supplier through purchase or rental. B. Authorization from the carrier must be obtained by a medical supplier prior to an injured employee receiving any medical equipment or supplies. C. The price for renting or selling medical equipment or furnishing other appliances, aids or supplies must be agreed on between the supplier and the carrier at the time authorization is given and accepted by the supplier. 1. The carrier may purchase the item from the supplier after considering and comparing the purchase price with the rental price for the estimated period of time. 2. The carrier may obtain a signed agreement from the supplier, stating that if the item is rented and the amount of the rental payments received equals the purchase price, that the item will become the property of the carrier or injured employee. D. Billing requirements. 1. Medical suppliers shall bill on LES Form DWC-10, in accordance with the billing instructions in rule 38F-7.602, F.A.C. 2. A copy of the physician’s original order for the supplies or equipment shall be submitted with the billing form. An invoice documenting the actual cost is not required. E. Reimbursement. Reimbursement to a medical supplier shall be made by a carrier at the agreed upon price. SECTION VI: MEDICAL SERVICES. A. Biofeedback Services. 1. Reimbursement to a health care provider for biofeedback services shall be limited to twelve (12) visits by the injured employee per date of accident. 2. Reimbursement to a provider for computer downloading of biofeedback data. a. Computer downloading of biofeedback data, stored on a machine used by the injured employee at home, shall not be reimbursed more than once per week and not more than a total of four (4) times. b. Downloading of biofeedback information by a health care provider during an injured employee’s visit for physical medicine services shall not be reimbursed. 9 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition B. Evaluation and Management Services. 1. Office visits. Reimbursement to a physician for evaluation and management services (new patient and established patient visits) shall be made by a carrier for only one (1) visit a day. Reimbursement to a physician for the one (1) visit shall be at the highest level of care provided by the physician. 2. Consultation, confirmatory consultation and follow-up consultation services. Reimbursement to a physician for a consultation shall include a review of all submitted medical records, paper and non-paper; an examination of the injured employee; and a written report. C. Impairment Rating. A treating physician shall perform an examination to evaluate an injured employee’s condition; shall certify the employee as having reached maximum medical improvement; and shall assign an impairment rating for the injured employee’s body as a whole, as mandated in section 440.15, F.S. 1. A physician shall be reimbursed for an impairment rating billed under procedure code 99455. 2. Reimbursement for an impairment rating shall include the evaluation visit; the establishment of the date of maximum medical improvement, as defined in section 440.02(9), F.S., and the assignment of an impairment rating; the completion of the required information on LES Form DWC-9a; and the submission of the LES Form DWC9a to the appropriate parties within ten (10) days in accordance with rule 38F-7.603, F.A.C. D. Independent Medical Examination (IME). An independent medical examination shall be performed by a physician pursuant to section 440.13(5), F.S. 1. A physician shall be reimbursed for an independent medical examination (IME) under procedure code 99456. The reimbursement amount shall be determined from the number of hours reported by the provider to perform the services and the listed MRA. Reimbursement for an IME shall be limited to payment not to exceed a maximum of two (2) hours. 2. Reimbursement for an IME shall include the review of applicable paper and non-paper medical records; an examination of the injured employee; and a written report. E. Injections. 1. Subcutaneous, intramuscular and intravenous injections (J-codes and CPT procedure codes). 10 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition a. Reimbursement shall be made to a provider for subcutaneous, intramuscular and intravenous injections (J-codes). Reimbursement for an injection includes a local anesthetic, if necessary. (1) Reimbursement shall be made at the provider’s charge or the maximum reimbursement allowance, whichever is less. (a) When an injection is the only service provided during a visit, reimbursement shall be made for both the administration of an injection (CPT procedure code) and the injectable medication (J-code). (b) When an injection is provided during an evaluation and management service, additional reimbursement shall be made for the injection (J-code). Administration of the injection is included in the evaluation and management service. (2) Reimbursement for an unlisted injectable medication, reported as J-code J3490, shall be made BR and shall be limited to no more than twenty (20) percent above the actual cost of the injectable medication, based on submitting the following documentation with the claim form. (a) The name, strength and dosage of the medication. (b) An invoice, verifying the cost of the medication, including shipping and handling and taxes, when applicable. (3) Reimbursement shall be made as follows when multiple medications are administered from the same syringe: (a) Reimbursement shall be made at the provider’s charge or the maximum reimbursement allowance, whichever is less for the first drug (J-code). (b) Reimbursement for each additional drug shall be made at the provider’s charge or fifty (50) percent of the maximum reimbursement allowance, whichever is less. Each additional drug shall be identified by adding modifier –51 to the procedure code (J-code). b. Reimbursement shall be made for immunizations that are documented as medically necessary for treatment. Routine immunizations are not covered. (1) Reimbursement shall be made at the provider’s charge or the maximum reimbursement allowance, whichever is less. (a) When a medically necessary immunization is the only service provided during a visit, reimbursement shall be made for both the administration of the immunization (CPT procedure code) and the vaccine or toxoid (CPT procedure code). 11 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition (b) When a medically necessary immunization is provided during an evaluation and management service, additional reimbursement shall be made for the vaccine or toxoid (CPT procedure code). The administration of the immunization is included in the evaluation and management service reimbursement. (2) Reimbursement for an unlisted vaccine or toxoid, reported as procedure code 90749, shall be made BR and shall be limited to no more than twenty (20) percent above the actual cost of the vaccine or toxoid, based on the following documentation submitted with the claim form: (a) The name, strength and dosage of the vaccine or toxoid. (b) An invoice substantiating the provider’s actual cost of the vaccine or toxoid, including shipping and handling and taxes, when applicable. 2. Injection procedures (CPT procedure codes). a. Reimbursement shall be made to a provider for injection procedures (CPT procedure codes), such as trigger point injections or an arthrocentesis, aspiration and/or injection into joints and bursa. Reimbursement shall include the administration, anesthetic used for local infiltration and supplies necessary to perform the procedure. b. Reimbursement shall be made to a provider at the provider’s charge or the maximum reimbursement allowance, whichever is less. c. Reimbursement for an injectable therapeutic medication, reported as procedure code 99070, shall be made in addition to the reimbursement for the injection procedure (CPT procedure code). (1) Reimbursement for the therapeutic medication shall be made BR and shall be limited to an amount not to exceed twenty (20) percent above the actual cost of the medication to the provider. (2) The reimbursement shall be based on the submission of the following information with the claim form. (a) The name, strength and the dosage of the medication. (b) An invoice verifying the provider’s actual cost of the injectable medication including shipping and handling, and taxes, when applicable. F. Neurology and Neuromuscular Services. 1. Extremity testing, muscle testing and range of motion measurements. a. Reimbursement for an evaluation and management service shall include extremity testing, muscle testing and range of motion measurements when the testing and measurements are performed during the visit. 12 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition b. When an office visit is made solely for the purpose of conducting tests on a patient, only the tests shall be reimbursed. An evaluation and management service shall not be reimbursed in addition to the testing. c. When two (2) or more muscle tests are performed during a visit, reimbursement shall not exceed the maximum reimbursement allowance for a total evaluation of the body, reported as procedure code 95834. 2. Needle electromyography (EMG). a. Reimbursement for needle electromyography shall be made to physicians. Only physicians are qualified to perform needle EMGs and make interpretations of EMG studies. b. When an initial evaluation and management service and a needle EMG are performed during a visit, reimbursement shall be made for both services. c. Reimbursement shall be made to a physician for both a follow-up evaluation and management service and a needle EMG when the EMG is performed on the same day and when the documentation validates the medical necessity of the follow-up evaluation and management service. d. Reimbursement shall be made to a physician for an interpretation of a needle EMG performed in a hospital or other facility when modifier –26 is added to the appropriate procedure code. e. Reimbursement to a physician for needle electromyography shall include the testing and a report and shall be limited to two (2) electromyography procedures in a ninety (90) day period of time. 3. Nerve conduction studies (NCS). a. Reimbursement for nerve conduction studies shall only be made to physicians. (1) An initial evaluation must be performed by the physician to determine the nerves to test and the appropriate NCS to be performed. (2) A non-invasive NCS may be performed by a physician-employed technician under the direct supervision of the physician. (3) The interpretation of the NCS must be made by a physician. b. When an initial evaluation and management service and nerve conduction studies are performed during the same visit, reimbursement shall be made for both services. c. Reimbursement shall be made to a physician for both a follow-up evaluation and management service and nerve conduction studies when nerve conduction studies are performed on the same day and when the documentation supports the medical necessity of the follow-up evaluation and management service. 13 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition d. Reimbursement to a physician for nerve conduction studies shall include the testing and a report and shall be made for only two (2) nerve conduction studies in a ninety (90) day period of time. However, there is no restriction on the number of nerves tested in a single study. G. Ophthalmological Services. 1. Reimbursement for ophthalmological services shall be made for all medically necessary services. 2. Reimbursement shall only be made for spectacles, contact lens or frames of comparable quality to the original when they are damaged, lost or required for treatment as a result of an injury. H. Psychiatric and Psychological Services. 1. Reimbursement for psychiatric and psychological services shall be made by the carrier to an authorized, licensed medical doctor, osteopathic physician, a psychologist, or mental health practitioner. 2. Reimbursement shall be made for individual psychotherapy services. 3. Reimbursement shall be made to a physician for individual psychotherapy with medical evaluation and management services provided at the therapy session by a physician. An evaluation and management service provided on the same day as psychotherapy with medical evaluation and management services by the same physician shall not be reimbursed. 4. Reimbursement shall only be made for an evaluation and management service when psychotherapy is not provided. Reimbursement shall only be made to physicians for evaluation and management services. 5. When multiple psychotherapy sessions are provided on the same day, only the session lasting the longest period of time shall be reimbursed. 6. Reimbursement for family psychotherapy with or without the injured employee shall be made if the documentation supports that the purpose is related to the treatment of the injured employee’s compensable injury. Reimbursement shall not be made for psychological services provided directly to members of the injured employee’s family for support and assistance in adjusting to the injured employee’s condition. 7. Reimbursement shall be made for central nervous system assessments and tests. a. Reimbursement includes the administration of the test, the interpretation of the test and the report. b. The amount of reimbursement for these services shall be based on the procedure code’s descriptor, indicating that the service is per hour or all inclusive. 14 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition I. Radiology. 1. Reimbursement shall be made for radiology services, including nuclear medicine and diagnostic ultrasound services. 2. Reimbursement shall be made to a physician for a radiology consultation on an x-ray made by another physician, when documented. a. Reimbursement shall be made for a radiology consultation reported using procedure code 76140. b. Reimbursement for a radiology consultation shall be made only to radiologists and physicians who are certified to perform radiological services. 3. Reimbursement for radiological services, provided in a hospital, ambulatory surgical center or similar facility, shall be made only to radiologists for the professional component, when modifier –26 is added to the radiology code. 4. Reimbursement shall not be made for a professional component (modifier –26) billed in the following situations: a. A professional component billed by a physician for x-rays taken and interpreted by another physician and reviewed during an IME, medical visit or consultation. b. A professional component billed by a physician for reviewing x-rays during an emergency department or hospital visit, when the x-rays were interpreted by the radiologist at the hospital. 5. Additional reimbursement for radiological services, provided in an independent radiology facility, shall be made only to radiologists for a facility charge when the descriptor of the procedure code specifies “supervision and interpretation” services. a. Reimbursement for a facility charge shall be made BR when the workers’ compensation unique modifier –FC is added to the radiology code to identify specific “supervision and interpretation” radiological services provided in an independent radiology facility. b. Reimbursement shall not be made for both a technical component (modifier –TC) and a facility charge (modifier –FC) when billed with the same “supervision and interpretation” radiology procedure code. Reimbursement shall only be made for the facility charge as indicated by the radiology procedure code plus modifier –FC. J. Supplies. 1. Reimbursement shall not be made separately for medical and surgical supplies that are necessary to perform the service. Reimbursement for these supplies is included in the reimbursement for the service. 15 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition 2. Reimbursement shall be made for special supplies, reported as procedure code 99070. a. Reimbursement shall not exceed twenty (20) percent above the provider’s actual cost of the supply. b. Reimbursement by the carrier shall be determined from the invoice substantiating the provider’s cost of the supply, including shipping and handling, and taxes when applicable, that must be submitted by the provider with the bill. K. Thermography. 1. Authorization. The carrier shall not authorize a physician to perform thermography any earlier than forty-five (45) days after the date of accident unless documentation of medical necessity is submitted to the carrier along with the request for authorization. 2. Reimbursement. a. Reimbursement for thermography shall be limited to one body area, either major or limited. (1) Major body areas. (The following areas include all views.) (a) Head. (b) Cervical spine and upper extremities. (c) Lumbosacral spine and lower extremities. (2) Limited body areas. (The following areas include all views.) (a) Thoracic spine. (b) Any portion of a major area. b. Reimbursement for thermography to a major body area shall be made at the provider’s charge or the MRA, whichever is less. c. Reimbursement for thermography to a limited body area, reported by adding modifier –52 to the procedure code shall be made at the provider’s charge or fifty (50) percent of the MRA, whichever is less. d. Reimbursement shall be made for diagnostic technical services, performed by independent authorized technicians not employed by physicians, per the guidelines in this manual. L. Transcutaneous Neurostimulator. 1. Reimbursement for the transcutaneous neurostimulator (TNS). 16 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition a. Reimbursement for a transcutaneous (surface) neurostimulator, prescribed by a physician and provided to an injured employee, shall be made to an authorized physician or provider. (1) Authorization and a prior agreement shall be obtained from the carrier for rental or purchase of a TNS prior to a physician or provider furnishing a TNS to the injured employee. (2) Reimbursement for a TNS shall be made at the price agreed upon between the provider and the carrier when authorization was given by the carrier. (3) Reimbursement shall not exceed twenty (20) percent above the provider’s documented cost when the TNS is purchased. A copy of the provider’s invoice substantiating the purchase price shall be submitted with the claim form. b. Reimbursement for a transcutaneous neurostimulator, prescribed by a physician and provided to an injured employee through rental or purchase, shall be made to an authorized medical supplier. (1) Authorization from the carrier must be obtained by a medical supplier prior to an injured employee receiving the TNS. (2) The price for renting or selling the TNS must be agreed on between the supplier and the carrier at the time authorization is given and accepted by the supplier. (a) The carrier may purchase the TNS from the supplier after considering and comparing the purchase price with the rental price for the estimated period of time. (b) The carrier may obtain a signed agreement from the supplier stating that if the TNS is rented and the amount of the rental payments received equals the purchase price that the TNS will become the property of the carrier or injured employee. (3) A copy of the physician’s original order for the TNS shall be submitted with the claim form. An invoice documenting the actual cost is not required. 2. Reimbursement shall be made to an authorized physician or provider for furnishing limited training to an injured employee on the application of a transcutaneous neurostimulator, reported as procedure code 64550. Reimbursement is limited to no more than four (4) training sessions. SECTION VII: PHYSICAL MEDICINE AND REHABILITATION SERVICES. A. General Information. 1. Physical medicine and rehabilitation services shall be prescribed by a physician. 17 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition 2. The Florida workers’ compensation program shall reimburse authorized providers, as specified in this section, for three levels of physical medicine and rehabilitation services: a. Level I applies to acute injuries which are evaluated, tested and treated with modalities and therapeutic procedures to reduce symptoms, restore function and return the injured employee to work. b. Level II focuses on injuries requiring intensive physical reconditioning services to restore the injured employee to pre-injury level of physical health and function. The goal shall be for the employee to return to a job or become physically reconditioned. c. Level III covers multidisciplinary intervention services that address the physical, psychological, social, functional and vocational needs of an injured employee. Specifically, work hardening services and pain program services shall only be performed in a facility accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). These services are provided through the following CARF programs: Outpatient Medical Rehabilitation Program; Occupational Rehabilitation Program; or Interdisciplinary Pain Rehabilitation Program. B. Level I: Physical Medicine Services. 1. Authorization. a. Reimbursement shall only be made for carrier authorized Level I services, based on a signed order from the authorized, treating physician. All services shall be authorized prior to the initiation of services. b. Reimbursement for physical medicine services shall only be made to the following providers: (1) A licensed physician, including physical medicine services provided by a physician-employed therapist and billed by the physician. (2) A licensed therapist or provider, not employed by a physician. c. Reimbursement for physical medicine services shall not exceed one (1) visit per day, unless specifically authorized by the carrier. d. Reimbursement for Level I services shall only be made for six (6) months after the date of injury, unless specifically determined to be medically necessary by the treating physician and authorized by the carrier. 2. Initial evaluation. a. Reimbursement for an initial evaluation, provided by a physician or a physicianemployed therapist shall be made when billed by a physician as an evaluation and management service. Separate reimbursement shall not be made to a physician and to a physician-employed therapist for an evaluation by each. 18 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition b. Reimbursement for an initial evaluation performed by a therapist, not employed by a physician, shall be made when billed by the therapist under procedure code 97001 or 97003. c. Reimbursement for an initial evaluation shall include an evaluation and a plan of care or treatment. The documentation shall be submitted to the carrier with the claim form within fifteen (15) days following the evaluation. At a minimum, the documentation shall contain: (1) The evaluation findings, including any functional limitations. (2) The proposed therapy, specifying the frequency and duration of the services. (3) The anticipated degree of restoration of function with measurable goals. d. If the carrier questions the appropriateness of the therapy in the plan of care, it shall be the responsibility of the authorized treating physician to provide documentation of medical necessity for the therapy to the carrier. e. Reimbursement shall not be made for an initial evaluation by an authorized therapist or provider when the referral received from the treating physician only orders a specific therapy. 3. Re-evaluation. a. A re-evaluation shall only be performed when the re-evaluation is authorized by the carrier based on a documented exacerbation of the injury or a surgical intervention by the treating physician. b. Reimbursement shall only be made for a re-evaluation, when one of the conditions in Section VII.B.3.a. is documented and only when the service is performed by a therapist not employed by a physician. A re-evaluation must be billed using either procedure code 97002 or 97004. 4. Revised plan. a. A revised plan of care or treatment shall be submitted by the physician or therapist to the carrier, when appropriate. b. An authorized treating physician has the responsibility of providing documentation of medical necessity for the therapy if questioned by the carrier. 5. Modalities and therapeutic procedures. a. Reimbursement to a provider for therapy shall be limited to one (1) visit a day. b. Reimbursement to a provider shall be made for the modalities and therapeutic procedures listed in the plan of care with the limitation that no more than four (4) units of service shall be reimbursed per visit. 19 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition (1) Procedure codes 97010-97542 shall each equal one (1) unit of service. (2) Procedure code 97150 shall be restricted to one (1) reimbursable unit of service per visit. 6. Manipulative treatment. a. Reimbursement to a physician for a manipulative treatment shall be limited to one (1) visit a day. b. Reimbursement for manipulative treatment under workers’ compensation shall be limited to two (2) body regions. (1) The entire spine is one (1) region. (2) Each of the following is one (1) region: head; two (2) upper extremities; two (2) lower extremities; one (1) upper and one (1) lower extremity; rib cage; and abdomen. c. Reimbursement for manipulative treatment to the two (2) regions, listed in Section VII.B.6.b., shall be made for workers’ compensation unique procedure codes 97260 and 97261, specifically designated for physicians other than osteopaths and chiropractors. (1) Reimbursement shall be made for procedure code 97260, when used to bill for a spinal manipulation. The spine shall be reimbursed as one (1) entity for workers’ compensation, although there are four (4) spinal regions (cervical; thoracic; lumbosacral; and sacroiliac). (2) Reimbursement shall be made for procedure code 97261, when used to bill for a manipulation of the temporomandibular joint; the upper extremities, including the hand and wrist; the lower extremities; and other regions. d. Reimbursement for osteopathic manipulative treatment (OMT) to the two (2) regions, listed in Section VII.B.6.b., shall be made for procedure codes 98926 and 98928. (1) Reimbursement shall be made for procedure code 98926, when used to bill for a spinal manipulation. The spine shall be reimbursed as one (1) entity for workers’ compensation, although there are five (5) spinal regions (cervical region; thoracic region; lumbar region; sacral region; pelvic region). (2) Reimbursement shall be made for procedure code 98928, when used to bill for a manipulation to the head region; lower extremities; upper extremities; rib cage region; and abdomen and viscera region. e. Reimbursement for chiropractic manipulative therapy (CMT) to the two (2) regions, listed in Section VII.B.6.b., shall be made for procedure codes 98941 and 98943. These manipulation codes are specifically designated for chiropractic physicians. 20 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition (1) Reimbursement shall be made for procedure code 98941, when used to bill for a spinal manipulation. The spine shall be reimbursed as one (1) entity for workers’ compensation, although there are five (5) spinal regions: cervical region (includes atlanto-occipital joint); thoracic region (includes costovertebral and costotransverse joints); lumbar region; sacral region; and pelvic (sacroiliac joint) region. (2) Reimbursement shall be made for procedure code 98943, when used to bill for a manipulation to the head (including temporomandibular joint, excluding atlantooccipital) region; lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints); and abdomen, which are extraspinal regions. 7. Acupuncture. a. Reimbursement for acupuncture with one (1) or more needles shall be made to a physician or licensed provider not employed by a physician. b. Reimbursement for acupuncture shall be limited to one (1) visit a day. 8. Tests and measurements. a. Reimbursement for muscle testing and range of motion measurements shall include the testing and a report. Reimbursement to a provider shall be limited to one (1) visit by an injured employee per thirty (30) days for each test performed to the same body area. b. Reimbursement shall be made for the workers’ compensation unique procedure code 97752, specifically designated to use in billing a test or measurement performed manually or by mechanical equipment. Reimbursement shall include a report of the results of the testing or measurement. 9. Medical supplies. a. Reimbursement shall be made to a provider for procedure code 99070 when medical supplies are used in addition to the normal supplies for a physical medicine service. b. Reimbursement to a provider shall not exceed twenty (20) percent above the provider’s actual cost of the item. An invoice substantiating the provider’s cost of the item, including shipping and handling, and taxes when applicable, shall be submitted to the carrier with the claim form for reimbursement. C. Level II: Physical Reconditioning Services. 1. Authorization. a. Reimbursement shall only be made for carrier authorized Level II services, based on a signed order from the authorized, treating physician. 21 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition (1) An authorization for physical reconditioning services shall be based on the results of one of the following evaluations: a routine evaluation by a physician; functional capacity evaluation by an interdisciplinary team accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF); or a physical reconditioning assessment performed by an independently practicing occupational or physical therapist. (2) Authorization shall not be made for services to begin any earlier than thirty (30) days following the employee’s date of accident except when recommended by a CARF accredited interdisciplinary team. (3) Authorization shall not be made for services to continue beyond one-hundred and eighty (180) days after the employee’s date of accident except when recommended by a CARF accredited interdisciplinary team. b. Reimbursement for physical reconditioning services shall only be made to an authorized occupational or physical therapist not employed by a physician. 2. Physical reconditioning assessment. a. Reimbursement shall be made for a physical reconditioning assessment that includes procedures to test and identify an injured employee’s specific strength, endurance, flexibility and motor control needs. b. Reimbursement for a physical reconditioning assessment shall be limited to reimbursement for an assessment lasting no longer than eight (8) hours. (1) Reimbursement shall be made for workers’ compensation unique procedure codes 97850 and 97851, specifically designated to use in reporting physical reconditioning assessments. (2) Reimbursement shall be made for procedure code 97850, when used to bill per hour charges for a physical reconditioning assessment. (3) Reimbursement shall be made for procedure code 97851, when used to bill each additional thirty (30) minutes of a physical reconditioning assessment. c. Reimbursement for an assessment shall include a written report, which shall be used in determining an employee’s eligibility for a physical reconditioning program, in designing a physical reconditioning program; or in discharging an injured employee from a program. 3. Physical reconditioning program. a. Reimbursement for a physical reconditioning program shall be limited to reimbursement for a program lasting no longer than sixty (60) hours during a six (6) week period, including up to eight (8) hours for a physical reconditioning assessment. 22 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition (1) Reimbursement shall be made for workers’ compensation unique procedure codes 97801 and 97802, specifically designated to use in reporting for physical reconditioning. (2) Reimbursement shall be made for procedure code 97801, when used to bill per hour charges for physical reconditioning. (3) Reimbursement shall be made for procedure code 97802, when used to bill each additional thirty (30) minutes for physical reconditioning. b. Reimbursement shall be made for physical reconditioning services when the services are provided alone, concurrently with or subsequent to Level I services by the same authorized occupational or physical therapist. c. Reimbursement for an extension of the program shall be limited to reimbursement for an additional twenty (20) hours during a two (2) week period. An extension shall be ordered by the physician and authorized by the carrier based on a recommendation from a CARF accredited interdisciplinary team. 4. Discharge from the physical reconditioning program. a. The treating physician shall determine if the injured employee shall be discharged from the physical reconditioning program before completion. If the injured employee has not completed the program and the treating physician recommends discontinuance of the program, the physician shall provide discharge information to the injured employee, the carrier and the therapist without charge. b. Upon program completion, a report of the following shall be sent by the therapist without charge to the treating physician and the carrier with the final bill: (1) The injured employee’s current clinical status and degree of reconditioning/ restoration; and (2) Return to work recommendations. 