18 CRR-NY 533.4NY-CRR
18 CRR-NY 533.4
18 CRR-NY 533.4
533.4 Medicine.
(a) Conversion factor.
The conversion factor for the services and procedures listed in subdivision (g) of this section shall be $5.
(b) Services and values.
For the numbered and described items of services or procedures set forth in subdivision (g) of this section, the maximum reimbursable fee shall be computed on the basis of the respective assigned value multiplied by the conversion factor of $5.
(c) Clinic services.
(1) Maximum reimbursable allowances established for payment to a physician for clinic services (items 9023, 9024, 9032, 9033, 9026, 9027, 9030, 9031) shall not apply when the physician receives any form of compensation from the facility for providing such services.
(2) Clinic fees (items 9023, 9024, 9032, 9033, 9026, 9027, 9030, 9031) shall be prorated according to the number of medical assistance patients treated as a percentage of the total number of patients seen during a clinic session.
(d) Hospital visits.
(1) Hospital visit fees shall not apply to preoperative consultations or follow-up visits as designated in accordance with the surgical fees listed in section 533.5 of this Part.
(2) Reimbursement for hospital visits shall only be made for care provided in accordance with the provisions of Part 505 of this Subchapter.
(e) Newborn care.
Newborn care (fee codes 9035 and 9038) is in addition to any appropriate fee for maternity care.
(f) Psychiatric services by a private practicing physician require prior approval of the local professional director when more than 15 visits within a continuous six-month period are required to complete the course of treatment.
(g) Maximum reimbursable medical fee schedule.
GENERAL PRACTITIONER
(or Specialist Providing Service in Nonspecialist Area)
OFFICE VISITS
| Unit or Dollar Value | ||
|---|---|---|
| 9000 | First visit, new patient or new illness, history, examination and treatment | $7.80 |
| 9001 | Subsequent visit, including treatment | $6.00 |
| 9002 | Complete physical examination with special report | $12.00 |
| HOME VISITS | ||
| 9010 | First visit, new patient or new illness, history, examination and treatment | 1.6 |
| 9011 | Subsequent visit, including treatment | 1.4 |
| 9012 | Complete physical examination with special report | 2.25 |
| 9018 | Home visit each additional member of same household | 1.0 |
| HOSPITAL VISITS | ||
| 9020 | First visit, new patient or new illness, history, examination and treatment | 1.3 |
| 9021 | Subsequent visit, including treatment | 1.0 |
| 9022 | Complete physical examination with special report | 2.0 |
| NURSING HOME VISITS | ||
| 9003 | First visit, new patient or new illness, history, examination and treatment | 1.6 |
| 9005 | Subsequent visit, including treatment | 1.4 |
| 9014 | Complete physical examination with special report | 2.25 |
| 9019 | Visit, each additional patient, same nursing home, same session | 1.0 |
| CLINIC VISITS, NONSPECIALIST | ||
| 9023 | One-hour session | 3.0 |
| 9024 | Two-hour session | 5.0 |
| 9032 | Three-hour session | 7.0 |
| 9033 | Each additional hour (per hour) | 1.4 |
| OSTEOPATHIC PHYSICIAN | ||
| 9041 | Osteopathic manipulation, where indicated, additional | .2 |
| SPECIALIST PROCEDURES CONSULTATION BY SPECIALIST | ||
| 9028G | Initial consultation (office) | $24.00 |
| 9029G | Subsequent consultation when required to complete diagnosis (office) | $18.00 |
| 9028J | Initial consultation (other than office) | 4.0 |
| 9029J | Subsequent consultation when required to complete diagnosis (other than office) | 3.0 |
| INTERNIST | ||
| Office Visits | ||
| Comprehensive diagnostic history, physical examination and treatment, including screening test for anemia and urinary glucose and albumin, taking of blood specimens, and furnishing of reports when requested. | ||
| 9002B | Up to 45 minutes | $15.00 |
| 9002M | 46 minutes to one hour | $20.00 |
| 9002E | More than one hour | $25.00 |
| 9004 | Follow-up visit, routine | $7.50 |
| 9006 | Follow-up visit, prolonged (over 20 minutes) | $10.00 |
| Home Visits | ||
| 9012B | Initial home visit, routine, new patient or new illness, history and examination | 3.0 |
| 9012M | Initial home visit, complete diagnostic history and physical examination, established patient or minor chronic illness, including initiation of diagnostic and treatment programs | 4.0 |
| 9021E | Initial home visit, complete diagnostic history and physical examination, new patient or major illness, including initiation of diagnostic and treatment programs | 5.0 |
| 9015 | Examination or evaluation, routine | 2.0 |
| Hospital Visits | ||
| 9020B | Initial hospital visit, brief history and physical examination, including initiation of diagnostic and treatment programs and preparation of hospital records | 3.0 |
| 9021M | Initial hospital visit, complete diagnostic history and physical examination, established patient or minor chronic illness, including initiation of diagnostic and treatment programs and preparation of hospital records | 4.0 |
| 9022E | Initial hospital visit, complete diagnostic history, and physical examination, new patient or major illness, including initiation of diagnostic and treatment programs and preparation of hospital records | 5.0 |
| 9025 | Examination or evaluation, routine follow-up | 1.5 |
| PEDIATRICIAN | ||
| Office Home and Hospital Visits | ||
| 9007F | Comprehensive diagnostic history and physical examination, new patient or new illness, office | $12.00 |
| 9007R | Comprehensive diagnostic history and physical examination, new patient or new illness, home | 2.0 |
| 9007H | Comprehensive diagnostic history and physical examination, new patient or new illness, hospital | 2.0 |
| 9009F | Routine office visit, including treatment | $7.20 |
| 9009H | Routine hospital visit, including treatment | 1.2 |
| 9013 | Routine home visit, including treatment | 1.8 |
| 9018P | Each additional child at home | 1.0 |
| 9037 | Pediatrician in attendance at problem deliveries | 5.0 |
| 9038 | Total newborn care in hospital, including physical examinations of the baby and discussion with the mother during the hospital stay (total fee for minimum 3-day stay) | 4.0 |
| OTOLARYNGOLOGIST | ||
| Office Visits | ||
| 9042 | Complete diagnosis, history, physical examination, new patient or new illness | $12.00 |
| 9043 | Routine visit and treatment | $7.20 |
| Hospital Visits | ||
| 9044 | Initial visit | 2.0 |
| 9045 | Follow-up visit, including treatment | 1.2 |
| UROLOGIST | ||
| Office Visits | ||
| 9078 | Complete diagnosis, history, physical examination, new patient or new illness | $12.00 |
| 9079 | Routine visit, including treatment | $7.20 |
| Hospital Visits | ||
| 9080 | Initial visit | 2.0 |
| 9081 | Follow-up visit, including treatment | 1.2 |
| DERMATOLOGIST | ||
| Office Visits | ||
| 9065 | Comprehensive diagnosis, history, physical examination, new patient or new illness | $12.00 |
| 9066 | Routine visit, including treatment | $7.30 |
| Hospital Visits | ||
| 9067 | Initial visit | 2.0 |
| 9068 | Follow-up visit including treatment: | 1.2 |
| SURGEON (excluding neurosurgeon) | ||
| Office Visits | ||
| 9074 | Complete diagnosis, history, physical examination, new patient or new illness | $12.00 |
| 9075 | Routine visit, including treatment: | $7.20 |
| Hospital Visits | ||