5. Limitations of program. a. Reimbursement to a therapist shall be made for only one (1) physical reconditioning program for an injured employee per date of accident, unless authorized by the carrier for a documented exacerbation of the injury or surgical intervention by the treating physician. b. Reimbursement to a therapist shall be made for either a functional capacity evaluation or a physical reconditioning assessment when both are provided to the injured employee in a CARF accredited facility in conjunction with a physical reconditioning program. 23 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition D. Level III: Multidisciplinary Services. 1. Authorization. a. Reimbursement shall only be made to a facility for carrier authorized Level III services, based on a signed order from the authorized, treating physician. All services shall be authorized prior to the initiation of services. b. Reimbursement for Level III services shall only be made to a facility, accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), except for a facility operating pursuant to Chapter 395, F.S., as part of a hospital. 2. Functional Capacity Evaluation (FCE). a. Reimbursement for a functional capacity evaluation shall be made when an evaluation is provided in a CARF accredited facility in one of the appropriate interdisciplinary programs. b. Reimbursement for a functional capacity evaluation shall be made when an evaluation is performed by a licensed provider, employed by the facility to determine the injured worker’s functional or vocational status. An evaluation must include one or more of the following: (1) A baseline evaluation of the injured worker’s functional ability to perform work activities. (2) A job capacity evaluation of the match between the injured worker’s capabilities and the demands of a specific job. (3) An occupational capacity evaluation of the match between the injured worker’s capabilities and the demands of an occupational group. (4) A work capacity evaluation by the match between the injured worker’s capabilities and the demands of competitive employment. c. Reimbursement shall be made for workers’ compensation unique procedure code 97750, specifically designated for use solely by a CARF accredited facility in reporting a functional capacity evaluation. (1) The reimbursement for a functional capacity evaluation includes a written program plan or a written report if a program is not recommended. (2) If an interdisciplinary program is not recommended for the employee based on this evaluation, the facility shall provide the results of the evaluation and recommendations to the injured employee, the carrier and the treating physician without charge. 24 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition 3. Work hardening program. (a) Reimbursement for a work hardening program shall be made to a facility for the duration of the recommended individualized program. (1) Reimbursement shall be made for workers’ compensation unique procedure codes 97545 and 97546, specifically designated to use exclusively in reporting for a work hardening program. (2) Reimbursement shall be made for procedure code 97545 when used to bill the initial two (2) hours each day of a work hardening program. (3) Reimbursement shall be made for procedure code 97546 when used to bill each additional hour each day of a work hardening program. 4. Interdisciplinary pain program. a. Reimbursement for an interdisciplinary pain management program shall be made to a facility for the recommended time indicated in the injured employee’s individual program plan. b. Reimbursement shall be made for biofeedback; physical and rehabilitation medicine services; pharmacy services; psychological and psychiatric services and testing; musculoskeletal services tests and measurements; neuromuscular services tests and studies and other medically necessary services during the course of the program. (1) The services provided must relate to the physical, psychological, social, functional and vocational goals of the program’s plan for the employee. (2) Reimbursement shall be made for the reported CPT procedure codes and submitted with documentation. 5. Discharge from a CARF accredited program. a. The facility’s program director shall determine if the injured employee shall be discharged from the work hardening or pain program before completion. If the injured employee has not completed the program and the program director recommends discontinuance of the program, the director shall provide discharge information to the injured employee, the carrier and the treating physician without charge. b. Upon program completion, a report shall be sent by the facility’s program director without charge to the treating physician and to the carrier with the final bill. The report shall include: (1) The injured employee’s current clinical status and plan for transition from the program; and (2) Return to work recommendations including mechanisms for facility coordination. 25 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition SECTION VIII: SURGICAL SERVICES. A. General reimbursement information. 1. Reimbursement for a surgical package (global reimbursement) shall be made to a physician for the provision of certain services before and after surgery. These services include: a. The immediate pre-operative visit, regardless of location of service. b. Local anesthesia, if appropriate. c. The surgical procedure and operative report. d. The normal, uncomplicated follow-up care for the time periods listed in the follow-up days column (FU days) in Section X. 2. Reimbursement shall be made for other services in addition to the surgical package in the following situations when: a. A preoperative visit is the initial visit, when prolonged detention or evaluation is necessary to prepare an injured employee and when there is a need to establish the reason for a particular type of surgery. b. The preoperative visit is a consultation. c. The preoperative services are not part of the usual preparation for the particular surgical procedure. d. The services are to treat complications, exacerbations, recurrences, or other diseases and injuries. Documentation substantiating the medical necessity of the additional services rendered shall be submitted with the claim form. 3. Reimbursement shall be made for additional surgery performed during the follow-up period. a. Reimbursement for surgical services shall be made when an additional surgery is performed during the postoperative period of another surgical procedure. b. Reimbursement for normal postoperative care shall be made according to the separate follow-up day periods that shall run concurrently. B. Reimbursement for surgical assistants, two (2) surgeons and surgical team. 1. Surgical assistants. a. Reimbursement shall be made by the carrier to a physician for surgical assistant services. Reimbursement to the physician shall be the physician’s usual and customary charge or twenty-five (25) percent of the MRA, whichever is less. 26 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition b. Reimbursement shall be made by the carrier to a non-physician assistant for surgical assistant services at an amount not to exceed seventy-five (75) percent of the allowance that would have been reimbursed if a physician had assisted at surgery, based on carrier compliance with the following: (1) Reimbursement to a non-physician assistant shall only be made if the assistant is qualified by state licensure to assist at surgery. (2) Reimbursement to a non-physician assistant shall only be made when a carrier has provided written authorization to the non-physician assistant prior to the surgery or a physician is not available to assist at surgery when an emergency medical condition exists. (3) Reimbursement shall be made to a non-physician assistant for services rendered after the carrier receives a properly completed claim in accordance with rule 38F7.602, F.A.C. 2. Two surgeons. a. Reimbursement shall be made to two (2) different surgeons at the same operative session for their performance of separate surgical services. The services shall be identified by the same procedure code with modifier –62 added. Reimbursement to each surgeon shall be made at each provider’s usual and customary charge or sixtytwo and one-half (62.5) percent of the MRA, whichever is less. b. Reimbursement shall be made to two (2) surgeons for performing different surgical procedures, identified by distinct, unmodified procedure codes, at the same operative session. Reimbursement to each surgeon shall be made at each surgeon’s usual and customary charge or the MRA, whichever is less. c. Reimbursement shall not be made to either surgeon until the carrier has received and reviewed each surgeon’s bill and individual operative report. 3. Surgical team. Reimbursement for a surgical team shall be made BR to each team member for each surgeon’s surgical service. Each team member shall identify the specific procedure with modifier –66 added to the procedure code. C. Reimbursement for multiple procedures. 1. Reimbursement shall be made for all medically necessary procedures when more than one (1) procedure is performed at a single operative session. 2. Reimbursement for the primary surgical procedure shall be made at the provider’s charge or the MRA, whichever is less. 27 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition 3. Reimbursement for an additional procedure shall be made at the provider’s charge or fifty (50) percent of the listed MRA, whichever is less. The additional procedure shall be identified when modifier –51 is added to the procedure code to indicate the performance of multiple procedures. D. Reimbursement for bilateral procedures. 1. Reimbursement shall be made for bilateral procedures that are performed at the same operative session. 2. Reimbursement for a bilateral procedure that contains the word “bilateral” in the descriptor shall be made at the provider’s charge or the listed MRA, whichever is less. 3. Reimbursement for a bilateral procedure that does not indicate that it is bilateral shall be made, as follows, when the procedure is billed twice: a. Reimbursement for the first procedure shall be made at the provider’s charge or the listed MRA, whichever is less. b. Reimbursement for the second procedure, identified by adding modifier –50 to the procedure code, shall be made at the provider’s charge or fifty (50) percent of the listed MRA, whichever is less. SECTION IX: ANESTHESIA SERVICES. A. Anesthesia definitions. 1. “Anesthesia Reimbursement Allowance (ARA)” means the maximum reimbursement allowance paid to a provider for an anesthesia procedure. 2. “Basic Value (BV) or base unit” means the value of all usual anesthesia services, except the time actually spent in anesthesia care and any modifiers. 3. “CRNA” means a certified registered nurse anesthetist licensed by section 464.002, F.S. 4. “Time (TM) Units” means the number of units of time that a procedure requires, which is calculated by dividing the total anesthesia time (total minutes) by either ten (10) minute intervals for anesthesiologists, or fifteen (15) minute intervals for CRNAs. B. Reimbursement shall be made for authorized medically necessary anesthesia services. Anesthesia reimbursement is based on several variables specific to the particular anesthesia service billed. The charge submitted for a specific anesthesia code varies each time a service is reported for reimbursement. Reimbursement shall be based on application of the following values, physical status modifiers and certain qualifying circumstances. 1. Basic value (BV) or base unit. 28 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition a. The usual preoperative and postoperative visits, the administration of fluids and/or blood products incident to the anesthesia care and interpretation of non-invasive monitoring (ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry) are included in the basic value. b. When multiple surgical procedures are performed during an operative session, the basic value for the anesthesia procedure with the highest value is billed and reimbursed. c. The basic value units, listed in Section X. under Anesthesia, for each anesthesia procedure code, are used in calculating reimbursement. 2. Time (TM) units. a. Anesthesia time begins when the provider starts to prepare the injured employee for anesthesia care in the operating room or in an equivalent area, and stops when the provider is no longer in personal attendance. b. Anesthesia time shall be billed as the total number of minutes of anesthesia according to the instructions in rule 38F-7.602, F.A.C. For example, one (1) hour and fifteen (15) minutes of anesthesia must be billed as 75 minutes of anesthesia. c. The minutes of anesthesia must be converted into time (TM) units as follows: (1) For anesthesiologists, each ten (10) minutes of anesthesia time equals one (1) unit of anesthesia and each minute over a unit has a value of one-tenth (1/10) unit. (2) For CRNAs, each fifteen (15) minutes of anesthesia time equals one (1) unit of anesthesia and each minute over a unit has a value of one-fifteenth (1/15) unit. (3) For codes providing BV + TM, time units shall be calculated and added to the listed BV to determine the reimbursement for the anesthesia services. (4) Only the BV units apply for codes without a time unit (TM) after the base unit. For some anesthesia services, time is not reported additionally. Therefore, additional units of time are not calculated for these codes when determining reimbursement. 3. Physical status modifiers. a. Anesthesia services shall warrant additional reimbursement for units based upon the injured employee’s condition and the complexity of the anesthesia service provided. b. A physical status modifier shall be determined to rank the injured employee’s condition. Additional reimbursement shall be based on the unit value for the specific physical status modifier. 29 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition Physical Status Modifiers Unit Values P1 A normal healthy patient 0 P2 A patient with mild systemic disease 0 P3 A patient with severe systemic disease 1 P4 A patient with severe systemic disease that is a constant threat to life 2 A moribund patient who is not expected to survive without the operation 3 A declared brain dead patient whose organs are being removed for donor purposes 0 P5 P6 4. Anesthesia services, which are provided under particularly difficult circumstances, may warrant additional reimbursement for unit values based on unusual events. This subsection includes a list of important qualifying circumstances that impact on the anesthesia service provided. These procedures are not reported alone but are reported as additional procedure numbers qualifying an anesthesia procedure for additional reimbursement. The listed unit value must be added to the basic unit values to obtain the reimbursement. List each of the following codes separately in addition to the procedure code for the primary anesthesia procedure. Unit Values Qualifying Circumstances 99100 99116 99135 99140 Anesthesia for patient of extreme age, under one year and over seventy 1 Anesthesia complicated by utilization of total body hypothermia 5 Anesthesia complicated by utilization of controlled hypotension 5 Anesthesia complicated by emergency conditions (specify) 2 C. Reimbursement for anesthesia services shall be made at the provider’s usual charge or the anesthesia reimbursement allowance (ARA), whichever is less. 1. Methodology for calculating the anesthesia reimbursement allowance (ARA) for procedures that are listed basic value (BV) + time (TM). a. Select the applicable anesthesia procedure code and basic value from the schedule in Section X. 30 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition b. Determine the time units according to Section IX.B.2.c. (ten [10] minutes = one [1] time unit for an anesthesiologist and fifteen [15] minutes = one [1] time unit for a CRNA). c. Any minutes that exceed a whole unit are counted as partial units (fractions of units), such as one (1) minute is one-tenth (1/10) unit for an anesthesiologist and onefifteenth (1/15) unit for a CRNA. d. Determine any additional units that are justified by the physical status modifiers or qualifying circumstances addressed above in Section IX.B.3. and B.4. respectively. e. Add the basic value, time units, physical status modifier and applicable qualifying circumstances to determine the total anesthesia value. f. Multiply the total anesthesia value by the conversion factor of $28.08 to obtain the anesthesia reimbursement allowance. 2. Methodology for calculating the anesthesia reimbursement allowance (ARA) for procedures that are listed only basic value (BV) and no time. Multiply the basic value by the conversation factor of $28.08 to obtain the anesthesia reimbursement allowance. 3. Methodology for calculating the anesthesia reimbursement allowance (ARA) for monitored anesthesia care. a. Follow the guidelines, as applicable, in Section IX.C.1. as though anesthesia was administered (basic value + time). b. Multiply the total anesthesia value by the conversion factor of $28.08 to obtain the anesthesia reimbursement allowance. D. Reimbursement for medical direction provided by anesthesiologist. 1. Medical direction for CRNA employed by anesthesiologist. a. Reimbursement shall be made to the anesthesiologist only for anesthesia services which are billed under the name and license number of the physician-employer. b. No additional reimbursement shall be made for supervisory services rendered by the physician. 2. Medical direction for a CRNA not employed by the anesthesiologist. a. The CRNA shall bill and shall be reimbursed based on the number of units of time that a procedure requires which is calculated by dividing the total anesthesia time by fifteen (15) minute intervals for CRNAs. 31 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition b. Reimbursement shall be made to an anesthesiologist for providing medical direction, including preoperative and postoperative evaluations. Medical direction shall be billed by the anesthesiologist by adding a unique workers’ compensation modifier –QY to the anesthesia procedure code. c. Reimbursement for medical direction by anesthesiologists shall be the provider’s charges or fifty (50) percent of the anesthesia reimbursement allowance, whichever is less. E. Reimbursement for local anesthesia. Reimbursement for infiltration, digital block or topical anesthesia administered by an operating surgeon or surgeon’s assistant is included in the global reimbursement for the surgical procedure and shall not be separately reimbursed. F. Reimbursement for regional or general anesthesia provided by an operating surgeon or surgeon’s assistant. 1. Reimbursement shall be made for regional or general anesthesia to an operating surgeon or surgeon’s assistant in addition to the surgical procedure performed by adding modifier –47 to the surgical procedure code billed. Anesthesia procedure codes and nerve block codes shall not be used for billing regional anesthesia for a surgical procedure. 2. Reimbursement shall be the provider’s usual charge or the anesthesia reimbursement allowance, whichever is less. 32 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition SECTION X SCHEDULE OF MAXIMUM REIMBURSEMENT ALLOWANCES 33 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Anesthesia Code BV + TM 00100 5 + TM 00102 6 + TM 00103 5 + TM 00104 4 + TM 00120 5 + TM 00124 4 + TM 00126 4 + TM 00140 5 + TM 00142 6 + TM 00144 6 + TM 00145 6 + TM 00147 6 + TM 00148 4 + TM 00160 5 + TM 00162 7 + TM 00164 4 + TM 00170 5 + TM 00172 6 + TM 00174 6 + TM 00176 7 + TM 00190 5 + TM 00192 7 + TM 00210 11 + TM 00212 5 + TM 00214 9 + TM 00215 9 + TM 00216 15 + TM 00218 13 + TM 00220 10 + TM 00222 6 + TM 00300 5 + TM 00320 6 + TM 00322 3 + TM 00350 10 + TM 00352 5 + TM 00400 3 + TM 00402 5 + TM 00404 5 + TM 00406 13 + TM 00410 4 + TM 00450 5 + TM 00452 6 + TM 00454 3 + TM 00470 6 + TM 00472 10 + TM 00474 13 + TM 00500 15 + TM 00520 6 + TM 00522 4 + TM 00524 4 + TM Anesthesia Code BV + TM 00528 8 + TM 00530 4 + TM 00532 4 + TM 00534 7 + TM 00540 13 + TM 00542 15 + TM 00544 15 + TM 00546 15 + TM 00548 15 + TM 00560 15 + TM 00562 20 + TM 00580 20 + TM 00600 10 + TM 00604 13 + TM 00620 10 + TM 00622 13 + TM 00630 8 + TM 00632 7 + TM 00634 10 + TM 00670 13 + TM 00700 3 + TM 00702 4 + TM 00730 5 + TM 00740 5 + TM 00750 4 + TM 00752 6 + TM 00754 7 + TM 00756 7 + TM 00770 15 + TM 00790 7 + TM 00792 13 + TM 00794 8 + TM 00796 30 + TM 00800 3 + TM 00802 5 + TM 00810 5 + TM 00820 5 + TM 00830 4 + TM 00832 6 + TM 00840 6 + TM 00842 4 + TM 00844 7 + TM 00846 8 + TM 00848 8 + TM 00850 7 + TM 00855 8 + TM 00857 7 + TM 00860 6 + TM 00862 7 + TM 00864 8 + TM CPT only © 1999 American Medical Association. All Rights Reserved. Anesthesia Code BV + TM 00865 8 + TM 00866 10 + TM 00868 10 + TM 00870 5 + TM 00872 7 + TM 00873 5 + TM 00880 15 + TM 00882 10 + TM 00884 5 + TM 00900 3 + TM 00902 4 + TM 00904 7 + TM 00906 4 + TM 00908 6 + TM 00910 3 + TM 00912 5 + TM 00914 5 + TM 00916 5 + TM 00918 5 + TM 00920 3 + TM 00922 6 + TM 00924 4 + TM 00926 4 + TM 00928 6 + TM 00930 4 + TM 00932 4 + TM 00934 6 + TM 00936 8 + TM 00938 4 + TM 00940 3 + TM 00942 4 + TM 00944 6 + TM 00946 5 + TM 00948 4 + TM 00950 5 + TM 00952 4 + TM 00955 5 + TM 01120 6 + TM 01130 3 + TM 01140 15 + TM 01150 8 + TM 01160 4 + TM 01170 8 + TM 01180 3 + TM 01190 4 + TM 01200 4 + TM 01202 4 + TM 01210 6 + TM 01212 10 + TM 01214 8 + TM 34 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Anesthesia Code BV + TM 01220 4 + TM 01230 6 + TM 01232 5 + TM 01234 8 + TM 01250 4 + TM 01260 3 + TM 01270 8 + TM 01272 4 + TM 01274 6 + TM 01320 4 + TM 01340 4 + TM 01360 5 + TM 01380 3 + TM 01382 3 + TM 01390 3 + TM 01392 4 + TM 01400 4 + TM 01402 7 + TM 01404 5 + TM 01420 3 + TM 01430 3 + TM 01432 6 + TM 01440 5 + TM 01442 8 + TM 01444 8 + TM 01462 3 + TM 01464 3 + TM 01470 3 + TM 01472 5 + TM 01474 5 + TM 01480 3 + TM 01482 4 + TM 01484 4 + TM 01486 7 + TM 01490 3 + TM 01500 8 + TM 01502 6 + TM 01520 3 + TM 01522 5 + TM 01610 5 + TM 01620 4 + TM 01622 4 + TM 01630 5 + TM 01632 6 + TM 01634 9 + TM 01636 15 + TM 01638 10 + TM 01650 6 + TM 01652 10 + TM 01654 8 + TM Anesthesia Code BV + TM 01656 10 + TM 01670 4 + TM 01680 3 + TM 01682 4 + TM 01710 3 + TM 01712 5 + TM 01714 5 + TM 01716 5 + TM 01730 3 + TM 01732 3 + TM 01740 4 + TM 01742 5 + TM 01744 5 + TM 01756 6 + TM 01758 5 + TM 01760 7 + TM 01770 6 + TM 01772 6 + TM 01780 3 + TM 01782 4 + TM 01784 6 + TM 01810 3 + TM 01820 3 + TM 01830 3 + TM 01832 6 + TM 01840 6 + TM 01842 6 + TM 01844 6 + TM 01850 3 + TM 01852 4 + TM 01860 3 + TM 01904 7 + TM 01906 5 + TM 01908 5 + TM 01910 9 + TM 01912 5 + TM 01914 6 + TM 01916 5 + TM 01918 5 + TM 01920 7 + TM 01921 7 + TM 01922 7 + TM 01990 0 01995 5 01996 3 01999 BR CPT only © 1999 American Medical Association. All Rights Reserved. 35 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 10040 10060 10061 10080 10081 10120 10121 10140 10160 10180 11000 11001 11010 11011 11012 11040 11041 11042 11043 11044 11055 11056 11057 11100 11101 11200 11201 11300 11301 11302 11303 11305 11306 11307 11308 11310 11311 11312 11313 11400 11401 11402 11403 11404 11406 11420 11421 11422 11423 11424 MRA $54.00 $53.00 $133.00 $59.00 $203.00 $53.00 $169.00 $53.00 $45.00 $164.00 $45.00 $27.00 $348.00 $432.00 $597.00 $43.00 $45.00 $88.00 $210.00 $283.00 $26.00 $35.00 $39.00 $78.00 $41.00 $66.00 $26.00 $59.00 $80.00 $96.00 $119.00 $61.00 $86.00 $100.00 $125.00 $75.00 $95.00 $110.00 $144.00 $81.00 $114.00 $145.00 $178.00 $200.00 $246.00 $98.00 $92.00 $157.00 $163.00 $221.00 FU Days 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 0 0 7 0 0 0 0 0 0 0 0 0 0 0 0 15 15 15 15 15 15 15 15 15 15 15 Surgery CPT Code 11426 11440 11441 11442 11443 11444 11446 11450 11451 11462 11463 11470 11471 11600 11601 11602 11603 11604 11606 11620 11621 11622 11623 11624 11626 11640 11641 11642 11643 11644 11646 11719 11720 11721 11730 11732 11740 11750 11752 11755 11760 11762 11765 11770 11771 11772 11900 11901 11920 11921 MRA $303.00 $105.00 $102.00 $174.00 $221.00 $276.00 $344.00 $282.00 $366.00 $264.00 $351.00 $320.00 $391.00 $148.00 $180.00 $199.00 $226.00 $249.00 $315.00 $150.00 $191.00 $223.00 $259.00 $305.00 $373.00 $168.00 $227.00 $260.00 $305.00 $380.00 $494.00 $22.00 $32.00 $50.00 $62.00 $31.00 $41.00 $156.00 $234.00 $106.00 $131.00 $223.00 $65.00 $275.00 $496.00 $585.00 $33.00 $37.00 $147.00 $172.00 FU Days 15 15 15 15 15 15 15 15 15 15 15 15 15 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 60 90 60 30 60 60 0 0 90 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 11922 11950 11951 11952 11954 11960 11970 11971 11976 12001 12002 12004 12005 12006 12007 12011 12013 12014 12015 12016 12017 12018 12020 12021 12031 12032 12034 12035 12036 12037 12041 12042 12044 12045 12046 12047 12051 12052 12053 12054 12055 12056 12057 13100 13101 13102 13120 13121 13122 13131 MRA $40.00 $107.00 $114.00 $155.00 $165.00 $829.00 $632.00 $280.00 $111.00 $75.00 $88.00 $110.00 $148.00 $182.00 $339.00 $88.00 $126.00 $148.00 $185.00 $239.00 $316.00 $515.00 $211.00 $87.00 $93.00 $110.00 $148.00 $223.00 $356.00 $411.00 $104.00 $126.00 $158.00 $224.00 $341.00 $324.00 $126.00 $148.00 $223.00 $301.00 $380.00 $487.00 $539.00 $178.00 $240.00 $89.00 $223.00 $348.00 $104.00 $252.00 FU Days 90 30 30 30 30 90 90 30 15 0 0 0 7 7 7 0 0 7 7 7 7 7 7 7 0 0 15 15 15 15 0 15 15 15 15 15 0 15 15 15 15 15 15 30 30 30 30 30 30 30 36 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 13132 13133 13150 13151 13152 13153 13160 14000 14001 14020 14021 14040 14041 14060 14061 14300 14350 15000 15001 15050 15100 15101 15120 15121 15200 15201 15220 15221 15240 15241 15260 15261 15350 15351 15400 15401 15570 15572 15574 15576 15600 15610 15620 15630 15650 15732 15734 15736 15738 15740 MRA FU Days $484.00 30 $154.00 30 $260.00 30 $375.00 30 $542.00 30 $169.00 30 $655.00 30 $512.00 60 $695.00 60 $590.00 90 $818.00 90 $701.00 60 $936.00 60 $766.00 60 $1,330.00 90 $1,040.00 90 $734.00 60 $287.00 0 $70.00 0 $349.00 30 $679.00 45 $146.00 45 $788.00 45 $235.00 45 $644.00 45 $126.00 45 $687.00 45 $114.00 45 $763.00 45 $334.00 45 $841.00 45 $207.00 45 $232.00 0 $66.00 0 $223.00 0 $66.00 0 $748.00 90 $721.00 90 $775.00 90 $457.00 90 $259.00 45 $320.00 45 $506.00 45 $362.00 45 $427.00 45 $1,465.00 90 $1,557.00 90 $1,862.00 90 $1,415.00 90 $913.00 90 Surgery CPT Code 15750 15756 15757 15758 15760 15770 15775 15776 15780 15781 15782 15783 15786 15787 15788 15789 15792 15793 15810 15811 15819 15820 15821 15822 15823 15824 15825 15826 15828 15829 15831 15832 15833 15834 15835 15836 15837 15838 15839 15840 15841 15842 15845 15850 15851 15852 15860 15876 15877 15878 MRA FU Days $1,064.00 90 $2,892.00 90 $2,892.00 90 $2,884.00 90 $810.00 45 $674.00 60 $327.00 90 $475.00 90 $532.00 90 $420.00 90 $314.00 90 $340.00 60 $146.00 0 $27.00 30 $194.00 60 $360.00 60 $130.00 60 $232.00 60 $401.00 30 $440.00 30 $780.00 60 $556.00 60 $607.00 60 $499.00 30 $718.00 60 NC 30 NC 30 NC 30 NC 60 NC 60 $990.00 60 $926.00 60 $833.00 60 $837.00 60 $865.00 60 $721.00 60 $696.00 60 $600.00 60 $643.00 60 $1,187.00 90 $1,859.00 90 $3,099.00 90 $1,116.00 90 $57.00 30 $37.00 30 $32.00 30 $151.00 0 NC 60 NC 60 NC 60 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 15879 15920 15922 15931 15933 15934 15935 15936 15937 15940 15941 15944 15945 15946 15950 15951 15952 15953 15956 15958 15999 16000 16010 16015 16020 16025 16030 16035 17000 17003 17004 17106 17107 17108 17110 17111 17250 17260 17261 17262 17263 17264 17266 17270 17271 17272 17273 17274 17276 17280 MRA FU Days NC 60 $571.00 90 $771.00 90 $638.00 90 $860.00 90 $1,064.00 90 $1,184.00 90 $1,032.00 90 $1,223.00 90 $318.00 90 $919.00 90 $954.00 90 $1,078.00 90 $1,737.00 90 $549.00 60 $872.00 60 $876.00 90 $1,013.00 90 $1,382.00 90 $1,379.00 90 BR 0 $48.00 0 $53.00 0 $213.00 0 $45.00 0 $67.00 0 $153.00 0 $341.00 0 $60.00 0 $16.00 0 $233.00 0 $341.00 0 $648.00 0 $1,015.00 0 $55.00 0 $83.00 0 $27.00 0 $96.00 15 $117.00 15 $150.00 15 $172.00 15 $189.00 15 $225.00 15 $125.00 15 $143.00 15 $170.00 15 $195.00 15 $240.00 15 $281.00 15 $123.00 15 37 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 17281 17282 17283 17284 17286 17304 17305 17306 17307 17310 17340 17360 17380 17999 19000 19001 19020 19030 19100 19101 19110 19112 19120 19125 19126 19140 19160 19162 19180 19182 19200 19220 19240 19260 19271 19272 19290 19291 19316 19318 19324 19325 19328 19330 19340 19342 19350 19355 19357 19361 MRA FU Days $165.00 15 $194.00 15 $239.00 15 $282.00 15 $373.00 15 $590.00 0 $247.00 0 $227.00 0 $232.00 0 $62.00 0 $37.00 0 $96.00 0 NC 0 BR 0 $74.00 0 $40.00 0 $288.00 0 $88.00 0 $117.00 0 $338.00 30 $406.00 30 $354.00 30 $429.00 30 $468.00 30 $201.00 30 $541.00 60 $485.00 60 $1,054.00 60 $689.00 60 $628.00 60 $1,192.00 90 $1,211.00 120 $1,195.00 60 $1,101.00 90 $1,561.00 120 $1,674.00 120 $101.00 0 $52.00 0 $954.00 90 $1,313.00 90 $440.00 90 $656.00 90 $457.00 90 $569.00 90 $545.00 90 $963.00 90 $853.00 90 $755.00 90 $1,449.00 90 $1,667.00 90 Surgery CPT Code 19364 19366 19367 19368 19369 19370 19371 19380 19396 19499 20000 20005 20100 20101 20102 20103 20150 20200 20205 20206 20220 20225 20240 20245 20250 20251 20500 20501 20520 20525 20550 20600 20605 20610 20615 20650 20660 20661 20662 20663 20665 20670 20680 20690 20692 20693 20694 20802 20805 20808 MRA FU Days $2,737.00 90 $1,676.00 90 $2,056.00 90 $2,444.00 90 $2,317.00 90 $662.00 90 $788.00 90 $780.00 90 $231.00 90 BR 0 $45.00 0 $267.00 21 $727.00 90 $261.00 90 $314.00 90 $405.00 90 $1,141.00 90 $134.00 7 $243.00 15 $119.00 0 $114.00 15 $192.00 15 $279.00 21 $364.00 30 $447.00 45 $511.00 45 $53.00 0 $54.00 0 $75.00 0 $331.00 30 $37.00 0 $41.00 0 $48.00 0 $45.00 0 $85.00 60 $170.00 0 $320.00 21 $476.00 21 $559.00 21 $465.00 21 $105.00 0 $80.00 0 $332.00 21 $298.00 21 $516.00 21 $477.00 21 $421.00 21 $3,363.00 180 $4,317.00 180 $5,324.00 180 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 20816 20822 20824 20827 20838 20900 20902 20910 20912 20920 20922 20924 20926 20930 20931 20936 20937 20938 20950 20955 20956 20957 20962 20969 20970 20972 20973 20974 20975 20979 20999 21010 21015 21025 21026 21029 21030 21031 21032 21034 21040 21041 21044 21045 21050 21060 21070 21076 21077 21079 MRA FU Days $3,060.00 180 $2,511.00 180 $3,027.00 180 $3,920.00 180 $3,484.00 180 $454.00 0 $658.00 0 $338.00 0 $549.00 0 $460.00 0 $634.00 0 $583.00 15 $444.00 15 BR 0 $156.00 0 BR 0 $234.00 0 $257.00 0 $123.00 0 $3,332.00 90 $3,167.00 90 $3,074.00 90 $3,122.00 90 $3,716.00 90 $3,650.00 90 $3,420.00 90 $3,821.00 90 $266.00 0 $334.00 90 $19.00 0 BR 0 $854.00 90 $520.00 90 $546.00 90 $413.00 90 $700.00 90 $496.00 90 $310.00 90 $315.00 90 $1,140.00 90 $227.00 90 $570.00 90 $957.00 90 $1,313.00 90 $1,026.00 90 $972.00 90 $679.00 90 $1,192.00 90 $3,002.00 90 $2,086.00 90 38 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 21080 21081 21082 21083 21084 21085 21086 21087 21088 21089 21100 21110 21116 21120 21121 21122 21123 21125 21127 21137 21138 21139 21141 21142 21143 21145 21146 21147 21150 21151 21154 21155 21159 21160 21172 21175 21179 21180 21181 21182 21183 21184 21188 21193 21194 21195 21196 21198 21206 21208 MRA FU Days $2,346.00 90 $2,138.00 90 $1,855.00 90 $1,802.00 90 $2,105.00 90 $801.00 90 $2,333.00 90 $2,217.00 90 BR 90 BR 90 $297.00 0 $371.00 30 $207.00 0 $500.00 90 $651.00 90 $700.00 90 $903.00 90 $656.00 90 $909.00 90 $797.00 90 $960.00 90 $1,168.00 90 $1,438.00 90 $1,527.00 90 $1,511.00 90 $1,513.00 90 $1,570.00 90 $1,639.00 90 $1,914.00 90 $2,264.00 90 $2,364.00 90 $2,640.00 90 $3,302.00 90 $3,500.00 90 $2,111.00 90 $2,604.00 90 $1,826.00 90 $2,035.00 90 $813.00 90 $2,570.00 90 $2,770.00 90 $3,150.00 90 $1,786.00 90 $1,331.00 90 $1,540.00 90 $1,360.00 90 $1,764.00 90 $1,268.00 90 $1,112.00 90 $946.00 90 Surgery CPT Code 21209 21210 21215 21230 21235 21240 21242 21243 21244 21245 21246 21247 21248 21249 21255 21256 21260 21261 21263 21267 21268 21270 21275 21280 21282 21295 21296 21299 21300 21310 21315 21320 21325 21330 21335 21336 21337 21338 21339 21340 21343 21344 21345 21346 21347 21348 21355 21356 21360 21365 MRA FU Days $576.00 90 $930.00 90 $970.00 90 $956.00 90 $707.00 90 $1,281.00 90 $1,207.00 90 $1,501.00 90 $1,062.00 90 $1,038.00 90 $1,010.00 90 $2,003.00 90 $1,023.00 90 $1,525.00 90 $1,459.00 90 $1,470.00 90 $1,372.00 90 $2,347.00 90 $2,361.00 90 $1,539.00 90 $1,946.00 90 $890.00 90 $963.00 90 $571.00 90 $360.00 90 $144.00 90 $384.00 90 BR 90 $107.00 0 $73.00 0 $180.00 0 $235.00 90 $348.00 90 $639.00 90 $852.00 90 $478.00 90 $300.00 90 $550.00 90 $689.00 90 $907.00 90 $1,043.00 90 $1,450.00 90 $738.00 90 $917.00 90 $1,048.00 90 $1,286.00 90 $295.00 0 $372.00 0 $590.00 90 $1,239.