| 9076 | Initial visit | 2.0 |
| 9077 | Follow-up visit, including treatment | 1.2 |
| PHYSIATRIST | ||
| 9082 | Complete diagnosis, history, physical examination, new patient or new illness, office | $12.00 |
| 9083 | Routine visit, including treatment, office | $7.20 |
| 9084 | Initial visit, hospital | 2.0 |
| 9085 | Follow-up visit, including treatment, hospital | 1.2 |
| FAMILY PRACTITIONER | ||
| Office Visits | ||
| Comprehensive diagnostic history and physical examination—new patient or now illness | ||
| 9660 | Child up to and including 16 years | $12.00 |
| 9661 | Persons over 16 years | $12.50 |
| Routine Office Visit, including treatment | ||
| 9662 | Child up to and including 16 years | $7.20 |
| 9663 | Persons over 16 years | $7.50 |
| Home Visits | ||
| Comprehensive diagnostic history and physical examination—new patient or new illness | ||
| 9666 | Child up to and including 16 years | 2.0 |
| 9667 | Persons over 16 years | 2.5 |
Routine home visit including treatment | ||
| 9668 | Child up to and including 16 years | 1.8 |
| 9669 | Persons over 16 years | 2.0 |
| 9670 | Each additional person at home | 1.0 |
| Hospital Visits | ||
| Initial Visit | ||
| 9671 | Child up to and including 16 years | 2.0 |
| 9672 | Persons over 16 years | 2.5 |
| Follow-up visit, including treatment | ||
| 9673 | Child up to and including 16 years | 1.2 |
| 9674 | Persons over 16 years | 1.5 |
| ORTHOPEDIST | ||
| Office Visits | ||
| 9086 | Complete diagnosis, physical examination, history, new patient or new illness | $12.00 |
| 9087 | Routine visit, including treatment | $7.20 |
| Home Visits | ||
| 9088 | Home visit, including treatment | 1.8 |
| Hospital Visits | ||
| 9089 | Initial visit | 2.0 |
| 9090 | Follow-up visit, including treatment | 1.2 |
| OBSTETRICIAN-GYNECOLOGIST | ||
| Office Visits | ||
| 9091 | Pelvic examination, breast examination, Pap smear exclusive of laboratory charge, or new illness | $12.00 |
| 9092 | Follow-up visit | $7.20 |
| Hospital Visits | ||
| 9093 | Initial visit | 2.0 |
| 9094 | Follow-up visit, including treatment | 1.2 |
| NEUROLOGIST AND NEUROSURGEON | ||
| Office Visits | ||
| Comprehensive diagnostic history, physical examination and treatment | ||
| 9500 | Up to 45 minutes | $15.00 |
| 9501 | 46 minutes to one hour | $20.00 |
| 9502 | More than one hour | $25.00 |
| 9503 | Follow-up visit, routine | $7.50 |
| 9504 | Follow-up visit, prolonged (over 20 minutes) | $10.00 |
| Home Visits | ||
| 9505 | Initial home visit, routine, new patient or new illness, history and examination | 3.0 |
| 9506 | Initial home visit, complete diagnostic history and physical examination, established patient, including initiation of diagnostic and treatment programs | 4.0 |
| 9507 | Initial home visit, complete diagnostic history and physical examination, new patient, including initiation of diagnostic and treatment programs | 5.0 |
| 9508 | Examination or evaluation, routine follow-up | 2.0 |
| Hospital Visits | ||
| 9509 | Initial hospital visit, brief history and physical examination, including initiation of diagnostic and treatment programs and preparation of hospital records | 3.0 |
| 9510 | Initial hospital visit, complete diagnostic history and physical examination, established patient, including initiation of diagnostic and treatment programs and preparation of hospital records | 4.0 |
| 9511 | Initial hospital visit, complete diagnostic history and physical examination, new patient, including initiation of diagnostic and treatment programs and preparation of hospital records | 5.0 |
| 9512 | Examination or evaluation, routine follow-up | 1.5 |
| CLINIC VISITS, SPECIALISTS | ||