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 21366 21385 21386 21387 21390 21395 21400 21401 21406 21407 21408 21421 21422 21423 21431 21432 21433 21435 21436 21440 21445 21450 21451 21452 21453 21454 21461 21462 21465 21470 21480 21485 21490 21493 21494 21495 21497 21499 21501 21502 21510 21550 21555 21556 21557 21600 21610 21615 21616 21620 MRA FU Days $1,386.00 90 $810.00 90 $812.00 90 $958.00 90 $920.00 90 $1,384.00 90 $128.00 0 $313.00 90 $852.00 90 $736.00 90 $1,007.00 90 $528.00 90 $761.00 90 $890.00 90 $598.00 90 $744.00 90 $1,981.00 90 $1,404.00 90 $2,045.00 90 $308.00 30 $533.00 30 $325.00 90 $498.00 90 $195.00 90 $902.00 90 $905.00 90 $769.00 90 $1,012.00 90 $923.00 90 $1,331.00 90 $82.00 30 $318.00 90 $865.00 90 $107.00 0 $529.00 90 $500.00 90 $372.00 90 BR 90 $315.00 21 $612.00 30 $534.00 21 $165.00 0 $337.00 15 $431.00 15 $794.00 180 $631.00 60 $828.00 60 $938.00 60 $1,042.00 60 $689.00 60 39 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 21627 21630 21632 21700 21705 21720 21725 21740 21750 21800 21805 21810 21820 21825 21899 21920 21925 21930 21935 22100 22101 22102 22103 22110 22112 22114 22116 22210 22212 22214 22216 22220 22222 22224 22226 22305 22310 22315 22318 22319 22325 22326 22327 22328 22505 22548 22554 22556 22558 22585 MRA FU Days $686.00 60 $1,455.00 60 $1,514.00 60 $576.00 60 $746.00 60 $523.00 60 $588.00 60 $1,387.00 90 $1,009.00 90 $75.00 30 $236.00 60 $500.00 60 $143.00 30 $810.00 60 BR 30 $165.00 30 $371.00 60 $403.00 60 $1,280.00 90 $850.00 90 $862.00 90 $781.00 90 $198.00 0 $889.00 90 $1,090.00 90 $1,062.00 90 $195.00 0 $1,892.00 90 $1,668.00 90 $819.00 90 $492.00 0 $1,801.00 90 $1,604.00 90 $1,731.00 90 $488.00 0 $213.00 90 $272.00 90 $711.00 90 $1,755.00 90 $1,983.00 90 $1,407.00 90 $1,710.00 90 $1,660.00 90 $391.00 0 $156.00 0 $2,271.00 90 $1,727.00 90 $2,054.00 90 $1,907.00 90 $473.00 0 Surgery CPT Code 22590 22595 22600 22610 22612 22614 22630 22632 22800 22802 22804 22808 22810 22812 22818 22819 22830 22840 22841 22842 22843 22844 22845 22846 22847 22848 22849 22850 22851 22852 22855 22899 22900 22999 23000 23020 23030 23031 23035 23040 23044 23065 23066 23075 23076 23077 23100 23101 23105 23106 MRA FU Days $1,895.00 90 $1,960.00 90 $1,567.00 90 $1,494.00 90 $1,861.00 90 $530.00 0 $1,201.00 90 $442.00 0 $1,960.00 90 $2,633.00 90 $2,951.00 90 $2,157.00 90 $2,356.00 90 $2,675.00 90 $2,701.00 90 $2,968.00 90 $1,176.00 90 $943.00 0 BR 0 $2,352.00 0 $1,028.00 0 $1,277.00 0 $1,853.00 0 $999.00 0 $1,077.00 0 $529.00 0 $2,235.00 0 $872.00 90 $600.00 0 $854.00 90 $1,193.00 90 BR 90 $446.00 30 BR 0 $447.00 60 $807.00 60 $323.00 15 $185.00 15 $861.00 30 $898.00 60 $708.00 45 $171.00 0 $302.00 0 $247.00 7 $613.00 15 $1,228.00 90 $616.00 60 $583.00 60 $814.00 90 $581.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 23107 23120 23125 23130 23140 23145 23146 23150 23155 23156 23170 23172 23174 23180 23182 23184 23190 23195 23200 23210 23220 23221 23222 23330 23331 23332 23350 23395 23397 23400 23405 23406 23410 23412 23415 23420 23430 23440 23450 23455 23460 23462 23465 23466 23470 23472 23480 23485 23490 23491 MRA FU Days $851.00 90 $645.00 60 $865.00 60 $722.00 60 $597.00 60 $889.00 90 $704.00 90 $755.00 30 $945.00 90 $794.00 90 $645.00 90 $638.00 30 $882.00 90 $566.00 90 $865.00 30 $962.00 30 $656.00 60 $902.00 30 $1,095.00 30 $1,095.00 30 $1,307.00 30 $1,559.00 90 $1,921.00 90 $59.00 60 $520.00 60 $1,029.00 60 $67.00 0 $1,366.00 60 $1,403.00 60 $1,196.00 60 $799.00 60 $977.00 60 $1,119.00 90 $1,229.00 60 $622.00 60 $1,276.00 120 $884.00 90 $906.00 90 $1,210.00 90 $1,340.00 90 $1,364.00 90 $1,383.00 90 $1,398.00 90 $1,332.00 90 $1,540.00 90 $1,570.00 90 $926.00 90 $1,181.00 90 $1,038.00 90 $1,251.00 90 40 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 23500 23505 23515 23520 23525 23530 23532 23540 23545 23550 23552 23570 23575 23585 23600 23605 23615 23616 23620 23625 23630 23650 23655 23660 23665 23670 23675 23680 23700 23800 23802 23900 23920 23921 23929 23930 23931 23935 24000 24006 24065 24066 24075 24076 24077 24100 24101 24102 24105 24110 MRA FU Days $148.00 0 $293.00 90 $688.00 90 $205.00 0 $320.00 90 $659.00 90 $713.00 90 $148.00 0 $148.00 60 $701.00 60 $753.00 90 $88.00 90 $306.00 90 $809.00 90 $318.00 90 $511.00 90 $900.00 90 $1,895.00 90 $286.00 90 $422.00 90 $712.00 90 $296.00 30 $374.00 30 $712.00 90 $440.00 90 $759.00 90 $550.00 90 $1,064.00 90 $237.00 0 $1,346.00 90 $1,368.00 90 $1,561.00 90 $1,300.00 90 $497.00 30 BR 0 $71.00 30 $62.00 0 $630.00 0 $550.00 60 $793.00 60 $166.00 0 $461.00 0 $349.00 21 $529.00 30 $1,058.00 90 $467.00 60 $591.00 60 $755.00 90 $360.00 60 $724.00 60 Surgery CPT Code 24115 24116 24120 24125 24126 24130 24134 24136 24138 24140 24145 24147 24149 24150 24151 24152 24153 24155 24160 24164 24200 24201 24220 24301 24305 24310 24320 24330 24331 24340 24341 24342 24350 24351 24352 24354 24356 24360 24361 24362 24363 24365 24366 24400 24410 24420 24430 24435 24470 24495 MRA FU Days $898.00 90 $1,037.00 90 $595.00 60 $663.00 90 $731.00 90 $595.00 60 $966.00 30 $720.00 30 $697.00 30 $963.00 60 $592.00 30 $703.00 60 $1,224.00 90 $1,265.00 90 $1,383.00 90 $829.00 90 $936.00 90 $1,019.00 60 $533.00 60 $564.00 30 $52.00 30 $444.00 30 $80.00 0 $869.00 30 $579.00 60 $511.00 30 $944.00 90 $845.00 90 $927.00 90 $697.00 90 $702.00 90 $950.00 90 $444.00 30 $522.00 30 $585.00 30 $578.00 30 $634.00 30 $1,125.00 90 $1,215.00 90 $1,269.00 90 $1,663.00 90 $747.00 60 $850.00 60 $991.00 90 $1,319.00 90 $1,265.00 90 $1,209.00 90 $1,260.00 90 $774.00 90 $742.00 60 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 24498 24500 24505 24515 24516 24530 24535 24538 24545 24546 24560 24565 24566 24575 24576 24577 24579 24582 24586 24587 24600 24605 24615 24620 24635 24650 24655 24665 24666 24670 24675 24685 24800 24802 24900 24920 24925 24930 24931 24935 24940 24999 25000 25020 25023 25028 25031 25035 25040 25065 MRA FU Days $1,076.00 90 $288.00 90 $574.00 90 $1,018.00 90 $1,029.00 90 $88.00 90 $671.00 90 $850.00 90 $946.00 90 $1,273.00 90 $266.00 90 $526.00 90 $705.00 90 $872.00 90 $295.00 60 $575.00 60 $964.00 90 $773.00 90 $1,314.00 90 $1,278.00 90 $360.00 60 $371.00 60 $836.00 90 $560.00 90 $1,329.00 90 $262.00 60 $436.00 90 $749.00 90 $905.00 90 $263.00 60 $490.00 90 $819.00 90 $984.00 90 $1,181.00 90 $858.00 90 $851.00 90 $661.00 30 $928.00 90 $1,063.00 90 $1,327.00 90 BR 90 BR 0 $381.00 30 $594.00 30 $1,040.00 30 $417.00 30 $266.00 30 $794.00 60 $654.00 60 $164.00 0 41 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code MRA FU Days 25066 $322.00 0 25075 $352.00 30 25076 $544.00 60 25077 $957.00 90 25085 $562.00 60 25100 $420.00 60 25101 $492.00 60 25105 $635.00 60 25107 $600.00 60 25110 $403.00 30 25111 $356.00 30 25112 $441.00 30 25115 $837.00 60 25116 $807.00 60 25118 $466.00 60 25119 $653.00 60 25120 $712.00 60 25125 $803.00 90 25126 $781.00 90 25130 $502.00 60 25135 $631.00 90 25136 $546.00 90 25145 $713.00 90 25150 $720.00 60 25151 $771.00 60 25170 $1,085.00 60 25210 $561.00 60 25215 $817.00 60 25230 $531.00 60 25240 $567.00 60 25246 $65.00 0 25248 $236.00 60 25250 $616.00 30 25251 $933.00 30 25260 $728.00 60 25263 $809.00 60 25265 $998.00 90 25270 $549.00 60 25272 $613.00 60 25274 $887.00 90 25280 $670.00 60 25290 $436.00 60 25295 $562.00 60 25300 $592.00 90 25301 $757.00 90 25310 $865.00 90 25312 $968.00 90 25315 $1,004.00 90 25316 $1,203.00 90 25320 $834.00 90 Surgery CPT Code 25332 25335 25337 25350 25355 25360 25365 25370 25375 25390 25391 25392 25393 25400 25405 25415 25420 25425 25426 25440 25441 25442 25443 25444 25445 25446 25447 25449 25450 25455 25490 25491 25492 25500 25505 25515 25520 25525 25526 25530 25535 25545 25560 25565 25574 25575 25600 25605 25611 25620 MRA FU Days $1,022.00 90 $1,166.00 90 $946.00 90 $913.00 90 $1,014.00 90 $468.00 90 $1,216.00 90 $1,214.00 90 $1,280.00 90 $1,043.00 90 $1,349.00 90 $1,294.00 90 $1,473.00 90 $1,112.00 90 $1,388.00 90 $1,343.00 90 $1,554.00 90 $1,403.00 90 $1,401.00 90 $931.00 90 $1,147.00 90 $936.00 90 $970.00 90 $1,031.00 90 $959.00 90 $1,542.00 90 $952.00 90 $395.00 90 $805.00 90 $899.00 90 $955.00 90 $1,006.00 90 $1,170.00 90 $200.00 60 $517.00 90 $800.00 90 $644.00 90 $1,097.00 90 $1,293.00 90 $270.00 60 $516.00 90 $803.00 90 $276.00 60 $590.00 60 $804.00 90 $974.00 90 $312.00 60 $540.00 90 $707.00 90 $769.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 25622 25624 25628 25630 25635 25645 25650 25660 25670 25675 25676 25680 25685 25690 25695 25800 25805 25810 25820 25825 25830 25900 25905 25907 25909 25915 25920 25922 25924 25927 25929 25931 25999 26010 26011 26020 26025 26030 26034 26035 26037 26040 26045 26055 26060 26070 26075 26080 26100 26105 MRA FU Days $148.00 60 $482.00 90 $716.00 90 $148.00 60 $458.00 60 $668.00 90 $185.00 90 $378.00 90 $731.00 90 $404.00 60 $741.00 90 $471.00 60 $887.00 90 $518.00 90 $520.00 60 $703.00 90 $1,078.00 90 $1,008.00 90 $2,276.00 90 $895.00 90 $991.00 90 $871.00 90 $900.00 90 $799.00 30 $849.00 90 $1,523.00 60 $771.00 90 $670.00 30 $768.00 90 $830.00 90 $645.00 30 $731.00 90 BR 0 $53.00 0 $223.00 0 $484.00 30 $548.00 30 $655.00 30 $601.00 30 $741.00 60 $730.00 30 $367.00 30 $621.00 60 $343.00 30 $293.00 15 $440.00 30 $400.00 30 $382.00 30 $398.00 30 $481.00 30 42 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code MRA FU Days 26110 $282.00 30 26115 $344.00 30 26116 $544.00 30 26117 $806.00 90 26121 $833.00 90 26123 $959.00 90 26125 $342.00 90 26130 $629.00 90 26135 $668.00 90 26140 $678.00 90 26145 $660.00 90 26160 $319.00 30 26170 $452.00 30 26180 $444.00 30 26185 $511.00 90 26200 $598.00 60 26205 $788.00 90 26210 $543.00 60 26215 $731.00 90 26230 $624.00 60 26235 $612.00 60 26236 $444.00 60 26250 $814.00 90 26255 $1,184.00 90 26260 $758.00 90 26261 $949.00 90 26262 $624.00 90 26320 $414.00 30 26350 $715.00 90 26352 $855.00 90 26356 $886.00 90 26357 $932.00 90 26358 $979.00 90 26370 $832.00 60 26372 $945.00 60 26373 $904.00 90 26390 $889.00 90 26392 $1,123.00 60 26410 $371.00 60 26412 $737.00 60 26415 $846.00 60 26416 $1,093.00 60 26418 $444.00 90 26420 $741.00 90 26426 $733.00 90 26428 $790.00 90 26432 $430.00 30 26433 $371.00 30 26434 $656.00 90 26437 $491.00 60 Surgery CPT Code 26440 26442 26445 26449 26450 26455 26460 26471 26474 26476 26477 26478 26479 26480 26483 26485 26489 26490 26492 26494 26496 26497 26498 26499 26500 26502 26504 26508 26510 26516 26517 26518 26520 26525 26530 26531 26535 26536 26540 26541 26542 26545 26546 26548 26550 26551 26553 26554 26555 26556 MRA FU Days $458.00 60 $548.00 60 $455.00 60 $738.00 60 $353.00 30 $364.00 30 $346.00 30 $592.00 90 $586.00 90 $543.00 90 $553.00 90 $608.00 90 $653.00 90 $808.00 90 $986.00 90 $891.00 90 $738.00 90 $496.00 90 $971.00 90 $946.00 90 $949.00 90 $946.00 90 $1,317.00 90 $934.00 90 $557.00 90 $715.00 90 $761.00 90 $334.00 90 $564.00 90 $630.00 90 $890.00 90 $877.00 90 $583.00 90 $531.00 90 $708.00 90 $877.00 90 $546.00 90 $770.00 90 $726.00 90 $926.00 90 $716.00 90 $722.00 90 $918.00 90 $665.00 90 $1,861.00 90 $3,901.00 90 $3,868.00 90 $4,551.00 90 $1,567.00 90 $4,005.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 26560 26561 26562 26565 26567 26568 26580 26585 26587 26590 26591 26593 26596 26597 26600 26605 26607 26608 26615 26641 26645 26650 26665 26670 26675 26676 26685 26686 26700 26705 26706 26715 26720 26725 26727 26735 26740 26742 26746 26750 26755 26756 26765 26770 26775 26776 26785 26820 26841 26842 MRA FU Days $576.00 45 $1,067.00 45 $1,017.00 90 $730.00 90 $622.00 90 $1,003.00 90 $1,585.00 90 $1,225.00 90 BR 90 $1,609.00 90 $431.00 90 $587.00 90 $809.00 90 $968.00 90 $133.00 60 $296.00 60 $334.00 60 $497.00 60 $521.00 60 $71.00 60 $371.00 45 $533.00 45 $693.00 60 $148.00 30 $501.00 45 $527.00 45 $592.00 60 $710.00 60 $88.00 30 $296.00 45 $469.00 45 $526.00 45 $96.00 45 $187.00 45 $187.00 45 $532.00 60 $148.00 60 $148.00 60 $548.00 60 $96.00 45 $133.00 30 $366.00 60 $398.00 60 $79.00 30 $275.00 45 $401.00 60 $408.00 60 $854.00 90 $756.00 90 $901.00 90 43 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 26843 26844 26850 26852 26860 26861 26862 26863 26910 26951 26952 26989 26990 26991 26992 27000 27001 27003 27005 27006 27025 27030 27033 27035 27036 27040 27041 27047 27048 27049 27050 27052 27054 27060 27062 27065 27066 27067 27070 27071 27075 27076 27077 27078 27079 27080 27086 27087 27090 27091 MRA FU Days $800.00 90 $875.00 90 $704.00 90 $829.00 90 $542.00 90 $151.00 90 $747.00 90 $317.00 90 $747.00 90 $444.00 45 $608.00 45 BR 0 $592.00 30 $466.00 30 $1,146.00 30 $421.00 30 $550.00 30 $698.00 45 $738.00 60 $788.00 60 $896.00 90 $1,148.00 90 $1,173.00 90 $1,413.00 90 $1,176.00 90 $175.00 0 $699.00 0 $535.00 7 $588.00 15 $1,162.00 90 $449.00 90 $624.00 90 $843.00 90 $491.00 60 $499.00 60 $583.00 60 $931.00 90 $1,234.00 90 $1,040.00 60 $1,112.00 60 $1,485.00 60 $1,859.00 90 $1,976.00 90 $1,164.00 90 $1,170.00 90 $568.00 90 $57.00 0 $555.00 30 $981.00 90 $1,482.00 90 Surgery CPT Code 27093 27095 27096 27097 27098 27100 27105 27110 27111 27120 27122 27125 27130 27132 27134 27137 27138 27140 27146 27147 27151 27156 27158 27161 27165 27170 27175 27176 27177 27178 27179 27181 27185 27187 27193 27194 27200 27202 27215 27216 27217 27218 27220 27222 27226 27227 27228 27230 27232 27235 MRA FU Days $62.00 0 $109.00 0 $491.00 0 $795.00 90 $799.00 90 $987.00 90 $946.00 90 $1,174.00 90 $1,099.00 90 $1,603.00 120 $1,406.00 120 $1,371.00 90 $1,853.00 90 $2,128.00 90 $2,576.00 90 $2,190.00 90 $2,025.00 90 $1,092.00 90 $1,432.00 90 $1,744.00 90 $1,732.00 90 $2,017.00 90 $1,588.00 90 $1,443.00 90 $1,572.00 90 $1,453.00 90 $491.00 90 $1,024.00 90 $1,257.00 90 $1,020.00 90 $1,107.00 90 $1,206.00 90 $676.00 90 $1,280.00 120 $425.00 90 $740.00 90 $180.00 60 $776.00 90 $954.00 90 $1,085.00 90 $1,285.00 90 $1,570.00 90 $444.00 90 $973.00 90 $1,350.00 90 $1,967.00 90 $2,195.00 90 $491.00 90 $916.00 90 $1,128.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 27236 27238 27240 27244 27245 27246 27248 27250 27252 27253 27254 27256 27257 27258 27259 27265 27266 27275 27280 27282 27284 27286 27290 27295 27299 27301 27303 27305 27306 27307 27310 27315 27320 27323 27324 27327 27328 27329 27330 27331 27332 27333 27334 27335 27340 27345 27347 27350 27355 27356 MRA FU Days $1,421.00 90 $504.00 90 $1,043.00 90 $1,426.00 90 $1,691.00 90 $459.00 0 $980.00 90 $535.00 60 $520.00 90 $1,162.00 90 $1,478.00 90 $338.00 0 $455.00 0 $1,355.00 90 $1,803.00 90 $442.00 90 $614.00 90 $220.00 0 $1,179.00 90 $990.00 90 $1,435.00 120 $1,503.00 120 $2,073.00 120 $1,594.00 120 BR 0 $193.00 30 $520.00 30 $555.00 45 $377.00 30 $503.00 30 $877.00 90 $570.00 30 $522.00 30 $211.00 0 $433.00 0 $400.00 15 $503.00 15 $1,249.00 90 $492.00 90 $585.00 90 $786.00 90 $719.00 90 $840.00 90 $959.00 90 $405.00 60 $565.00 60 $394.00 90 $786.00 60 $763.00 60 $882.00 90 44 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 27357 27358 27360 27365 27370 27372 27380 27381 27385 27386 27390 27391 27392 27393 27394 27395 27396 27397 27400 27403 27405 27407 27409 27418 27420 27422 27424 27425 27427 27428 27429 27430 27435 27437 27438 27440 27441 27442 27443 27445 27446 27447 27448 27450 27454 27455 27457 27465 27466 27468 MRA FU Days $950.00 90 $394.00 90 $977.00 90 $1,421.00 90 $68.00 0 $371.00 30 $698.00 90 $1,118.00 90 $753.00 90 $1,064.00 90 $506.00 30 $647.00 45 $834.00 45 $608.00 30 $748.00 30 $1,093.00 30 $742.00 90 $989.00 90 $832.00 90 $792.00 90 $842.00 90 $918.00 90 $1,212.00 90 $1,596.00 90 $927.00 90 $930.00 90 $927.00 90 $639.00 90 $1,118.00 90 $1,266.00 90 $2,333.00 90 $884.00 90 $501.00 90 $819.00 90 $1,065.00 90 $1,064.00 90 $1,006.00 90 $1,117.00 90 $1,037.00 90 $1,618.00 90 $1,764.00 90 $1,960.00 120 $1,060.00 90 $1,311.00 90 $1,524.00 90 $1,157.00 90 $1,209.00 90 $1,253.00 90 $1,441.00 90 $1,613.00 90 Surgery CPT Code 27470 27472 27475 27477 27479 27485 27486 27487 27488 27495 27496 27497 27498 27499 27500 27501 27502 27503 27506 27507 27508 27509 27510 27511 27513 27514 27516 27517 27519 27520 27524 27530 27532 27535 27536 27538 27540 27550 27552 27556 27557 27558 27560 27562 27566 27570 27580 27590 27591 27592 MRA FU Days $1,501.00 90 $1,665.00 90 $782.00 90 $938.00 90 $1,123.00 90 $797.00 90 $1,771.00 90 $2,352.00 90 $1,438.00 90 $1,477.00 90 $563.00 90 $652.00 90 $701.00 90 $782.00 90 $520.00 90 $659.00 90 $909.00 90 $911.00 90 $1,522.00 90 $1,297.00 90 $400.00 90 $649.00 90 $755.00 90 $1,281.00 90 $1,562.00 90 $1,508.00 90 $579.00 90 $820.00 90 $1,311.00 90 $266.00 60 $910.00 90 $408.00 90 $641.00 90 $1,075.00 90 $1,282.00 90 $487.00 90 $1,106.00 90 $296.00 45 $619.00 45 $832.00 90 $1,479.00 90 $1,529.00 90 $88.00 45 $514.00 45 $1,047.00 90 $184.00 0 $1,644.00 90 $1,059.00 90 $1,182.00 90 $911.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 27594 27596 27598 27599 27600 27601 27602 27603 27604 27605 27606 27607 27610 27612 27613 27614 27615 27618 27619 27620 27625 27626 27630 27635 27637 27638 27640 27641 27645 27646 27647 27648 27650 27652 27654 27656 27658 27659 27664 27665 27675 27676 27680 27681 27685 27686 27687 27690 27691 27692 MRA FU Days $600.00 90 $931.00 90 $976.00 120 BR 0 $517.00 30 $516.00 30 $621.00 30 $412.00 60 $308.00 30 $236.00 0 $362.00 30 $608.00 30 $777.00 60 $701.00 60 $165.00 0 $327.00 0 $1,106.00 90 $421.00 21 $730.00 30 $587.00 60 $796.00 90 $863.00 90 $430.00 45 $781.00 60 $921.00 90 $978.00 90 $1,122.00 90 $922.00 90 $1,302.00 90 $1,212.00 90 $1,044.00 90 $65.00 0 $869.00 90 $935.00 90 $937.00 90 $458.00 45 $527.00 90 $725.00 90 $504.00 90 $618.00 90 $656.00 30 $762.00 60 $523.00 60 $634.00 60 $565.00 90 $706.00 90 $589.00 90 $757.00 90 $889.00 90 $159.00 90 45 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 27695 27696 27698 27700 27702 27703 27704 27705 27707 27709 27712 27715 27720 27722 27724 27725 27727 27730 27732 27734 27740 27742 27745 27750 27752 27756 27758 27759 27760 27762 27766 27780 27781 27784 27786 27788 27792 27808 27810 27814 27816 27818 27822 27823 27824 27825 27826 27827 27828 27829 MRA FU Days $658.00 90 $758.00 90 $881.00 90 $835.00 90 $1,278.00 120 $1,337.00 90 $683.00 30 $985.00 90 $484.00 90 $1,118.00 90 $1,227.00 90 $1,285.00 90 $1,147.00 90 $1,076.00 90 $1,402.00 90 $1,312.00 90 $1,175.00 90 $647.00 90 $611.00 90 $766.00 90 $1,044.00 90 $1,045.00 90 $940.00 90 $319.00 90 $614.00 90 $708.00 90 $1,115.00 90 $1,262.00 90 $223.00 90 $495.00 90 $759.00 90 $244.00 90 $296.00 90 $643.00 90 $223.00 90 $422.00 90 $706.00 90 $332.00 90 $567.00 90 $972.00 90 $386.00 90 $613.00 90 $1,201.00 90 $1,472.00 90 $384.00 90 $670.00 90 $1,080.00 90 $1,310.00 90 $1,823.00 90 $742.00 90 Surgery CPT Code 27830 27831 27832 27840 27842 27846 27848 27860 27870 27871 27880 27881 27882 27884 27886 27888 27889 27892 27893 27894 27899 28001 28002 28003 28005 28008 28010 28011 28020 28022 28024 28030 28035 28043 28045 28046 28050 28052 28054 28060 28062 28070 28072 28080 28086 28088 28090 28092 28100 28102 MRA FU Days $412.00 90 $415.00 30 $617.00 90 $334.00 45 $373.00 45 $877.00 90 $1,224.00 90 $211.00 0 $1,269.00 120 $843.00 120 $1,015.00 90 $1,120.00 90 $854.00 90 $579.00 45 $835.00 45 $911.00 90 $879.00 90 $575.00 90 $574.00 90 $712.00 90 BR 0 $185.00 0 $362.00 0 $520.00 21 $520.00 45 $296.00 60 $235.00 30 $340.00 30 $509.00 60 $422.00 60 $371.00 60 $453.00 60 $532.00 30 $305.00 21 $456.00 21 $814.00 180 $414.00 60 $402.00 60 $236.00 60 $495.00 60 $657.00 90 $476.00 90 $445.00 90 $392.00 30 $462.00 60 $414.00 60 $414.00 45 $330.00 30 $571.00 60 $700.00 120 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code MRA FU Days 28103 $709.00 120 28104 $491.00 60 28106 $632.00 120 28107 $517.00 120 28108 $418.00 60 28110 $421.00 60 28111 $537.00 30 28112 $457.00 60 28113 $481.00 30 28114 $890.00 60 28116 $648.00 60 28118 $568.00 60 28119 $524.00 60 28120 $601.00 60 28122 $622.00 60 28124 $480.00 60 28126 $393.00 60 28130 $727.00 90 28140 $533.00 60 28150 $416.00 30 28153 $400.00 30 28160 $412.00 30 28171 $789.00 90 28173 $747.00 90 28175 $571.00 90 28190 $75.00 0 28192 $326.00 30 28193 $341.00 30 28200 $478.00 90 28202 $613.00 90 28208 $406.00 90 28210 $609.00 90 28220 $435.00 60 28222 $555.00 60 28225 $345.00 60 28226 $334.00 60 28230 $380.00 30 28232 $286.00 30 28234 $178.00 30 28238 $695.00 60 28240 $370.00 60 28250 $535.00 60 28260 $641.00 60 28261 $881.00 60 28262 $1,363.00 90 28264 $912.00 90 28270 $266.00 60 28272 $336.00 60 28280 $426.00 45 28285 $463.00 60 46 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 28286 28288 28289 28290 28292 28293 28294 28296 28297 28298 28299 28300 28302 28304 28305 28306 28307 28308 28309 28310 28312 28313 28315 28320 28322 28340 28341 28344 28345 28360 28400 28405 28406 28415 28420 28430 28435 28436 28445 28450 28455 28456 28465 28470 28475 28476 28485 28490 28495 28496 MRA FU Days $441.00 60 $452.00 60 $458.00 90 $557.00 90 $666.00 90 $845.00 90 $797.00 90 $832.00 90 $838.00 90 $755.00 90 $829.00 90 $845.00 90 $930.00 90 $776.00 90 $1,030.00 90 $530.00 90 $614.00 90 $516.00 90 $955.00 60 $505.00 90 $469.00 90 $436.00 90 $462.00 90 $833.00 120 $667.00 120 $649.00 90 $753.00 90 $414.00 90 $557.00 90 $1,197.00 90 $266.00 90 $473.00 90 $616.00 90 $1,354.00 90 $1,619.00 90 $110.00 90 $371.00 90 $463.00 90 $874.00 90 $148.00 90 $321.00 90 $288.00 90 $533.00 90 $178.00 60 $296.00 60 $364.00 60 $521.00 90 $80.00 30 $133.00 30 $261.00 30 Surgery CPT Code MRA FU Days 28505 $399.00 60 28510 $75.00 30 28515 $115.00 30 28525 $345.00 60 28530 $120.00 60 28531 $243.00 60 28540 $145.00 45 28545 $208.00 45 28546 $325.00 45 28555 $592.00 90 28570 $189.00 45 28575 $308.00 45 28576 $382.00 45 28585 $742.00 90 28600 $144.00 45 28605 $287.00 45 28606 $487.00 45 28615 $621.00 90 28630 $145.00 7 28635 $189.00 0 28636 $318.00 7 28645 $434.00 90 28660 $106.00 0 28665 $172.00 0 28666 $309.00 45 28675 $348.00 60 28705 $1,353.00 120 28715 $1,179.00 120 28725 $1,015.00 120 28730 $945.00 120 28735 $961.00 120 28737 $873.00 120 28740 $690.00 120 28750 $690.00 120 28755 $466.00 120 28760 $654.00 120 28800 $731.00 90 28805 $731.00 90 28810 $543.00 90 28820 $377.00 45 28825 $339.00 45 28899 BR 0 29000 $247.00 2 29010 $271.00 2 29015 $289.00 2 29020 $237.00 2 29025 $188.00 2 29035 $213.00 2 29040 $260.00 2 29044 $260.00 2 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 29046 29049 29055 29058 29065 29075 29085 29105 29125 29126 29130 29131 29200 29220 29240 29260 29280 29305 29325 29345 29355 29358 29365 29405 29425 29435 29440 29445 29450 29505 29515 29520 29530 29540 29550 29580 29590 29700 29705 29710 29715 29720 29730 29740 29750 29799 29800 29804 29815 29819 MRA $286.00 $45.00 $180.00 $110.00 $88.00 $72.00 $59.00 $59.00 $45.00 $53.00 $26.00 $53.00 $26.00 $37.00 $45.00 $26.00 $29.00 $223.00 $260.00 $126.00 $133.00 $241.00 $101.00 $96.00 $101.00 $133.00 $22.00 $214.00 $84.00 $75.00 $59.00 $22.00 $55.00 $41.00 $37.00 $39.00 $32.00 $29.00 $26.00 $29.00 $109.00 $29.00 $29.00 $37.00 $105.00 BR $557.00 $902.00 $546.00 $756.00 FU Days 2 2 2 2 2 2 2 2 2 2 2 2 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 60 0 60 47 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 29820 29821 29822 29823 29825 29826 29830 29834 29835 29836 29837 29838 29840 29843 29844 29845 29846 29847 29848 29850 29851 29855 29856 29860 29861 29862 29863 29870 29871 29874 29875 29876 29877 29879 29880 29881 29882 29883 29884 29885 29886 29887 29888 29889 29891 29892 29893 29894 29895 29897 MRA FU Days $718.00 60 $863.00 60 $749.00 60 $1,330.00 60 $941.00 60 $980.00 60 $524.00 0 $635.00 60 $612.00 60 $680.00 60 $830.00 60 $931.00 60 $501.00 0 $580.00 60 $612.00 60 $931.00 60 $976.00 60 $1,277.00 60 $608.00 90 $752.00 90 $1,137.00 90 $1,007.00 90 $1,231.00 90 $658.00 0 $845.00 90 $907.00 90 $880.00 90 $460.00 0 $631.00 60 $676.00 60 $639.00 60 $809.00 60 $852.00 60 $1,064.00 60 $1,169.00 60 $745.00 60 $819.00 60 $1,235.00 60 $721.00 60 $832.00 60 $697.00 60 $949.00 60 $1,296.00 60 $1,255.00 60 $796.00 90 $835.00 90 $472.00 90 $690.00 60 $679.00 60 $704.00 60 Surgery CPT Code 29898 29909 30000 30020 30100 30110 30115 30117 30118 30120 30124 30125 30130 30140 30150 30160 30200 30210 30220 30300 30310 30320 30400 30410 30420 30430 30435 30450 30460 30462 30520 30540 30545 30560 30580 30600 30620 30630 30801 30802 30901 30903 30905 30906 30915 30920 30930 30999 31000 31002 MRA FU Days $863.00 60 BR 0 $96.00 0 $117.00 0 $86.00 0 $157.00 7 $360.00 15 $301.00 7 $819.00 30 $500.00 60 $243.00 30 $599.00 30 $275.00 30 $320.00 90 $790.00 90 $875.00 90 $68.00 0 $75.00 0 $154.00 30 $45.00 0 $170.00 7 $419.00 30 $741.00 90 $1,173.00 90 $1,424.00 90 $626.00 45 $1,005.00 45 $1,445.00 45 $857.00 45 $1,633.00 45 $533.00 90 $643.00 60 $981.00 60 $104.00 7 $566.00 90 $466.00 90 $564.00 90 $624.00 90 $88.00 0 $172.00 15 $75.00 0 $110.00 0 $224.00 0 $208.00 0 $596.00 30 $862.00 30 $213.00 30 BR 0 $81.00 0 $135.00 0 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 31020 31030 31032 31040 31050 31051 31070 31075 31080 31081 31084 31085 31086 31087 31090 31200 31201 31205 31225 31230 31231 31233 31235 31237 31238 31239 31240 31254 31255 31256 31267 31276 31287 31288 31290 31291 31292 31293 31294 31299 31300 31320 31360 31365 31367 31368 31370 31375 31380 31382 MRA FU Days $281.00 90 $531.00 90 $604.00 90 $772.00 90 $489.00 90 $654.00 90 $410.00 90 $839.00 120 $942.00 120 $1,089.00 120 $1,210.00 120 $1,281.00 120 $1,081.00 90 $1,075.00 90 $877.00 120 $463.00 90 $716.00 90 $851.00 90 $1,683.00 120 $1,908.00 120 $122.00 0 $221.00 0 $217.00 0 $266.00 0 $311.00 0 $775.00 15 $224.00 0 $588.00 0 $601.00 0 $292.00 0 $453.00 0 $690.00 0 $339.00 0 $396.00 0 $1,462.00 15 $1,551.00 15 $1,235.00 15 $1,346.00 15 $1,587.00 15 BR 90 $1,295.00 90 $508.00 60 $1,630.00 120 $2,238.00 120 $1,913.00 90 $2,478.00 90 $1,891.00 120 $1,720.00 120 $1,782.00 120 $1,822.00 120 48 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 31390 31395 31400 31420 31500 31502 31505 31510 31511 31512 31513 31515 31520 31525 31526 31527 31528 31529 31530 31531 31535 31536 31540 31541 31560 31561 31570 31571 31575 31576 31577 31578 31579 31580 31582 31584 31585 31586 31587 31588 31590 31595 31599 31600 31601 31603 31605 31610 31611 31612 MRA FU Days $2,513.00 90 $2,937.00 90 $969.00 120 $969.00 90 $112.00 0 $74.00 0 $62.00 0 $145.00 14 $88.00 14 $197.00 14 $182.00 14 $160.00 14 $189.00 0 $234.00 0 $222.00 0 $262.00 30 $202.00 14 $217.00 14 $284.00 30 $311.00 30 $272.00 30 $308.00 30 $357.00 30 $453.00 30 $446.00 60 $509.00 60 $369.00 30 $363.00 60 $128.00 0 $186.00 14 $230.00 30 $264.00 30 $219.00 14 $1,213.00 90 $1,881.00 90 $1,616.00 90 $474.00 0 $778.00 0 $913.00 90 $1,206.00 90 $691.00 120 $773.00 120 BR 0 $306.00 14 $379.00 14 $343.00 14 $297.00 14 $794.00 14 $614.00 14 $99.00 0 Surgery CPT Code 31613 31614 31615 31622 31623 31624 31625 31628 31629 31630 31631 31635 31640 31641 31643 31645 31646 31656 31700 31708 31710 31715 31717 31720 31725 31730 31750 31755 31760 31766 31770 31775 31780 31781 31785 31786 31800 31805 31820 31825 31830 31899 32000 32002 32005 32020 32035 32036 32095 32100 MRA FU Days $384.00 60 $736.00 60 $213.00 0 $205.00 0 $210.00 0 $203.00 0 $231.00 14 $260.00 14 $198.00 14 $308.00 14 $252.00 14 $298.00 14 $399.00 14 $304.00 30 $208.00 0 $208.00 0 $161.00 0 $127.00 0 $102.00 0 $69.00 0 $67.00 0 $51.00 0 $124.00 0 $80.00 0 $103.00 0 $183.00 0 $1,088.00 90 $1,448.00 90 $1,648.00 90 $2,315.00 90 $1,815.00 90 $1,973.00 90 $1,577.00 90 $1,936.00 90 $1,320.00 90 $1,866.00 90 $628.00 30 $1,175.00 30 $458.00 0 $659.00 0 $460.00 0 BR 0 $122.00 0 $111.00 0 $147.00 0 $286.00 0 $821.00 90 $908.00 90 $848.00 90 $1,120.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 32110 32120 32124 32140 32141 32150 32151 32160 32200 32201 32215 32220 32225 32310 32320 32400 32402 32405 32420 32440 32442 32445 32480 32482 32484 32486 32488 32491 32500 32501 32520 32522 32525 32540 32601 32602 32603 32604 32605 32606 32650 32651 32652 32653 32654 32655 32656 32657 32658 32659 MRA FU Days $1,223.00 90 $1,077.00 90 $1,144.00 90 $1,284.00 90 $1,267.00 90 $1,226.00 90 $1,231.00 90 $842.00 90 $1,132.00 90 $387.00 10 $1,024.00 90 $1,680.00 90 $1,268.00 90 $1,221.00 90 $1,787.00 90 $115.00 0 $798.00 0 $142.00 0 $113.00 0 $1,837.00 90 $2,093.00 90 $2,093.00 90 $1,622.00 90 $1,714.00 90 $1,771.00 90 $1,974.00 90 $2,094.00 90 $1,784.00 90 $1,331.00 90 $374.00 0 $1,935.00 90 $2,102.00 90 $2,264.00 90 $1,308.00 90 $456.00 0 $494.00 15 $585.00 15 $663.00 15 $550.00 15 $637.00 15 $957.00 15 $1,166.00 15 $1,615.00 15 $1,144.00 15 $1,096.00 15 $1,213.00 15 $1,222.00 15 $1,261.00 15 $1,142.00 15 $1,141.00 15 49 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 32660 32661 32662 32663 32664 32665 32800 32810 32815 32820 32851 32852 32853 32854 32900 32905 32906 32940 32960 32997 32999 33010 33011 33015 33020 33025 33030 33031 33050 33120 33130 33140 33200 33201 33206 33207 33208 33210 33211 33212 33213 33214 33216 33217 33218 33220 33222 33223 33233 33234 MRA FU Days $1,691.00 15 $1,165.00 15 $1,459.00 15 $1,636.00 15 $1,197.00 15 $1,360.00 15 $1,166.00 30 $1,085.00 60 $1,917.00 60 $1,848.00 60 $3,100.00 90 $3,339.00 90 $3,787.00 90 $4,038.00 90 $1,532.00 90 $1,661.00 90 $2,100.00 90 $1,555.00 90 $113.00 0 $292.00 0 BR 90 $124.00 0 $116.00 0 $555.00 10 $1,178.00 90 $1,165.00 90 $1,786.00 90 $1,816.00 90 $1,224.00 90 $2,358.00 90 $1,734.00 90 $1,571.00 90 $1,170.00 90 $1,052.00 90 $642.00 90 $753.00 90 $573.00 90 $204.00 7 $210.00 7 $511.00 7 $420.00 7 $489.00 15 $380.00 15 $396.00 15 $488.00 15 $370.00 15 $471.00 15 $585.00 15 $241.00 15 $598.00 15 Surgery CPT Code 33235 33236 33237 33238 33240 33241 33243 33244 33245 33246 33249 33250 33251 33253 33261 33282 33284 33300 33305 33310 33315 33320 33321 33322 33330 33332 33335 33400 33401 33403 33404 33405 33406 33410 33411 33412 33413 33414 33415 33416 33417 33420 33422 33425 33426 33427 33430 33460 33463 33464 MRA FU Days $523.00 15 $933.00 90 $1,184.00 90 $1,235.00 90 $648.00 15 $301.00 15 $1,650.00 90 $1,081.00 15 $1,400.00 15 $1,888.00 90 $1,271.00 90 $1,687.00 90 $2,071.00 90 $2,563.00 90 $1,993.00 90 $470.00 90 $365.00 90 $1,576.00 90 $1,889.00 90 $1,577.00 90 $1,875.00 90 $1,485.00 90 $1,890.00 90 $1,935.00 90 $1,726.00 90 $1,915.00 90 $2,336.00 90 $2,401.00 90 $2,228.00 90 $2,369.00 90 $2,698.00 90 $2,745.00 90 $2,962.00 90 $2,637.00 90 $2,981.00 90 $3,213.00 90 $3,282.00 90 $2,904.00 90 $2,563.00 90 $2,684.00 90 $2,756.00 90 $1,796.00 90 $2,431.00 90 $2,509.00 90 $2,806.00 90 $3,026.00 90 $2,891.00 90 $2,215.00 90 $2,396.00 90 $2,547.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 33465 33468 33470 33471 33472 33474 33475 33476 33478 33496 33500 33501 33502 33503 33504 33505 33506 33510 33511 33512 33513 33514 33516 33517 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33545 33572 33600 33602 33606 33608 33610 33611 33612 33615 33617 33619 33641 33645 33647 MRA FU Days $2,665.00 90 $2,952.00 90 $1,749.00 90 $1,929.00 90 $2,001.00 90 $2,173.00 90 $2,666.00 90 $2,270.00 90 $2,544.00 90 $2,595.00 90 $2,370.00 90 $1,546.00 90 $1,938.00 90 $1,983.00 90 $2,416.00 90 $2,423.00 90 $2,448.00 90 $2,354.00 90 $2,546.00 90 $2,732.00 90 $2,933.00 90 $3,197.00 90 $3,404.00 90 $219.00 0 $414.00 0 $607.00 0 $801.00 0 $994.00 0 $1,189.00 0 $521.00 0 $2,415.00 90 $2,654.00 90 $2,899.00 90 $3,143.00 90 $2,693.00 90 $3,250.00 90 $340.00 0 $2,644.00 90 $2,556.00 90 $2,831.00 90 $2,940.00 90 $2,871.00 90 $2,985.00 90 $3,152.00 90 $3,051.00 90 $3,272.00 90 $3,678.00 90 $1,981.00 90 $2,352.00 90 $2,732.00 90 50 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 33660 33665 33670 33681 33684 33688 33690 33692 33694 33697 33702 33710 33720 33722 33730 33732 33735 33736 33737 33750 33755 33762 33764 33766 33767 33770 33771 33774 33775 33776 33777 33778 33779 33780 33781 33786 33788 33800 33802 33803 33813 33814 33820 33822 33824 33840 33845 33851 33852 33853 MRA FU Days $2,444.00 90 $2,700.00 90 $2,820.00 90 $2,657.00 90 $2,740.00 90 $2,602.00 90 $1,884.00 90 $2,816.00 90 $2,856.00 90 $3,064.00 90 $2,549.00 90 $2,731.00 90 $2,508.00 90 $2,704.00 90 $2,785.00 90 $2,622.00 90 $2,036.00 90 $2,288.00 90 $1,977.00 90 $1,877.00 90 $1,831.00 90 $1,900.00 90 $1,895.00 90 $2,119.00 90 $2,173.00 90 $2,954.00 90 $2,924.00 90 $2,681.00 90 $2,654.00 90 $2,844.00 90 $2,724.00 90 $3,199.00 90 $3,121.00 90 $3,232.00 90 $3,057.00 90 $2,970.00 90 $2,288.00 90 $1,546.00 90 $1,752.00 90 $1,746.00 90 $1,935.00 90 $2,464.00 90 $1,619.00 90 $1,559.00 90 $1,884.00 90 $2,029.00 90 $2,129.00 90 $2,129.00 90 $2,311.00 90 $3,057.00 90 Surgery CPT Code 33860 33861 33863 33870 33875 33877 33910 33915 33916 33917 33918 33919 33920 33922 33924 33935 33945 33960 33961 33968 33970 33971 33973 33974 33975 33976 33977 33978 33999 34001 34051 34101 34111 34151 34201 34203 34401 34421 34451 34471 34490 34501 34502 34510 34520 34530 35001 35002 35005 35011 MRA FU Days $3,044.00 90 $3,069.00 90 $3,183.00 90 $3,638.00 90 $2,876.00 90 $3,767.00 90 $1,987.00 90 $1,588.00 90 $2,096.00 90 $2,345.00 90 $2,349.00 90 $2,873.00 90 $2,981.00 90 $2,227.00 90 $421.00 0 $5,415.00 0 $3,813.00 0 $1,221.00 0 $800.00 0 $51.00 0 $576.00 15 $578.00 15 $756.00 15 $1,095.00 15 $1,758.00 15 $2,056.00 15 $1,561.00 15 $1,754.00 15 BR 0 $1,012.00 60 $1,134.00 60 $800.00 60 $669.00 60 $1,288.00 60 $777.00 60 $949.00 60 $953.00 90 $779.00 90 $1,117.00 90 $685.00 90 $660.00 90 $910.00 90 $2,044.00 90 $1,108.00 90 $1,077.00 90 $1,368.00 90 $1,564.00 90 $1,547.00 90 $1,268.00 90 $1,007.