| 9026 | One-hour session | 4.0 |
| 9027 | Two-hour session | 7.0 |
| 9030 | Three-hour session | 10.0 |
| 9031 | Each additional hour (per hour) | 2.0 |
| CHAP (Child Health Assurance Program) | ||
| The following composite fee codes for use in the Medicaid program, effective April 1, 1974, include: office visit, 9040; immunization, 9998; average cost of materials, L112; hemoglobin or hematocrit; and L557 urinalysis for CHAP when performed by a pediatrician, internist, obstetrician-gynecologist, general practitioner or other specialist. | ||
| 9008P | Pediatrician | $21.20 |
| 9008B | Internist | $21.20 |
| 9008Y | Obstetrician-Gynecologist | $21.20 |
| 9008G | General Practitioner or other specialist | $21.20 |
| No provider shall be paid such a composite fee more than once annually per patient. | ||
| In addition to the above composite fee codes, optional tests, when indicated and when performed in accordance with criteria outlined in Item 44 of the State Medical Handbook, are eligible for additional payment on a fee-for-service basis at fees established in applicable fee schedules; e.g., 9340—audiometric hearing screening, etc. | ||
| For completion of the Child Health Care Status Report, effective Sept. 27, 1974: | ||
| 9008R | Child Health Care Status Report (once per patient per period of eligibility) | $5.00 |
| PSYCHIATRIC TREATMENT | ||
| 9050G | Psychotherapy, office, verbal, drug augmented or other methods, one hour (office) | $30.00 |
| 9051G | Comprehensive psychiatric examination with written report (office) | $30.00 |
| 9053G | Group (maximum eight persons per group) one and one half hours, per person (office) | $9.00 |
| 9050J | Psychotherapy, hospital or home, verbal, drug augmented or other methods, one hour | 5.0 |
| 9051J | Comprehensive psychiatric examination with written report (other than office) | 5.0 |
| 9053J | Group (maximum eight persons per group) one and one half hours, per person (other than office) | 1.5 |
| 9055 | Electroshock (per treatment), | |
subconvulsive | 4.0 | |
| 9056 | convulsive | 5.0 |
for anesthetist | 3.0+T | |
| 9057 | Insulin shock (per treatment), | |
subcoma | 4.0 | |
| 9058 | coma | 6.0 |
| 9059 | Metrazol convulsive shock (per treatment) | 5.0 |
| 9060 | Psychometric testing (one hour) with written report | 5.0 |
| 9061G | Initial routine office visit to include general history, physical and treatment | $12.00 |
| 9062G | Routine follow-up visit | $7.20 |
| 9061J | Initial routine visit to include general history, physical and treatment (other than office) | 2.0 |
| 9062J | Routine follow-up visit (other than office) | 1.2 |
| 9064 | Inpatient care, prolonged (chronic case) | by report |
| FAMILY PLANNING VISITS | ||
| Office Visits | ||
| 9160 | Family planning visit, specialist in obstetrics-gynecology, initial visit | $12.00 |
| 9161 | Follow-up visit | $7.20 |
| 9165 | Family planning visit, nonspecialist, initial visit | $7.80 |
| 9166 | Follow-up visit | $6.00 |
| OTHER SERVICES | ||
| In calculating fees please refer to general instructions, rules 10, 11, 12 | ||
| 9035 | Total newborn care in hospital provided by a physician other than a pediatrician, including physical examinations of the baby and discussions with the mother during the hospital stay (total fee for minimum 3-day stay) | 3.0 |
| 9040 | Immunization(s), per visit (plus cost of materials) | 0.4 |
| 9049 | Therapeutic injectable material used for each injection may be charged at acquisition cost rounded to the nearest one-dollar amount, (effective 3/15/78). | |
| 9070 | Mileage, per mile, one way, beyond 10 mile radius of point of origin (office or home) | 0.1 |