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 35013 35021 35022 35045 35081 35082 35091 35092 35102 35103 35111 35112 35121 35122 35131 35132 35141 35142 35151 35152 35161 35162 35180 35182 35184 35188 35189 35190 35201 35206 35207 35211 35216 35221 35226 35231 35236 35241 35246 35251 35256 35261 35266 35271 35276 35281 35286 35301 35311 35321 MRA FU Days $1,376.00 90 $1,635.00 90 $1,686.00 90 $995.00 90 $2,175.00 90 $2,661.00 90 $2,634.00 90 $2,872.00 90 $2,346.00 90 $2,587.00 90 $1,398.00 90 $1,351.00 90 $2,000.00 90 $2,382.00 90 $1,495.00 90 $1,742.00 90 $1,231.00 90 $1,339.00 90 $1,390.00 90 $1,229.00 90 $1,516.00 90 $1,633.00 90 $997.00 90 $1,345.00 90 $976.00 90 $1,048.00 90 $1,380.00 90 $1,018.00 90 $852.00 60 $835.00 60 $935.00 60 $1,833.00 90 $1,494.00 90 $1,243.00 90 $841.00 90 $1,053.00 90 $947.00 90 $1,926.00 90 $1,701.00 90 $1,260.00 90 $1,568.00 90 $1,008.00 90 $921.00 90 $1,814.00 90 $1,541.00 90 $1,396.00 90 $1,036.00 90 $1,486.00 60 $1,999.00 90 $1,031.00 60 51 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 35331 35341 35351 35355 35361 35363 35371 35372 35381 35390 35400 35450 35452 35454 35456 35458 35459 35460 35470 35471 35472 35473 35474 35475 35476 35480 35481 35482 35483 35484 35485 35490 35491 35492 35493 35494 35495 35500 35501 35506 35507 35508 35509 35511 35515 35516 35518 35521 35526 35531 MRA FU Days $1,724.00 90 $1,908.00 90 $1,555.00 90 $1,336.00 90 $1,859.00 90 $2,006.00 90 $1,006.00 90 $1,085.00 90 $1,278.00 90 $225.00 0 $224.00 0 $643.00 90 $518.00 90 $520.00 90 $631.00 90 $804.00 90 $736.00 90 $430.00 90 $537.00 90 $626.00 90 $360.00 90 $375.00 90 $456.00 90 $569.00 90 $303.00 90 $935.00 90 $565.00 90 $577.00 90 $696.00 90 $853.00 90 $670.00 90 $691.00 90 $406.00 90 $423.00 90 $523.00 90 $605.00 90 $507.00 90 $423.00 0 $1,569.00 90 $1,641.00 90 $1,606.00 90 $1,564.00 90 $1,529.00 90 $1,256.00 90 $1,387.00 90 $1,391.00 90 $1,313.00 90 $1,393.00 90 $1,527.00 90 $2,000.00 90 Surgery CPT Code 35533 35536 35541 35546 35548 35549 35551 35556 35558 35560 35563 35565 35566 35571 35582 35583 35585 35587 35601 35606 35612 35616 35621 35623 35626 35631 35636 35641 35642 35645 35646 35650 35651 35654 35656 35661 35663 35665 35666 35671 35681 35682 35683 35691 35693 35694 35695 35700 35701 35721 MRA FU Days $1,716.00 90 $1,888.00 90 $2,005.00 90 $2,022.00 90 $1,751.00 90 $1,902.00 90 $2,036.00 90 $1,745.00 90 $1,219.00 90 $1,899.00 90 $1,115.00 90 $1,312.00 90 $2,161.00 90 $1,612.00 90 $2,166.00 90 $1,843.00 90 $2,277.00 90 $1,698.00 90 $1,495.00 90 $1,539.00 90 $1,349.00 90 $1,346.00 90 $1,265.00 90 $1,193.00 90 $1,921.00 90 $1,891.00 90 $1,656.00 90 $1,966.00 90 $1,298.00 90 $1,304.00 90 $2,105.00 90 $1,236.00 90 $2,055.00 90 $1,603.00 90 $1,589.00 90 $1,145.00 90 $1,237.00 90 $1,333.00 90 $1,686.00 90 $1,315.00 90 $751.00 0 $627.00 0 $702.00 0 $1,546.00 90 $1,140.00 90 $1,353.00 90 $1,351.00 90 $264.00 0 $494.00 90 $500.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 35741 35761 35800 35820 35840 35860 35870 35875 35876 35879 35881 35901 35903 35905 35907 36000 36005 36010 36011 36012 36013 36014 36015 36100 36120 36140 36145 36160 36200 36215 36216 36217 36218 36245 36246 36247 36248 36260 36261 36262 36299 36410 36415 36425 36430 36455 36468 36469 36470 36471 MRA FU Days $499.00 90 $532.00 90 $567.00 90 $951.00 90 $771.00 90 $496.00 90 $1,583.00 90 $827.00 90 $1,232.00 90 $1,163.00 90 $1,275.00 90 $709.00 90 $818.00 90 $1,343.00 90 $1,335.00 90 $46.00 0 $62.00 0 $136.00 0 $194.00 0 $186.00 0 $141.00 0 $159.00 0 $186.00 0 $176.00 0 $120.00 0 $106.00 0 $10.00 0 $196.00 0 $240.00 0 $237.00 0 $267.00 0 $322.00 0 $79.00 0 $249.00 0 $272.00 0 $321.00 0 $53.00 0 $749.00 45 $388.00 45 $297.00 45 BR 0 $17.00 0 BR 0 $80.00 0 $36.00 0 $141.00 0 NC 0 NC 0 $76.00 0 $96.00 0 52 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 36481 36489 36490 36491 36493 36500 36510 36520 36521 36522 36530 36531 36532 36533 36534 36535 36550 36600 36620 36625 36640 36680 36800 36810 36815 36819 36821 36822 36823 36825 36830 36831 36832 36833 36834 36835 36860 36861 37140 37145 37160 37180 37181 37195 37200 37201 37202 37203 37204 37205 MRA FU Days $499.00 0 $120.00 0 $93.00 0 $87.00 0 $59.00 0 $142.00 0 $51.00 0 $106.00 0 $82.00 0 $305.00 0 $493.00 15 $412.00 15 $237.00 15 $448.00 15 $235.00 15 $213.00 15 $37.00 0 $23.00 0 $64.00 0 $133.00 0 $130.00 0 $72.00 7 $153.00 7 $345.00 14 $236.00 14 $977.00 30 $721.00 30 $630.00 30 $1,461.00 30 $867.00 30 $967.00 30 $488.00 30 $810.00 30 $780.00 30 $761.00 30 $542.00 30 $149.00 0 $224.00 0 $1,666.00 90 $1,741.00 90 $1,681.00 90 $1,769.00 90 $1,923.00 90 $284.00 0 $209.00 0 $408.00 0 $339.00 0 $278.00 0 $957.00 0 $589.00 0 Surgery CPT Code 37206 37207 37208 37209 37250 37251 37565 37600 37605 37606 37607 37609 37615 37616 37617 37618 37620 37650 37660 37700 37720 37730 37735 37760 37780 37785 37788 37790 37799 38100 38101 38102 38115 38120 38129 38200 38230 38231 38240 38241 38300 38305 38308 38380 38381 38382 38500 38505 38510 38520 MRA FU Days $288.00 0 $613.00 0 $299.00 0 $106.00 0 $112.00 0 $85.00 0 $364.00 30 $414.00 30 $521.00 30 $563.00 60 $456.00 30 $278.00 0 $495.00 30 $1,128.00 60 $1,132.00 60 $514.00 30 $818.00 90 $430.00 30 $789.00 90 $336.00 30 $480.00 30 $624.00 30 $847.00 60 $813.00 120 $301.00 30 $270.00 30 $1,654.00 90 $690.00 90 BR 0 $974.00 45 $982.00 45 $332.00 0 $1,020.00 45 $1,138.00 15 BR 15 $180.00 0 $246.00 30 $86.00 0 $128.00 30 $128.00 30 $104.00 0 $375.00 30 $425.00 30 $628.00 45 $1,087.00 60 $798.00 60 $234.00 0 $139.00 0 $349.00 0 $431.00 0 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 38525 38530 38542 38550 38555 38562 38564 38570 38571 38572 38589 38700 38720 38724 38740 38745 38746 38747 38760 38765 38770 38780 38790 38792 38794 38999 39000 39010 39200 39220 39400 39499 39501 39502 39503 39520 39530 39531 39540 39541 39545 39560 39561 39599 40490 40500 40510 40520 40525 40527 MRA FU Days $369.00 0 $517.00 0 $507.00 60 $519.00 60 $1,115.00 60 $799.00 60 $831.00 60 $695.00 15 $902.00 15 $1,049.00 15 BR 15 $863.00 60 $1,328.00 60 $1,366.00 60 $539.00 60 $770.00 60 $312.00 0 $337.00 0 $699.00 60 $1,283.00 60 $1,111.00 60 $1,357.00 60 $141.00 0 $24.00 0 $298.00 0 BR 0 $664.00 0 $1,148.00 90 $1,249.00 90 $1,542.00 90 $614.00 0 BR 0 $1,083.00 90 $1,268.00 90 $2,726.00 90 $1,345.00 90 $1,295.00 90 $1,243.00 90 $1,133.00 90 $1,179.00 90 $1,102.00 90 $968.00 90 $1,328.00 90 BR 0 $108.00 0 $422.00 30 $469.00 30 $467.00 30 $714.00 30 $851.00 90 53 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 40530 40650 40652 40654 40700 40701 40702 40720 40761 40799 40800 40801 40804 40805 40806 40808 40810 40812 40814 40816 40818 40819 40820 40830 40831 40840 40842 40843 40844 40845 40899 41000 41005 41006 41007 41008 41009 41010 41015 41016 41017 41018 41100 41105 41108 41110 41112 41113 41114 41115 MRA FU Days $501.00 30 $368.00 30 $436.00 30 $529.00 30 $1,009.00 90 $1,452.00 90 $1,030.00 90 $1,107.00 90 $1,202.00 90 BR 0 $110.00 0 $208.00 0 $105.00 0 $245.00 0 $38.00 0 $100.00 0 $141.00 0 $202.00 30 $319.00 30 $336.00 60 $249.00 60 $208.00 0 $104.00 0 $140.00 7 $213.00 30 $687.00 90 $684.00 90 $947.00 90 $1,232.00 90 $1,593.00 120 BR 0 $119.00 0 $109.00 0 $237.00 0 $283.00 0 $248.00 0 $319.00 0 $91.00 0 $267.00 0 $357.00 0 $300.00 0 $424.00 0 $140.00 0 $136.00 0 $110.00 0 $159.00 7 $255.00 7 $301.00 7 $682.00 7 $176.00 7 Surgery CPT Code 41116 41120 41130 41135 41140 41145 41150 41153 41155 41250 41251 41252 41500 41510 41520 41599 41800 41805 41806 41820 41821 41822 41823 41825 41826 41827 41828 41830 41850 41870 41872 41874 41899 42000 42100 42104 42106 42107 42120 42140 42145 42160 42180 42182 42200 42205 42210 42215 42220 42225 MRA FU Days $242.00 7 $813.00 120 $937.00 120 $1,869.00 120 $2,005.00 120 $2,406.00 120 $1,897.00 120 $2,091.00 120 $2,448.00 120 $168.00 0 $203.00 0 $294.00 0 $334.00 30 $313.00 30 $255.00 30 BR 0 $107.00 0 $115.00 0 $217.00 0 NC 0 NC 0 $237.00 0 $312.00 0 $144.00 0 $211.00 0 $322.00 7 $176.00 0 $156.00 0 NC 0 NC 90 $249.00 90 $193.00 90 BR 0 $106.00 0 $122.00 0 $161.00 0 $204.00 0 $409.00 90 $573.00 90 $174.00 15 $741.00 90 $176.00 0 $222.00 15 $324.00 15 $946.00 90 $863.00 90 $1,174.00 90 $766.00 90 $586.00 90 $803.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 42226 42227 42235 42260 42280 42281 42299 42300 42305 42310 42320 42325 42326 42330 42335 42340 42400 42405 42408 42409 42410 42415 42420 42425 42426 42440 42450 42500 42505 42507 42508 42509 42510 42550 42600 42650 42660 42665 42699 42700 42720 42725 42800 42802 42804 42806 42808 42809 42810 42815 MRA FU Days $848.00 90 $762.00 90 $631.00 90 $491.00 90 $148.00 90 $160.00 90 BR 0 $165.00 0 $448.00 0 $145.00 0 $208.00 0 $245.00 30 $369.00 30 $184.00 15 $287.00 30 $411.00 30 $94.00 0 $258.00 0 $377.00 15 $266.00 15 $746.00 60 $1,364.00 60 $1,577.00 60 $1,097.00 60 $1,882.00 60 $634.00 60 $395.00 60 $407.00 60 $559.00 60 $522.00 60 $767.00 60 $915.00 60 $711.00 60 $74.00 0 $445.00 60 $67.00 0 $89.00 0 $238.00 0 BR 0 $144.00 0 $270.00 0 $720.00 15 $123.00 7 $150.00 7 $136.00 7 $167.00 7 $250.00 30 $152.00 0 $335.00 30 $659.00 30 54 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 42820 42821 42825 42826 42830 42831 42835 42836 42842 42844 42845 42860 42870 42890 42892 42894 42900 42950 42953 42955 42960 42961 42962 42970 42971 42972 42999 43020 43030 43045 43100 43101 43107 43108 43112 43113 43116 43117 43118 43121 43122 43123 43124 43130 43135 43200 43202 43204 43205 43215 MRA FU Days $336.00 30 $378.00 30 $297.00 30 $320.00 30 $214.00 30 $235.00 30 $208.00 30 $286.00 30 $729.00 30 $1,173.00 30 $1,958.00 30 $207.00 30 $427.00 30 $1,047.00 60 $1,262.00 60 $1,825.00 60 $429.00 30 $745.00 60 $752.00 60 $561.00 0 $178.00 0 $406.00 0 $602.00 0 $253.00 0 $472.00 0 $562.00 0 BR 0 $696.00 90 $712.00 90 $1,574.00 90 $744.00 90 $1,248.00 90 $2,325.00 90 $2,664.00 90 $2,471.00 90 $2,755.00 90 $2,509.00 90 $2,469.00 90 $2,607.00 90 $2,350.00 90 $2,287.00 90 $2,661.00 90 $2,242.00 90 $1,020.00 90 $1,332.00 90 $266.00 0 $183.00 0 $228.00 0 $203.00 0 $160.00 0 Surgery CPT Code 43216 43217 43219 43220 43226 43227 43228 43234 43235 43239 43241 43243 43244 43245 43246 43247 43248 43249 43250 43251 43255 43258 43259 43260 43261 43262 43263 43264 43265 43267 43268 43269 43271 43272 43280 43289 43300 43305 43310 43312 43320 43324 43325 43326 43330 43331 43340 43341 43350 43351 MRA FU Days $149.00 0 $176.00 0 $171.00 0 $128.00 0 $142.00 0 $218.00 0 $230.00 0 $173.00 0 $213.00 0 $220.00 0 $157.00 0 $276.00 0 $249.00 0 $206.00 0 $485.00 0 $229.00 0 $191.00 0 $175.00 0 $194.00 0 $224.00 0 $343.00 0 $276.00 0 $271.00 0 $349.00 0 $362.00 0 $447.00 0 $356.00 0 $522.00 0 $484.00 0 $434.00 0 $446.00 0 $365.00 0 $437.00 0 $401.00 0 $1,314.00 15 BR 15 $837.00 90 $1,428.00 90 $2,138.00 90 $2,331.00 90 $1,299.00 90 $1,280.00 90 $1,261.00 90 $1,198.00 90 $1,236.00 90 $1,378.00 90 $1,292.00 90 $1,351.00 90 $986.00 90 $1,180.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 43352 43360 43361 43400 43401 43405 43410 43415 43420 43425 43450 43453 43456 43458 43460 43496 43499 43500 43501 43502 43510 43520 43600 43605 43610 43611 43620 43621 43622 43631 43632 43633 43634 43635 43638 43639 43640 43641 43651 43652 43653 43659 43750 43760 43761 43800 43810 43820 43825 43830 MRA FU Days $1,028.00 90 $2,277.00 90 $2,596.00 90 $1,261.00 90 $1,299.00 90 $1,330.00 90 $946.00 90 $1,382.00 90 $854.00 90 $1,338.00 90 $82.00 0 $102.00 0 $149.00 0 $153.00 0 $188.00 0 BR 90 BR 0 $649.00 45 $1,105.00 45 $1,247.00 45 $606.00 45 $599.00 45 $87.00 0 $686.00 45 $861.00 45 $1,001.00 90 $1,691.00 90 $1,718.00 90 $1,798.00 90 $1,445.00 90 $1,443.00 90 $1,467.00 90 $1,786.00 90 $143.00 0 $1,575.00 60 $1,605.00 60 $1,119.00 60 $1,138.00 60 $716.00 15 $856.00 15 $617.00 15 BR 15 $278.00 0 $73.00 0 $98.00 0 $793.00 45 $846.00 45 $896.00 45 $1,128.00 45 $592.00 45 55 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 43831 43832 43840 43842 43843 43846 43847 43848 43850 43855 43860 43865 43870 43880 43999 44005 44010 44015 44020 44021 44025 44050 44055 44100 44110 44111 44120 44121 44125 44130 44139 44140 44141 44143 44144 44145 44146 44147 44150 44151 44152 44153 44155 44156 44160 44200 44201 44202 44209 44300 MRA FU Days $593.00 30 $904.00 45 $893.00 45 $1,260.00 45 $1,249.00 45 $1,528.00 45 $1,678.00 45 $1,795.00 45 $1,425.00 60 $1,454.00 60 $1,435.00 60 $1,549.00 60 $590.00 45 $1,352.00 45 BR 0 $1,171.00 90 $809.00 60 $1,171.00 60 $891.00 60 $888.00 60 $905.00 60 $862.00 90 $957.00 60 $108.00 0 $784.00 60 $963.00 60 $1,078.00 60 $308.00 0 $1,135.00 60 $938.00 60 $154.00 0 $1,350.00 90 $1,488.00 90 $1,536.00 90 $1,442.00 90 $1,678.00 90 $1,840.00 90 $1,452.00 90 $1,661.00 90 $1,499.00 90 $1,890.00 90 $2,110.00 90 $1,892.00 90 $1,709.00 90 $1,236.00 60 $1,046.00 15 $649.00 15 $1,603.00 15 BR 15 $697.00 60 Surgery CPT Code 44310 44312 44314 44316 44320 44322 44340 44345 44346 44360 44361 44363 44364 44365 44366 44369 44372 44373 44376 44377 44378 44380 44382 44385 44386 44388 44389 44390 44391 44392 44393 44394 44500 44602 44603 44604 44605 44615 44620 44625 44626 44640 44650 44660 44661 44680 44700 44799 44800 44820 MRA FU Days $950.00 60 $453.00 60 $892.00 60 $1,229.00 60 $1,029.00 60 $1,015.00 60 $397.00 60 $816.00 60 $923.00 60 $177.00 0 $195.00 0 $213.00 0 $255.00 0 $226.00 0 $300.00 0 $308.00 0 $301.00 0 $238.00 0 $305.00 0 $320.00 0 $410.00 0 $91.00 0 $110.00 0 $219.00 0 $163.00 0 $326.00 0 $269.00 0 $285.00 0 $336.00 0 $320.00 0 $368.00 0 $352.00 0 $25.00 0 $815.00 60 $1,041.00 60 $1,027.00 60 $1,132.00 60 $994.00 60 $741.00 60 $1,277.00 60 $1,581.00 60 $1,036.00 60 $1,076.00 60 $1,050.00 60 $1,326.00 60 $1,049.00 60 $1,115.00 90 BR 0 $791.00 45 $755.00 45 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 44850 44899 44900 44901 44950 44955 44960 44970 44979 45000 45005 45020 45100 45108 45110 45111 45112 45113 45114 45116 45119 45120 45121 45123 45126 45130 45135 45150 45160 45170 45190 45300 45303 45305 45307 45308 45309 45315 45317 45320 45321 45330 45331 45332 45333 45334 45337 45338 45339 45355 MRA FU Days $708.00 45 BR 0 $644.00 45 $310.00 10 $643.00 45 $136.00 45 $790.00 45 $631.00 15 BR 15 $329.00 0 $197.00 15 $364.00 30 $321.00 15 $419.00 90 $1,801.00 90 $1,270.00 90 $1,904.00 90 $1,885.00 90 $1,732.00 90 $1,485.00 90 $1,911.00 90 $1,845.00 90 $1,870.00 90 $1,126.00 90 $2,444.00 90 $1,041.00 90 $1,354.00 90 $475.00 90 $949.00 90 $697.00 30 $623.00 90 $75.00 0 $72.00 0 $102.00 0 $172.00 0 $137.00 0 $174.00 0 $211.00 0 $209.00 0 $230.00 0 $154.00 0 $78.00 0 $108.00 0 $156.00 0 $158.00 0 $171.00 0 $144.00 0 $189.00 0 $212.00 0 $167.00 0 56 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 45378 45379 45380 45382 45383 45384 45385 45500 45505 45520 45540 45541 45550 45560 45562 45563 45800 45805 45820 45825 45900 45905 45910 45915 45999 46030 46040 46045 46050 46060 46070 46080 46083 46200 46210 46211 46220 46221 46230 46250 46255 46257 46258 46260 46261 46262 46270 46275 46280 46285 MRA FU Days $304.00 0 $370.00 0 $329.00 0 $429.00 0 $430.00 0 $370.00 0 $427.00 0 $584.00 90 $510.00 90 $42.00 0 $1,009.00 90 $888.00 90 $1,350.00 90 $618.00 90 $915.00 90 $1,412.00 90 $1,050.00 90 $1,273.00 90 $1,066.00 90 $1,241.00 90 $120.00 0 $133.00 0 $163.00 0 $127.00 0 BR 0 $94.00 0 $393.00 15 $312.00 15 $105.00 0 $482.00 90 $221.00 0 $246.00 0 $88.00 0 $323.00 60 $196.00 30 $353.00 90 $118.00 15 $124.00 30 $198.00 15 $400.00 90 $501.00 90 $504.00 90 $539.00 90 $598.00 90 $655.00 90 $686.00 90 $328.00 90 $442.00 90 $514.00 90 $335.00 30 Surgery CPT Code 46288 46320 46500 46600 46604 46606 46608 46610 46611 46612 46614 46615 46700 46705 46715 46716 46730 46735 46740 46742 46744 46746 46748 46750 46751 46753 46754 46760 46761 46762 46900 46910 46916 46917 46922 46924 46934 46935 46936 46937 46938 46940 46942 46945 46946 46999 47000 47001 47010 47011 MRA FU Days $521.00 30 $126.00 0 $109.00 0 $35.00 0 $92.00 0 $66.00 0 $103.00 0 $114.00 0 $149.00 0 $196.00 0 $169.00 0 $202.00 0 $585.00 90 $526.00 90 $545.00 90 $906.00 90 $1,584.00 90 $1,881.00 90 $1,671.00 90 $2,236.00 90 $2,412.00 90 $2,725.00 90 $2,933.00 90 $636.00 90 $643.00 90 $511.00 90 $188.00 90 $846.00 90 $813.00 90 $731.00 90 $128.00 0 $144.00 0 $145.00 7 $228.00 7 $189.00 7 $297.00 7 $223.00 15 $181.00 15 $282.00 15 $268.00 15 $405.00 15 $165.00 15 $145.00 15 $199.00 15 $270.00 15 BR 0 $195.00 0 $141.00 0 $788.00 60 $347.00 0 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 47015 47100 47120 47122 47125 47130 47134 47135 47136 47300 47350 47360 47361 47362 47399 47400 47420 47425 47460 47480 47490 47500 47505 47510 47511 47525 47530 47550 47552 47553 47554 47555 47556 47560 47561 47562 47563 47564 47570 47579 47600 47605 47610 47612 47620 47630 47700 47701 47711 47712 MRA FU Days $755.00 60 $550.00 45 $1,663.00 45 $2,512.00 45 $2,293.00 45 $2,482.00 45 $2,711.00 30 $6,164.00 30 $4,985.00 30 $778.00 90 $942.00 90 $1,305.00 90 $2,129.00 90 $849.00 90 BR 0 $1,435.00 45 $1,222.00 45 $1,275.00 45 $950.00 45 $755.00 45 $416.00 0 $103.00 0 $87.00 0 $451.00 45 $559.00 0 $263.00 0 $32.00 45 $209.00 45 $364.00 14 $316.00 14 $594.00 14 $341.00 14 $379.00 14 $345.00 0 $388.00 0 $837.00 15 $900.00 15 $1,069.00 15 $961.00 15 BR 15 $868.00 45 $935.00 45 $1,164.00 45 $1,276.00 45 $1,295.00 45 $427.00 45 $1,111.00 45 $1,913.00 45 $1,442.00 60 $1,793.00 60 57 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 47715 47716 47720 47721 47740 47741 47760 47765 47780 47785 47800 47801 47802 47900 47999 48000 48001 48005 48020 48100 48102 48120 48140 48145 48146 48148 48150 48152 48153 48154 48155 48160 48180 48400 48500 48510 48511 48520 48540 48545 48547 48554 48556 48999 49000 49002 49010 49020 49021 49040 MRA FU Days $1,157.00 60 $989.00 60 $1,040.00 60 $1,248.00 60 $1,188.00 60 $1,425.00 60 $1,568.00 60 $1,624.00 60 $1,635.00 60 $1,871.00 60 $1,485.00 60 $906.00 60 $1,352.00 60 $1,331.00 60 BR 0 $1,053.00 60 $1,305.00 60 $1,533.00 60 $983.00 60 $779.00 60 $304.00 0 $1,083.00 60 $1,546.00 60 $1,661.00 60 $1,830.00 60 $1,149.00 60 $3,101.00 60 $2,888.00 60 $3,099.00 60 $2,893.00 60 $1,855.00 60 BR 0 $1,616.00 60 $96.00 0 $1,012.00 60 $938.00 60 $255.00 0 $1,103.00 60 $1,350.00 60 $1,170.00 60 $1,630.00 60 $2,365.00 0 $1,117.00 90 BR 0 $862.00 90 $784.00 90 $915.00 90 $910.00 90 $259.00 90 $763.00 90 Surgery CPT Code MRA FU Days 49041 $273.00 0 49060 $827.00 90 49061 $257.00 0 49062 $892.00 10 49080 $111.00 0 49081 $88.00 0 49085 $632.00 90 49180 $189.00 0 49200 $823.00 60 49201 $1,180.00 60 49215 $1,551.00 60 49220 $1,182.00 60 49250 $622.00 60 49255 $591.00 60 49320 $415.00 0 49321 $443.00 15 49322 $460.00 15 49323 $712.00 15 49329 BR 15 49400 $127.00 0 49420 $162.00 0 49421 $452.00 0 49422 $468.00 30 49423 $106.00 0 49424 $54.00 0 49425 $914.00 30 49426 $725.00 30 49427 $44.00 0 49428 $184.00 30 49429 $522.00 30 49505 $510.00 45 49507 $636.00 45 49520 $631.00 45 49521 $730.00 45 49525 $584.00 45 49540 $668.00 45 49550 $557.00 45 49553 $598.00 45 49555 $621.00 45 49557 $715.00 45 49560 $734.00 45 49561 $856.00 45 49565 $754.00 45 49566 $881.00 45 49568 $339.00 45 49570 $411.00 45 49572 $491.00 45 49585 $444.00 45 49587 $501.00 45 49590 $585.00 45 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 49600 49605 49606 49610 49611 49650 49651 49659 49900 49905 49906 49999 50010 50020 50021 50040 50045 50060 50065 50070 50075 50080 50081 50100 50120 50125 50130 50135 50200 50205 50220 50225 50230 50234 50236 50240 50280 50290 50320 50340 50360 50365 50370 50380 50390 50392 50393 50394 50395 50396 MRA FU Days $774.00 45 $1,648.00 45 $1,416.00 45 $784.00 60 $770.00 60 $484.00 15 $621.00 15 BR 15 $512.00 30 $454.00 30 BR 90 BR 0 $886.00 90 $1,084.00 90 $299.00 0 $811.00 90 $1,137.00 90 $1,394.00 90 $1,514.00 90 $1,476.00 90 $1,839.00 90 $1,186.00 90 $1,635.00 90 $1,250.00 90 $1,180.00 90 $1,228.00 90 $1,301.00 90 $1,506.00 90 $151.00 0 $807.00 30 $1,316.00 90 $1,554.00 90 $1,695.00 90 $1,671.00 90 $1,873.00 90 $1,679.00 90 $1,170.00 90 $1,080.00 90 $1,680.00 90 $1,083.00 90 $2,475.00 90 $2,941.00 90 $1,128.00 90 $1,507.00 90 $118.00 0 $189.00 0 $235.00 0 $58.00 0 $203.00 0 $91.00 0 58 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 50398 50400 50405 50500 50520 50525 50526 50540 50541 50544 50546 50547 50548 50549 50551 50553 50555 50557 50559 50561 50570 50572 50574 50575 50576 50578 50580 50590 50600 50605 50610 50620 50630 50650 50660 50684 50686 50688 50690 50700 50715 50722 50725 50727 50728 50740 50750 50760 50770 50780 MRA FU Days $99.00 0 $1,441.00 90 $1,802.00 90 $1,471.00 90 $1,281.00 90 $1,644.00 90 $1,639.00 90 $1,468.00 90 $1,037.00 15 $1,428.00 15 $1,325.00 15 $1,702.00 15 $1,555.00 15 BR 15 $411.00 0 $447.00 0 $668.00 0 $676.00 0 $396.00 0 $755.00 0 $549.00 0 $728.00 0 $762.00 0 $991.00 0 $801.00 0 $711.00 0 $726.00 0 $980.00 90 $1,150.00 90 $1,054.00 90 $1,209.00 90 $1,152.00 90 $1,170.00 90 $1,297.00 90 $1,426.00 90 $74.00 0 $109.00 0 $89.00 0 $85.00 0 $1,192.00 90 $1,397.00 90 $1,211.00 90 $1,371.00 90 $640.00 90 $924.00 90 $1,386.00 90 $1,457.00 90 $1,389.00 90 $1,485.00 90 $1,391.00 90 Surgery CPT Code 50782 50783 50785 50800 50810 50815 50820 50825 50830 50840 50845 50860 50900 50920 50930 50940 50945 50951 50953 50955 50957 50959 50961 50970 50972 50974 50976 50978 50980 51000 51005 51010 51020 51030 51040 51045 51050 51060 51065 51080 51500 51520 51525 51530 51535 51550 51555 51565 51570 51575 MRA FU Days $1,465.00 90 $1,515.00 90 $1,548.00 90 $1,226.00 90 $1,527.00 120 $1,643.00 120 $1,729.00 120 $2,351.00 120 $2,292.00 120 $1,493.00 120 $1,513.00 90 $1,163.00 90 $1,043.00 90 $1,075.00 90 $1,380.00 90 $1,107.00 0 $1,096.00 15 $414.00 0 $461.00 0 $546.00 0 $546.00 0 $316.00 0 $510.00 0 $510.00 0 $408.00 0 $661.00 0 $641.00 0 $379.00 0 $443.00 0 $75.00 0 $87.00 0 $191.00 0 $587.00 90 $538.00 90 $439.00 90 $548.00 90 $596.00 90 $768.00 90 $704.00 90 $510.00 90 $775.00 90 $764.00 90 $1,069.00 90 $957.00 90 $932.00 90 $1,171.00 90 $1,514.00 90 $1,624.00 90 $1,762.00 90 $2,284.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 51580 51585 51590 51595 51596 51597 51600 51605 51610 51700 51705 51710 51715 51720 51725 51726 51736 51741 51772 51784 51785 51792 51795 51797 51800 51820 51840 51841 51845 51860 51865 51880 51900 51920 51925 51940 51960 51980 51990 51992 52000 52005 52007 52010 52204 52214 52224 52234 52235 52240 MRA FU Days $2,252.00 70 $2,601.00 90 $2,441.00 90 $2,900.00 90 $3,063.00 90 $2,914.00 90 $54.00 0 $83.00 0 $45.00 0 $29.00 0 $37.00 0 $119.00 0 $322.00 0 $140.00 0 $116.00 0 $136.00 0 $47.00 0 $81.00 0 $96.00 0 $119.00 0 $52.00 0 $143.00 0 $132.00 0 $109.00 0 $1,294.00 90 $1,236.00 90 $858.00 90 $1,040.00 90 $843.00 90 $912.00 90 $1,150.00 90 $590.00 90 $1,050.00 90 $881.00 90 $1,167.00 90 $2,082.00 90 $1,848.00 90 $858.00 90 $850.00 15 $925.00 15 $190.00 0 $265.00 0 $230.00 0 $292.00 0 $286.00 7 $367.00 7 $339.00 7 $471.00 15 $546.00 30 $887.00 30 59 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code MRA FU Days 52250 $311.00 7 52260 $262.00 7 52265 $243.00 30 52270 $374.00 15 52275 $446.00 15 52276 $490.00 30 52277 $448.00 30 52281 $259.00 0 52282 $560.00 30 52283 $309.00 0 52285 $375.00 15 52290 $304.00 15 52300 $370.00 15 52301 $382.00 15 52305 $370.00 15 52310 $348.00 15 52315 $553.00 15 52317 $772.00 15 52318 $684.00 15 52320 $369.00 15 52325 $494.00 15 52327 $369.00 15 52330 $507.00 15 52332 $451.00 15 52334 $340.00 15 52335 $428.00 15 52336 $552.00 15 52337 $638.00 15 52338 $537.00 15 52339 $617.00 15 52340 $685.00 15 52450 $602.00 90 52500 $705.00 90 52510 $604.00 90 52601 $1,021.00 90 52606 $581.00 0 52612 $711.00 90 52614 $609.00 90 52620 $554.00 90 52630 $653.00 90 52640 $573.00 90 52647 $858.00 90 52648 $957.00 90 52700 $517.00 60 53000 $224.00 15 53010 $336.00 30 53020 $153.00 15 53025 $114.00 15 53040 $460.00 30 53060 $180.00 15 Surgery CPT Code 53080 53085 53200 53210 53215 53220 53230 53235 53240 53250 53260 53265 53270 53275 53400 53405 53410 53415 53420 53425 53430 53440 53442 53443 53445 53447 53449 53450 53460 53502 53505 53510 53515 53520 53600 53601 53605 53620 53621 53660 53661 53665 53670 53675 53850 53852 53899 54001 54015 54050 MRA FU Days $567.00 0 $836.00 0 $218.00 7 $904.00 60 $1,142.00 60 $546.00 60 $760.00 60 $541.00 60 $506.00 15 $464.00 15 $240.00 15 $295.00 15 $226.00 15 $332.00 15 $929.00 60 $1,088.00 60 $1,151.00 60 $1,381.00 60 $1,088.00 60 $1,150.00 90 $1,116.00 90 $1,057.00 90 $639.00 60 $1,373.00 60 $1,197.00 90 $991.00 60 $784.00 90 $447.00 30 $494.00 30 $590.00 30 $586.00 30 $777.00 90 $987.00 90 $661.00 90 $37.00 0 $37.00 0 $81.00 0 $59.00 0 $45.00 0 $49.00 0 $50.00 0 $50.00 0 $42.00 0 $67.00 0 $741.00 90 $728.00 90 BR 0 $175.00 0 $348.00 0 $91.00 0 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 54055 54056 54057 54060 54065 54100 54105 54110 54111 54112 54115 54120 54125 54130 54135 54152 54161 54200 54205 54220 54230 54231 54235 54240 54250 54300 54304 54308 54312 54316 54318 54322 54324 54326 54328 54332 54336 54340 54344 54348 54352 54360 54380 54385 54390 54400 54401 54402 54405 54407 MRA FU Days $106.00 0 $100.00 7 $149.00 7 $180.00 7 $281.00 7 $149.00 7 $261.00 7 $775.00 30 $1,035.00 30 $1,210.00 30 $588.00 30 $777.00 30 $1,092.00 90 $1,532.00 90 $1,945.00 90 $186.00 15 $245.00 30 $78.00 0 $633.00 0 $189.00 0 $104.00 7 $172.00 7 $81.00 7 $109.00 7 $104.00 0 $830.00 30 $988.00 90 $881.00 90 $1,067.00 90 $1,316.00 90 $900.00 90 $974.00 90 $1,260.00 90 $1,212.00 90 $1,201.00 90 $1,327.00 90 $1,672.00 90 $727.00 90 $1,360.00 90 $1,318.00 90 $1,820.00 90 $898.00 90 $1,054.00 30 $1,217.00 30 $1,635.00 30 $784.00 30 $892.00 30 $701.00 90 $1,294.00 90 $1,764.00 90 60 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code MRA FU Days 54409 $932.00 90 54420 $899.00 30 54430 $799.00 30 54435 $503.00 30 54440 BR 0 54450 $88.00 0 54500 $102.00 0 54505 $259.00 0 54510 $400.00 30 54520 $445.00 30 54530 $683.00 30 54535 $922.00 45 54550 $588.00 30 54560 $842.00 30 54600 $524.00 30 54620 $373.00 30 54640 $594.00 30 54650 $861.00 45 54660 $401.00 45 54670 $485.00 45 54680 $948.00 45 54690 $825.00 15 54692 $850.00 15 54699 BR 15 54700 $133.00 7 54800 $257.00 7 54820 $379.00 30 54830 $411.00 30 54840 $432.00 45 54860 $503.00 45 54861 $696.00 45 54900 $969.00 90 54901 $1,340.00 90 55000 $109.00 0 55040 $439.00 45 55041 $634.00 45 55060 $430.00 45 55100 $156.00 0 55110 $223.00 0 55120 $350.00 0 55150 $562.00 30 55175 $426.00 30 55180 $796.00 30 55200 $310.00 30 55250 $349.00 30 55300 $167.00 30 55400 $660.00 90 55450 $391.00 30 55500 $445.00 45 55520 $446.00 30 Surgery CPT Code 55530 55535 55540 55550 55559 55600 55605 55650 55680 55700 55705 55720 55725 55801 55810 55812 55815 55821 55831 55840 55842 55845 55859 55860 55862 55865 55870 55899 56405 56420 56440 56441 56501 56515 56605 56606 56620 56625 56630 56631 56632 56633 56634 56637 56640 56700 56720 56740 56800 56805 MRA FU Days $467.00 45 $496.00 45 $572.00 45 $486.00 15 BR 15 $486.00 60 $609.00 60 $853.00 45 $426.00 45 $183.00 15 $368.00 30 $555.00 30 $670.00 60 $1,331.00 90 $1,711.00 90 $1,989.00 90 $2,328.00 90 $1,153.00 90 $1,252.00 90 $1,705.00 90 $1,859.00 90 $2,222.00 90 $843.00 90 $1,012.00 90 $1,351.00 90 $1,890.00 90 $149.00 0 BR 0 $131.00 0 $130.00 0 $271.00 0 $183.00 0 $122.00 0 $200.00 0 $96.00 0 $49.00 0 $607.00 60 $735.00 60 $1,061.00 90 $1,400.00 90 $1,636.00 90 $1,350.00 90 $1,537.00 90 $1,806.00 90 $1,777.00 90 $227.00 30 $72.00 0 $321.00 30 $310.00 30 $1,349.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 56810 57000 57010 57020 57061 57065 57100 57105 57106 57107 57109 57110 57111 57112 57120 57130 57135 57150 57160 57170 57180 57200 57210 57220 57230 57240 57250 57260 57265 57268 57270 57280 57282 57284 57288 57289 57291 57292 57300 57305 57307 57308 57310 57311 57320 57330 57335 57400 57410 57415 MRA FU Days $316.00 30 $237.00 30 $429.00 30 $118.00 0 $124.00 15 $251.00 15 $90.00 0 $132.00 0 $409.00 90 $1,467.00 90 $1,787.00 90 $1,015.00 90 $1,793.00 90 $1,907.00 90 $612.00 60 $220.00 7 $231.00 30 $50.00 0 $67.00 0 $74.00 0 $124.00 0 $313.00 7 $395.00 7 $378.00 7 $442.00 7 $536.00 60 $485.00 60 $700.00 60 $902.00 60 $577.00 60 $867.00 60 $1,071.00 60 $734.00 60 $950.00 90 $1,009.00 60 $879.00 60 $622.00 90 $925.00 90 $653.00 90 $995.00 90 $997.00 90 $769.00 90 $517.00 60 $612.00 0 $693.00 60 $916.00 60 $963.00 90 $70.00 0 $57.00 0 $75.00 0 61 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 57452 57454 57460 57500 57505 57510 57511 57513 57520 57522 57530 57531 57540 57545 57550 57555 57556 57700 57720 57800 57820 58100 58120 58140 58145 58150 58152 58180 58200 58210 58240 58260 58262 58263 58267 58270 58275 58280 58285 58300 58301 58321 58322 58323 58340 58345 58350 58400 58410 58520 MRA FU Days $96.00 0 $125.00 0 $223.00 0 $89.00 0 $105.00 0 $140.00 7 $159.00 0 $191.00 45 $359.00 45 $319.00 45 $386.00 45 $2,036.00 90 $815.00 45 $700.00 45 $486.00 45 $774.00 45 $718.00 45 $279.00 45 $328.00 45 $71.00 0 $182.00 15 $74.00 0 $297.00 0 $1,010.00 45 $677.00 45 $1,110.00 45 $1,159.00 45 $1,118.00 45 $1,562.00 120 $2,080.00 120 $2,898.00 120 $926.00 45 $1,026.00 45 $1,120.00 45 $1,133.00 45 $1,019.00 45 $1,121.00 45 $1,132.00 45 $1,360.00 90 $96.00 0 $71.00 0 $81.00 45 $90.00 45 $24.00 45 $87.00 0 $335.00 45 $103.00 0 $519.00 45 $752.00 45 $663.00 45 Surgery CPT Code 58540 58550 58551 58555 58558 58559 58560 58561 58562 58563 58578 58579 58600 58605 58611 58615 58660 58661 58662 58670 58671 58672 58673 58679 58700 58720 58740 58750 58752 58760 58770 58800 58805 58820 58822 58823 58825 58900 58920 58925 58940 58943 58950 58951 58952 58960 58970 58974 58976 58999 MRA FU Days $923.00 45 $1,038.00 15 $929.00 15 $261.00 15 $340.00 15 $436.00 15 $482.00 15 $677.00 15 $339.00 15 $450.00 15 BR 15 BR 15 $337.00 45 $298.00 45 $47.00 45 $319.00 45 $793.00 15 $804.00 15 $807.00 15 $450.00 15 $463.00 15 $872.00 15 $928.00 15 BR 15 $544.00 90 $844.00 90 $508.00 45 $949.00 45 $893.00 45 $769.00 45 $763.00 45 $343.00 15 $509.00 45 $326.00 15 $603.00 45 $209.00 0 $469.00 45 $489.00 45 $571.00 45 $820.00 45 $592.00 45 $1,368.00 45 $1,170.00 60 $1,703.00 60 $1,876.00 60 $1,174.00 60 $284.00 0 NC 0 $221.00 0 BR 0 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 59000 59012 59015 59020 59025 59030 59050 59051 59100 59120 59121 59130 59135 59136 59140 59150 59151 59160 59200 59300 59320 59325 59350 59400 59409 59410 59412 59414 59425 59426 59430 59510 59514 59515 59525 59610 59612 59614 59618 59620 59622 59812 59820 59821 59830 59840 59841 59850 59851 59852 MRA FU Days $123.00 0 $267.00 0 $168.00 0 $85.00 0 $54.00 0 $155.00 0 $71.00 0 $47.00 0 $633.00 45 $893.00 45 $768.00 45 $832.00 45 $1,083.00 45 $934.00 45 $461.00 45 $543.00 45 $690.00 45 $279.00 15 $79.00 0 $179.00 0 $196.00 0 $316.00 0 $375.00 45 $1,816.00 45 $1,019.00 45 $1,123.00 45 $141.00 0 $134.00 0 $414.00 0 $708.00 0 $140.00 45 $2,064.00 45 $1,199.00 45 $1,324.00 45 $591.00 45 $1,805.00 45 $1,113.00 45 $1,208.00 45 $2,035.00 45 $1,293.00 45 $1,397.00 45 $343.00 30 $389.00 30 $398.00 30 $496.00 30 $331.00 30 $443.00 30 $449.00 30 $464.00 30 $642.00 45 62 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 59855 59856 59857 59866 59870 59871 59898 59899 60000 60001 60100 60200 60210 60212 60220 60225 60240 60252 60254 60260 60270 60271 60280 60281 60500 60502 60505 60512 60520 60521 60522 60540 60545 60600 60605 60650 60659 60699 61000 61001 61020 61026 61050 61055 61070 61105 61107 61108 61120 61140 MRA FU Days $477.00 30 $577.00 30 $711.00 45 $304.00 0 $348.00 30 $192.00 0 BR 15 BR 0 $102.00 0 $79.00 0 $87.00 0 $744.00 30 $872.00 30 $1,170.00 30 $851.00 45 $1,107.00 30 $1,228.00 30 $1,427.00 30 $1,911.00 30 $1,022.00 30 $1,468.00 30 $1,210.00 90 $546.00 30 $670.00 30 $1,232.00 45 $1,475.00 45 $1,631.00 30 $310.00 30 $1,405.00 90 $1,591.00 90 $1,820.00 90 $1,272.00 30 $1,505.00 30 $1,477.00 30 $1,624.00 30 $1,340.00 15 BR 15 BR 0 $135.00 0 $127.00 0 $150.00 0 $128.00 0 $95.00 0 $133.00 0 $61.00 0 $503.00 0 $863.00 0 $959.00 7 $733.00 30 $1,389.00 30 Surgery CPT Code 61150 61151 61154 61156 61210 61215 61250 61253 61304 61305 61312 61313 61314 61315 61320 61321 61330 61332 61333 61334 61340 61343 61345 61440 61450 61458 61460 61470 61480 61490 61500 61501 61510 61512 61514 61516 61518 61519 61520 61521 61522 61524 61526 61530 61531 61533 61534 61535 61536 61538 MRA FU Days $1,503.00 30 $795.00 30 $1,393.00 90 $1,473.00 90 $527.00 0 $637.00 0 $888.00 90 $1,042.00 90 $2,005.00 90 $2,419.00 90 $2,187.00 90 $2,207.00 90 $2,200.00 90 $2,393.00 90 $2,118.00 90 $2,310.00 90 $1,706.00 90 $2,307.00 90 $2,231.00 90 $1,525.00 90 $1,584.00 90 $2,673.00 90 $2,259.00 90 $2,110.00 90 $2,173.00 90 $2,433.00 90 $2,426.00 90 $1,982.00 90 $1,922.00 90 $1,687.00 90 $1,637.00 90 $1,353.00 90 $2,506.00 90 $2,981.00 90 $2,262.00 90 $2,253.00 90 $3,163.00 90 $3,450.00 90 $4,349.00 90 $3,667.00 90 $2,415.00 90 $2,484.00 90 $3,918.00 90 $3,611.00 90 $1,344.00 90 $1,712.00 90 $1,535.00 90 $958.00 90 $2,862.00 90 $2,466.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 61539 61541 61542 61543 61544 61545 61546 61548 61550 61552 61556 61557 61558 61559 61563 61564 61570 61571 61575 61576 61580 61581 61582 61583 61584 61585 61586 61590 61591 61592 61595 61596 61597 61598 61600 61601 61605 61606 61607 61608 61609 61610 61611 61612 61613 61615 61616 61618 61619 61624 MRA FU Days $2,660.00 90 $2,363.00 90 $2,533.00 90 $2,307.00 90 $2,271.00 90 $3,474.00 90 $2,695.00 90 $1,964.00 90 $1,141.00 90 $1,463.00 90 $1,760.00 90 $1,807.00 90 $2,085.00 90 $2,700.00 90 $2,175.00 90 $2,597.00 90 $1,975.00 90 $2,140.00 90 $2,992.00 90 $3,772.00 90 $2,383.00 90 $2,674.00 90 $2,557.00 90 $2,972.00 90 $2,830.00 90 $3,142.00 90 $2,097.00 90 $3,299.00 90 $3,491.00 90 $3,245.00 90 $2,350.00 90 $2,827.00 90 $3,046.00 90 $2,693.00 90 $2,039.00 90 $2,279.00 90 $2,299.00 90 $3,178.00 90 $2,961.00 90 $3,458.00 90 $798.00 0 $2,354.00 0 $584.00 0 $2,219.00 0 $3,375.00 90 $2,576.00 90 $3,535.00 90 $1,389.00 90 $1,682.00 90 $1,073.00 90 63 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 61626 61680 61682 61684 61686 61690 61692 61700 61702 61703 61705 61708 61710 61711 61720 61735 61750 61751 61760 61770 61790 61791 61793 61795 61850 61860 61862 61870 61875 61880 61885 61886 61888 62000 62005 62010 62100 62115 62116 62117 62120 62121 62140 62141 62142 62143 62145 62146 62147 62180 MRA FU Days $877.00 90 $2,758.00 90 $4,798.00 90 $3,341.00 90 $5,012.00 90 $2,556.00 90 $4,007.00 90 $4,037.00 90 $4,019.00 90 $1,444.00 90 $3,043.00 90 $2,546.00 90 $2,129.00 90 $3,150.00 90 $1,558.00 90 $1,664.00 90 $1,521.00 90 $1,628.00 90 $1,670.00 90 $1,867.00 90 $952.00 90 $1,205.00 90 $1,594.00 90 $371.00 0 $1,090.00 90 $1,197.00 90 $1,551.00 90 $616.00 90 $984.00 90 $559.00 90 $262.00 90 $678.00 90 $331.00 90 $848.00 90 $1,282.00 90 $1,754.00 90 $1,962.00 90 $1,686.00 90 $1,928.00 90 $2,211.00 90 $1,898.00 90 $1,822.00 90 $1,221.00 90 $1,955.00 90 $1,011.00 90 $1,096.00 90 $1,566.00 90 $1,327.00 90 $1,566.00 90 $1,695.00 7 Surgery CPT Code 62190 62192 62194 62200 62201 62220 62223 62225 62230 62256 62258 62263 62268 62269 62270 62272 62273 62280 62281 62282 62284 62287 62290 62291 62292 62294 62310 62311 62318 62319 62350 62351 62355 62360 62361 62362 62365 62367 62368 63001 63003 63005 63011 63012 63015 63016 63017 63020 63030 63035 MRA FU Days $1,034.00 7 $1,146.00 7 $213.00 7 $1,625.00 7 $1,200.00 7 $1,215.00 7 $1,199.00 7 $488.00 7 $935.00 7 $616.00 7 $1,308.00 7 $380.00 0 $258.00 0 $242.00 0 $98.00 0 $123.00 0 $116.00 0 $178.00 0 $166.00 0 $188.00 0 $196.00 0 $784.00 0 $210.00 0 $207.00 0 $1,064.00 0 $821.00 0 $179.00 0 $180.00 0 $186.00 0 $182.00 0 $488.00 90 $782.00 90 $402.00 90 $195.00 90 $390.00 90 $517.00 90 $418.00 90 BR 0 BR 0 $1,882.00 90 $1,591.00 90 $1,390.00 90 $1,151.00 90 $1,568.00 90 $1,862.00 90 $1,788.00 90 $1,489.00 90 $1,395.00 90 $1,145.00 90 $280.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 63040 63042 63045 63046 63047 63048 63055 63056 63057 63064 63066 63075 63076 63077 63078 63081 63082 63085 63086 63087 63088 63090 63091 63170 63172 63173 63180 63182 63185 63190 63191 63194 63195 63196 63197 63198 63199 63200 63250 63251 63252 63265 63266 63267 63268 63270 63271 63272 63273 63275 MRA FU Days $1,764.00 90 $1,620.00 90 $1,647.00 90 $2,117.00 90 $1,907.00 90 $367.00 90 $2,029.00 90 $1,960.00 90 $421.00 90 $2,200.00 90 $263.00 90 $1,720.00 90 $383.00 90 $1,828.00 90 $261.00 90 $2,203.00 90 $391.00 90 $2,416.00 90 $282.00 90 $2,930.00 90 $381.00 90 $2,490.00 90 $249.00 90 $1,788.00 90 $1,672.00 90 $1,851.00 90 $1,486.00 90 $1,711.00 90 $1,347.00 90 $1,610.00 90 $1,444.00 90 $1,593.00 90 $1,603.00 90 $1,810.00 90 $1,725.00 90 $1,956.00 90 $2,258.00 90 $1,569.00 90 $3,182.00 90 $3,207.00 90 $3,319.00 90 $1,940.00 90 $2,053.00 90 $1,651.00 90 $1,469.00 90 $2,197.00 90 $2,401.00 90 $2,206.00 90 $2,012.00 90 $2,166.00 90 64 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 63276 63277 63278 63280 63281 63282 63283 63285 63286 63287 63290 63300 63301 63302 63303 63304 63305 63306 63307 63308 63600 63610 63615 63650 63655 63660 63685 63688 63700 63702 63704 63706 63707 63709 63710 63740 63741 63744 63746 64400 64402 64405 64408 64410 64412 64413 64415 64417 64418 64420 MRA FU Days $2,135.00 90 $1,905.00 90 $1,877.00 90 $2,529.00 90 $2,496.00 90 $2,305.00 90 $2,041.00 90 $2,934.00 90 $3,003.00 90 $3,012.00 90 $3,073.00 90 $2,006.00 90 $2,209.00 90 $2,290.00 90 $2,357.00 90 $2,513.00 90 $2,574.00 90 $2,596.00 90 $2,522.00 90 $425.00 90 $797.00 90 $474.00 90 $1,348.00 90 $819.00 90 $1,064.00 90 $707.00 90 $615.00 90 $707.00 90 $1,340.00 90 $1,512.00 90 $1,708.00 90 $1,873.00 90 $1,041.00 90 $1,310.00 90 $1,165.00 90 $1,062.00 7 $741.00 7 $738.00 7 $529.00 7 $70.00 0 $75.00 0 $96.00 0 $108.00 0 $98.00 0 $80.00 0 $118.00 0 $98.00 0 $94.00 0 $97.00 0 $80.00 0 Surgery CPT Code 64421 64425 64430 64435 64445 64450 64470 64472 64475 64476 64479 64480 64483 64484 64505 64508 64510 64520 64530 64550 64553 64555 64560 64565 64573 64575 64577 64580 64585 64590 64595 64600 64605 64610 64612 64613 64620 64622 64623 64626 64627 64630 64640 64680 64702 64704 64708 64712 64713 64714 MRA $114.00 $104.00 $130.00 $114.00 $62.00 $53.00 $184.00 $154.00 $163.00 $154.00 $200.00 $180.00 $184.00 $170.00 $93.00 $89.00 $92.00 $117.00 $121.00 $22.00 $123.00 $117.00 $197.00 $109.00 $464.00 $367.00 $381.00 $343.00 $37.00 $217.00 $153.00 $204.00 $285.00 $274.00 $188.00 $168.00 $165.00 $320.00 $101.00 $234.00 $140.00 $181.00 $186.00 $161.00 $383.00 $402.00 $562.00 $678.00 $867.00 $715.00 FU Days 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 7 7 7 7 7 7 7 0 0 7 7 7 90 90 90 90 90 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 64716 64718 64719 64721 64722 64726 64727 64732 64734 64736 64738 64740 64742 64744 64746 64752 64755 64760 64761 64763 64766 64771 64772 64774 64776 64778 64782 64783 64784 64786 64787 64788 64790 64792 64795 64802 64804 64809 64818 64820 64831 64832 64834 64835 64836 64837 64840 64856 64857 64858 MRA FU Days $523.00 90 $558.00 90 $446.00 90 $439.00 90 $411.00 90 $271.00 90 $261.00 0 $405.00 30 $432.00 30 $388.00 30 $475.00 30 $461.00 30 $517.00 30 $798.00 30 $494.00 30 $560.00 45 $1,042.00 60 $578.00 45 $495.00 45 $561.00 45 $713.00 45 $632.00 30 $636.00 30 $392.00 30 $390.00 30 $249.00 30 $482.00 30 $298.00 30 $751.00 30 $1,281.00 30 $458.00 30 $381.00 30 $884.00 60 $1,148.00 60 $247.00 0 $711.00 60 $1,202.00 60 $1,080.00 60 $845.00 60 $838.00 90 $592.00 90 $171.00 90 $711.00 90 $834.00 90 $856.00 90 $480.00 90 $1,058.00 90 $1,063.00 90 $1,137.00 90 $1,313.00 90 65 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 64859 64861 64862 64864 64865 64866 64868 64870 64872 64874 64876 64885 64886 64890 64891 64892 64893 64895 64896 64897 64898 64901 64902 64905 64907 64999 65091 65093 65101 65103 65105 65110 65112 65114 65125 65130 65135 65140 65150 65155 65175 65205 65210 65220 65222 65235 65260 65265 65270 65272 MRA FU Days $341.00 90 $1,524.00 90 $1,798.00 90 $970.00 90 $1,250.00 90 $1,238.00 90 $1,162.00 90 $1,313.00 90 $155.00 90 $230.00 90 $189.00 90 $1,382.00 90 $1,636.00 90 $1,112.00 120 $1,243.00 120 $1,177.00 120 $1,321.00 120 $1,500.00 120 $1,185.00 120 $1,419.00 120 $1,549.00 120 $865.00 120 $982.00 120 $1,059.00 120 $1,472.00 120 BR 0 $678.00 30 $712.00 30 $726.00 30 $769.00 30 $846.00 30 $1,305.00 30 $1,386.00 30 $1,456.00 30 $312.00 30 $730.00 30 $678.00 30 $738.00 30 $652.00 30 $862.00 30 $654.00 30 $45.00 0 $53.00 0 $52.00 0 $62.00 0 $627.00 45 $956.00 45 $1,104.00 45 $88.00 0 $223.00 7 Surgery CPT Code 65273 65275 65280 65285 65286 65290 65400 65410 65420 65426 65430 65435 65436 65450 65600 65710 65730 65750 65755 65770 65772 65775 65800 65805 65810 65815 65820 65850 65855 65860 65865 65870 65875 65880 65900 65920 65930 66020 66030 66130 66150 66155 66160 66165 66170 66172 66180 66185 66220 66225 MRA FU Days $376.00 7 $75.00 60 $711.00 60 $1,177.00 60 $692.00 30 $519.00 30 $603.00 30 $142.00 0 $448.00 30 $534.00 30 $81.00 0 $88.00 0 $319.00 0 $52.00 0 $325.00 30 $1,124.00 90 $1,314.00 90 $1,381.00 90 $1,373.00 90 $1,461.00 90 $449.00 90 $595.00 90 $88.00 0 $178.00 0 $516.00 90 $327.00 90 $813.00 30 $968.00 45 $441.00 45 $339.00 30 $540.00 30 $572.00 30 $597.00 30 $641.00 30 $945.00 30 $752.00 30 $700.00 30 $164.00 0 $160.00 0 $631.00 45 $798.00 45 $795.00 45 $942.00 45 $769.00 45 $1,089.00 45 $1,264.00 45 $1,313.00 45 $769.00 45 $711.00 90 $1,006.00 90 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code 66250 66500 66505 66600 66605 66625 66630 66635 66680 66682 66700 66710 66720 66740 66761 66762 66770 66820 66821 66825 66830 66840 66850 66852 66920 66930 66940 66983 66984 66985 66986 66999 67005 67010 67015 67025 67027 67028 67030 67031 67036 67038 67039 67040 67101 67105 67107 67108 67110 67112 MRA FU Days $602.00 90 $359.00 30 $359.00 30 $825.00 45 $1,136.00 45 $543.00 45 $623.00 45 $595.00 45 $526.00 45 $627.00 45 $506.00 45 $513.00 45 $506.00 45 $473.00 45 $506.00 45 $433.00 30 $483.00 30 $433.00 45 $275.00 45 $753.00 45 $651.00 90 $707.00 90 $805.00 90 $878.00 90 $785.00 90 $906.00 90 $819.00 90 $763.00 90 $898.00 90 $744.00 120 $1,038.00 90 BR 0 $639.00 90 $647.00 90 $637.00 60 $774.00 60 $1,089.00 60 $338.00 45 $485.00 45 $402.00 45 $1,384.00 60 $1,860.00 60 $1,490.00 60 $1,960.00 60 $767.00 90 $941.00 90 $1,350.00 90 $1,878.00 90 $1,040.00 90 $1,500.00 90 66 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 67115 67120 67121 67141 67145 67208 67210 67218 67220 67227 67228 67250 67255 67299 67311 67312 67314 67316 67318 67320 67331 67332 67334 67335 67340 67343 67345 67350 67399 67400 67405 67412 67413 67414 67415 67420 67430 67440 67445 67450 67500 67505 67515 67550 67560 67570 67599 67700 67710 67715 MRA FU Days $496.00 30 $751.00 30 $962.00 30 $536.00 30 $514.00 30 $655.00 90 $779.00 90 $1,217.00 90 $894.00 90 $652.00 90 $1,025.00 90 $793.00 90 $872.00 90 BR 0 $616.00 30 $773.00 30 $688.00 30 $857.00 30 $663.00 30 $602.00 30 $560.00 30 $621.00 30 $447.00 30 $253.00 0 $559.00 30 $628.00 30 $275.00 0 $240.00 0 BR 0 $960.00 30 $799.00 30 $976.00 60 $909.00 30 $1,023.00 30 $146.00 0 $1,729.00 30 $1,203.00 30 $1,257.00 30 $1,269.00 30 $1,300.00 30 $75.00 0 $109.00 7 $53.00 0 $946.00 30 $936.00 30 $1,148.00 30 BR 0 $87.00 0 $117.00 0 $102.00 0 Surgery CPT Code MRA FU Days 67800 $119.00 15 67801 $189.00 15 67805 $208.00 15 67808 $308.00 15 67810 $133.00 0 67820 $36.00 0 67825 $130.00 0 67830 $239.00 7 67835 $500.00 30 67840 $187.00 0 67850 $143.00 0 67875 $163.00 30 67880 $442.00 30 67882 $643.00 30 67900 $487.00 60 67901 $646.00 60 67902 $650.00 60 67903 $657.00 60 67904 $720.00 60 67906 $633.00 60 67908 $550.00 30 67909 $577.00 30 67911 $517.00 30 67914 $487.00 15 67915 $252.00 15 67916 $675.00 30 67917 $631.00 30 67921 $419.00 15 67922 $243.00 15 67923 $718.00 30 67924 $605.00 30 67930 $280.00 30 67935 $520.00 30 67938 $67.00 0 67950 $584.00 45 67961 $571.00 60 67966 $645.00 60 67971 $875.00 60 67973 $1,126.00 60 67974 $1,140.00 60 67975 $681.00 60 67999 BR 0 68020 $106.00 0 68040 $75.00 0 68100 $137.00 0 68110 $172.00 15 68115 $248.00 15 68130 $378.00 15 68135 $146.00 0 68200 $59.00 0 CPT only © 1999 American Medical Association. All Rights Reserved. Surgery CPT Code MRA FU Days 68320 $502.00 30 68325 $672.00 30 68326 $654.00 30 68328 $741.00 30 68330 $488.00 30 68335 $636.00 30 68340 $413.00 0 68360 $449.00 30 68362 $691.00 30 68399 BR 0 68400 $154.00 15 68420 $191.00 15 68440 $96.00 0 68500 $882.00 45 68505 $921.00 45 68510 $491.00 0 68520 $687.00 45 68525 $340.00 45 68530 $379.00 30 68540 $875.00 45 68550 $1,107.00 45 68700 $628.00 30 68705 $176.00 15 68720 $807.00 60 68745 $704.00 90 68750 $792.00 15 68760 $109.00 15 68761 $130.00 15 68770 $634.00 30 68801 $202.00 0 68810 $290.00 0 68811 $191.00 0 68815 $399.00 0 68840 $100.00 0 68850 $76.00 0 68899 BR 0 69000 $52.00 0 69005 $175.00 0 69020 $109.00 0 69100 $85.00 0 69105 $87.00 0 69110 $294.00 30 69120 $274.00 90 69140 $722.00 90 69145 $248.00 90 69150 $1,111.00 90 69155 $1,680.00 90 69200 $48.00 0 69205 $110.00 0 69210 $36.00 0 67 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Surgery CPT Code 69220 69222 69300 69310 69320 69399 69400 69401 69405 69410 69420 69421 69424 69433 69436 69440 69450 69501 69502 69505 69511 69530 69535 69540 69550 69552 69554 69601 69602 69603 69604 69605 69610 69620 69631 69632 69633 69635 69636 69637 69641 69642 69643 69644 69645 69646 69650 69660 69661 69662 MRA FU Days $78.00 7 $123.00 14 $522.00 180 $937.00 180 $1,434.00 180 BR 0 $76.00 0 $52.00 0 $176.00 0 $53.00 0 $117.00 0 $155.00 0 $84.00 0 $145.00 0 $182.00 30 $699.00 30 $525.00 30 $829.00 90 $1,118.00 90 $1,176.00 90 $1,221.00 90 $1,616.00 180 $2,824.00 90 $126.00 15 $998.00 90 $1,621.00 90 $2,600.00 90 $1,195.00 90 $1,225.00 90 $1,264.00 90 $1,263.00 90 $1,526.00 90 $41.00 7 $651.00 90 $985.00 90 $1,166.00 90 $1,110.00 90 $1,207.00 90 $1,381.00 90 $1,370.00 90 $1,154.00 90 $1,519.00 90 $1,389.00 90 $1,529.00 90 $1,479.00 90 $1,620.00 90 $879.00 90 $1,072.00 90 $1,412.00 90 $1,386.00 90 Surgery CPT Code 69666 69667 69670 69676 69700 69710 69711 69720 69725 69740 69745 69799 69801 69802 69805 69806 69820 69840 69905 69910 69915 69930 69949 69950 69955 69960 69970 69979 69990 MRA FU Days $887.00 90 $887.00 90 $988.00 90 $828.00 90 $702.00 90 BR 90 $878.00 90 $1,307.00 90 $1,922.00 90 $1,274.00 90 $1,447.00 90 BR 0 $785.00 90 $1,115.00 90 $1,187.00 90 $1,123.00 90 $876.00 90 $869.00 90 $1,013.00 90 $1,228.00 90 $1,754.00 90 $1,498.00 90 BR 0 $2,017.00 90 $2,185.00 90 $2,116.00 90 $2,306.00 90 BR 0 $262.00 0 CPT only © 1999 American Medical Association. All Rights Reserved. 68 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Radiology CPT Code 70010 70010-26 70010-TC 70015 70015-26 70015-TC 70030 70030-26 70030-TC 70100 70100-26 70100-TC 70110 70110-26 70110-TC 70120 70120-26 70120-TC 70130 70130-26 70130-TC 70134 70134-26 70134-TC 70140 70140-26 70140-TC 70150 70150-26 70150-TC 70160 70160-26 70160-TC 70170 70170-26 70170-TC 70190 70190-26 70190-TC 70200 70200-26 70200-TC 70210 70210-26 70210-TC 70220 70220-26 70220-TC 70240 70240-26 MRA $63.00 NC NC $52.00 NC NC $24.00 $10.00 $15.00 $27.00 $9.00 $18.00 $34.00 $12.00 $22.00 $31.00 $9.00 $22.00 $44.00 $17.00 $28.00 $42.00 $16.00 $26.00 $31.00 $9.00 $22.00 $40.00 $12.00 $28.00 $26.00 $8.00 $18.00 $48.00 NC NC $32.00 $10.00 $22.00 $41.00 $13.00 $28.00 $30.00 $8.00 $22.00 $40.00 $12.00 $28.00 $24.00 $9.00 Radiology CPT Code 70240-TC 70250 70250-26 70250-TC 70260 70260-26 70260-TC 70300 70300-26 70300-TC 70310 70310-26 70310-TC 70320 70320-26 70320-TC 70328 70328-26 70328-TC 70330 70330-26 70330-TC 70332 70332-26 70332-TC 70336 70336-26 70336-TC 70350 70350-26 70350-TC 70355 70355-26 70360 70360-26 70360-TC 70370 70370-26 70370-TC 70371 70371-26 70371-TC 70373 70373-26 70373-TC 70380 70380-26 70380-TC 70390 70390-26 MRA $15.00 $33.00 $12.00 $22.00 $48.00 $16.00 $32.00 $15.00 $5.00 $10.00 $23.00 $8.00 $15.00 $38.00 $11.00 $28.00 $27.00 $10.00 $17.00 $41.00 $12.00 $30.00 $100.00 NC NC $459.00 $65.00 $394.00 $24.00 $10.00 $14.00 $30.00 $10.00 $23.00 $8.00 $15.00 $61.00 $15.00 $46.00 $113.00 $39.00 $74.00 $84.00 NC NC $32.00 $8.00 $23.00 $81.00 NC CPT only © 1999 American Medical Association. All Rights Reserved. Radiology CPT Code 70390-TC 70450 70450-26 70450-TC 70460 70460-26 70460-TC 70470 70470-26 70470-TC 70480 70480-26 70480-TC 70481 70481-26 70481-TC 70482 70482-26 70482-TC 70486 70486-26 70486-TC 70487 70487-26 70487-TC 70488 70488-26 70488-TC 70490 70490-26 70490-TC 70491 70491-26 70491-TC 70492 70492-26 70492-TC 70540 70540-26 70540-TC 70541 70541-26 70541-TC 70551 70551-26 70551-TC 70552 70552-26 70552-TC 70553 MRA NC $206.00 $41.00 $166.00 $252.00 $53.00 $199.00 $308.00 $59.00 $248.00 $226.00 $60.00 $166.00 $263.00 $64.00 $199.00 $316.00 $68.00 $248.00 $219.00 $53.00 $166.00 $260.00 $61.00 $199.00 $315.00 $67.00 $248.00 $226.00 $60.00 $166.00 $263.00 $64.00 $199.00 $316.00 $68.00 $248.00 $463.00 $70.00 $394.00 $476.00 $82.00 $394.00 $463.00 $70.00 $394.00 $556.00 $84.00 $472.00 $985.00 69 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Radiology CPT Code MRA 70553-26 $111.00 70553-TC $875.00 71010 $25.00 71010-26 $9.00 71010-TC $17.00 71015 $28.00 71015-26 $10.00 71015-TC $18.00 71020 $32.00 71020-26 $11.00 71020-TC $22.00 71021 $39.00 71021-26 $13.00 71021-TC $26.00 71022 $41.00 71022-26 $15.00 71022-TC $26.00 71023 $46.00 71023-26 $18.00 71023-TC $28.00 71030 $42.00 71030-26 $15.00 71030-TC $28.00 71034 $73.00 71034-26 $22.00 71034-TC $51.00 71035 $56.00 71035-26 $19.00 71035-TC $38.00 71036 $81.00 71036-26 NC 71036-TC NC 71040 $31.00 71040-26 NC 71040-TC NC 71060 $97.00 71060-26 NC 71060-TC NC 71090 $86.00 71090-26 NC 71090-TC NC 71100 $31.00 71100-26 $11.00 71100-TC $20.00 71101 $36.00 71101-26 $13.00 71101-TC $23.00 71110 $41.00 71110-26 $13.00 71110-TC $28.00 Radiology CPT Code 71111 71111-26 71111-TC 71120 71120-26 71120-TC 71130 71130-26 71130-TC 71250 71250-26 71250-TC 71260 71260-26 71260-TC 71270 71270-26 71270-TC 71550 71550-26 71550-TC 71555 71555-26 71555-TC 72010 72010-26 72010-TC 72020 72020-26 72020-TC 72040 72040-26 72040-TC 72050 72050-26 72050-TC 72052 72052-26 72052-TC 72069 72069-26 72069-TC 72070 72070-26 72070-TC 72072 72072-26 72072-TC 72074 72074-26 MRA $47.00 $15.00 $32.00 $32.00 $10.00 $23.00 $35.00 $11.00 $25.00 $262.00 $54.00 $208.00 $307.00 $58.00 $248.00 $375.00 $64.00 $311.00 $469.00 $75.00 $394.00 $477.00 $83.00 $394.00 $58.00 $21.00 $36.00 $22.00 $7.00 $15.00 $32.00 $11.00 $21.00 $46.00 $15.00 $32.00 $57.00 $17.00 $40.00 $40.00 $17.00 $24.00 $33.00 $11.00 $23.00 $37.00 $11.00 $26.00 $43.00 $11.00 CPT only © 1999 American Medical Association. All Rights Reserved. Radiology CPT Code 72074-TC 72080 72080-26 72080-TC 72090 72090-26 72090-TC 72100 72100-26 72100-TC 72110 72110-26 72110-TC 72114 72114-26 72114-TC 72120 72120-26 72120-TC 72125 72125-26 72125-TC 72126 72126-26 72126-TC 72127 72127-26 72127-TC 72128 72128-26 72128-TC 72129 72129-26 72129-TC 72130 72130-26 72130-TC 72131 72131-26 72131-TC 72132 72132-26 72132-TC 72133 72133-26 72133-TC 72141 72141-26 72141-TC 72142 MRA $32.00 $34.00 $11.00 $23.00 $37.00 $13.00 $23.00 $34.00 $11.00 $23.00 $47.00 $15.00 $32.00 $59.00 $17.00 $42.00 $42.00 $11.00 $32.00 $262.00 $54.00 $208.00 $306.00 $57.00 $248.00 $370.00 $59.00 $311.00 $262.00 $54.00 $208.00 $306.00 $57.00 $248.00 $370.00 $59.00 $311.00 $262.00 $54.00 $208.00 $306.00 $57.00 $248.00 $349.00 $60.00 $288.00 $469.00 $75.00 $394.00 $562.00 70 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Radiology CPT Code 72142-26 72142-TC 72146 72146-26 72146-TC 72147 72147-26 72147-TC 72148 72148-26 72148-TC 72149 72149-26 72149-TC 72156 72156-26 72156-TC 72157 72157-26 72157-TC 72158 72158-26 72158-TC 72159 72159-26 72159-TC 72170 72170-26 72170-TC 72190 72190-26 72190-TC 72192 72192-26 72192-TC 72193 72193-26 72193-TC 72194 72194-26 72194-TC 72196 72196-26 72196-TC 72198 72198-26 72198-TC 72200 72200-26 72200-TC MRA $90.00 $472.00 $512.00 $75.00 $437.00 $562.00 $90.00 $472.00 $507.00 $70.00 $437.00 $556.00 $84.00 $472.00 $995.00 $120.00 $875.00 $995.00 $120.00 $875.00 $985.00 $111.00 $875.00 $522.00 $85.00 $437.00 $26.00 $8.00 $18.00 $34.00 $10.00 $23.00 $259.00 $51.00 $208.00 $295.00 $54.00 $241.00 $355.00 $57.00 $298.00 $469.00 $75.00 $394.00 $480.00 $86.00 $394.00 $26.00 $9.00 $18.00 Radiology CPT Code 72202 72202-26 72202-TC 72220 72220-26 72220-TC 72240 72240-26 72240-TC 72255 72255-26 72255-TC 72265 72265-26 72265-TC 72270 72270-26 72270-TC 72275 72275-26 72275-TC 72285 72285-26 72285-TC 72295 72295-26 72295-TC 73000 73000-26 73000-TC 73010 73010-26 73010-TC 73020 73020-26 73020-TC 73030 73030-26 73030-TC 73040 73040-26 73040-TC 73050 73050-26 73050-TC 73060 73060-26 73060-TC 73070 73070-26 MRA $31.00 $9.00 $22.00 $28.00 $8.00 $20.00 $118.00 NC NC $115.00 NC NC $118.00 NC NC $158.00 NC NC $100.00 NC NC $91.00 NC NC $96.00 NC NC $26.00 $8.00 $18.00 $26.00 $8.00 $18.00 $24.00 $7.00 $17.00 $29.00 $9.00 $20.00 $62.00 NC NC $33.00 $10.00 $23.00 $28.00 $8.00 $20.00 $25.00 $7.00 CPT only © 1999 American Medical Association. All Rights Reserved. Radiology CPT Code 73070-TC 73080 73080-26 73080-TC 73085 73085-26 73085-TC 73090 73090-26 73090-TC 73100 73100-26 73100-TC 73110 73110-26 73110-TC 73115 73115-26 73115-TC 73120 73120-26 73120-TC 73130 73130-26 73130-TC 73140 73140-26 73140-TC 73200 73200-26 73200-TC 73201 73201-26 73201-TC 73202 73202-26 73202-TC 73220 73220-26 73220-TC 73221 73221-26 73221-TC 73225 73225-26 73225-TC 73500 73500-26 73500-TC 73510 MRA $18.00 $28.00 $8.00 $20.00 $67.00 NC NC $26.00 $8.00 $18.00 $25.00 $8.00 $17.00 $27.00 $8.00 $18.00 $49.00 NC NC $25.00 $8.00 $17.00 $27.00 $8.00 $18.00 $21.00 $7.00 $15.00 $225.00 $51.00 $174.00 $262.00 $54.00 $208.00 $318.00 $57.00 $261.00 $463.00 $70.00 $394.00 $459.00 $65.00 $394.00 $476.00 $83.00 $394.00 $25.00 $8.00 $17.00 $30.00 71 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Radiology CPT Code 73510-26 73510-TC 73520 73520-26 73520-TC 73525 73525-26 73525-TC 73530 73530-26 73530-TC 73542 73542-26 73542-TC 73550 73550-26 73550-TC 73560 73560-26 73560-TC 73562 73562-26 73562-TC 73564 73564-26 73564-TC 73565 73565-26 73565-TC 73580 73580-26 73580-TC 73590 73590-26 73590-TC 73600 73600-26 73600-TC 73610 73610-26 73610-TC 73615 73615-26 73615-TC 73620 73620-26 73620-TC 73630 73630-26 73630-TC MRA $10.00 $20.00 $36.00 $12.00 $23.00 $75.00 NC NC $32.00 $14.00 $18.00 $97.00 NC NC $28.00 $8.00 $20.00 $26.00 $8.00 $18.00 $29.00 $9.00 $20.00 $32.00 $11.00 $22.00 $26.00 $8.00 $17.00 $75.00 NC NC $26.00 $8.00 $18.00 $25.00 $8.00 $17.00 $27.00 $8.00 $18.00 $65.00 NC NC $25.00 $8.00 $17.00 $27.00 $8.00 $18.00 Radiology CPT Code 73650 73650-26 73650-TC 73660 73660-26 73660-TC 73700 73700-26 73700-TC 73701 73701-26 73701-TC 73702 73702-26 73702-TC 73720 73720-26 73720-TC 73721 73721-26 73721-TC 73725 73725-26 73725-TC 74000 74000-26 74000-TC 74010 74010-26 74010-TC 74020 74020-26 74020-TC 74022 74022-26 74022-TC 74150 74150-26 74150-TC 74160 74160-26 74160-TC 74170 74170-26 74170-TC 74181 74181-26 74181-TC 74185 74185-26 MRA $25.00 $8.00 $17.00 $21.00 $7.00 $15.00 $225.00 $51.00 $174.00 $266.00 $61.00 $208.00 $318.00 $57.00 $261.00 $463.00 $70.00 $394.00 $459.00 $65.00 $394.00 $476.00 $83.00 $394.00 $27.00 $9.00 $18.00 $31.00 $11.00 $20.00 $35.00 $13.00 $22.00 $41.00 $15.00 $26.00 $255.00 $56.00 $199.00 $300.00 $59.00 $241.00 $364.00 $66.00 $298.00 $481.00 $85.00 $396.00 $477.00 $83.00 CPT only © 1999 American Medical Association. All Rights Reserved. Radiology CPT Code 74185-TC 74190 74190-26 74190-TC 74210 74210-26 74210-TC 74220 74220-26 74220-TC 74230 74230-26 74230-TC 74235 74235-26 74235-TC 74240 74240-26 74240-TC 74241 74241-26 74241-TC 74245 74245-26 74245-TC 74246 74246-26 74246-TC 74247 74247-26 74247-TC 74249 74249-26 74249-TC 74250 74250-26 74250-TC 74251 74251-26 74251-TC 74260 74260-26 74260-TC 74270 74270-26 74270-TC 74280 74280-26 74280-TC 74283 MRA $394.00 $67.00 NC NC $59.00 $17.00 $42.00 $64.00 $22.00 $42.00 $71.00 $25.00 $46.00 $148.00 NC NC $84.00 $33.00 $51.00 $85.00 $33.00 $52.00 $127.00 $43.00 $84.00 $91.00 $33.00 $58.00 $92.00 $33.00 $60.00 $133.00 $43.00 $90.00 $68.00 $22.00 $46.00 $77.00 $31.00 $46.00 $76.00 $24.00 $52.00 $93.00 $33.00 $60.00 $125.00 $47.00 $79.00 $185.00 72 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Radiology CPT Code 74283-26 74283-TC 74290 74290-26 74290-TC 74291 74291-26 74291-TC 74300 74300-26 74300-TC 74301 74301-26 74301-TC 74305 74305-26 74305-TC 74320 74320-26 74320-TC 74327 74327-26 74327-TC 74328 74328-26 74328-TC 74329 74329-26 74329-TC 74330 74330-26 74330-TC 74340 74340-26 74340-TC 74350 74350-26 74350-TC 74355 74355-26 74355-TC 74360 74360-26 74360-TC 74363 74363-26 74363-TC 74400 74400-26 74400-TC MRA $95.00 $90.00 $41.00 $15.00 $26.00 $24.00 $10.00 $15.00 $30.00 NC NC BR NC NC $48.00 NC NC $136.00 NC NC $95.00 NC NC $144.00 NC NC $144.00 NC NC $152.00 NC NC $109.00 NC NC $147.00 NC NC $128.00 NC NC $137.00 NC NC $256.00 NC NC $83.00 $23.00 $60.00 Radiology CPT Code 74410 74410-26 74410-TC 74415 74415-26 74415-TC 74420 74420-26 74420-TC 74425 74425-26 74425-TC 74430 74430-26 74430-TC 74440 74440-26 74440-TC 74445 74445-26 74445-TC 74450 74450-26 74450-TC 74455 74455-26 74455-TC 74470 74470-26 74470-TC 74475 74475-26 74475-TC 74480 74480-26 74480-TC 74485 74485-26 74485-TC 74710 74710-26 74710-TC 74740 74740-26 74740-TC 74742 74742-26 74742-TC 74775 74775-26 MRA $92.00 $23.00 $69.00 $98.00 $23.00 $75.00 $109.00 $17.00 $92.00 $63.00 NC NC $44.00 NC NC $58.00 NC NC $94.00 NC NC $54.00 NC NC $68.00 NC NC $69.00 NC NC $169.00 NC NC $169.00 NC NC $136.00 NC NC $53.00 $16.00 $37.00 $64.00 NC NC $139.00 NC NC $81.00 $30.00 CPT only © 1999 American Medical Association. All Rights Reserved. Radiology CPT Code 74775-TC 75552 75552-26 75552-TC 75553 75553-26 75553-TC 75554 75554-26 75554-TC 75555 75555-26 75555-TC 75600 75600-26 75600-TC 75605 75605-26 75605-TC 75625 75625-26 75625-TC 75630 75630-26 75630-TC 75650 75650-26 75650-TC 75658 75658-26 75658-TC 75660 75660-26 75660-TC 75662 75662-26 75662-TC 75665 75665-26 75665-TC 75671 75671-26 75671-TC 75676 75676-26 75676-TC 75680 75680-26 75680-TC 75685 MRA $51.00 $469.00 $75.00 $394.00 $484.00 $90.00 $394.00 $479.00 $85.00 $394.00 $477.00 $83.00 $394.00 $467.00 NC NC $163.00 NC NC $128.00 NC NC $213.00 NC NC $195.00 NC NC $506.00 NC NC $504.00 NC NC $522.00 NC NC $505.00 NC NC $196.00 NC NC $505.00 NC NC $185.00 NC NC $143.00 73 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Radiology CPT Code 75685-26 75685-TC 75705 75705-26 75705-TC 75710 75710-26 75710-TC 75716 75716-26 75716-TC 75722 75722-26 75722-TC 75724 75724-26 75724-TC 75726 75726-26 75726-TC 75731 75731-26 75731-TC 75733 75733-26 75733-TC 75736 75736-26 75736-TC 75741 75741-26 75741-TC 75743 75743-26 75743-TC 75746 75746-26 75746-TC 75756 75756-26 75756-TC 75774 75774-26 75774-TC 75790 75790-26 75790-TC 75801 75801-26 75801-TC MRA NC NC $545.00 NC NC $174.00 NC NC $262.00 NC NC $184.00 NC NC $191.00 NC NC $496.00 NC NC $496.00 NC NC $504.00 NC NC $496.00 NC NC $504.00 NC NC $226.00 NC NC $496.00 NC NC $163.00 NC NC $72.00 NC NC $135.00 NC NC $229.00 NC NC Radiology CPT Code 75803 75803-26 75803-TC 75805 75805-26 75805-TC 75807 75807-26 75807-TC 75809 75809-26 75809-TC 75810 75810-26 75810-TC 75820 75820-26 75820-TC 75822 75822-26 75822-TC 75825 75825-26 75825-TC 75827 75827-26 75827-TC 75831 75831-26 75831-TC 75833 75833-26 75833-TC 75840 75840-26 75840-TC 75842 75842-26 75842-TC 75860 75860-26 75860-TC 75870 75870-26 75870-TC 75872 75872-26 75872-TC 75880 75880-26 MRA $245.00 NC NC $253.00 NC NC $269.00 NC NC $50.00 NC NC $496.00 NC NC $67.00 NC NC $102.00 NC NC $174.00 NC NC $496.00 NC NC $49.00 NC NC $512.00 NC NC $496.00 NC NC $512.00 NC NC $496.00 NC NC $496.00 NC NC $496.00 NC NC $67.00 NC CPT only © 1999 American Medical Association. All Rights Reserved. Radiology CPT Code 75880-TC 75885 75885-26 75885-TC 75887 75887-26 75887-TC 75889 75889-26 75889-TC 75891 75891-26 75891-TC 75893 75893-26 75893-TC 75894 75894-26 75894-TC 75896 75896-26 75896-TC 75898 75898-26 75898-TC 75900 75900-26 75900-TC 75940 75940-26 75940-TC 75945 75945-26 75945-TC 75946 75946-26 75946-TC 75960 75960-26 75960-TC 75961 75961-26 75961-TC 75962 75962-26 75962-TC 75964 75964-26 75964-TC 75966 MRA NC $510.00 NC NC $510.00 NC NC $496.00 NC NC $496.00 NC NC $468.00 NC NC $909.00 NC NC $215.00 NC NC $115.00 $78.00 $37.00 $760.00 NC NC $136.00 NC NC $182.00 NC NC $101.00 $20.00 $81.00 $562.00 NC NC $568.00 NC NC $579.00 NC NC $312.00 NC NC $616.00 74 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Radiology CPT Code 75966-26 75966-TC 75968 75968-26 75968-TC 75970 75970-26 75970-TC 75978 75978-26 75978-TC 75980 75980-26 75980-TC 75982 75982-26 75982-TC 75984 75984-26 75984-TC 75989 75989-26 75989-TC 75992 75992-26 75992-TC 75993 75993-26 75993-TC 75994 75994-26 75994-TC 75995 75995-26 75995-TC 75996 75996-26 75996-TC 76000 76000-26 76000-TC 76001 76001-26 76001-TC 76003 76003-26 76003-TC 76005 76005-26 76005-TC MRA NC NC $312.00 NC NC $445.00 NC NC $583.00 NC NC $258.00 NC NC $282.00 NC NC $103.00 NC NC $167.00 NC NC $579.00 NC NC $312.00 NC NC $616.00 NC NC $615.00 NC NC $312.00 NC NC $54.00 $8.00 $46.00 $124.00 $32.00 $92.00 $71.00 $25.00 $46.00 $72.00 $26.00 $45.00 Radiology CPT Code 76006 76020 76020-26 76020-TC 76040 76040-26 76040-TC 76061 76061-26 76061-TC 76062 76062-26 76062-TC 76066 76066-26 76066-TC 76070 76070-26 76070-TC 76075 76075-26 76075-TC 76076 76076-26 76076-TC 76078 76078-26 76078-TC 76080 76080-26 76080-TC 76086 76086-26 76086-TC 76088 76088-26 76088-TC 76090 76090-26 76090-TC 76091 76091-26 76091-TC 76093 76093-26 76093-TC 76094 76094-26 76094-TC 76095 MRA $18.00 $27.00 $9.00 $18.00 $41.00 $13.00 $28.00 $56.00 $21.00 $35.00 $76.00 $25.00 $51.00 $54.00 $15.00 $39.00 $116.00 $13.00 $104.00 $123.00 $14.00 $109.00 $37.00 $11.00 $27.00 $37.00 $10.00 $27.00 $63.00 NC NC $109.00 NC NC $150.00 NC NC $62.00 $16.00 $37.00 $76.00 $27.00 $46.00 $695.00 $76.00 $619.00 $916.00 $76.00 $840.00 $327.00 CPT only © 1999 American Medical Association. All Rights Reserved. Radiology CPT Code 76095-26 76095-TC 76096 76096-26 76096-TC 76098 76098-26 76098-TC 76100 76100-26 76100-TC 76101 76101-26 76101-TC 76102 76102-26 76102-TC 76120 76120-26 76120-TC 76125 76125-26 76125-TC 76140 76150 76350 76355 76355-26 76355-TC 76360 76360-26 76360-TC 76365 76365-26 76365-TC 76370 76370-26 76370-TC 76375 76375-26 76375-TC 76380 76380-26 76380-TC 76390 76390-26 76390-TC 76400 76400-26 76400-TC MRA NC NC $72.00 NC NC $23.00 $8.00 $15.00 $71.00 $27.00 $44.00 $94.00 $36.00 $59.00 $89.00 $27.00 $61.00 $157.00 $56.00 $102.00 $49.00 $17.00 $33.00 $30.00 $15.00 BR $347.00 $57.00 $290.00 $150.00 NC NC $179.00 NC NC $144.00 $40.00 $104.00 $132.00 $8.00 $124.00 $169.00 $46.00 $123.00 $460.00 $66.00 $394.00 $469.00 $75.00 $394.00 75 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Radiology CPT Code 76499 76499-26 76499-TC 76506 76506-26 76506-TC 76511 76511-26 76511-TC 76512 76512-26 76512-TC 76513 76513-26 76513-TC 76516 76516-26 76516-TC 76519 76519-26 76519-TC 76529 76529-26 76529-TC 76536 76536-26 76536-TC 76604 76604-26 76604-TC 76645 76645-26 76645-TC 76700 76700-26 76700-TC 76705 76705-26 76705-TC 76770 76770-26 76770-TC 76775 76775-26 76775-TC 76778 76778-26 76778-TC 76800 76800-26 MRA BR BR BR $81.00 $30.00 $50.00 $87.00 $44.00 $44.00 $87.00 $33.00 $54.00 $87.00 $33.00 $54.00 $94.00 $37.00 $57.00 $79.00 $31.00 $48.00 $77.00 $29.00 $48.00 $83.00 $31.00 $52.00 $72.00 $26.00 $46.00 $69.00 $31.00 $39.00 $107.00 $38.00 $69.00 $78.00 $28.00 $50.00 $104.00 $35.00 $69.00 $78.00 $27.00 $50.00 $104.00 $35.00 $69.00 $112.00 $61.00 Radiology CPT Code 76800-TC 76805 76805-26 76805-TC 76810 76810-26 76810-TC 76815 76815-26 76815-TC 76816 76816-26 76816-TC 76818 76818-26 76818-TC 76825 76825-26 76825-TC 76826 76826-26 76826-TC 76827 76827-26 76827-TC 76828 76828-26 76828-TC 76830 76830-26 76830-TC 76831 76831-26 76831-TC 76856 76856-26 76856-TC 76857 76857-26 76857-TC 76870 76870-26 76870-TC 76872 76872-26 76872-TC 76873 76873-26 76873-TC 76880 MRA $52.00 $121.00 $47.00 $74.00 $241.00 $93.00 $148.00 $81.00 $31.00 $50.00 $67.00 $27.00 $39.00 $94.00 $37.00 $57.00 $143.00 $59.00 $69.00 $71.00 $46.00 $25.00 $96.00 $35.00 $61.00 $68.00 $28.00 $40.00 $86.00 $33.00 $54.00 $88.00 $34.00 $54.00 $86.00 $33.00 $54.00 $55.00 $18.00 $37.00 $84.00 $30.00 $54.00 $89.00 $36.00 $54.00 $136.00 $62.00 $74.00 $83.00 CPT only © 1999 American Medical Association. All Rights Reserved. Radiology CPT Code 76880-26 76880-TC 76930 76930-26 76930-TC 76932 76932-26 76932-TC 76934 76934-26 76934-TC 76936 76936-26 76936-TC 76938 76938-26 76938-TC 76941 76941-26 76941-TC 76942 76942-26 76942-TC 76945 76945-26 76945-TC 76946 76946-26 76946-TC 76948 76948-26 76948-TC 76950 76950-26 76950-TC 76960 76960-26 76960-TC 76965 76965-26 76965-TC 76970 76970-26 76970-TC 76975 76975-26 76975-TC 76977 76977-26 76977-TC MRA $32.00 $52.00 $86.00 NC NC $87.00 NC NC $85.00 NC NC $323.00 $93.00 $221.00 $85.00 NC NC $119.00 NC NC $86.00 NC NC $91.00 NC NC $72.00 NC NC $72.00 NC NC $74.00 $28.00 $46.00 $74.00 $28.00 $46.00 $276.00 $84.00 $196.00 $56.00 $19.00 $37.00 $92.00 NC NC $31.00 $3.00 $29.00 76 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Radiology CPT Code 76986 76986-26 76986-TC 76999 76999-26 76999-TC 77261 77262 77263 77280 77280-26 77280-TC 77285 77285-26 77285-TC 77290 77290-26 77290-TC 77295 77295-26 77295-TC 77299 77299-26 77299-TC 77300 77300-26 77300-TC 77305 77305-26 77305-TC 77310 77310-26 77310-TC 77315 77315-26 77315-TC 77321 77321-26 77321-TC 77326 77326-26 77326-TC 77327 77327-26 77327-TC 77328 77328-26 77328-TC 77331 77331-26 MRA $149.00 $57.00 $92.00 BR BR BR $67.00 $102.00 $151.00 $155.00 $34.00 $122.00 $246.00 $50.00 $196.00 $304.00 $75.00 $229.00 $1,200.00 $218.00 $982.00 BR BR BR $87.00 $36.00 $52.00 $99.00 $34.00 $66.00 $132.00 $50.00 $82.00 $168.00 $75.00 $93.00 $187.00 $46.00 $142.00 $128.00 $45.00 $83.00 $188.00 $66.00 $122.00 $274.00 $99.00 $174.00 $59.00 $41.00 Radiology CPT Code 77331-TC 77332 77332-26 77332-TC 77333 77333-26 77333-TC 77334 77334-26 77334-TC 77336 77370 77399 77399-26 77399-TC 77401 77402 77403 77404 77406 77407 77408 77409 77411 77412 77413 77414 77416 77417 77427 77431 77432 77470 77470-26 77470-TC 77499 77499-26 77499-TC 77520 77523 77600 77600-26 77600-TC 77605 77605-26 77605-TC 77610 77610-26 77610-TC 77615 MRA $18.00 $73.00 $26.00 $47.00 $107.00 $40.00 $67.00 $173.00 $59.00 $114.00 $105.00 $122.00 BR BR BR $63.00 $63.00 $63.00 $63.00 $63.00 $74.00 $74.00 $74.00 $74.00 $82.00 $82.00 $82.00 $82.00 $21.00 $149.00 $88.00 $409.00 $491.00 $100.00 $392.00 BR BR BR BR BR $181.00 $74.00 $107.00 $244.00 $101.00 $143.00 $181.00 $74.00 $107.00 $242.00 CPT only © 1999 American Medical Association. All Rights Reserved. Radiology CPT Code 77615-26 77615-TC 77620 77620-26 77620-TC 77750 77750-26 77750-TC 77761 77761-26 77761-TC 77762 77762-26 77762-TC 77763 77763-26 77763-TC 77776 77776-26 77776-TC 77777 77777-26 77777-TC 77778 77778-26 77778-TC 77781 77781-26 77781-TC 77782 77782-26 77782-TC 77783 77783-26 77783-TC 77784 77784-26 77784-TC 77789 77789-26 77789-TC 77790 77790-26 77790-TC 77799 77799-26 77799-TC 78000 78000-26 78000-TC MRA $99.00 $143.00 $183.00 $76.00 $107.00 $278.00 $231.00 $47.00 $266.00 $178.00 $88.00 $398.00 $271.00 $127.00 $563.00 $405.00 $158.00 $293.00 $216.00 $77.00 $504.00 $355.00 $149.00 $708.00 $527.00 $181.00 $792.00 $79.00 $713.00 $831.00 $118.00 $713.00 $889.00 $176.00 $713.00 $977.00 $264.00 $713.00 $69.00 $53.00 $16.00 $68.00 $50.00 $18.00 BR BR BR $44.00 $9.00 $34.00 77 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Radiology CPT Code 78001 78001-26 78001-TC 78003 78003-26 78003-TC 78006 78006-26 78006-TC 78007 78007-26 78007-TC 78010 78010-26 78010-TC 78011 78011-26 78011-TC 78015 78015-26 78015-TC 78016 78016-26 78016-TC 78018 78018-26 78018-TC 78020 78020-26 78020-TC 78070 78070-26 78070-TC 78075 78075-26 78075-TC 78099 78099-26 78099-TC 78102 78102-26 78102-TC 78103 78103-26 78103-TC 78104 78104-26 78104-TC 78110 78110-26 MRA $58.00 $12.00 $46.00 $50.00 $16.00 $34.00 $107.00 $23.00 $84.00 $114.00 $24.00 $90.00 $83.00 $18.00 $64.00 $106.00 $21.00 $85.00 $122.00 $32.00 $90.00 $161.00 $39.00 $122.00 $232.00 $41.00 $191.00 $32.00 $27.00 $5.00 $100.00 $33.00 $64.00 $226.00 $35.00 $191.00 BR BR BR $98.00 $26.00 $72.00 $147.00 $36.00 $112.00 $181.00 $38.00 $143.00 $43.00 $9.00 Radiology CPT Code 78110-TC 78111 78111-26 78111-TC 78120 78120-26 78120-TC 78121 78121-26 78121-TC 78122 78122-26 78122-TC 78130 78130-26 78130-TC 78135 78135-26 78135-TC 78140 78140-26 78140-TC 78160 78160-26 78160-TC 78162 78162-26 78162-TC 78170 78170-26 78170-TC 78172 78172-26 78172-TC 78185 78185-26 78185-TC 78190 78190-26 78190-TC 78191 78191-26 78191-TC 78195 78195-26 78195-TC 78199 78199-26 78199-TC 78201 MRA $34.00 $101.00 $11.00 $90.00 $73.00 $11.00 $61.00 $117.00 $15.00 $102.00 $183.00 $21.00 $162.00 $129.00 $29.00 $100.00 $201.00 $30.00 $171.00 $167.00 $29.00 $138.00 $144.00 $16.00 $129.00 $134.00 $22.00 $113.00 $206.00 $19.00 $186.00 BR $25.00 BR $102.00 $19.00 $83.00 $253.00 $52.00 $201.00 $286.00 $29.00 $257.00 $196.00 $45.00 $143.00 BR BR BR $104.00 CPT only © 1999 American Medical Association. All Rights Reserved. Radiology CPT Code 78201-26 78201-TC 78202 78202-26 78202-TC 78205 78205-26 78205-TC 78206 78206-26 78206-TC 78215 78215-26 78215-TC 78216 78216-26 78216-TC 78220 78220-26 78220-TC 78223 78223-26 78223-TC 78230 78230-26 78230-TC 78231 78231-26 78231-TC 78232 78232-26 78232-TC 78258 78258-26 78258-TC 78261 78261-26 78261-TC 78262 78262-26 78262-TC 78264 78264-26 78264-TC 78267 78267-26 78267-TC 78268 78268-26 78268-TC MRA $21.00 $83.00 $125.00 $24.00 $101.00 $242.00 $34.00 $208.00 $241.00 $42.00 $199.00 $126.00 $23.00 $103.00 $149.00 $27.00 $122.00 $154.00 $23.00 $131.00 $168.00 $39.00 $129.00 $99.00 $22.00 $77.00 $136.00 $25.00 $112.00 $147.00 $22.00 $124.00 $136.00 $35.00 $101.00 $177.00 $33.00 $144.00 $182.00 $32.00 $149.00 $182.00 $37.00 $145.00 BR BR BR BR BR BR 78 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Radiology CPT Code 78270 78270-26 78270-TC 78271 78271-26 78271-TC 78272 78272-26 78272-TC 78278 78278-26 78278-TC 78282 78282-26 78282-TC 78290 78290-26 78290-TC 78291 78291-26 78291-TC 78299 78299-26 78299-TC 78300 78300-26 78300-TC 78305 78305-26 78305-TC 78306 78306-26 78306-TC 78315 78315-26 78315-TC 78320 78320-26 78320-TC 78350 78350-26 78350-TC 78351 78351-26 78351-TC 78399 78399-26 78399-TC 78414 78414-26 MRA $65.00 $10.00 $55.00 $68.00 $10.00 $58.00 $95.00 $13.00 $82.00 $218.00 $47.00 $171.00 BR $18.00 BR $139.00 $32.00 $107.00 $149.00 $41.00 $108.00 BR BR BR $117.00 $29.00 $88.00 $168.00 $39.00 $129.00 $190.00 $40.00 $150.00 $216.00 $48.00 $168.00 $257.00 $49.00 $208.00 $37.00 $11.00 $27.00 $22.00 $5.00 $12.00 BR BR BR BR $22.00 Radiology CPT Code 78414-TC 78428 78428-26 78428-TC 78445 78445-26 78445-TC 78455 78455-26 78455-TC 78456 78456-26 78456-TC 78457 78457-26 78457-TC 78458 78458-26 78458-TC 78459 78459-26 78459-TC 78460 78460-26 78460-TC 78461 78461-26 78461-TC 78464 78464-26 78464-TC 78465 78465-26 78465-TC 78466 78466-26 78466-TC 78468 78468-26 78468-TC 78469 78469-26 78469-TC 78472 78472-26 78472-TC 78473 78473-26 78473-TC 78478 MRA BR $118.00 $38.00 $80.00 $94.00 $28.00 $66.00 $175.00 $35.00 $140.00 $185.00 $45.00 $140.00 $130.00 $36.00 $93.00 $183.00 $42.00 $141.00 BR $100.00 BR $124.00 $41.00 $83.00 $294.00 $82.00 $213.00 $300.00 $51.00 $248.00 $484.00 $70.00 $414.00 $125.00 $33.00 $92.00 $166.00 $38.00 $129.00 $227.00 $44.00 $184.00 $241.00 $47.00 $194.00 $359.00 $70.00 $290.00 $85.00 CPT only © 1999 American Medical Association. All Rights Reserved. Radiology CPT Code 78478-26 78478-TC 78480 78480-26 78480-TC 78481 78481-26 78481-TC 78483 78483-26 78483-TC 78491 78491-26 78491-TC 78492 78492-26 78492-TC 78494 78494-26 78494-TC 78496 78496-26 78496-TC 78499 78499-26 78499-TC 78580 78580-26 78580-TC 78584 78584-26 78584-TC 78585 78585-26 78585-TC 78586 78586-26 78586-TC 78587 78587-26 78587-TC 78588 78588-26 78588-TC 78591 78591-26 78591-TC 78593 78593-26 78593-TC MRA $30.00 $55.00 $85.00 $30.00 $55.00 $231.00 $47.00 $184.00 $347.00 $71.00 $277.00 BR $85.00 BR BR $100.00 BR $296.00 $53.00 $243.00 $83.00 $23.00 $60.00 BR BR BR $153.00 $35.00 $115.00 $159.00 $47.00 $113.00 $153.00 $33.00 $119.00 $110.00 $19.00 $91.00 $121.00 $23.00 $98.00 $239.00 $48.00 $192.00 $119.00 $19.00 $100.00 $136.00 $23.00 $113.00 79 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Radiology CPT Code 78594 78594-26 78594-TC 78596 78596-26 78596-TC 78599 78599-26 78599-TC 78600 78600-26 78600-TC 78601 78601-26 78601-TC 78605 78605-26 78605-TC 78606 78606-26 78606-TC 78607 78607-26 78607-TC 78608 78608-26 78608-TC 78609 78609-26 78609-TC 78610 78610-26 78610-TC 78615 78615-26 78615-TC 78630 78630-26 78630-TC 78635 78635-26 78635-TC 78645 78645-26 78645-TC 78647 78647-26 78647-TC 78650 78650-26 MRA $200.00 $25.00 $175.00 $308.00 $60.00 $248.00 BR BR BR $122.00 $21.00 $101.00 $144.00 $24.00 $119.00 $145.00 $25.00 $119.00 $221.00 $45.00 $177.00 $289.00 $58.00 $231.00 BR BR BR BR BR BR $70.00 $14.00 $56.00 $156.00 $20.00 $135.00 $210.00 $32.00 $177.00 $120.00 $30.00 $90.00 $147.00 $27.00 $120.00 $250.00 $42.00 $208.00 $192.00 $29.00 Radiology CPT Code 78650-TC 78660 78660-26 78660-TC 78699 78699-26 78699-TC 78700 78700-26 78700-TC 78701 78701-26 78701-TC 78704 78704-26 78704-TC 78707 78707-26 78707-TC 78708 78708-26 78708-TC 78709 78709-26 78709-TC 78710 78710-26 78710-TC 78715 78715-26 78715-TC 78725 78725-26 78725-TC 78730 78730-26 78730-TC 78740 78740-26 78740-TC 78760 78760-26 78760-TC 78761 78761-26 78761-TC 78799 78799-26 78799-TC 78800 MRA $163.00 $100.00 $25.00 $75.00 BR BR BR $128.00 $21.00 $107.00 $148.00 $23.00 $125.00 $174.00 $35.00 $139.00 $202.00 $45.00 $157.00 $212.00 $55.00 $157.00 $219.00 $62.00 $157.00 $239.00 $31.00 $208.00 $70.00 $15.00 $56.00 $81.00 $18.00 $63.00 $69.00 $17.00 $51.00 $101.00 $27.00 $75.00 $125.00 $31.00 $94.00 $146.00 $34.00 $113.00 BR BR BR $151.00 CPT only © 1999 American Medical Association. All Rights Reserved. Radiology CPT Code 78800-26 78800-TC 78801 78801-26 78801-TC 78802 78802-26 78802-TC 78803 78803-26 78803-TC 78805 78805-26 78805-TC 78806 78806-26 78806-TC 78807 78807-26 78807-TC 78810 78810-26 78810-TC 78890 78890-26 78890-TC 78891 78891-26 78891-TC 78990 78999 78999-26 78999-TC 79000 79000-26 79000-TC 79001 79001-26 79001-TC 79020 79020-26 79020-TC 79030 79030-26 79030-TC 79035 79035-26 79035-TC 79100 79100-26 MRA $31.00 $119.00 $186.00 $37.00 $149.00 $235.00 $41.00 $195.00 $282.00 $51.00 $231.00 $154.00 $35.00 $119.00 $267.00 $40.00 $226.00 $282.00 $51.00 $231.00 BR $103.00 BR $48.00 $3.00 $46.00 $97.00 $5.00 $92.00 BR BR BR BR $177.00 $85.00 $92.00 $95.00 $50.00 $46.00 $177.00 $85.00 $92.00 $191.00 $99.00 $92.00 $211.00 $119.00 $92.00 $154.00 $62.00 80 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Radiology CPT Code MRA 79100-TC $92.00 79200 $186.00 79200-26 $94.00 79200-TC $92.00 79300 BR 79300-26 $76.00 79300-TC BR 79400 $184.00 79400-26 $92.00 79400-TC $92.00 79420 BR 79420-26 $72.00 79420-TC BR 79440 $186.00 79440-26 $94.00 79440-TC $92.00 79900 BR 79999 BR 79999-26 BR 79999-TC BR CPT only © 1999 American Medical Association. All Rights Reserved. 81 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 80048 $23.00 80048-26 $4.00 80048-TC $19.00 80050 $44.00 80050-26 $18.00 80050-TC $26.00 80051 $16.00 80051-26 $6.00 80051-TC $10.00 80053 $29.00 80053-26 $8.00 80053-TC $21.00 80055 $64.00 80055-26 $21.00 80055-TC $42.00 80061 $30.00 80061-26 $11.00 80061-TC $19.00 80069 $26.00 80069-26 $6.00 80069-TC $20.00 80072 $41.00 80072-26 $15.00 80072-TC $26.00 80074 $103.00 80074-26 $42.00 80074-TC $61.00 80076 $18.00 80076-26 $7.00 80076-TC $11.00 80090 $91.00 80090-26 $38.00 80090-TC $53.00 80100 $37.00 80100-26 $11.00 80100-TC $26.00 80101 $13.00 80101-26 $3.00 80101-TC $9.00 80102 $23.00 80102-26 $6.00 80102-TC $16.00 80103 $12.00 80103-26 $4.00 80103-TC $7.00 80150 $39.00 80150-26 $13.00 80150-TC $26.00 80152 $42.00 80152-26 $14.00 Pathology & Laboratory CPT Code MRA 80152-TC $29.00 80154 $48.00 80154-26 $15.00 80154-TC $33.00 80156 $34.00 80156-26 $11.00 80156-TC $23.00 80158 $34.00 80158-26 $12.00 80158-TC $22.00 80160 $34.00 80160-26 $12.00 80160-TC $22.00 80162 $13.00 80162-26 $3.00 80162-TC $9.00 80164 $42.00 80164-26 $14.00 80164-TC $29.00 80166 $34.00 80166-26 $10.00 80166-TC $24.00 80168 $42.00 80168-26 $17.00 80168-TC $25.00 80170 $18.00 80170-26 $6.00 80170-TC $11.00 80172 $43.00 80172-26 $13.00 80172-TC $31.00 80174 $40.00 80174-26 $12.00 80174-TC $29.00 80176 $34.00 80176-26 $11.00 80176-TC $23.00 80178 $17.00 80178-26 $6.00 80178-TC $11.00 80182 $42.00 80182-26 $14.00 80182-TC $29.00 80184 $33.00 80184-26 $10.00 80184-TC $23.00 80185 $35.00 80185-26 $10.00 80185-TC $25.00 80186 $37.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 80186-26 $11.00 80186-TC $26.00 80188 $34.00 80188-26 $11.00 80188-TC $23.00 80190 $40.00 80190-26 $13.00 80190-TC $28.00 80192 $43.00 80192-26 $17.00 80192-TC $26.00 80194 $32.00 80194-26 $10.00 80194-TC $22.00 80196 $13.00 80196-26 $3.00 80196-TC $9.00 80197 $33.00 80197-26 $11.00 80197-TC $22.00 80198 $20.00 80198-26 $5.00 80198-TC $15.00 80200 $24.00 80200-26 $7.00 80200-TC $16.00 80201 $32.00 80201-26 $11.00 80201-TC $21.00 80202 $41.00 80202-26 $14.00 80202-TC $28.00 80299 BR 80299-26 BR 80299-TC BR 80400 $53.00 80400-26 $18.00 80400-TC $35.00 80402 $132.00 80402-26 $41.00 80402-TC $91.00 80406 $132.00 80406-26 $41.00 80406-TC $91.00 80408 $204.00 80408-26 $74.00 80408-TC $130.00 80410 $159.00 80410-26 $53.00 80410-TC $106.00 82 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 80412 $508.00 80412-26 $169.00 80412-TC $339.00 80414 $85.00 80414-26 $26.00 80414-TC $58.00 80415 $89.00 80415-26 $28.00 80415-TC $61.00 80416 $244.00 80416-26 $85.00 80416-TC $159.00 80417 $244.00 80417-26 $85.00 80417-TC $159.00 80418 $890.00 80418-26 $254.00 80418-TC $635.00 80420 $103.00 80420-26 $32.00 80420-TC $71.00 80422 $60.00 80422-26 $18.00 80422-TC $42.00 80424 $90.00 80424-26 $26.00 80424-TC $64.00 80426 $222.00 80426-26 $53.00 80426-TC $169.00 80428 $89.00 80428-26 $19.00 80428-TC $70.00 80430 $95.00 80430-26 $24.00 80430-TC $71.00 80432 $233.00 80432-26 $55.00 80432-TC $178.00 80434 $154.00 80434-26 $48.00 80434-TC $106.00 80435 $159.00 80435-26 $48.00 80435-TC $111.00 80436 $115.00 80436-26 $34.00 80436-TC $82.00 80438 $79.00 80438-26 $24.00 Pathology & Laboratory CPT Code MRA 80438-TC $55.00 80439 $169.00 80439-26 $32.00 80439-TC $138.00 80440 $180.00 80440-26 $35.00 80440-TC $145.00 80500 $33.00 80500-26 $33.00 80500-TC BR 80502 $69.00 80502-26 $69.00 80502-TC BR 81000 $7.00 81000-26 $3.00 81000-TC $4.00 81001 $7.00 81001-26 $3.00 81001-TC $4.00 81002 $5.00 81002-26 $3.00 81002-TC $3.00 81003 $5.00 81003-26 $2.00 81003-TC $3.00 81005 $3.00 81005-26 $1.00 81005-TC $3.00 81007 $5.00 81007-26 $2.00 81007-TC $4.00 81015 $5.00 81015-26 $3.00 81015-TC $3.00 81020 $8.00 81020-26 $3.00 81020-TC $5.00 81025 $7.00 81025-26 $4.00 81025-TC $4.00 81050 $32.00 81050-26 $11.00 81050-TC $21.00 81099 BR 81099-26 BR 81099-TC BR 82000 $24.00 82000-26 $7.00 82000-TC $17.00 82003 $35.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 82003-26 $10.00 82003-TC $25.00 82009 $10.00 82009-26 $3.00 82009-TC $6.00 82010 $22.00 82010-26 $7.00 82010-TC $15.00 82013 $24.00 82013-26 $7.00 82013-TC $17.00 82024 $26.00 82024-26 $7.00 82024-TC $18.00 82030 $42.00 82030-26 $17.00 82030-TC $25.00 82040 $11.00 82040-26 $3.00 82040-TC $7.00 82042 $12.00 82042-26 $3.00 82042-TC $8.00 82043 $14.00 82043-26 $4.00 82043-TC $10.00 82044 $12.00 82044-26 $4.00 82044-TC $9.00 82055 $32.00 82055-26 $10.00 82055-TC $22.00 82075 $31.00 82075-26 $10.00 82075-TC $21.00 82085 $24.00 82085-26 $7.00 82085-TC $17.00 82088 $88.00 82088-26 $28.00 82088-TC $60.00 82101 $58.00 82101-26 $18.00 82101-TC $40.00 82103 $21.00 82103-26 $7.00 82103-TC $14.00 82104 $22.00 82104-26 $7.00 82104-TC $15.00 83 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 82105 $26.00 82105-26 $8.00 82105-TC $18.00 82106 $26.00 82106-26 $8.00 82106-TC $18.00 82108 $44.00 82108-26 $14.00 82108-TC $31.00 82120 BR 82120-26 BR 82120-TC BR 82128 $26.00 82128-26 $6.00 82128-TC $19.00 82131 $56.00 82131-26 $13.00 82131-TC $43.00 82135 $40.00 82135-26 $13.00 82135-TC $28.00 82136 $37.00 82136-26 $14.00 82136-TC $23.00 82139 $37.00 82139-26 $14.00 82139-TC $23.00 82140 $39.00 82140-26 $12.00 82140-TC $28.00 82143 $28.00 82143-26 $8.00 82143-TC $19.00 82145 $34.00 82145-26 $10.00 82145-TC $24.00 82150 $16.00 82150-26 $5.00 82150-TC $11.00 82154 $33.00 82154-26 $13.00 82154-TC $20.00 82157 $56.00 82157-26 $17.00 82157-TC $39.00 82160 $64.00 82160-26 $21.00 82160-TC $42.00 82163 $41.00 82163-26 $12.00 Pathology & Laboratory CPT Code MRA 82163-TC $30.00 82164 $31.00 82164-26 $10.00 82164-TC $21.00 82172 $32.00 82172-26 $10.00 82172-TC $22.00 82175 $47.00 82175-26 $15.00 82175-TC $32.00 82180 $25.00 82180-26 $8.00 82180-TC $17.00 82190 $24.00 82190-26 $8.00 82190-TC $16.00 82205 $33.00 82205-26 $10.00 82205-TC $23.00 82232 $42.00 82232-26 $14.00 82232-TC $29.00 82239 $23.00 82239-26 $8.00 82239-TC $15.00 82240 $48.00 82240-26 $15.00 82240-TC $33.00 82247 $10.00 82247-26 $3.00 82247-TC $7.00 82248 $10.00 82248-26 $3.00 82248-TC $7.00 82251 $10.00 82251-26 $3.00 82251-TC $6.00 82252 $11.00 82252-26 $3.00 82252-TC $7.00 82261 $37.00 82261-26 $13.00 82261-TC $24.00 82270 $5.00 82270-26 $2.00 82270-TC $3.00 82273 $8.00 82273-26 $2.00 82273-TC $6.00 82286 $12.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 82286-26 $3.00 82286-TC $8.00 82300 $47.00 82300-26 $15.00 82300-TC $32.00 82306 $76.00 82306-26 $25.00 82306-TC $51.00 82307 $56.00 82307-26 $19.00 82307-TC $37.00 82308 $60.00 82308-26 $18.00 82308-TC $42.00 82310 $11.00 82310-26 $3.00 82310-TC $7.00 82330 $36.00 82330-26 $11.00 82330-TC $25.00 82331 $14.00 82331-26 $4.00 82331-TC $10.00 82340 $13.00 82340-26 $4.00 82340-TC $8.00 82355 $30.00 82355-26 $10.00 82355-TC $20.00 82360 $30.00 82360-26 $10.00 82360-TC $20.00 82365 $30.00 82365-26 $8.00 82365-TC $21.00 82370 $22.00 82370-26 $7.00 82370-TC $15.00 82374 $10.00 82374-26 $3.00 82374-TC $6.00 82375 $26.00 82375-26 $7.00 82375-TC $18.00 82376 $11.00 82376-26 $3.00 82376-TC $7.00 82378 $30.00 82378-26 $8.00 82378-TC $21.00 84 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 82379 $37.00 82379-26 $13.00 82379-TC $24.00 82380 $21.00 82380-26 $6.00 82380-TC $15.00 82382 $37.00 82382-26 $12.00 82382-TC $25.00 82383 $60.00 82383-26 $18.00 82383-TC $42.00 82384 $60.00 82384-26 $18.00 82384-TC $42.00 82387 $33.00 82387-26 $10.00 82387-TC $23.00 82390 $24.00 82390-26 $7.00 82390-TC $17.00 82397 $22.00 82397-26 $7.00 82397-TC $15.00 82415 $28.00 82415-26 $8.00 82415-TC $19.00 82435 $8.00 82435-26 $2.00 82435-TC $6.00 82436 $14.00 82436-26 $4.00 82436-TC $10.00 82438 $13.00 82438-26 $4.00 82438-TC $8.00 82441 $16.00 82441-26 $5.00 82441-TC $11.00 82465 $8.00 82465-26 $2.00 82465-TC $6.00 82480 $23.00 82480-26 $6.00 82480-TC $17.00 82482 $23.00 82482-26 $7.00 82482-TC $15.00 82485 $36.00 82485-26 $8.00 Pathology & Laboratory CPT Code MRA 82485-TC $28.00 82486 $41.00 82486-26 $14.00 82486-TC $27.00 82487 $42.00 82487-26 $14.00 82487-TC $29.00 82488 $56.00 82488-26 $19.00 82488-TC $37.00 82489 $46.00 82489-26 $15.00 82489-TC $31.00 82491 $57.00 82491-26 $17.00 82491-TC $40.00 82492 $41.00 82492-26 $13.00 82492-TC $28.00 82495 $47.00 82495-26 $16.00 82495-TC $31.00 82507 $54.00 82507-26 $16.00 82507-TC $38.00 82520 $26.00 82520-26 $8.00 82520-TC $18.00 82523 $42.00 82523-26 $17.00 82523-TC $25.00 82525 $33.00 82525-26 $10.00 82525-TC $23.00 82528 $39.00 82528-26 $13.00 82528-TC $26.00 82530 $37.00 82530-26 $12.00 82530-TC $25.00 82533 $34.00 82533-26 $10.00 82533-TC $24.00 82540 $10.00 82540-26 $3.00 82540-TC $6.00 82541 $41.00 82541-26 $13.00 82541-TC $28.00 82542 $41.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 82542-26 $13.00 82542-TC $28.00 82543 $41.00 82543-26 $13.00 82543-TC $28.00 82544 $41.00 82544-26 $13.00 82544-TC $28.00 82550 $16.00 82550-26 $4.00 82550-TC $12.00 82552 $32.00 82552-26 $10.00 82552-TC $22.00 82553 $16.00 82553-26 $5.00 82553-TC $11.00 82554 $19.00 82554-26 $6.00 82554-TC $13.00 82565 $13.00 82565-26 $2.00 82565-TC $11.00 82570 $10.00 82570-26 $2.00 82570-TC $7.00 82575 $25.00 82575-26 $8.00 82575-TC $17.00 82585 $15.00 82585-26 $3.00 82585-TC $12.00 82595 $30.00 82595-26 $10.00 82595-TC $21.00 82600 $39.00 82600-26 $12.00 82600-TC $28.00 82607 $37.00 82607-26 $10.00 82607-TC $27.00 82608 $39.00 82608-26 $13.00 82608-TC $26.00 82615 $17.00 82615-26 $5.00 82615-TC $12.00 82626 $58.00 82626-26 $19.00 82626-TC $39.00 85 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 82627 $36.00 82627-26 $12.00 82627-TC $24.00 82633 $78.00 82633-26 $23.00 82633-TC $55.00 82634 $78.00 82634-26 $23.00 82634-TC $55.00 82638 $23.00 82638-26 $7.00 82638-TC $16.00 82646 $36.00 82646-26 $11.00 82646-TC $25.00 82649 $42.00 82649-26 $17.00 82649-TC $25.00 82651 $42.00 82651-26 $17.00 82651-TC $25.00 82652 $86.00 82652-26 $25.00 82652-TC $60.00 82654 $36.00 82654-26 $11.00 82654-TC $25.00 82657 $41.00 82657-26 $13.00 82657-TC $28.00 82658 $41.00 82658-26 $13.00 82658-TC $28.00 82664 $39.00 82664-26 $13.00 82664-TC $26.00 82666 $57.00 82666-26 $17.00 82666-TC $40.00 82668 $44.00 82668-26 $14.00 82668-TC $31.00 82670 $59.00 82670-26 $18.00 82670-TC $41.00 82671 $59.00 82671-26 $17.00 82671-TC $42.00 82672 $56.00 82672-26 $16.00 Pathology & Laboratory CPT Code MRA 82672-TC $40.00 82677 $51.00 82677-26 $17.00 82677-TC $34.00 82679 $67.00 82679-26 $20.00 82679-TC $47.00 82690 $52.00 82690-26 $21.00 82690-TC $31.00 82693 $23.00 82693-26 $7.00 82693-TC $16.00 82696 $56.00 82696-26 $19.00 82696-TC $37.00 82705 $14.00 82705-26 $6.00 82705-TC $9.00 82710 $41.00 82710-26 $13.00 82710-TC $29.00 82715 $32.00 82715-26 $11.00 82715-TC $21.00 82725 $28.00 82725-26 $8.00 82725-TC $19.00 82726 $41.00 82726-26 $13.00 82726-TC $28.00 82728 $24.00 82728-26 $7.00 82728-TC $17.00 82735 $35.00 82735-26 $12.00 82735-TC $23.00 82742 $41.00 82742-26 $13.00 82742-TC $29.00 82746 $38.00 82746-26 $13.00 82746-TC $25.00 82747 $29.00 82747-26 $10.00 82747-TC $19.00 82757 $35.00 82757-26 $11.00 82757-TC $24.00 82759 $37.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 82759-26 $12.00 82759-TC $25.00 82760 $26.00 82760-26 $8.00 82760-TC $18.00 82775 $46.00 82775-26 $14.00 82775-TC $32.00 82776 $14.00 82776-26 $3.00 82776-TC $11.00 82784 $15.00 82784-26 $5.00 82784-TC $11.00 82785 $32.00 82785-26 $11.00 82785-TC $21.00 82787 $53.00 82787-26 $17.00 82787-TC $36.00 82800 $22.00 82800-26 $6.00 82800-TC $16.00 82803 $52.00 82803-26 $16.00 82803-TC $36.00 82805 $35.00 82805-26 $10.00 82805-TC $24.00 82810 $28.00 82810-26 $8.00 82810-TC $19.00 82820 $16.00 82820-26 $5.00 82820-TC $11.00 82926 $20.00 82926-26 $5.00 82926-TC $15.00 82928 $12.00 82928-26 $4.00 82928-TC $7.00 82938 $47.00 82938-26 $16.00 82938-TC $31.00 82941 $46.00 82941-26 $15.00 82941-TC $31.00 82943 $37.00 82943-26 $12.00 82943-TC $25.00 86 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 82946 $29.00 82946-26 $7.00 82946-TC $21.00 82947 $11.00 82947-26 $3.00 82947-TC $7.00 82948 $5.00 82948-26 $3.00 82948-TC $3.00 82950 $12.00 82950-26 $4.00 82950-TC $7.00 82951 $22.00 82951-26 $7.00 82951-TC $15.00 82952 $11.00 82952-26 $3.00 82952-TC $7.00 82953 $40.00 82953-26 $14.00 82953-TC $26.00 82955 $25.00 82955-26 $7.00 82955-TC $18.00 82960 $14.00 82960-26 $4.00 82960-TC $10.00 82962 $5.00 82962-26 $1.00 82962-TC $4.00 82963 $53.00 82963-26 $17.00 82963-TC $36.00 82965 $16.00 82965-26 $5.00 82965-TC $11.00 82975 $28.00 82975-26 $8.00 82975-TC $19.00 82977 $16.00 82977-26 $4.00 82977-TC $12.00 82978 $25.00 82978-26 $7.00 82978-TC $18.00 82979 $18.00 82979-26 $5.00 82979-TC $13.00 82980 $15.00 82980-26 $3.00 Pathology & Laboratory CPT Code MRA 82980-TC $11.00 82985 $40.00 82985-26 $12.00 82985-TC $29.00 83001 $39.00 83001-26 $12.00 83001-TC $28.00 83002 $41.00 83002-26 $13.00 83002-TC $29.00 83003 $35.00 83003-26 $10.00 83003-TC $25.00 83008 $33.00 83008-26 $10.00 83008-TC $23.00 83010 $26.00 83010-26 $8.00 83010-TC $18.00 83012 $35.00 83012-26 $14.00 83012-TC $21.00 83013 $127.00 83013-26 $37.00 83013-TC $90.00 83014 $19.00 83014-26 $6.00 83014-TC $13.00 83015 $50.00 83015-26 $15.00 83015-TC $35.00 83018 $55.00 83018-26 $16.00 83018-TC $39.00 83020 $24.00 83020-26 $6.00 83020-TC $18.00 83021 $38.00 83021-26 $13.00 83021-TC $25.00 83026 $8.00 83026-26 $5.00 83026-TC $3.00 83030 $18.00 83030-26 $6.00 83030-TC $12.00 83033 $15.00 83033-26 $4.00 83033-TC $11.00 83036 $15.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 83036-26 $5.00 83036-TC $10.00 83045 $13.00 83045-26 $4.00 83045-TC $8.00 83050 $16.00 83050-26 $5.00 83050-TC $11.00 83051 $16.00 83051-26 $5.00 83051-TC $11.00 83055 $13.00 83055-26 $4.00 83055-TC $8.00 83060 $22.00 83060-26 $6.00 83060-TC $16.00 83065 $18.00 83065-26 $6.00 83065-TC $12.00 83068 $20.00 83068-26 $5.00 83068-TC $15.00 83069 $11.00 83069-26 $3.00 83069-TC $7.00 83070 $13.00 83070-26 $4.00 83070-TC $8.00 83071 $18.00 83071-26 $5.00 83071-TC $13.00 83080 $37.00 83080-26 $11.00 83080-TC $26.00 83088 $58.00 83088-26 $18.00 83088-TC $40.00 83150 $48.00 83150-26 $16.00 83150-TC $32.00 83491 $36.00 83491-26 $11.00 83491-TC $25.00 83497 $34.00 83497-26 $11.00 83497-TC $23.00 83498 $60.00 83498-26 $20.00 83498-TC $40.00 87 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 83499 $50.00 83499-26 $15.00 83499-TC $35.00 83500 $66.00 83500-26 $21.00 83500-TC $44.00 83505 $74.00 83505-26 $21.00 83505-TC $53.00 83516 $26.00 83516-26 $8.00 83516-TC $18.00 83518 $21.00 83518-26 $7.00 83518-TC $14.00 83519 $21.00 83519-26 $7.00 83519-TC $14.00 83520 $20.00 83520-26 $6.00 83520-TC $14.00 83525 $30.00 83525-26 $8.00 83525-TC $21.00 83527 $34.00 83527-26 $11.00 83527-TC $23.00 83528 $42.00 83528-26 $14.00 83528-TC $29.00 83540 $16.00 83540-26 $3.00 83540-TC $13.00 83550 $20.00 83550-26 $5.00 83550-TC $15.00 83570 $23.00 83570-26 $7.00 83570-TC $16.00 83582 $33.00 83582-26 $8.00 83582-TC $24.00 83586 $37.00 83586-26 $13.00 83586-TC $24.00 83593 $58.00 83593-26 $18.00 83593-TC $40.00 83605 $19.00 83605-26 $6.00 Pathology & Laboratory CPT Code MRA 83605-TC $13.00 83615 $16.00 83615-26 $5.00 83615-TC $11.00 83625 $23.00 83625-26 $6.00 83625-TC $17.00 83632 $41.00 83632-26 $14.00 83632-TC $28.00 83633 $15.00 83633-26 $4.00 83633-TC $11.00 83634 $31.00 83634-26 $10.00 83634-TC $21.00 83655 $30.00 83655-26 $8.00 83655-TC $21.00 83661 $17.00 83661-26 $5.00 83661-TC $12.00 83662 $28.00 83662-26 $10.00 83662-TC $18.00 83670 $18.00 83670-26 $5.00 83670-TC $13.00 83690 $18.00 83690-26 $6.00 83690-TC $12.00 83715 $21.00 83715-26 $5.00 83715-TC $16.00 83716 $53.00 83716-26 $19.00 83716-TC $34.00 83718 $16.00 83718-26 $5.00 83718-TC $11.00 83719 $41.00 83719-26 $14.00 83719-TC $28.00 83721 $16.00 83721-26 $5.00 83721-TC $11.00 83727 $42.00 83727-26 $14.00 83727-TC $29.00 83735 $15.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 83735-26 $5.00 83735-TC $10.00 83775 $17.00 83775-26 $5.00 83775-TC $12.00 83785 $57.00 83785-26 $17.00 83785-TC $40.00 83788 $38.00 83788-26 $13.00 83788-TC $25.00 83789 $38.00 83789-26 $13.00 83789-TC $25.00 83805 $43.00 83805-26 $15.00 83805-TC $29.00 83825 $33.00 83825-26 $11.00 83825-TC $22.00 83835 $40.00 83835-26 $12.00 83835-TC $29.00 83840 $41.00 83840-26 $14.00 83840-TC $28.00 83857 $26.00 83857-26 $8.00 83857-TC $18.00 83858 $36.00 83858-26 $12.00 83858-TC $24.00 83864 $31.00 83864-26 $8.00 83864-TC $22.00 83866 $26.00 83866-26 $7.00 83866-TC $19.00 83872 $13.00 83872-26 $4.00 83872-TC $8.00 83873 $53.00 83873-26 $18.00 83873-TC $35.00 83874 $25.00 83874-26 $8.00 83874-TC $17.00 83883 $11.00 83883-26 $3.00 83883-TC $7.00 88 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 83885 $44.00 83885-26 $14.00 83885-TC $31.00 83887 $57.00 83887-26 $17.00 83887-TC $40.00 83890 $7.00 83890-26 $2.00 83890-TC $5.00 83891 $7.00 83891-26 $2.00 83891-TC $5.00 83892 $7.00 83892-26 $2.00 83892-TC $5.00 83893 $7.00 83893-26 $2.00 83893-TC $5.00 83894 $7.00 83894-26 $2.00 83894-TC $5.00 83896 $7.00 83896-26 $2.00 83896-TC $5.00 83897 BR 83897-26 BR 83897-TC BR 83898 $42.00 83898-26 $14.00 83898-TC $29.00 83901 $43.00 83901-26 $14.00 83901-TC $29.00 83902 $37.00 83902-26 $13.00 83902-TC $24.00 83903 $43.00 83903-26 $14.00 83903-TC $29.00 83904 $43.00 83904-26 $14.00 83904-TC $29.00 83905 $43.00 83905-26 $14.00 83905-TC $29.00 83906 $43.00 83906-26 $14.00 83906-TC $29.00 83912 $38.00 83912-26 $11.00 Pathology & Laboratory CPT Code MRA 83912-TC $28.00 83915 $30.00 83915-26 $10.00 83915-TC $20.00 83916 $53.00 83916-26 $18.00 83916-TC $35.00 83918 $40.00 83918-26 $12.00 83918-TC $29.00 83919 $41.00 83919-26 $12.00 83919-TC $29.00 83925 $13.00 83925-26 $3.00 83925-TC $9.00 83930 $11.00 83930-26 $3.00 83930-TC $7.00 83935 $17.00 83935-26 $5.00 83935-TC $12.00 83937 $29.00 83937-26 $10.00 83937-TC $19.00 83945 $31.00 83945-26 $11.00 83945-TC $20.00 83970 $90.00 83970-26 $30.00 83970-TC $60.00 83986 $8.00 83986-26 $3.00 83986-TC $5.00 83992 $39.00 83992-26 $12.00 83992-TC $28.00 84022 $40.00 84022-26 $13.00 84022-TC $28.00 84030 $11.00 84030-26 $3.00 84030-TC $7.00 84035 $12.00 84035-26 $3.00 84035-TC $8.00 84060 $20.00 84060-26 $6.00 84060-TC $14.00 84061 $14.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 84061-26 $4.00 84061-TC $10.00 84066 $18.00 84066-26 $6.00 84066-TC $12.00 84075 $12.00 84075-26 $3.00 84075-TC $8.00 84078 $19.00 84078-26 $5.00 84078-TC $14.00 84080 $35.00 84080-26 $11.00 84080-TC $24.00 84081 $44.00 84081-26 $15.00 84081-TC $30.00 84085 $15.00 84085-26 $5.00 84085-TC $10.00 84087 $25.00 84087-26 $7.00 84087-TC $18.00 84100 $11.00 84100-26 $3.00 84100-TC $7.00 84105 $11.00 84105-26 $3.00 84105-TC $7.00 84106 $10.00 84106-26 $2.00 84106-TC $7.00 84110 $21.00 84110-26 $6.00 84110-TC $15.00 84119 $21.00 84119-26 $6.00 84119-TC $15.00 84120 $37.00 84120-26 $11.00 84120-TC $26.00 84126 $68.00 84126-26 $20.00 84126-TC $48.00 84127 $18.00 84127-26 $6.00 84127-TC $12.00 84132 $11.00 84132-26 $3.00 84132-TC $7.00 89 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 84133 $11.00 84133-26 $3.00 84133-TC $7.00 84134 $24.00 84134-26 $7.00 84134-TC $17.00 84135 $56.00 84135-26 $19.00 84135-TC $37.00 84138 $55.00 84138-26 $18.00 84138-TC $37.00 84140 $40.00 84140-26 $8.00 84140-TC $32.00 84143 $60.00 84143-26 $20.00 84143-TC $40.00 84144 $37.00 84144-26 $7.00 84144-TC $30.00 84146 $52.00 84146-26 $17.00 84146-TC $35.00 84150 $66.00 84150-26 $20.00 84150-TC $46.00 84153 $32.00 84153-26 $11.00 84153-TC $21.00 84154 $32.00 84154-26 $11.00 84154-TC $21.00 84155 $12.00 84155-26 $4.00 84155-TC $7.00 84160 $5.00 84160-26 $2.00 84160-TC $2.00 84165 $24.00 84165-26 $8.00 84165-TC $16.00 84181 $29.00 84181-26 $10.00 84181-TC $19.00 84182 $32.00 84182-26 $11.00 84182-TC $21.00 84202 $38.00 84202-26 $13.00 Pathology & Laboratory CPT Code MRA 84202-TC $25.00 84203 $16.00 84203-26 $5.00 84203-TC $11.00 84206 $31.00 84206-26 $10.00 84206-TC $21.00 84207 $53.00 84207-26 $16.00 84207-TC $37.00 84210 $24.00 84210-26 $10.00 84210-TC $15.00 84220 $25.00 84220-26 $8.00 84220-TC $17.00 84228 $31.00 84228-26 $10.00 84228-TC $21.00 84233 $112.00 84233-26 $34.00 84233-TC $78.00 84234 $112.00 84234-26 $34.00 84234-TC $78.00 84235 $110.00 84235-26 $33.00 84235-TC $77.00 84238 $93.00 84238-26 $31.00 84238-TC $62.00 84244 $46.00 84244-26 $15.00 84244-TC $31.00 84252 $46.00 84252-26 $14.00 84252-TC $32.00 84255 $57.00 84255-26 $17.00 84255-TC $40.00 84260 $53.00 84260-26 $16.00 84260-TC $37.00 84270 $35.00 84270-26 $11.00 84270-TC $24.00 84275 $36.00 84275-26 $11.00 84275-TC $25.00 84285 $58.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 84285-26 $17.00 84285-TC $41.00 84295 $10.00 84295-26 $3.00 84295-TC $6.00 84300 $10.00 84300-26 $3.00 84300-TC $6.00 84305 $33.00 84305-26 $11.00 84305-TC $22.00 84307 $26.00 84307-26 $8.00 84307-TC $18.00 84311 $11.00 84311-26 $3.00 84311-TC $7.00 84315 $5.00 84315-26 $2.00 84315-TC $3.00 84375 $36.00 84375-26 $11.00 84375-TC $25.00 84376 $10.00 84376-26 $3.00 84376-TC $7.00 84377 $10.00 84377-26 $3.00 84377-TC $7.00 84378 $25.00 84378-26 $8.00 84378-TC $17.00 84379 $25.00 84379-26 $8.00 84379-TC $17.00 84392 $8.00 84392-26 $2.00 84392-TC $6.00 84402 $69.00 84402-26 $21.00 84402-TC $48.00 84403 $64.00 84403-26 $19.00 84403-TC $44.00 84425 $53.00 84425-26 $17.00 84425-TC $36.00 84430 $30.00 84430-26 $10.00 84430-TC $20.00 90 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 84432 $28.00 84432-26 $8.00 84432-TC $19.00 84436 $14.00 84436-26 $3.00 84436-TC $11.00 84437 $13.00 84437-26 $4.00 84437-TC $8.00 84439 $16.00 84439-26 $4.00 84439-TC $12.00 84442 $25.00 84442-26 $6.00 84442-TC $19.00 84443 $31.00 84443-26 $7.00 84443-TC $23.00 84445 $94.00 84445-26 $29.00 84445-TC $66.00 84446 $34.00 84446-26 $11.00 84446-TC $23.00 84449 $37.00 84449-26 $13.00 84449-TC $24.00 84450 $11.00 84450-26 $3.00 84450-TC $7.00 84460 $13.00 84460-26 $4.00 84460-TC $8.00 84466 $22.00 84466-26 $7.00 84466-TC $15.00 84478 $12.00 84478-26 $3.00 84478-TC $8.00 84479 $15.00 84479-26 $5.00 84479-TC $10.00 84480 $20.00 84480-26 $6.00 84480-TC $14.00 84481 $32.00 84481-26 $10.00 84481-TC $22.00 84482 $44.00 84482-26 $15.00 Pathology & Laboratory CPT Code MRA 84482-TC $30.00 84484 $21.00 84484-26 $6.00 84484-TC $15.00 84485 $15.00 84485-26 $4.00 84485-TC $11.00 84488 $15.00 84488-26 $4.00 84488-TC $11.00 84490 $15.00 84490-26 $4.00 84490-TC $11.00 84510 $26.00 84510-26 $8.00 84510-TC $18.00 84512 $17.00 84512-26 $5.00 84512-TC $12.00 84520 $12.00 84520-26 $3.00 84520-TC $8.00 84525 $7.00 84525-26 $2.00 84525-TC $5.00 84540 $13.00 84540-26 $4.00 84540-TC $8.00 84545 $18.00 84545-26 $5.00 84545-TC $13.00 84550 $12.00 84550-26 $4.00 84550-TC $7.00 84560 $12.00 84560-26 $3.00 84560-TC $8.00 84577 $33.00 84577-26 $11.00 84577-TC $22.00 84578 $7.00 84578-26 $2.00 84578-TC $5.00 84580 $17.00 84580-26 $5.00 84580-TC $12.00 84583 $11.00 84583-26 $3.00 84583-TC $7.00 84585 $35.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 84585-26 $11.00 84585-TC $24.00 84586 $41.00 84586-26 $14.00 84586-TC $27.00 84588 $70.00 84588-26 $23.00 84588-TC $46.00 84590 $32.00 84590-26 $11.00 84590-TC $21.00 84597 $36.00 84597-26 $11.00 84597-TC $25.00 84600 $42.00 84600-26 $13.00 84600-TC $30.00 84620 $29.00 84620-26 $8.00 84620-TC $20.00 84630 $26.00 84630-26 $8.00 84630-TC $18.00 84681 $51.00 84681-26 $17.00 84681-TC $34.00 84702 $37.00 84702-26 $11.00 84702-TC $26.00 84703 $22.00 84703-26 $6.00 84703-TC $15.00 84830 $17.00 84830-26 $5.00 84830-TC $12.00 84999 BR 84999-26 BR 84999-TC BR 85002 $10.00 85002-26 $3.00 85002-TC $6.00 85007 $6.00 85007-26 $3.00 85007-TC $4.00 85008 $5.00 85008-26 $2.00 85008-TC $3.00 85009 $8.00 85009-26 $3.00 85009-TC $5.00 91 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 85013 $3.00 85013-26 $1.00 85013-TC $2.00 85014 $4.00 85014-26 $1.00 85014-TC $3.00 85018 $5.00 85018-26 $2.00 85018-TC $3.00 85021 $11.00 85021-26 $3.00 85021-TC $7.00 85022 $15.00 85022-26 $4.00 85022-TC $11.00 85023 $16.00 85023-26 $5.00 85023-TC $11.00 85024 $13.00 85024-26 $3.00 85024-TC $9.00 85025 $20.00 85025-26 $6.00 85025-TC $14.00 85027 $15.00 85027-26 $5.00 85027-TC $10.00 85031 $12.00 85031-26 $3.00 85031-TC $8.00 85041 $7.00 85041-26 $3.00 85041-TC $4.00 85044 $10.00 85044-26 $3.00 85044-TC $6.00 85045 $6.00 85045-26 $2.00 85045-TC $4.00 85046 BR 85046-26 BR 85046-TC BR 85048 $7.00 85048-26 $3.00 85048-TC $4.00 85060 $25.00 85060-26 $7.00 85060-TC $18.00 85095 $79.00 85095-26 $24.00 Pathology & Laboratory CPT Code MRA 85095-TC $55.00 85097 $58.00 85097-26 $58.00 85097-TC BR 85102 $104.00 85102-26 $31.00 85102-TC $73.00 85130 $19.00 85130-26 $6.00 85130-TC $13.00 85170 $7.00 85170-26 $2.00 85170-TC $5.00 85175 $10.00 85175-26 $3.00 85175-TC $6.00 85210 $30.00 85210-26 $8.00 85210-TC $21.00 85220 $46.00 85220-26 $15.00 85220-TC $31.00 85230 $46.00 85230-26 $14.00 85230-TC $32.00 85240 $47.00 85240-26 $15.00 85240-TC $32.00 85244 $48.00 85244-26 $15.00 85244-TC $33.00 85245 $53.00 85245-26 $18.00 85245-TC $35.00 85246 $53.00 85246-26 $18.00 85246-TC $35.00 85247 $53.00 85247-26 $18.00 85247-TC $35.00 85250 $48.00 85250-26 $14.00 85250-TC $34.00 85260 $48.00 85260-26 $14.00 85260-TC $34.00 85270 $48.00 85270-26 $14.00 85270-TC $34.00 85280 $48.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 85280-26 $14.00 85280-TC $34.00 85290 $43.00 85290-26 $13.00 85290-TC $31.00 85291 $20.00 85291-26 $6.00 85291-TC $14.00 85292 $50.00 85292-26 $17.00 85292-TC $33.00 85293 $50.00 85293-26 $17.00 85293-TC $33.00 85300 $34.00 85300-26 $12.00 85300-TC $23.00 85301 $29.00 85301-26 $10.00 85301-TC $19.00 85302 $32.00 85302-26 $11.00 85302-TC $21.00 85303 $26.00 85303-26 $8.00 85303-TC $18.00 85305 $21.00 85305-26 $7.00 85305-TC $14.00 85306 $29.00 85306-26 $10.00 85306-TC $19.00 85335 $21.00 85335-26 $7.00 85335-TC $14.00 85337 $19.00 85337-26 $6.00 85337-TC $13.00 85345 $10.00 85345-26 $2.00 85345-TC $7.00 85347 $8.00 85347-26 $2.00 85347-TC $6.00 85348 $10.00 85348-26 $3.00 85348-TC $6.00 85360 $16.00 85360-26 $4.00 85360-TC $12.00 92 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 85362 $18.00 85362-26 $7.00 85362-TC $11.00 85366 $13.00 85366-26 $3.00 85366-TC $10.00 85370 $20.00 85370-26 $5.00 85370-TC $15.00 85378 $13.00 85378-26 $4.00 85378-TC $8.00 85379 $18.00 85379-26 $6.00 85379-TC $12.00 85384 $11.00 85384-26 $3.00 85384-TC $7.00 85385 $16.00 85385-26 $5.00 85385-TC $11.00 85390 $10.00 85390-26 $2.00 85390-TC $7.00 85400 $12.00 85400-26 $3.00 85400-TC $8.00 85410 $12.00 85410-26 $3.00 85410-TC $8.00 85415 $28.00 85415-26 $10.00 85415-TC $18.00 85420 $16.00 85420-26 $3.00 85420-TC $13.00 85421 $38.00 85421-26 $12.00 85421-TC $26.00 85441 $7.00 85441-26 $2.00 85441-TC $5.00 85445 $16.00 85445-26 $5.00 85445-TC $11.00 85460 $15.00 85460-26 $4.00 85460-TC $11.00 85461 $12.00 85461-26 $3.00 Pathology & Laboratory CPT Code MRA 85461-TC $8.00 85475 $15.00 85475-26 $4.00 85475-TC $11.00 85520 $22.00 85520-26 $6.00 85520-TC $16.00 85525 $20.00 85525-26 $6.00 85525-TC $14.00 85530 $38.00 85530-26 $12.00 85530-TC $26.00 85535 $15.00 85535-26 $5.00 85535-TC $10.00 85540 $24.00 85540-26 $7.00 85540-TC $17.00 85547 $23.00 85547-26 $6.00 85547-TC $17.00 85549 $44.00 85549-26 $15.00 85549-TC $30.00 85555 $17.00 85555-26 $5.00 85555-TC $12.00 85557 $33.00 85557-26 $10.00 85557-TC $23.00 85576 $21.00 85576-26 $5.00 85576-TC $16.00 85585 $8.00 85585-26 $2.00 85585-TC $6.00 85590 $11.00 85590-26 $3.00 85590-TC $7.00 85595 $8.00 85595-26 $3.00 85595-TC $5.00 85597 $31.00 85597-26 $10.00 85597-TC $21.00 85610 $6.00 85610-26 $3.00 85610-TC $4.00 85611 $6.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 85611-26 $2.00 85611-TC $4.00 85612 $22.00 85612-26 $6.00 85612-TC $16.00 85613 $15.00 85613-26 $4.00 85613-TC $11.00 85635 $26.00 85635-26 $8.00 85635-TC $18.00 85651 $8.00 85651-26 $2.00 85651-TC $6.00 85652 $8.00 85652-26 $2.00 85652-TC $6.00 85660 $10.00 85660-26 $3.00 85660-TC $6.00 85670 $13.00 85670-26 $3.00 85670-TC $10.00 85675 $13.00 85675-26 $4.00 85675-TC $8.00 85705 $13.00 85705-26 $4.00 85705-TC $8.00 85730 $11.00 85730-26 $3.00 85730-TC $7.00 85732 $17.00 85732-26 $5.00 85732-TC $12.00 85810 $19.00 85810-26 $4.00 85810-TC $15.00 85999 BR 85999-26 BR 85999-TC BR 86000 $16.00 86000-26 $5.00 86000-TC $11.00 86003 $6.00 86003-26 $2.00 86003-TC $3.00 86005 $11.00 86005-26 $4.00 86005-TC $6.00 93 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 86021 $40.00 86021-26 $12.00 86021-TC $29.00 86022 $56.00 86022-26 $18.00 86022-TC $38.00 86023 $28.00 86023-26 $10.00 86023-TC $18.00 86038 $22.00 86038-26 $7.00 86038-TC $15.00 86039 $19.00 86039-26 $6.00 86039-TC $13.00 86060 $13.00 86060-26 $3.00 86060-TC $10.00 86063 $21.00 86063-26 $6.00 86063-TC $15.00 86077 $88.00 86077-26 $26.00 86077-TC $61.00 86078 $88.00 86078-26 $26.00 86078-TC $61.00 86079 $76.00 86079-26 $25.00 86079-TC $51.00 86140 $14.00 86140-26 $4.00 86140-TC $10.00 86147 $52.00 86147-26 $16.00 86147-TC $35.00 86148 $58.00 86148-26 $21.00 86148-TC $37.00 86155 $26.00 86155-26 $8.00 86155-TC $18.00 86156 $11.00 86156-26 $3.00 86156-TC $7.00 86157 $13.00 86157-26 $4.00 86157-TC $8.00 86160 $21.00 86160-26 $5.00 Pathology & Laboratory CPT Code MRA 86160-TC $16.00 86161 $21.00 86161-26 $5.00 86161-TC $16.00 86162 $53.00 86162-26 $18.00 86162-TC $35.00 86171 $25.00 86171-26 $7.00 86171-TC $18.00 86185 $19.00 86185-26 $6.00 86185-TC $13.00 86215 $35.00 86215-26 $12.00 86215-TC $23.00 86225 $35.00 86225-26 $11.00 86225-TC $24.00 86226 $24.00 86226-26 $8.00 86226-TC $16.00 86235 $32.00 86235-26 $10.00 86235-TC $22.00 86243 $49.00 86243-26 $15.00 86243-TC $34.00 86255 $25.00 86255-26 $8.00 86255-TC $17.00 86256 $25.00 86256-26 $8.00 86256-TC $17.00 86277 $40.00 86277-26 $14.00 86277-TC $26.00 86280 $15.00 86280-26 $3.00 86280-TC $12.00 86308 $8.00 86308-26 $3.00 86308-TC $5.00 86309 $12.00 86309-26 $3.00 86309-TC $8.00 86310 $19.00 86310-26 $6.00 86310-TC $13.00 86316 $36.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 86316-26 $11.00 86316-TC $25.00 86317 $30.00 86317-26 $10.00 86317-TC $20.00 86318 $23.00 86318-26 $10.00 86318-TC $14.00 86320 $48.00 86320-26 $19.00 86320-TC $29.00 86325 $48.00 86325-26 $16.00 86325-TC $32.00 86327 $60.00 86327-26 $19.00 86327-TC $41.00 86329 $36.00 86329-26 $12.00 86329-TC $24.00 86331 $22.00 86331-26 $6.00 86331-TC $15.00 86332 $53.00 86332-26 $18.00 86332-TC $35.00 86334 $62.00 86334-26 $18.00 86334-TC $44.00 86337 $53.00 86337-26 $18.00 86337-TC $35.00 86340 $38.00 86340-26 $13.00 86340-TC $25.00 86341 $37.00 86341-26 $13.00 86341-TC $24.00 86343 $32.00 86343-26 $11.00 86343-TC $21.00 86344 $21.00 86344-26 $7.00 86344-TC $14.00 86353 $98.00 86353-26 $30.00 86353-TC $69.00 86359 $59.00 86359-26 $19.00 86359-TC $40.00 94 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 86360 $95.00 86360-26 $32.00 86360-TC $64.00 86361 $63.00 86361-26 $21.00 86361-TC $42.00 86376 $34.00 86376-26 $11.00 86376-TC $23.00 86378 $44.00 86378-26 $15.00 86378-TC $30.00 86382 $44.00 86382-26 $14.00 86382-TC $31.00 86384 $24.00 86384-26 $8.00 86384-TC $16.00 86403 $18.00 86403-26 $3.00 86403-TC $14.00 86406 $21.00 86406-26 $5.00 86406-TC $16.00 86430 $13.00 86430-26 $4.00 86430-TC $8.00 86431 $17.00 86431-26 $6.00 86431-TC $11.00 86485 $13.00 86485-26 $4.00 86485-TC $8.00 86490 $17.00 86490-26 $5.00 86490-TC $12.00 86510 $13.00 86510-26 $4.00 86510-TC $8.00 86580 $13.00 86580-26 $4.00 86580-TC $8.00 86585 $10.00 86585-26 $3.00 86585-TC $6.00 86586 BR 86586-26 BR 86586-TC BR 86590 $18.00 86590-26 $6.00 Pathology & Laboratory CPT Code MRA 86590-TC $12.00 86592 $8.00 86592-26 $2.00 86592-TC $6.00 86593 $11.00 86593-26 $3.00 86593-TC $7.00 86602 $17.00 86602-26 $5.00 86602-TC $12.00 86603 $20.00 86603-26 $6.00 86603-TC $14.00 86606 $24.00 86606-26 $8.00 86606-TC $16.00 86609 $20.00 86609-26 $6.00 86609-TC $14.00 86612 $21.00 86612-26 $6.00 86612-TC $15.00 86615 $21.00 86615-26 $6.00 86615-TC $15.00 86617 $29.00 86617-26 $10.00 86617-TC $19.00 86618 $26.00 86618-26 $8.00 86618-TC $18.00 86619 $21.00 86619-26 $6.00 86619-TC $15.00 86622 $16.00 86622-26 $5.00 86622-TC $11.00 86625 $21.00 86625-26 $6.00 86625-TC $15.00 86628 $20.00 86628-26 $6.00 86628-TC $14.00 86631 $20.00 86631-26 $6.00 86631-TC $14.00 86632 $20.00 86632-26 $6.00 86632-TC $14.00 86635 $18.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 86635-26 $5.00 86635-TC $13.00 86638 $20.00 86638-26 $6.00 86638-TC $14.00 86641 $21.00 86641-26 $7.00 86641-TC $14.00 86644 $22.00 86644-26 $7.00 86644-TC $15.00 86645 $28.00 86645-26 $10.00 86645-TC $18.00 86648 $24.00 86648-26 $8.00 86648-TC $16.00 86651 $21.00 86651-26 $7.00 86651-TC $14.00 86652 $21.00 86652-26 $7.00 86652-TC $14.00 86653 $21.00 86653-26 $7.00 86653-TC $14.00 86654 $21.00 86654-26 $7.00 86654-TC $14.00 86658 $21.00 86658-26 $7.00 86658-TC $14.00 86663 $21.00 86663-26 $7.00 86663-TC $14.00 86664 $52.00 86664-26 $17.00 86664-TC $35.00 86665 $29.00 86665-26 $10.00 86665-TC $19.00 86668 $17.00 86668-26 $5.00 86668-TC $12.00 86671 $20.00 86671-26 $6.00 86671-TC $14.00 86674 $23.00 86674-26 $7.00 86674-TC $16.00 95 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 86677 $24.00 86677-26 $8.00 86677-TC $16.00 86682 $21.00 86682-26 $7.00 86682-TC $14.00 86684 $24.00 86684-26 $8.00 86684-TC $16.00 86687 $22.00 86687-26 $7.00 86687-TC $16.00 86688 $20.00 86688-26 $7.00 86688-TC $14.00 86689 $25.00 86689-26 $8.00 86689-TC $17.00 86692 $22.00 86692-26 $7.00 86692-TC $15.00 86694 $22.00 86694-26 $7.00 86694-TC $15.00 86695 $21.00 86695-26 $7.00 86695-TC $14.00 86698 $20.00 86698-26 $6.00 86698-TC $14.00 86701 $21.00 86701-26 $7.00 86701-TC $15.00 86702 $21.00 86702-26 $7.00 86702-TC $14.00 86703 $22.00 86703-26 $7.00 86703-TC $15.00 86704 $32.00 86704-26 $11.00 86704-TC $21.00 86705 $34.00 86705-26 $11.00 86705-TC $23.00 86706 $24.00 86706-26 $8.00 86706-TC $16.00 86707 $26.00 86707-26 $8.00 Pathology & Laboratory CPT Code MRA 86707-TC $18.00 86708 $31.00 86708-26 $10.00 86708-TC $21.00 86709 $29.00 86709-26 $10.00 86709-TC $19.00 86710 $22.00 86710-26 $7.00 86710-TC $15.00 86713 $23.00 86713-26 $7.00 86713-TC $16.00 86717 $20.00 86717-26 $6.00 86717-TC $14.00 86720 $21.00 86720-26 $7.00 86720-TC $14.00 86723 $21.00 86723-26 $7.00 86723-TC $14.00 86727 $20.00 86727-26 $6.00 86727-TC $14.00 86729 $19.00 86729-26 $6.00 86729-TC $13.00 86732 $21.00 86732-26 $7.00 86732-TC $14.00 86735 $21.00 86735-26 $7.00 86735-TC $14.00 86738 $21.00 86738-26 $7.00 86738-TC $14.00 86741 $21.00 86741-26 $7.00 86741-TC $14.00 86744 $21.00 86744-26 $7.00 86744-TC $14.00 86747 $23.00 86747-26 $7.00 86747-TC $16.00 86750 $21.00 86750-26 $7.00 86750-TC $14.00 86753 $20.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 86753-26 $6.00 86753-TC $14.00 86756 $20.00 86756-26 $6.00 86756-TC $14.00 86759 $21.00 86759-26 $7.00 86759-TC $14.00 86762 $22.00 86762-26 $7.00 86762-TC $15.00 86765 $20.00 86765-26 $6.00 86765-TC $14.00 86768 $21.00 86768-26 $7.00 86768-TC $14.00 86771 $21.00 86771-26 $7.00 86771-TC $14.00 86774 $23.00 86774-26 $7.00 86774-TC $16.00 86777 $22.00 86777-26 $7.00 86777-TC $15.00 86778 $23.00 86778-26 $7.00 86778-TC $16.00 86781 $22.00 86781-26 $7.00 86781-TC $15.00 86784 $21.00 86784-26 $7.00 86784-TC $14.00 86787 $20.00 86787-26 $6.00 86787-TC $14.00 86790 $21.00 86790-26 $7.00 86790-TC $14.00 86793 $21.00 86793-26 $7.00 86793-TC $14.00 86800 $26.00 86800-26 $8.00 86800-TC $18.00 86803 $24.00 86803-26 $8.00 86803-TC $16.00 96 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 86804 $26.00 86804-26 $8.00 86804-TC $18.00 86805 $93.00 86805-26 $32.00 86805-TC $61.00 86806 $84.00 86806-26 $28.00 86806-TC $56.00 86807 $71.00 86807-26 $21.00 86807-TC $50.00 86808 $51.00 86808-26 $15.00 86808-TC $36.00 86812 $104.00 86812-26 $31.00 86812-TC $72.00 86813 $97.00 86813-26 $29.00 86813-TC $68.00 86816 $61.00 86816-26 $18.00 86816-TC $43.00 86817 $128.00 86817-26 $38.00 86817-TC $90.00 86821 $118.00 86821-26 $35.00 86821-TC $83.00 86822 $92.00 86822-26 $31.00 86822-TC $61.00 86849 BR 86849-26 BR 86849-TC BR 86850 $10.00 86850-26 $3.00 86850-TC $6.00 86860 $43.00 86860-26 $15.00 86860-TC $29.00 86870 $17.00 86870-26 $6.00 86870-TC $11.00 86880 $13.00 86880-26 $4.00 86880-TC $8.00 86885 $15.00 86885-26 $4.00 Pathology & Laboratory CPT Code MRA 86885-TC $11.00 86886 $14.00 86886-26 $4.00 86886-TC $10.00 86890 $64.00 86890-26 $11.00 86890-TC $53.00 86891 $88.00 86891-26 $26.00 86891-TC $61.00 86900 $10.00 86900-26 $3.00 86900-TC $6.00 86901 $10.00 86901-26 $3.00 86901-TC $6.00 86903 $15.00 86903-26 $5.00 86903-TC $10.00 86904 $19.00 86904-26 $6.00 86904-TC $13.00 86905 $7.00 86905-26 $1.00 86905-TC $6.00 86906 $11.00 86906-26 $3.00 86906-TC $7.00 86910 $80.00 86910-26 $24.00 86910-TC $56.00 86911 $19.00 86911-26 $6.00 86911-TC $13.00 86915 $265.00 86915-26 $106.00 86915-TC $159.00 86920 $19.00 86920-26 $3.00 86920-TC $15.00 86921 $23.00 86921-26 $7.00 86921-TC $16.00 86922 $20.00 86922-26 $6.00 86922-TC $14.00 86927 $21.00 86927-26 $5.00 86927-TC $16.00 86930 $148.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 86930-26 $44.00 86930-TC $104.00 86931 $148.00 86931-26 $44.00 86931-TC $104.00 86932 $154.00 86932-26 $47.00 86932-TC $107.00 86940 $18.00 86940-26 $5.00 86940-TC $13.00 86941 $30.00 86941-26 $8.00 86941-TC $21.00 86945 $34.00 86945-26 $11.00 86945-TC $23.00 86950 $95.00 86950-26 $29.00 86950-TC $67.00 86965 $25.00 86965-26 $7.00 86965-TC $18.00 86970 $40.00 86970-26 $12.00 86970-TC $29.00 86971 $20.00 86971-26 $5.00 86971-TC $15.00 86972 $20.00 86972-26 $6.00 86972-TC $14.00 86975 $52.00 86975-26 $16.00 86975-TC $36.00 86976 $52.00 86976-26 $16.00 86976-TC $36.00 86977 $52.00 86977-26 $16.00 86977-TC $36.00 86978 $62.00 86978-26 $19.00 86978-TC $43.00 86985 $34.00 86985-26 $12.00 86985-TC $23.00 86999 BR 86999-26 BR 86999-TC BR 97 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 87001 $34.00 87001-26 $11.00 87001-TC $23.00 87003 $39.00 87003-26 $13.00 87003-TC $26.00 87015 $14.00 87015-26 $5.00 87015-TC $9.00 87040 $18.00 87040-26 $6.00 87040-TC $12.00 87045 $18.00 87045-26 $6.00 87045-TC $11.00 87060 $13.00 87060-26 $3.00 87060-TC $10.00 87070 $14.00 87070-26 $4.00 87070-TC $10.00 87072 $13.00 87072-26 $3.00 87072-TC $10.00 87075 $18.00 87075-26 $6.00 87075-TC $12.00 87076 $24.00 87076-26 $8.00 87076-TC $16.00 87081 $12.00 87081-26 $3.00 87081-TC $8.00 87082 $12.00 87082-26 $3.00 87082-TC $8.00 87083 $18.00 87083-26 $6.00 87083-TC $12.00 87084 $23.00 87084-26 $7.00 87084-TC $16.00 87085 $26.00 87085-26 $9.00 87085-TC $18.00 87086 $14.00 87086-26 $3.00 87086-TC $11.00 87087 $17.00 87087-26 $5.00 Pathology & Laboratory CPT Code MRA 87087-TC $12.00 87088 $18.00 87088-26 $6.00 87088-TC $12.00 87101 $20.00 87101-26 $6.00 87101-TC $14.00 87102 $20.00 87102-26 $6.00 87102-TC $14.00 87103 $31.00 87103-26 $11.00 87103-TC $20.00 87106 $25.00 87106-26 $7.00 87106-TC $18.00 87109 $26.00 87109-26 $8.00 87109-TC $18.00 87110 $23.00 87110-26 $7.00 87110-TC $15.00 87116 $15.00 87116-26 $3.00 87116-TC $11.00 87117 $25.00 87117-26 $8.00 87117-TC $17.00 87118 $28.00 87118-26 $9.00 87118-TC $20.00 87140 $24.00 87140-26 $7.00 87140-TC $17.00 87143 $33.00 87143-26 $11.00 87143-TC $22.00 87145 $18.00 87145-26 $5.00 87145-TC $13.00 87147 $26.00 87147-26 $8.00 87147-TC $18.00 87151 $15.00 87151-26 $5.00 87151-TC $10.00 87155 $10.00 87155-26 $2.00 87155-TC $7.00 87158 $5.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 87158-26 $1.00 87158-TC $3.00 87163 $15.00 87163-26 $5.00 87163-TC $10.00 87164 $24.00 87164-26 $8.00 87164-TC $16.00 87166 $24.00 87166-26 $7.00 87166-TC $17.00 87174 $23.00 87174-26 $7.00 87174-TC $16.00 87175 $26.00 87175-26 $8.00 87175-TC $18.00 87176 $16.00 87176-26 $5.00 87176-TC $11.00 87177 $18.00 87177-26 $6.00 87177-TC $12.00 87181 $13.00 87181-26 $3.00 87181-TC $8.00 87184 $13.00 87184-26 $3.00 87184-TC $10.00 87186 $16.00 87186-26 $4.00 87186-TC $12.00 87187 $20.00 87187-26 $3.00 87187-TC $17.00 87188 $18.00 87188-26 $5.00 87188-TC $13.00 87190 $7.00 87190-26 $2.00 87190-TC $5.00 87192 $18.00 87192-26 $5.00 87192-TC $13.00 87197 $29.00 87197-26 $10.00 87197-TC $19.00 87205 $11.00 87205-26 $3.00 87205-TC $7.00 98 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 87206 $15.00 87206-26 $3.00 87206-TC $12.00 87207 $10.00 87207-26 $3.00 87207-TC $6.00 87208 $15.00 87208-26 $5.00 87208-TC $10.00 87210 $8.00 87210-26 $2.00 87210-TC $6.00 87211 $10.00 87211-26 $3.00 87211-TC $6.00 87220 $12.00 87220-26 $4.00 87220-TC $7.00 87230 $34.00 87230-26 $11.00 87230-TC $23.00 87250 $32.00 87250-26 $13.00 87250-TC $19.00 87252 $43.00 87252-26 $14.00 87252-TC $30.00 87253 $32.00 87253-26 $10.00 87253-TC $22.00 87260 $26.00 87260-26 $8.00 87260-TC $18.00 87265 $26.00 87265-26 $8.00 87265-TC $18.00 87270 $26.00 87270-26 $8.00 87270-TC $18.00 87272 $26.00 87272-26 $8.00 87272-TC $18.00 87274 $26.00 87274-26 $8.00 87274-TC $18.00 87276 $26.00 87276-26 $8.00 87276-TC $18.00 87278 $26.00 87278-26 $8.00 Pathology & Laboratory CPT Code MRA 87278-TC $18.00 87280 $26.00 87280-26 $8.00 87280-TC $18.00 87285 $26.00 87285-26 $8.00 87285-TC $18.00 87290 $26.00 87290-26 $8.00 87290-TC $18.00 87299 $26.00 87299-26 $8.00 87299-TC $18.00 87301 $26.00 87301-26 $8.00 87301-TC $18.00 87320 $26.00 87320-26 $8.00 87320-TC $18.00 87324 $26.00 87324-26 $8.00 87324-TC $18.00 87328 $26.00 87328-26 $8.00 87328-TC $18.00 87332 $26.00 87332-26 $8.00 87332-TC $18.00 87335 $26.00 87335-26 $8.00 87335-TC $18.00 87338 $27.00 87338-26 $7.00 87338-TC $20.00 87340 $20.00 87340-26 $6.00 87340-TC $14.00 87350 $20.00 87350-26 $6.00 87350-TC $14.00 87380 $34.00 87380-26 $11.00 87380-TC $23.00 87385 $26.00 87385-26 $8.00 87385-TC $18.00 87390 $37.00 87390-26 $13.00 87390-TC $24.00 87391 $37.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 87391-26 $13.00 87391-TC $24.00 87420 $26.00 87420-26 $8.00 87420-TC $18.00 87425 $26.00 87425-26 $8.00 87425-TC $18.00 87430 $26.00 87430-26 $8.00 87430-TC $18.00 87449 $26.00 87449-26 $8.00 87449-TC $18.00 87450 $21.00 87450-26 $6.00 87450-TC $15.00 87470 $41.00 87470-26 $13.00 87470-TC $28.00 87471 $70.00 87471-26 $23.00 87471-TC $47.00 87472 $85.00 87472-26 $28.00 87472-TC $57.00 87475 $39.00 87475-26 $13.00 87475-TC $26.00 87476 $70.00 87476-26 $23.00 87476-TC $47.00 87477 $85.00 87477-26 $28.00 87477-TC $57.00 87480 $41.00 87480-26 $13.00 87480-TC $28.00 87481 $70.00 87481-26 $23.00 87481-TC $47.00 87482 $83.00 87482-26 $28.00 87482-TC $55.00 87485 $41.00 87485-26 $13.00 87485-TC $28.00 87486 $70.00 87486-26 $23.00 87486-TC $47.00 99 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 87487 $85.00 87487-26 $28.00 87487-TC $57.00 87490 $41.00 87490-26 $13.00 87490-TC $28.00 87491 $70.00 87491-26 $23.00 87491-TC $47.00 87492 $70.00 87492-26 $23.00 87492-TC $47.00 87495 $41.00 87495-26 $13.00 87495-TC $28.00 87496 $70.00 87496-26 $23.00 87496-TC $47.00 87497 $85.00 87497-26 $28.00 87497-TC $57.00 87510 $41.00 87510-26 $13.00 87510-TC $28.00 87511 $70.00 87511-26 $23.00 87511-TC $47.00 87512 $83.00 87512-26 $28.00 87512-TC $55.00 87515 $41.00 87515-26 $13.00 87515-TC $28.00 87516 $70.00 87516-26 $23.00 87516-TC $47.00 87517 $85.00 87517-26 $28.00 87517-TC $57.00 87520 $41.00 87520-26 $13.00 87520-TC $28.00 87521 $70.00 87521-26 $23.00 87521-TC $47.00 87522 $85.00 87522-26 $28.00 87522-TC $57.00 87525 $41.00 87525-26 $13.00 Pathology & Laboratory CPT Code MRA 87525-TC $28.00 87526 $70.00 87526-26 $23.00 87526-TC $47.00 87527 $83.00 87527-26 $28.00 87527-TC $55.00 87528 $41.00 87528-26 $13.00 87528-TC $28.00 87529 $70.00 87529-26 $23.00 87529-TC $47.00 87530 $85.00 87530-26 $28.00 87530-TC $57.00 87531 $41.00 87531-26 $13.00 87531-TC $28.00 87532 $70.00 87532-26 $23.00 87532-TC $47.00 87533 $83.00 87533-26 $28.00 87533-TC $55.00 87534 $41.00 87534-26 $13.00 87534-TC $28.00 87535 $70.00 87535-26 $23.00 87535-TC $47.00 87536 $83.00 87536-26 $28.00 87536-TC $55.00 87537 $41.00 87537-26 $13.00 87537-TC $28.00 87538 $70.00 87538-26 $23.00 87538-TC $47.00 87539 $85.00 87539-26 $28.00 87539-TC $57.00 87540 $41.00 87540-26 $13.00 87540-TC $28.00 87541 $70.00 87541-26 $23.00 87541-TC $47.00 87542 $83.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 87542-26 $28.00 87542-TC $55.00 87550 $41.00 87550-26 $13.00 87550-TC $28.00 87551 $70.00 87551-26 $23.00 87551-TC $47.00 87552 $85.00 87552-26 $28.00 87552-TC $57.00 87555 $41.00 87555-26 $13.00 87555-TC $28.00 87556 $70.00 87556-26 $23.00 87556-TC $47.00 87557 $85.00 87557-26 $28.00 87557-TC $57.00 87560 $41.00 87560-26 $13.00 87560-TC $28.00 87561 $70.00 87561-26 $23.00 87561-TC $47.00 87562 $85.00 87562-26 $28.00 87562-TC $57.00 87580 $41.00 87580-26 $13.00 87580-TC $28.00 87581 $70.00 87581-26 $23.00 87581-TC $47.00 87582 $83.00 87582-26 $28.00 87582-TC $55.00 87590 $41.00 87590-26 $13.00 87590-TC $28.00 87591 $70.00 87591-26 $23.00 87591-TC $47.00 87592 $85.00 87592-26 $28.00 87592-TC $57.00 87620 $41.00 87620-26 $13.00 87620-TC $28.00 100 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 87621 $70.00 87621-26 $23.00 87621-TC $47.00 87622 $83.00 87622-26 $28.00 87622-TC $55.00 87650 $41.00 87650-26 $13.00 87650-TC $28.00 87651 $70.00 87651-26 $23.00 87651-TC $47.00 87652 $83.00 87652-26 $28.00 87652-TC $55.00 87797 $41.00 87797-26 $13.00 87797-TC $28.00 87798 $70.00 87798-26 $23.00 87798-TC $47.00 87799 $85.00 87799-26 $28.00 87799-TC $57.00 87810 $26.00 87810-26 $8.00 87810-TC $18.00 87850 $26.00 87850-26 $8.00 87850-TC $18.00 87880 $26.00 87880-26 $8.00 87880-TC $18.00 87899 $26.00 87899-26 $8.00 87899-TC $18.00 87999 BR 87999-26 BR 87999-TC BR 88000 $424.00 88000-26 $424.00 88000-TC BR 88005 $477.00 88005-26 $477.00 88005-TC BR 88007 $530.00 88007-26 $530.00 88007-TC BR 88012 $445.00 88012-26 $445.00 Pathology & Laboratory CPT Code MRA 88012-TC BR 88014 $445.00 88014-26 $445.00 88014-TC BR 88016 $424.00 88016-26 $424.00 88016-TC BR 88020 $530.00 88020-26 $530.00 88020-TC BR 88025 $582.00 88025-26 $582.00 88025-TC BR 88027 $635.00 88027-26 $635.00 88027-TC BR 88028 $551.00 88028-26 $551.00 88028-TC BR 88029 $551.00 88029-26 $551.00 88029-TC BR 88036 $455.00 88036-26 $455.00 88036-TC BR 88037 $371.00 88037-26 $371.00 88037-TC BR 88040 $1,377.00 88040-26 $1,377.00 88040-TC BR 88045 BR 88045-26 BR 88045-TC BR 88099 BR 88099-26 BR 88099-TC BR 88104 $48.00 88104-26 $36.00 88104-TC $10.00 88106 $53.00 88106-26 $16.00 88106-TC $37.00 88107 $71.00 88107-26 $56.00 88107-TC $15.00 88108 $58.00 88108-26 $46.00 88108-TC $11.00 88125 $67.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 88125-26 $20.00 88125-TC $47.00 88130 $25.00 88130-26 $7.00 88130-TC $18.00 88140 $18.00 88140-26 $5.00 88140-TC $13.00 88141 $32.00 88141-26 NC 88141-TC NC 88142 $79.00 88142-26 $21.00 88142-TC $58.00 88143 $90.00 88143-26 $32.00 88143-TC $58.00 88144 $100.00 88144-26 $21.00 88144-TC $79.00 88145 $105.00 88145-26 $26.00 88145-TC $79.00 88147 $79.00 88147-26 NC 88147-TC $79.00 88148 $100.00 88148-26 $21.00 88148-TC $79.00 88150 $13.00 88150-26 $3.00 88150-TC $9.00 88152 $45.00 88152-26 $8.00 88152-TC $37.00 88153 $79.00 88153-26 $21.00 88153-TC $58.00 88154 $100.00 88154-26 $21.00 88154-TC $79.00 88155 $14.00 88155-26 $3.00 88155-TC $10.00 88160 $44.00 88160-26 $14.00 88160-TC $24.00 88161 $61.00 88161-26 $19.00 88161-TC $36.00 101 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 88162 $74.00 88162-26 $22.00 88162-TC $52.00 88164 $53.00 88164-26 $21.00 88164-TC $32.00 88165 $69.00 88165-26 $32.00 88165-TC $37.00 88166 $79.00 88166-26 $21.00 88166-TC $58.00 88167 $84.00 88167-26 $26.00 88167-TC $58.00 88170 $95.00 88170-26 $76.00 88170-TC $19.00 88171 $111.00 88171-26 $89.00 88171-TC $22.00 88172 $67.00 88172-26 $53.00 88172-TC $14.00 88173 $91.00 88173-26 $91.00 88173-TC $26.00 88180 $85.00 88180-26 $32.00 88180-TC $53.00 88182 $85.00 88182-26 $32.00 88182-TC $53.00 88199 BR 88199-26 BR 88199-TC BR 88233 $233.00 88233-26 $70.00 88233-TC $163.00 88235 $244.00 88235-26 $73.00 88235-TC $170.00 88240 $21.00 88240-26 $6.00 88240-TC $15.00 88241 $21.00 88241-26 $6.00 88241-TC $15.00 88300 $24.00 88300-26 $19.00 Pathology & Laboratory CPT Code MRA 88300-TC $5.00 88302 $52.00 88302-26 $41.00 88302-TC $11.00 88304 $67.00 88304-26 $53.00 88304-TC $14.00 88305 $104.00 88305-26 $83.00 88305-TC $21.00 88307 $201.00 88307-26 $161.00 88307-TC $40.00 88309 $307.00 88309-26 $246.00 88309-TC $61.00 88311 $23.00 88311-26 $19.00 88311-TC $4.00 88312 $23.00 88312-26 $7.00 88312-TC $16.00 88313 $23.00 88313-26 $7.00 88313-TC $16.00 88314 $21.00 88314-26 $6.00 88314-TC $15.00 88318 $32.00 88318-26 $14.00 88318-TC $18.00 88319 $26.00 88319-26 $13.00 88319-TC $14.00 88321 $42.00 88321-26 $42.00 88321-TC NC 88323 $59.00 88323-26 $59.00 88323-TC NC 88325 $53.00 88325-26 $53.00 88325-TC NC 88329 $50.00 88329-26 $50.00 88329-TC NC 88331 $98.00 88331-26 $67.00 88331-TC $32.00 88332 $52.00 CPT only © 1999 American Medical Association. All Rights Reserved. Pathology & Laboratory CPT Code MRA 88332-26 $35.00 88332-TC $17.00 88342 $52.00 88342-26 $35.00 88342-TC $17.00 88346 $92.00 88346-26 $63.00 88346-TC $28.00 88347 $127.00 88347-26 $95.00 88347-TC $32.00 88348 $182.00 88348-26 $139.00 88348-TC $43.00 88349 $182.00 88349-26 $139.00 88349-TC $43.00 88355 $104.00 88355-26 $77.00 88355-TC $26.00 88356 $104.00 88356-26 $77.00 88356-TC $26.00 88358 $104.00 88358-26 $77.00 88358-TC $26.00 88362 BR 88362-26 BR 88362-TC BR 88365 $24.00 88365-26 $24.00 88365-TC BR 88371 $33.00 88371-26 $10.00 88371-TC $23.00 88372 $37.00 88372-26 $11.00 88372-TC $26.00 88399 BR 88399-26 BR 88399-TC BR 89050 $10.00 89050-26 $3.00 89050-TC $6.00 89051 $13.00 89051-26 $4.00 89051-TC $8.00 89060 $13.00 89060-26 $5.00 89060-TC $8.00 102 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Pathology & Laboratory CPT Code MRA 89100 $50.00 89100-26 $15.00 89100-TC $35.00 89105 $62.00 89105-26 $19.00 89105-TC $43.00 89125 $14.00 89125-26 $4.00 89125-TC $10.00 89130 $43.00 89130-26 $13.00 89130-TC $31.00 89132 $20.00 89132-26 $6.00 89132-TC $14.00 89135 $36.00 89135-26 $11.00 89135-TC $25.00 89136 $42.00 89136-26 $14.00 89136-TC $29.00 89140 $49.00 89140-26 $16.00 89140-TC $33.00 89141 $55.00 89141-26 $19.00 89141-TC $36.00 89160 $6.00 89160-26 $2.00 89160-TC $4.00 89190 $10.00 89190-26 $3.00 89190-TC $6.00 89350 $18.00 89350-26 $6.00 89350-TC $12.00 89355 $10.00 89355-26 $3.00 89355-TC $6.00 89360 $15.00 89360-26 $4.00 89360-TC $11.00 89365 $24.00 89365-26 $7.00 89365-TC $17.00 89399 BR 89399-26 BR 89399-TC BR CPT only © 1999 American Medical Association. All Rights Reserved. 103 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Medicine CPT Code 90471 90472 90632 90636 90675 90703 90718 90746 90747 90749 90780 90781 90782 90783 90784 90788 90799 90801 90802 90804 90805 90806 90807 90808 90809 90810 90811 90812 90813 90814 90815 90816 90817 90818 90819 90821 90822 90823 90824 90826 90827 90828 90829 90845 90846 90847 90849 90853 90857 90862 MRA BR BR BR BR BR BR BR BR NC BR $40.00 $20.00 $5.00 $15.00 $20.00 $6.00 BR $125.00 $128.00 $56.00 $62.00 $85.00 $91.00 $131.00 $137.00 $64.00 $71.00 $91.00 $96.00 $128.00 $134.00 $58.00 $64.00 $87.00 $92.00 $134.00 $138.00 $68.00 $73.00 $94.00 $98.00 $131.00 $135.00 $76.00 $85.00 $99.00 $30.00 $30.00 $28.00 $46.00 Medicine CPT Code 90865 90870 90871 90875 90876 90880 90882 90885 90887 90889 90899 90901 90911 90921 90925 90935 90937 90945 90947 90997 90999 91000 91000-26 91000-TC 91010 91010-26 91010-TC 91011 91011-26 91011-TC 91012 91012-26 91012-TC 91020 91020-26 91020-TC 91030 91030-26 91030-TC 91032 91032-26 91032-TC 91033 91033-26 91033-TC 91052 91052-26 91052-TC 91055 91055-26 MRA $128.00 $85.00 $121.00 $67.00 $100.00 $100.00 $100.00 $45.00 $69.00 BR BR $43.00 $82.00 $231.00 $8.00 $73.00 $226.00 $75.00 $124.00 $111.00 BR $43.00 $40.00 $2.00 $104.00 $76.00 $29.00 $126.00 $89.00 $36.00 $128.00 $95.00 $41.00 $54.00 $45.00 $9.00 $51.00 $43.00 $8.00 $97.00 $71.00 $27.00 $126.00 $82.00 $48.00 $61.00 $52.00 $12.00 $57.00 $46.00 CPT only © 1999 American Medical Association. All Rights Reserved. Medicine CPT Code 91055-TC 91060 91060-26 91060-TC 91065 91065-26 91065-TC 91100 91105 91122 91122-26 91122-TC 91299 92002 92004 92012 92014 92015 92018 92019 92020 92060 92060-26 92060-TC 92065 92065-26 92065-TC 92070 92081 92081-26 92081-TC 92082 92082-26 92082-TC 92083 92083-26 92083-TC 92100 92120 92130 92135 92135-26 92135-TC 92140 92225 92226 92230 92235 92235-26 92235-TC MRA $11.00 $35.00 $27.00 $8.00 $31.00 $23.00 $13.00 $53.00 $35.00 $157.00 $122.00 $35.00 BR $57.00 $88.00 $48.00 $68.00 $31.00 $72.00 $63.00 $28.00 $37.00 $29.00 $7.00 $31.00 $19.00 $6.00 $62.00 $29.00 $18.00 $6.00 $44.00 $24.00 $9.00 $53.00 $31.00 $13.00 $37.00 $29.00 $50.00 $64.00 $17.00 $46.00 $35.00 $45.00 $39.00 $52.00 $93.00 $46.00 $48.00 104 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Medicine CPT Code 92240 92240-26 92240-TC 92250 92250-26 92250-TC 92260 92265 92265-26 92265-TC 92270 92270-26 92270-TC 92275 92275-26 92275-TC 92283 92283-26 92283-TC 92284 92284-26 92284-TC 92285 92285-26 92285-TC 92286 92286-26 92286-TC 92287 92310 92311 92312 92313 92314 92315 92316 92317 92325 92326 92330 92335 92340 92341 92342 92352 92353 92354 92355 92358 92370 MRA $118.00 $57.00 $61.00 $37.00 $23.00 $7.00 $20.00 $48.00 $34.00 $10.00 $58.00 $45.00 $18.00 $72.00 $56.00 $16.00 $23.00 $10.00 $5.00 $192.00 $151.00 $42.00 $24.00 $12.00 $6.00 $82.00 $53.00 $26.00 $89.00 $83.00 $70.00 $80.00 $63.00 $49.00 $40.00 $53.00 $36.00 $13.00 $40.00 $71.00 $65.00 $29.00 $39.00 $39.00 $28.00 $35.00 $198.00 $96.00 $23.00 $35.00 Medicine CPT Code 92371 92390 92391 92392 92393 92395 92396 92499 92502 92504 92506 92507 92508 92510 92511 92512 92516 92520 92525 92526 92531 92532 92533 92534 92541 92541-26 92541-TC 92542 92542-26 92542-TC 92543 92543-26 92543-TC 92544 92544-26 92544-TC 92545 92545-26 92545-TC 92546 92546-26 92546-TC 92547 92548 92548-26 92548-TC 92551 92552 92553 92555 MRA $17.00 $59.00 $80.00 $75.00 $236.00 $32.00 $47.00 BR $91.00 $23.00 $57.00 $37.00 $38.00 $102.00 $80.00 $42.00 $33.00 $43.00 $94.00 $44.00 $10.00 $14.00 $40.00 BR $34.00 $25.00 $9.00 $30.00 $20.00 $10.00 $28.00 $19.00 $10.00 $24.00 $16.00 $8.00 $21.00 $14.00 $8.00 $26.00 $17.00 $9.00 $20.00 $83.00 $30.00 $53.00 $17.00 $16.00 $24.00 $14.00 CPT only © 1999 American Medical Association. All Rights Reserved. Medicine CPT Code 92556 92557 92560 92561 92562 92563 92564 92565 92567 92568 92569 92571 92572 92573 92575 92576 92577 92579 92582 92583 92584 92585 92585-26 92585-TC 92587 92587-26 92587-TC 92588 92588-26 92588-TC 92589 92590 92591 92592 92593 92594 92595 92596 92597 92598 92599 92950 92953 92960 92961 92970 92971 92975 92977 92978 MRA $21.00 $44.00 $23.00 $26.00 $15.00 $14.00 $16.00 $15.00 $19.00 $14.00 $15.00 $14.00 $3.00 $13.00 $11.00 $17.00 $26.00 $26.00 $26.00 $32.00 $89.00 $114.00 $52.00 $66.00 $54.00 $8.00 $47.00 $73.00 $20.00 $53.00 $54.00 $40.00 BR BR BR BR BR $21.00 $89.00 $62.00 BR $199.00 $35.00 $145.00 $213.00 $201.00 $92.00 $400.00 $284.00 $254.00 105 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Medicine CPT Code MRA 92979 $155.00 92979-26 $74.00 92979-TC $81.00 92980 $952.00 92981 $268.00 92982 $705.00 92984 $191.00 92986 $1,208.00 92987 $1,251.00 92990 $948.00 92992 BR 92993 BR 92995 $776.00 92996 $210.00 92997 $765.00 92998 $331.00 93000 $26.00 93005 $16.00 93010 $12.00 93012 $84.00 93014 $28.00 93015 $103.00 93016 $25.00 93017 $60.00 93018 $54.00 93024 $111.00 93024-26 $71.00 93024-TC $40.00 93040 $14.00 93041 $31.00 93042 $9.00 93224 $153.00 93225 $44.00 93226 $78.00 93227 $50.00 93230 $162.00 93231 $54.00 93232 $77.00 93233 $55.00 93235 $119.00 93236 $92.00 93237 $28.00 93268 $98.00 93270 $44.00 93271 $84.00 93272 $28.00 93278 $57.00 93278-26 $24.00 93278-TC $42.00 93303 $207.00 Medicine CPT Code 93303-26 93303-TC 93304 93304-26 93304-TC 93307 93307-26 93307-TC 93308 93308-26 93308-TC 93312 93312-26 93312-TC 93313 93314 93314-26 93314-TC 93315 93315-26 93315-TC 93316 93317 93317-26 93317-TC 93320 93320-26 93320-TC 93321 93321-26 93321-TC 93325 93325-26 93325-TC 93350 93501 93503 93505 93505-26 93505-TC 93508 93508-26 93508-TC 93510 93510-26 93510-TC 93511 93511-26 93511-TC 93514 MRA $70.00 $137.00 $112.00 $43.00 $69.00 $192.00 $56.00 $137.00 $118.00 $46.00 $73.00 $322.00 $140.00 $182.00 $71.00 $198.00 $63.00 $136.00 $273.00 $137.00 $136.00 $73.00 $222.00 $87.00 $136.00 $84.00 $30.00 $61.00 $49.00 $10.00 $40.00 $108.00 $4.00 $104.00 $216.00 $600.00 $187.00 $318.00 $248.00 $70.00 $671.00 $232.00 $439.00 $1,544.00 $247.00 $1,297.00 $1,533.00 $270.00 $1,263.00 $2,208.00 CPT only © 1999 American Medical Association. All Rights Reserved. Medicine CPT Code 93514-26 93514-TC 93524 93524-26 93524-TC 93526 93526-26 93526-TC 93527 93527-26 93527-TC 93528 93528-26 93528-TC 93529 93529-26 93529-TC 93530 93530-26 93530-TC 93531 93531-26 93531-TC 93532 93532-26 93532-TC 93533 93533-26 93533-TC 93536 93539 93540 93541 93542 93543 93544 93545 93555 93555-26 93555-TC 93556 93556-26 93556-TC 93561 93561-26 93561-TC 93562 93562-26 93562-TC 93571 MRA $525.00 $1,683.00 $2,042.00 $392.00 $1,650.00 $2,059.00 $363.00 $1,695.00 $2,101.00 $451.00 $1,650.00 $2,130.00 $480.00 $1,650.00 $1,912.00 $262.00 $1,650.00 $843.00 $250.00 $594.00 $2,162.00 $467.00 $1,695.00 $2,219.00 $569.00 $1,650.00 $1,993.00 $343.00 $1,650.00 $312.00 $45.00 $49.00 $38.00 $38.00 $213.00 $30.00 $240.00 $257.00 $38.00 $219.00 $386.00 $42.00 $344.00 $59.00 $47.00 $19.00 $46.00 $33.00 $13.00 $243.00 106 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Medicine CPT Code 93571-26 93571-TC 93572 93572-26 93572-TC 93600 93600-26 93600-TC 93602 93602-26 93602-TC 93603 93603-26 93603-TC 93607 93607-26 93607-TC 93609 93609-26 93609-TC 93610 93610-26 93610-TC 93612 93612-26 93612-TC 93615 93615-26 93615-TC 93616 93616-26 93616-TC 93618 93618-26 93618-TC 93619 93619-26 93619-TC 93620 93620-26 93620-TC 93621 93621-26 93621-TC 93622 93622-26 93622-TC 93623 93623-26 93623-TC MRA $84.00 $158.00 $222.00 $67.00 $155.00 $198.00 $129.00 $69.00 $159.00 $119.00 $40.00 $187.00 $127.00 $60.00 $227.00 $174.00 $53.00 $578.00 $481.00 $96.00 $214.00 $166.00 $48.00 $224.00 $167.00 $57.00 $58.00 $46.00 $12.00 $94.00 $82.00 $12.00 $399.00 $258.00 $140.00 $717.00 $444.00 $273.00 $327.00 $243.00 $84.00 BR $769.00 BR BR $771.00 BR BR $167.00 BR Medicine CPT Code MRA 93624 $321.00 93624-26 $251.00 93624-TC $70.00 93631 $644.00 93631-26 $420.00 93631-TC $224.00 93640 $467.00 93640-26 $230.00 93640-TC $253.00 93641 $613.00 93641-26 $360.00 93641-TC $253.00 93642 $549.00 93642-26 $295.00 93642-TC $253.00 93650 $639.00 93651 $985.00 93652 $1,044.00 93660 BR 93660-26 $103.00 93660-TC BR 93720 $43.00 93721 $25.00 93722 $24.00 93724 $392.00 93724-26 $252.00 93724-TC $140.00 93727 $25.00 93731 $42.00 93731-26 $24.00 93731-TC $18.00 93732 $63.00 93732-26 $45.00 93732-TC $18.00 93733 $37.00 93733-26 $11.00 93733-TC $26.00 93734 $34.00 93734-26 $21.00 93734-TC $13.00 93735 $27.00 93735-26 $19.00 93735-TC $7.00 93736 $32.00 93736-26 $10.00 93736-TC $23.00 93737 $41.00 93737-26 $23.00 93737-TC $18.00 93738 $63.00 CPT only © 1999 American Medical Association. All Rights Reserved. Medicine CPT Code 93738-26 93738-TC 93740 93740-26 93740-TC 93741 93741-26 93741-TC 93742 93742-26 93742-TC 93743 93743-26 93743-TC 93744 93744-26 93744-TC 93760 93762 93770 93770-26 93770-TC 93784 93786 93788 93790 93797 93798 93799 93875 93875-26 93875-TC 93880 93880-26 93880-TC 93882 93882-26 93882-TC 93886 93886-26 93886-TC 93888 93888-26 93888-TC 93922 93922-26 93922-TC 93923 93923-26 93923-TC MRA $45.00 $18.00 $17.00 $12.00 $5.00 $62.00 $30.00 $32.00 $77.00 $34.00 $43.00 $70.00 $39.00 $32.00 $87.00 $44.00 $43.00 $300.00 $361.00 NC NC NC NC NC NC NC $16.00 $38.00 BR $53.00 $17.00 $40.00 $167.00 $31.00 $135.00 $111.00 $21.00 $90.00 $199.00 $46.00 $153.00 $133.00 $31.00 $102.00 $58.00 $16.00 $43.00 $108.00 $28.00 $80.00 107 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Medicine CPT Code 93924 93924-26 93924-TC 93925 93925-26 93925-TC 93926 93926-26 93926-TC 93930 93930-26 93930-TC 93931 93931-26 93931-TC 93965 93965-26 93965-TC 93970 93970-26 93970-TC 93971 93971-26 93971-TC 93975 93975-26 93975-TC 93976 93976-26 93976-TC 93978 93978-26 93978-TC 93979 93979-26 93979-TC 93980 93980-26 93980-TC 93981 93981-26 93981-TC 93990 93990-26 93990-TC 94010 94010-26 94010-TC 94014 94015 MRA $118.00 $31.00 $87.00 $167.00 $31.00 $136.00 $112.00 $21.00 $91.00 $170.00 $26.00 $144.00 $113.00 $17.00 $96.00 $61.00 $26.00 $40.00 $185.00 $35.00 $150.00 $109.00 $22.00 $87.00 $250.00 $80.00 $170.00 $167.00 $53.00 $114.00 $174.00 $34.00 $140.00 $116.00 $23.00 $93.00 $163.00 $65.00 $94.00 $143.00 $25.00 $117.00 $105.00 $14.00 $91.00 $27.00 $12.00 $15.00 $39.00 $14.00 Medicine CPT Code 94016 94060 94060-26 94060-TC 94070 94070-26 94070-TC 94150 94150-26 94150-TC 94200 94200-26 94200-TC 94240 94240-26 94240-TC 94250 94250-26 94250-TC 94260 94260-26 94260-TC 94350 94350-26 94350-TC 94360 94360-26 94360-TC 94370 94370-26 94370-TC 94375 94375-26 94375-TC 94400 94400-26 94400-TC 94450 94450-26 94450-TC 94620 94620-26 94620-TC 94621 94621-26 94621-TC 94640 94642 94650 94651 MRA $24.00 $51.00 $18.00 $33.00 $29.00 $11.00 $18.00 $8.00 $6.00 $3.00 $16.00 $7.00 $9.00 $39.00 $15.00 $24.00 $12.00 $8.00 $5.00 $27.00 $8.00 $18.00 $33.00 $14.00 $19.00 $37.00 $11.00 $26.00 $30.00 $18.00 $12.00 $33.00 $16.00 $17.00 $37.00 $24.00 $13.00 $34.00 $20.00 $14.00 $88.00 $38.00 $49.00 $118.00 $68.00 $50.00 $18.00 BR $17.00 $16.00 CPT only © 1999 American Medical Association. All Rights Reserved. Medicine CPT Code 94652 94656 94657 94660 94662 94664 94665 94667 94668 94680 94680-26 94680-TC 94681 94681-26 94681-TC 94690 94690-26 94690-TC 94720 94720-26 94720-TC 94725 94725-26 94725-TC 94750 94750-26 94750-TC 94760 94761 94762 94770 94770-26 94770-TC 94799 95004 95010 95015 95024 95027 95028 95044 95052 95056 95060 95065 95070 95071 95075 95078 95115 MRA $18.00 $75.00 $44.00 $49.00 $35.00 $17.00 $18.00 $22.00 $15.00 $43.00 $23.00 $21.00 $54.00 $12.00 $39.00 $23.00 $4.00 $19.00 $45.00 $15.00 $28.00 $76.00 $14.00 $62.00 $34.00 $14.00 $20.00 $9.00 $20.00 $28.00 $20.00 $9.00 $12.00 BR $3.00 $11.00 $11.00 $3.00 $5.00 $8.00 $7.00 $9.00 $6.00 $13.00 $7.00 $78.00 $99.00 $82.00 $9.00 $10.00 108 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Medicine CPT Code 95117 95120 95125 95130 95131 95132 95133 95134 95144 95145 95146 95147 95148 95149 95165 95170 95180 95199 95805 95805-26 95805-TC 95806 95806-26 95806-TC 95807 95807-26 95807-TC 95808 95808-26 95808-TC 95810 95810-26 95810-TC 95811 95811-26 95811-TC 95812 95812-26 95812-TC 95813 95813-26 95813-TC 95816 95816-26 95816-TC 95819 95819-26 95819-TC 95822 95822-26 MRA $9.00 BR BR BR BR BR BR BR $9.00 $16.00 $23.00 $31.00 $32.00 $33.00 $7.00 $13.00 $92.00 BR $321.00 $85.00 $228.00 $232.00 $109.00 $123.00 $327.00 $98.00 $228.00 $407.00 $149.00 $228.00 $464.00 $183.00 $228.00 $574.00 $196.00 $377.00 $123.00 $53.00 $62.00 $159.00 $80.00 $62.00 $119.00 $49.00 $70.00 $103.00 $53.00 $50.00 $116.00 $54.00 Medicine CPT Code 95822-TC 95824 95824-26 95824-TC 95827 95827-26 95827-TC 95829 95829-26 95829-TC 95830 95831 95832 95833 95834 95851 95852 95857 95858 95858-26 95858-TC 95860 95860-26 95860-TC 95861 95861-26 95861-TC 95863 95863-26 95863-TC 95864 95864-26 95864-TC 95867 95867-26 95867-TC 95868 95868-26 95868-TC 95869 95869-26 95869-TC 95870 95870-26 95870-TC 95872 95872-26 95872-TC 95875 95875-26 MRA $61.00 $50.00 $41.00 $10.00 $140.00 $59.00 $81.00 $293.00 $260.00 $6.00 $119.00 $24.00 $20.00 $31.00 $41.00 $17.00 $13.00 $37.00 $59.00 $50.00 $10.00 $66.00 $53.00 $14.00 $113.00 $86.00 $26.00 $136.00 $102.00 $33.00 $177.00 $114.00 $63.00 $64.00 $43.00 $20.00 $96.00 $71.00 $25.00 $29.00 $21.00 $8.00 $29.00 $21.00 $8.00 $95.00 $74.00 $21.00 $39.00 $31.00 CPT only © 1999 American Medical Association. All Rights Reserved. Medicine CPT Code 95875-TC 95900 95900-26 95900-TC 95903 95903-26 95903-TC 95904 95904-26 95904-TC 95920 95920-26 95920-TC 95921 95921-26 95921-TC 95922 95922-26 95922-TC 95923 95923-26 95923-TC 95925 95925-26 95925-TC 95926 95926-26 95926-TC 95927 95927-26 95927-TC 95930 95930-26 95930-TC 95933 95933-26 95933-TC 95934 95934-26 95934-TC 95936 95936-26 95936-TC 95937 95937-26 95937-TC 95950 95950-26 95950-TC 95951 MRA $7.00 $34.00 $24.00 $10.00 $39.00 $31.00 $9.00 $28.00 $20.00 $8.00 $159.00 $114.00 $46.00 $55.00 $42.00 $14.00 $59.00 $46.00 $14.00 $94.00 $43.00 $51.00 $94.00 $53.00 $41.00 $66.00 $34.00 $32.00 $67.00 $34.00 $32.00 $40.00 $25.00 $11.00 $61.00 $33.00 $28.00 $35.00 $27.00 $8.00 $37.00 $29.00 $8.00 $37.00 $28.00 $9.00 $255.00 $84.00 $171.00 $32.00 109 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Medicine CPT Code 95951-26 95951-TC 95953 95953-26 95953-TC 95954 95954-26 95954-TC 95955 95955-26 95955-TC 95956 95956-26 95956-TC 95957 95957-26 95957-TC 95958 95958-26 95958-TC 95961 95961-26 95961-TC 95962 95962-26 95962-TC 95970 95971 95972 95973 95974 95975 95999 96100 96105 96110 96111 96115 96117 96370 96400 96405 96406 96408 96410 96412 96414 96420 96422 96423 MRA $13.00 $19.00 $373.00 $148.00 $225.00 $186.00 $134.00 $22.00 $130.00 $59.00 $71.00 $482.00 $153.00 $280.00 $153.00 $93.00 $61.00 $293.00 $230.00 $62.00 $194.00 $149.00 $46.00 $204.00 $158.00 $46.00 $21.00 $36.00 $70.00 $43.00 $138.00 $79.00 BR $64.00 $64.00 $85.00 $64.00 $64.00 $64.00 See formula $20.00 $53.00 $80.00 $34.00 $5.00 $41.00 $47.00 $44.00 $44.00 $17.00 Medicine CPT Code 96425 96440 96445 96450 96520 96530 96542 96545 96549 96570 96571 96900 96902 96910 96912 96913 96999 97001 97002 97003 97004 97010 97012 97014 97016 97018 97020 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97260 97261 97504 97520 97530 MRA $50.00 $139.00 $140.00 $120.00 $32.00 $49.00 $113.00 BR BR $69.00 $38.00 $17.00 $23.00 $20.00 $23.00 $48.00 BR $56.00 $26.00 $56.00 $26.00 $10.00 $16.00 $14.00 $15.00 $10.00 $10.00 $14.00 $10.00 $9.00 $10.00 $15.00 $16.00 $13.00 $11.00 $18.00 $15.00 $21.00 $22.00 $23.00 $20.00 $18.00 $14.00 $24.00 $17.00 $23.00 $17.00 $22.00 $22.00 $21.00 CPT only © 1999 American Medical Association. All Rights Reserved. Medicine CPT Code 97535 97537 97542 97545 97546 97703 97750 97752 97770 97780 97781 97799 97801 97802 97850 97851 98925 98926 98927 98928 98929 98940 98941 98942 98943 MRA $22.00 $22.00 $16.00 $80.00 $40.00 $14.00 BR $47.00 $24.00 $31.00 BR BR $53.00 $26.00 $53.00 $26.00 NC $29.00 NC $22.00 NC NC $29.00 NC $22.00 110 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Evaluation & Management CPT Code MRA 99000 $6.00 99001 $4.00 99002 $34.00 99025 $30.00 99070 BR 99071 NC See 440.13(10) 99075 99078 NC 99080 BR 99082 BR 99090 BR 99141 $72.00 99142 $60.00 99173 BR 99175 $50.00 99183 $123.00 99185 $22.00 99186 $73.00 99190 BR 99191 BR 99192 BR 99195 $16.00 99199 BR 99201 $33.00 99202 $52.00 99203 $52.00 99204 $75.00 99205 $75.00 99211 $18.00 99212 $28.00 99213 $37.00 99214 $37.00 99215 $59.00 99217 $60.00 99218 $63.00 99219 $104.00 99220 $140.00 99221 $63.00 99222 $104.00 99223 $140.00 99231 $32.00 99232 $50.00 99233 $71.00 99234 $115.00 99235 $155.00 99236 $190.00 99238 $60.00 99239 $79.00 99241 $54.00 99242 $83.00 Evaluation & Management CPT Code MRA 99243 $105.00 99244 $146.00 99245 $189.00 99251 $54.00 99252 $69.00 99253 $92.00 99254 $129.00 99255 $177.00 99261 $24.00 99262 $43.00 99263 $64.00 99271 $49.00 99272 $55.00 99273 $77.00 99274 $104.00 99275 $136.00 99281 $18.00 99282 $28.00 99283 $58.00 99284 $89.00 99285 $92.00 99288 BR 99291 $172.00 99292 $86.00 99295 $719.00 99296 $359.00 99297 $180.00 99298 $125.00 99301 $52.00 99302 $59.00 99303 $97.00 99311 $22.00 99312 $47.00 99313 $65.00 99315 $54.00 99316 $69.00 99321 $38.00 99322 $54.00 99323 $71.00 99331 $33.00 99332 $43.00 99333 $53.00 99341 $53.00 99342 $76.00 99343 $98.00 99344 $143.00 99345 $173.00 99347 $42.00 99348 $64.00 99349 $96.00 CPT only © 1999 American Medical Association. All Rights Reserved. Evaluation & Management CPT Code MRA 99350 $139.00 99354 $95.00 99355 $93.00 99356 $83.00 99357 $84.00 99358 BR 99359 BR 99360 BR 99361 BR 99362 BR 99371 NC 99372 $17.00 99373 $22.00 99374 $68.00 99375 $68.00 99377 $68.00 99378 $93.00 99379 $68.00 99380 $93.00 99431 NC 99432 NC 99433 NC 99435 NC 99436 NC 99440 NC 99450 NC 99455 $87.00 99456 $200.00 99499 BR 111 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Dental D-Code D0120 D0140 D0150 D0160 D0170 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0274 D0277 D0290 D0310 D0320 D0321 D0322 D0330 D0340 D0350 D0415 D0425 D0460 D0470 D0472 D0473 D0474 D0480 D0501 D0502 D0999 D1110 D1204 D1205 D1310 D1320 D1330 D1351 D1510 D1515 D1520 D1525 D1550 D2110 D2120 D2130 D2131 MRA $17.00 $13.00 $20.00 $35.00 $18.00 $39.00 $10.00 $5.00 $12.00 $20.00 $14.00 $7.00 $12.00 $20.00 $18.00 $35.00 $49.00 $195.00 $61.00 $101.00 $29.00 $39.00 $10.00 $33.00 $25.00 $13.00 $24.00 BR BR BR BR $58.00 $53.00 BR $29.00 $10.00 $39.00 $23.00 $47.00 $13.00 $21.00 $78.00 $117.00 $98.00 $137.00 $14.00 $24.00 $37.00 $39.00 $55.00 Dental D-Code D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2336 D2337 D2380 D2381 D2382 D2385 D2386 D2387 D2388 D2410 D2420 D2430 D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643 D2644 D2650 D2651 D2652 D2662 D2663 D2664 D2710 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2780 D2781 D2782 D2783 MRA $37.00 $43.00 $53.00 $64.00 $39.00 $59.00 $63.00 $78.00 $49.00 $133.00 $24.00 $37.00 $49.00 $39.00 $78.00 $98.00 $111.00 $156.00 $194.00 $280.00 $148.00 $247.00 $234.00 $289.00 $303.00 $332.00 $197.00 $254.00 $332.00 $274.00 $313.00 $361.00 $197.00 $254.00 $332.00 $254.00 $313.00 $332.00 $185.00 $391.00 $293.00 $332.00 $391.00 $430.00 $313.00 $352.00 $352.00 $254.00 $293.00 $371.00 Dental D-Code D2790 D2791 D2792 D2799 D2910 D2920 D2930 D2931 D2932 D2933 D2940 D2950 D2951 D2952 D2953 D2954 D2955 D2957 D2960 D2961 D2962 D2970 D2980 D2999 D3110 D3120 D3220 D3221 D3230 D3240 D3310 D3320 D3330 D3331 D3332 D3333 D3346 D3347 D3348 D3351 D3352 D3353 D3410 D3421 D3425 D3426 D3430 D3450 D3460 D3470 MRA $371.00 $274.00 $313.00 $195.00 $29.00 $29.00 $78.00 $117.00 $74.00 $88.00 $29.00 $78.00 $20.00 $76.00 $127.00 $98.00 $78.00 $68.00 $117.00 $195.00 $281.00 $78.00 $80.00 BR $25.00 $20.00 $59.00 $78.00 $67.00 $72.00 $197.00 $195.00 $274.00 BR BR BR $215.00 $262.00 $322.00 $98.00 $78.00 $156.00 $172.00 $185.00 $197.00 $74.00 $54.00 $98.00 $303.00 $195.00 D-Codes: Health Care Financing Administration's Common Procedure Coding System, Level II, © 1999 112 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Dental D-Code D3910 D3920 D3950 D3999 D4210 D4211 D4220 D4240 D4245 D4249 D4260 D4263 D4264 D4266 D4267 D4268 D4270 D4271 D4273 D4274 D4320 D4321 D4341 D4355 D4381 D4910 D4920 D4999 D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5710 MRA $49.00 $98.00 $59.00 BR $110.00 $49.00 $84.00 $213.00 BR $199.00 $313.00 $186.00 $152.00 $272.00 $313.00 BR $148.00 $197.00 $322.00 $199.00 $74.00 $54.00 $76.00 $49.00 $66.00 $39.00 $27.00 BR $489.00 $489.00 $537.00 $537.00 $244.00 $247.00 $586.00 $586.00 $266.00 $27.00 $27.00 $27.00 $27.00 $59.00 $39.00 $59.00 $80.00 $22.00 $52.00 $59.00 $98.00 $195.00 Dental D-Code D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5810 D5811 D5820 D5821 D5850 D5851 D5860 D5861 D5862 D5867 D5875 D5899 D5911 D5912 D5913 D5914 D5915 D5916 D5919 D5922 D5923 D5924 D5925 D5926 D5927 D5928 D5929 D5931 D5932 D5933 D5934 D5935 D5936 D5937 D5951 D5952 D5953 D5954 D5955 MRA $195.00 $156.00 $156.00 $117.00 $117.00 $98.00 $98.00 $126.00 $156.00 $96.00 $156.00 $234.00 $234.00 $185.00 $195.00 $45.00 $49.00 $518.00 $528.00 $174.00 $35.00 BR BR $78.00 $117.00 $1,954.00 $1,954.00 $2,638.00 $2,736.00 BR $1,270.00 $1,563.00 BR BR $977.00 $977.00 $1,319.00 BR $625.00 $1,466.00 $293.00 $1,466.00 $1,466.00 $537.00 BR $586.00 $586.00 $586.00 BR $1,270.00 Dental D-Code D5958 D5959 D5960 D5982 D5983 D5984 D5985 D5986 D5987 D5988 D5999 D6010 D6020 D6040 D6050 D6055 D6056 D6057 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6080 D6090 D6095 D6100 D6199 D6210 D6211 D6212 D6240 D6241 MRA $743.00 $234.00 $156.00 $160.00 BR BR $547.00 $59.00 BR $209.00 BR $618.00 $247.00 $2,872.00 $1,483.00 $733.00 BR BR BR BR BR BR BR BR BR $489.00 $489.00 $489.00 BR BR BR BR BR BR BR BR BR BR $977.00 BR $68.00 $219.00 $236.00 $252.00 BR $391.00 $274.00 $313.00 $430.00 $352.00 D-Codes: Health Care Financing Administration's Common Procedure Coding System, Level II, © 1999 113 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Dental D-Code D6242 D6245 D6250 D6251 D6252 D6519 D6520 D6530 D6543 D6544 D6545 D6548 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6920 D6930 D6940 D6950 D6970 D6971 D6972 D6973 D6975 D6976 D6977 D6980 D6999 D7110 D7120 D7130 D7210 D7220 D7230 D7240 D7241 D7250 D7260 D7270 MRA $391.00 BR $391.00 $274.00 $352.00 BR $247.00 $234.00 $313.00 $352.00 $186.00 BR $391.00 $223.00 $332.00 BR $340.00 $313.00 $391.00 $371.00 BR BR BR $371.00 $274.00 $332.00 $266.00 $39.00 $98.00 $148.00 $156.00 $109.00 $117.00 $107.00 $205.00 BR BR $102.00 BR $39.00 $39.00 $51.00 $67.00 $107.00 $133.00 $141.00 $195.00 $78.00 $234.00 $141.00 Dental D-Code D7272 D7280 D7281 D7285 D7286 D7290 D7291 D7310 D7320 D7340 D7350 D7410 D7420 D7430 D7431 D7440 D7441 D7450 D7451 D7460 D7461 D7465 D7471 D7480 D7490 D7510 D7520 D7530 D7540 D7550 D7560 D7610 D7620 D7630 D7640 D7650 D7660 D7670 D7680 D7710 D7720 D7730 D7740 D7750 D7760 D7770 D7780 D7810 D7820 D7830 MRA $195.00 $117.00 $78.00 $102.00 $78.00 $127.00 $74.00 $82.00 $104.00 $186.00 $391.00 $98.00 $176.00 $127.00 $195.00 $154.00 $236.00 $133.00 $172.00 $131.00 $186.00 $68.00 BR $303.00 $2,423.00 $53.00 $117.00 $82.00 $117.00 $137.00 $254.00 $1,133.00 $938.00 $1,290.00 $782.00 $1,231.00 $743.00 $391.00 $1,856.00 $1,348.00 $860.00 $1,505.00 $879.00 $1,270.00 $997.00 $508.00 $2,384.00 $1,231.00 $106.00 $178.00 Dental D-Code D7840 D7850 D7852 D7854 D7856 D7858 D7860 D7865 D7870 D7871 D7872 D7873 D7874 D7875 D7876 D7877 D7880 D7899 D7910 D7911 D7912 D7920 D7940 D7941 D7943 D7944 D7945 D7946 D7947 D7948 D7949 D7950 D7955 D7960 D7970 D7971 D7980 D7981 D7982 D7983 D7990 D7991 D7995 D7996 D7997 D7999 D8010 D8020 D8030 D8040 MRA $1,680.00 $1,602.00 $1,915.00 BR BR $2,188.00 $586.00 $1,641.00 $78.00 BR $508.00 $557.00 $703.00 $752.00 $782.00 $723.00 BR BR $70.00 $106.00 $156.00 $645.00 $801.00 $2,736.00 $2,775.00 $2,188.00 $2,208.00 $2,443.00 $2,443.00 $2,736.00 $3,986.00 $840.00 $879.00 $117.00 $131.00 $64.00 $162.00 $782.00 $293.00 $234.00 $324.00 $782.00 BR BR BR BR $430.00 $508.00 $684.00 $556.00 D-Codes: Health Care Financing Administration's Common Procedure Coding System, Level II, © 1999 114 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Dental D-Code D8050 D8060 D8070 D8080 D8090 D8210 D8220 D8660 D8670 D8680 D8690 D8691 D8692 D8999 D9110 D9210 D9211 D9212 D9215 D9220 D9221 D9230 D9241 D9242 D9248 D9310 D9410 D9420 D9430 D9440 D9610 D9630 D9910 D9911 D9920 D9930 D9940 D9941 D9950 D9951 D9952 D9970 D9971 D9972 D9973 D9974 D9999 MRA $645.00 $723.00 $1,778.00 $1,778.00 $1,856.00 $148.00 $172.00 $70.00 $53.00 $164.00 $68.00 BR BR BR $39.00 $14.00 $14.00 $13.00 $7.00 $107.00 $39.00 $18.00 BR BR BR $40.00 $59.00 $45.00 $23.00 $40.00 $20.00 $10.00 $21.00 $21.00 $31.00 $33.00 $195.00 $57.00 $110.00 $45.00 $156.00 $80.00 BR $109.00 $39.00 $49.00 BR D-Codes: Health Care Financing Administration's Common Procedure Coding System, Level II, © 1999 115 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Injections J-Code MRA J0120 $12.00 J0130 BR J0150 $27.00 J0151 BR J0170 $1.00 J0190 $3.00 J0200 BR J0205 $37.00 J0207 BR J0210 $7.00 J0256 $97.00 J0280 $1.00 J0285 BR J0286 BR J0290 $2.00 J0295 $7.00 J0300 $2.00 J0330 $1.00 J0340 $3.00 J0350 $2,294.00 J0360 $6.00 J0380 $1.00 J0390 $3.00 J0395 BR J0400 $3.00 J0456 BR J0460 $1.00 J0470 $11.00 J0475 $192.00 J0476 BR J0500 $3.00 J0510 $6.00 J0515 $3.00 J0520 $5.00 J0530 $4.00 J0540 $8.00 J0550 $21.00 J0560 $6.00 J0570 $9.00 J0580 $26.00 J0585 $375.00 J0590 $4.00 J0600 $6.00 J0610 $1.00 J0620 $3.00 J0630 $21.00 J0635 $12.00 J0640 $22.00 J0670 NC J0690 $3.00 Injections J-Code J0694 J0695 J0696 J0697 J0698 J0702 J0704 J0710 J0713 J0715 J0720 J0725 J0730 J0735 J0740 J0743 J0745 J0760 J0770 J0780 J0800 J0810 J0835 J0850 J0895 J0900 J0945 J0970 J1000 J1020 J1030 J1040 J1050 J1055 J1060 J1070 J1080 J1090 J1095 J1100 J1110 J1120 J1160 J1165 J1170 J1180 J1190 J1200 J1205 J1212 MRA $10.00 $26.00 $11.00 $6.00 $11.00 $4.00 $2.00 $3.00 $8.00 $6.00 $6.00 $3.00 $1.00 BR BR $14.00 $1.00 $3.00 $31.00 $3.00 $18.00 $1.00 $12.00 $346.00 $10.00 $1.00 $1.00 $1.00 $3.00 $1.00 $2.00 $3.00 $9.00 BR $1.00 $1.00 $2.00 $1.00 $5.00 $1.00 $10.00 $34.00 $2.00 $1.00 $1.00 $1.00 BR $1.00 $9.00 $35.00 Injections J-Code J1230 J1240 J1245 J1250 J1260 J1320 J1325 J1327 J1330 J1362 J1364 J1380 J1390 J1410 J1435 J1436 J1438 J1440 J1441 J1450 J1455 J1460 J1470 J1480 J1490 J1500 J1510 J1520 J1530 J1540 J1550 J1560 J1561 J1562 J1565 J1570 J1580 J1600 J1610 J1620 J1626 J1630 J1631 J1642 J1644 J1645 J1650 J1670 J1690 J1700 MRA $1.00 $1.00 $30.00 $48.00 BR $1.00 BR BR $2.00 $6.00 $6.00 $1.00 $1.00 $32.00 $1.00 $65.00 BR $151.00 $242.00 BR $12.00 $2.00 $4.00 $7.00 $9.00 $11.00 $13.00 $15.00 $17.00 $20.00 $22.00 BR $36.00 $326.00 BR $35.00 $3.00 $10.00 $27.00 $66.00 BR $4.00 $28.00 $1.00 $1.00 BR $16.00 $23.00 $1.00 $1.00 J-Codes: Health Care Financing Administration's Common Procedure Coding System, Level II, © 1999 116 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Injections J-Code J1710 J1720 J1730 J1739 J1741 J1742 J1745 J1750 J1785 J1790 J1800 J1810 J1820 J1825 J1830 J1840 J1850 J1885 J1890 J1910 J1930 J1940 J1950 J1955 J1956 J1960 J1970 J1980 J1990 J2000 J2010 J2060 J2150 J2175 J2180 J2210 J2240 J2250 J2260 J2270 J2271 J2275 J2300 J2310 J2320 J2321 J2322 J2330 J2350 J2355 MRA $5.00 $4.00 $90.00 $1.00 $3.00 BR BR BR $4.00 $4.00 $10.00 $6.00 $2.00 BR $73.00 $7.00 $4.00 $7.00 $11.00 $9.00 $4.00 $1.00 $392.00 $36.00 BR $2.00 $23.00 $3.00 $8.00 $7.00 $2.00 $12.00 $3.00 $1.00 $3.00 $3.00 $1.00 $2.00 $31.00 $1.00 BR $13.00 $2.00 $3.00 $5.00 $6.00 $8.00 $2.00 $1.00 BR Injections J-Code J2360 J2370 J2400 J2405 J2410 J2430 J2440 J2460 J2480 J2500 J2510 J2512 J2515 J2540 J2543 J2545 J2550 J2560 J2590 J2597 J2640 J2650 J2670 J2675 J2680 J2690 J2700 J2710 J2720 J2725 J2730 J2760 J2765 J2780 J2790 J2792 J2800 J2810 J2820 J2860 J2910 J2912 J2920 J2930 J2950 J2970 J2994 J2995 J2996 J3000 MRA $2.00 $3.00 BR $6.00 $3.00 $181.00 $2.00 $1.00 $3.00 BR $1.00 $32.00 $1.00 $1.00 BR $101.00 $1.00 $5.00 $1.00 $20.00 $1.00 $1.00 BR $1.00 $16.00 $7.00 $2.00 $1.00 $1.00 $11.00 $29.00 $29.00 $2.00 BR $35.00 BR $3.00 $3.00 $111.00 $7.00 $11.00 $1.00 $5.00 $13.00 $1.00 $6.00 BR BR $282.00 $2.00 Injections J-Code J3010 J3030 J3070 J3080 J3105 J3120 J3130 J3140 J3150 J3230 J3240 J3245 J3250 J3260 J3265 J3270 J3280 J3301 J3302 J3303 J3305 J3310 J3320 J3350 J3360 J3364 J3365 J3370 J3390 J3400 J3410 J3420 J3430 J3450 J3470 J3475 J3480 J3490 J7030 J7040 J7042 J7050 J7051 J7060 J7070 J7100 J7110 J7120 J7130 J7190 MRA $2.00 $33.00 $4.00 $10.00 $2.00 $1.00 $1.00 $1.00 $1.00 $2.00 $205.00 BR $1.00 $7.00 $2.00 $2.00 $5.00 $1.00 $1.00 $1.00 $54.00 $5.00 $16.00 $69.00 $1.00 $51.00 $413.00 $9.00 $22.00 $12.00 $1.00 $1.00 $2.00 $2.00 $7.00 $1.00 $1.00 BR $11.00 $10.00 $10.00 $10.00 $1.00 $10.00 $11.00 $131.00 $89.00 $12.00 $6.00 $231.00 J-Codes: Health Care Financing Administration's Common Procedure Coding System, Level II, © 1999 117 Florida Workers' Compensation Health Care Provider Fee For Service Reimbursement Manual, 2001 Edition Injections J-Code J7191 J7192 J7194 J7197 J7198 J7199 J7310 J7315 J7320 J7501 J7504 J7505 J7513 J7516 J7599 MRA BR $302.00 $116.00 $271.00 BR BR BR BR BR $94.00 $269.00 $549.00 BR BR BR J-Codes: Health Care Financing Administration's Common Procedure Coding System, Level II, © 1999 118 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition APPENDIX A DEFINITIONS 119 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition APPENDIX A. DEFINITIONS. (1) “Agency” means the Agency for Health Care Administration. (2) “Authorization” means the approval given to a health care provider by the carrier or self-insured employer for the provision of medical services to an employee. (3) “Billing” means the completion and submission of a form to the carrier in order to receive reimbursement for health care services provided to an injured employee. (4) “Coding system” means a systematic listing of codes to identify either established diagnosis or procedures and services rendered by health care providers. (5) “Commission on Accreditation of Rehabilitation Facilities (CARF)” is a not-forprofit organization whose mission is to promote the quality, value and optimal outcomes of services through a consultative accreditation process that centers on enhancing the lives of people in need of rehabilitation and served by CARF accredited organizations and rehabilitation programs. (6) “Consultation” means services rendered by a physician whose opinion or advice is requested by another physician regarding the further evaluation and management of the injured employee. (7) “Descriptor” means the narrative description of a procedure or service which is represented in a coding system by a specific code. (8) “Durable medical equipment” means articles of a permanent nature which are prescribed for prolonged or continuous use. (9) “Exclusion” means a procedure, service or supply that is not reimbursable under the workers’ compensation program. (10) “Fee for service” means a payment for a medical service rendered outside a managed care arrangement. (11) “Health care provider” is defined in s. 440.13(1), F.S. (12) “Limitations” mean the restrictions placed on the reimbursement of medical services. (13) “Maximum reimbursement allowance (MRA)” means the maximum dollar amount established to reimburse a health care provider for medical services or supplies. (14) “Medical record” means the medical file that contains information that identifies the patient, supports the diagnosis, justifies the treatment and documents the care provided. 120 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition (15) “Medical supplier” means an individual or entity who furnishes medical equipment, supplies, appliances, devices, ocular and hearing aids, prosthetics or orthotics as prescribed by a physician. (16) “New patient” means an injured employee who is new to the health care provider or is an established patient with a new compensable injury or illness. (17) “Non-covered (NC)” means a service or supply that is not reimbursable under the workers’ compensation program. These services and supplies are identified by “NC” in the MRA column in the schedule of maximum reimbursement allowances. (18) “Orthotics” mean mechanical appliances that are used to support and correct deformities. (19) “Procedure” means a medical service rendered to an injured employee during the course of treatment. (20) “Professional component” means that portion of a diagnostic procedure that consists of the physician’s professional services. This includes examination of the patient when indicated, the performance and the supervision of the procedure and an interpretation and written report of the procedure. (21) “Prosthetics” mean artificial substitutes that are used to replace missing parts or devices to augment performance of a natural function. (22) “Referral” means the transfer of the total or specific care of a patient from one physician to another. (23) “Technical component” means the portion of certain diagnostic procedures that includes the provision of personnel, materials and equipment to perform the procedures or studies. (24) “Unlisted procedure” means a procedure code that is not listed in this schedule, but is in the Physicians’ Current Procedural Terminology, Fourth Edition, Copyright 1999, American Medical Association; the Current Dental Terminology, Third Edition, Copyright 1999, American Dental Association; or the 2000 Health Care Provider Coding System, Eleventh Edition, Copyright 1999, Ingenix. All of these references are incorporated by rule 38F-7.020, Florida Administrative Code. (25) “Usual charge” means the customary fee billed by a health care provider. 121 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition APPENDIX B DIRECTORY OF REFERENCES 122 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition APPENDIX B : DIRECTORY OF REFERENCES This directory includes a listing of references published by a national medical specialty society, national professional associations and publishing organizations. As medical information pertaining to coding systems and guidelines changes over time, users of this manual seeking up-to-date information should use the appropriate listed reference address, telephone/fax number or web site for specific answers to questions, inquiries and products. Complete Global Service Data for Orthopaedic Surgery, Vol. 1 & 2 American Academy of Orthopaedic Surgeons 6300 North River Road Rosemont, Illinois 60018 (847) 823-7186 (800) 346-AAOS (847) 823-8125 Fax Web site: www.aaos.org/ Current Dental Terminology ( CDT-3) American Dental Association 211 East Chicago, Illinois 60611 (312) 440-2500 (800) 621 –8099 (312) 440-2883 Fax Web site: www.ada.org Current Procedural Terminology, 4th Edition ( CPT) American Medical Association (AMA) 515 North State Street Chicago, Illinois 60610 AMA Information and Education Services (800) 634-6922 AMA Order Department P.O. Box 930876 Atlanta, Georgia 31193-0876 (800) 621–8335 (312) 464-5600 Fax Web site: www.ama-assn.org/cpt 123 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition Drug Topics Red Book Medical Economics Five Paragon Drive Montvale, New Jersey 07645-1742 (201) 358-7500 (800) 222-3045 Web site: www.pdr.net.com Web site: medec.bookstore.com 1996 Florida Uniform Permanent Impairment Rating Schedule (FUPIRS) Florida Workers’ Compensation Institute P. O. Box 200 Tallahasee, Florida 32302-0200 (850) 425-8156 (850) 222-9766 Fax Web site: www.fwciweb.org Guide To The Evaluation of Permanent Impairment, 5th Edition AMA Order Department P.O Box 930876 Atlanta, Georgia 31193-0876 (800) 621-8335 (312) 464-5600 Fax Web site: www.ama-assn.org/cpt International Classification of Diseases, Clinical Modification (ICD-9-CM), Volumes I & 2 INGENIX (Formerly Medicode) 2525 Lake Park Boulevard West Valley City, Utah 84102 (801) 982 3000 (801) 982-4000 Fax Web site: www.ingenix.com Price Alert First Data Bank (Formerly Medi-Span) 8425 Woodfield Crossing Boulevard P.O. Box 40930 Indianapolis, Indiana 46240-0930 (317) 469 –5200 (800) 428-4495 (317) 469-5256 Fax Web site: www.firstdatabank.com 124 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition APPENDIX C MODIFIERS 125 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition APPENDIX C. MODIFIERS. 1. Modifiers, used in the workers’ compensation program, change the basic services reported and require different reimbursements from the MRAs listed for the unmodified basic services. Modifiers are two (2) characters: alpha, numeric or an alpha-numeric combination. 2. The CPT has two (2) methods of reporting modified services. a. The CPT uses a five (5) digit numeric modifier code. (1) This code is separate and is not added to the basic service. (2) Reimbursement for a five (5) digit numeric modifier code is excluded. b. The CPT has a two (2) digit numeric modifier series, which adds the modifier to the procedure code of the basic procedure. (1) Reimbursement shall be made for all of the two (2) digit numeric modifiers provided in the CPT, when the service is medically necessary. (a) The guidelines in the CPT must be followed for each modifier reported by the provider. (b) In some situations, it may be necessary for the provider to submit a report with the bill to explain the circumstances in order for a carrier to determine reimbursement. (c) Certain modifiers shall be reimbursed the provider’s charge or the listed MRA, whichever is less. (2) There is no additional reimbursement for any two (2) digit CPT Level I and Level II modifiers reported on the claim form. 3. In addition to the CPT modifiers, workers’ compensation has three (3) unique modifiers for reporting a change to the basic service. These two (2) character alpha modifiers include the following: a. Modifier –FC (Facility Charge/“Supervision and Interpretation” Radiology Services) When a radiology procedure’s descriptor indicates that the service is for “supervision and interpretation” and the procedure is performed by a radiologist in a radiology facility, the facility charge shall be billed by adding modifier –FC to the basic radiology procedure code. Additional reimbursement shall be made by BR to a radiologist in an independent radiology facility for a facility charge. b. Modifier –TC (Technical Component) When the technical component of a procedure (personnel, materials, equipment, space and supplies) is rendered by a health care provider other than the physician performing 126 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition the professional component of the procedure, the provider shall bill the technical component by adding modifier –TC to the appropriate procedure code. Reimbursement shall be the provider’s charge, or the listed MRA whichever is less. c. Modifier –QY (Medical Direction/CRNA Anesthesia Services) When an anesthesiologist is not personally administering the anesthesia but is providing medical direction for the anesthesia services provided by a nurse anesthetist, not employed by the anesthesiologist, the physician shall bill for the medical direction service by adding modifier –QY to the anesthesia procedure code. The medical direction service includes the preoperative and postoperative anesthesia care. Reimbursement for medical direction services by an anesthesiologist shall be the provider’s charge, or fifty (50) percent of the anesthesia reimbursement allowance, whichever is less. 127 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition APPENDIX D WORKERS’ COMPENSATION UNIQUE PROCEDURE CODES 128 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition APPENDIX D. WORKERS’ COMPENSATION UNIQUE PROCEDURE CODES 96370 Legend or prescription drugs dispensed by a physician Page 7 97260 Manipulation of spine by a physician other than an osteopathic or chiropractic physician. Page 20 97261 Manipulation of the temporomandibular joint; upper extremities including the hand and wrist; the lower extremities; and other regions by a physician other than an osteopathic or chiropractic physician. Page 20 97545 Work hardening program; initial two (2) hours each day. Page 25 97546 Work hardening program; each additional hour each day. Page 25 97750 Functional capacity evaluation (FCE) with written report. Page 24 97752 Muscle testing and range of motion measurements with written report. This includes testing manually or by mechanical equipment. Page 21 97801 Physical reconditioning program; per hour. Page 23 97802 Physical reconditioning program; additional thirty (30) minutes. Page 23 97850 Physical reconditioning assessment; per hour. Page 22 97851 Physical reconditioning assessment; additional thirty (30) minutes. Page 22 129 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition INDEX 130 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition INDEX A E Acupuncture, 21 Anesthesia Anesthesia Reimbursement Allowance (ARA), 29 Basic Value (BV), 29 Physical status modifiers, 30 Qualifying circumstances, 31 Reimbursement methodology, 31 Time (TM) Unit, 29 Authorization, 1 Average Wholesale Price (AWP), 8 Evaluation and management services, 10 F Federal facilities, 1, 4 Failed appointments, 5 Follow-up days, 26 Functional capacity evaluation (FCE), 24 G B Global reimbursement, 26 Billing, 1 Biofeedback, 9 By Report (BR), 4 H Health care provider(s), 1, 4 C Central nervous system tests, 15 Certification, 1 Chiropractic manipulative treatment (CMT), 21 Commission on Accreditation of Rehabilitation Facilities (CARF), 18 Consultation, 10, Contact lens, see Ophthalmological services D Definitions, 33 Dental services General dental services, 6 Oral and maxillofacial surgery, 6 Temporomandibular joint services, 6 Drugs Average Wholesale Price (AWP), 8 Compounded, 7 National Drug Code (NDC), 7 Over-the-counter drugs, 8 Prescription drugs, 7 Reimbursement formula, 8 Durable medical equipment (DME), 9 I Immunizations, 11 Impairment rating, 10 Independent medical examination (IME), 10 Individual psychotherapy, 14 Interdisciplinary pain program, 25 Injections Intramuscular, 11 Intravenous, 11 Subcutaneous, 11 Injection procedures Arthrocentesis, 12 Aspiration/injection into joints, 12 Trigger point, 12 J J-codes, 11 131 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition L Level I: Physical Medicine Services, 18 Level II: Physical Reconditioning Services, 21 Level III: Multidisplinary Services, 24 Local anesthesia, 32 M Managed care, 1 Manipulative treatment, 20 Maximum medical improvement (MMI), 10 Maximum reimbursement allowance (MRA), 4 Medical necessity, 2 Medical records, 3 Medical supplier services, 9 Medical supplies, 24 Modifiers, 126 Muscle testing, 18 N National Drug Code (NDC), 7 Neurology and neuromuscular services Needle electromyography (EMG), 13 Nerve conduction studies (NCS), 13 Testing and measurements, 12 New patient, 10, 34 Manipulative treatment, 20 Medical supplies, 21 Modalities and therapeutic procedures,19 Physical reconditioning assessment, 22 Physical reconditioning program, 22 Revised plan of care, 19 Tests and measurements, 21 Therapy re-evaluation, 19 Work hardening program, 25 Psychiatric services, 14 Psychological services, 14 Psychotherapy, 14 R Radiology, 15 Facility charge modifier, 126 Professional component modifier, 15 Radiology consultation, 15 Technical component modifier, 126 Reference materials, 123-124 Reimbursement, 4-5 S Spectacles, see Ophthalmological services Supplies, 15-16 Surgical services, 26 Bilateral procedures, 28 Follow-up day period, 26 General reimbursement information, 26 Global reimbursement, 26 Multiple procedures, 27-28 Non-physician assistant, 27 Surgical assistants, 26 Surgical team, 27 Two surgeons, 27 O Office visits, 10 Ophthalmological services, 14 Osteopathic manipulative treatment (OMT), 21 Out-of-state providers, 4 P T Pain program services, 14 Pharmaceutical reimbursement formula, 8 Pharmacist, 8 Physical medicine and rehabilitation General information, 18 Initial evaluation and plan of care, 19 Temporomandibular joint services, 6 Thermography, 16 Transcutaneous neurostimulator, 16-17 132 Florida Workers’ Compensation Health Care Provider Fee for Service Reimbursement Manual, 2001 Edition U Unlisted procedures, 5,121 V Vaccine, 11 Visit(s) Consultation, 10 Confirmatory consultation, 10 Office visit, 10 Postoperative, 26 Preoperative, 26 W Work hardening program, 25 Workers’ compensation unique procedure codes, 129 Workers’ compensation unique modifiers, 126-127 X X-rays, 3, 15 133