| 9071 | Night emergency: additional fee for service rendered between hours of 10 p.m. and 8 a.m. | 1.0 |
| 9072 | Intensive care, minimum of one hour | 5.0 |
| 9073 | each additional half hour | 2.5 |
| 9998 | costs of materials | by report |
| SPECIFIC DIAGNOSTIC AND THERAPEUTIC PROCEDURES | ||
| Listed values may be added to other significant services rendered at the same visit. Values for items 9101 to 9227 include laboratory procedure(s), interpretation and physicians' services (except surgical and anesthesia services as listed in the section on Surgery), unless otherwise stated. For other similar services, see appropriate sections. | ||
| 9101 | Electrocardiogram with interpretation and report | 3.0 |
| 9102 | tracing only, without interpretation and report | 1.5 |
| 9103 | interpretation and report only | 1.5 |
| 9104 | with exercise test | 5.0 |
| 9105 | tracing only without interpretation and report | 2.5 |
| 9105 | interpretation and report only | 2.5 |
| 9107 | single lead (for rhythm) with interpretation | 1.0 |
| Continuous EKG Monitoring | ||
| (e.g., Holter Monitor) | ||
| 9109 | Up to 12 hours | 9.0 |
| 9110 | Over 12 to 16 hours | 10.0 |
| 9111 | Over 16 hours | 12.0 |
| 9112 | Phonocardiogram with interpretation and report | 4.0 |
| 9113 | with indirect carotid artery tracing or similar study | 5.0 |
| 9115 | Vectorcardiogram (VCG), with or without EKG, interpretation and report | 5.0 |
| 9116 | when part of other diagnostic studies | 4.0 |
| 9120 | Venous pressure determination | 1.0 |
| 9121 | Circulation time, per test (not to exceed 2.0 units) | 1.0 |
| (For radioisotope tests, see 7836.) | ||
| 9128 | Recording of direct arterial pressure tracings (independent procedure) | 4.0 |
| (Recording of intracardiac pressures with evaluation and interpretation included as part of items 2330-2335.) | ||
| 9126 | Cardiac output (Fick) (independent procedure) (excluding cardiac catheterization—see 2330-2335) | 5.0 |
| (For radioisotope methods, see 7835.) | ||
| 9127 | Dye dilution studies, indicator dye curves | 1.0 |
| 9128 | cardiac output, initial (independent procedure) | 5.0 |
| 9129 | subsequent, same study period, each (independent procedure) | 2.5 |
| (When dye dilution studies are part of right heart catheterization, maximum units allowed will be 18; when part of combined right and left heart catheterization, maximum units allowed will be 22.) | ||
| 9140 | Screening throat culture | 0.75 |
| 9190 | Peripheral vascular disease studies | by report |
| 9192 | Plethysmography | by report |
| 9193 | Temperature gradient studies | by report |
| 9194 | Thermogram | by report |
| NONSURGICAL OPERATING ROOM SERVICES | ||
| 9195 | Operation of pump with oxygenator or heart exchanger, per hour pump time | 6.0 |
| 9196 | Monitoring E.K.G., pressures, etc., in intrathoracic or other critical surgery, per hour | 5.0 |
| PULMONARY | ||
| 9201 | Spirometry, complete (respirometer) including graphic record, total and timed vital capacity and maximal breathing capacity, with written report | 3.0 |
| 9203 | Branchospirometry; expired gas analysis, (independent procedure) (for insertion of tube see 2126) | 5.0 |
| 9206 | Bronchospasm evaluation; spirometry as in 9201 before and after bronchodilator (aerosol or parenteral) | 5.0 |
| 9215 | Vital capacity, total | 0.6 |
| 9216 | total and timed | 1.0 |
| 9220 | Maximal breathing capacity | 2.0 |
| 9221 | Maximal expiratory flow rate measurement or equivalent (independent procedure) | 1.0 |
| 9224 | Residual air (helium method) including equilibration time, initial | 3.0 |
| 9225 | subsequent | 2.0 |
| 9228 | Residual air (open circuit method) including alveolar nitrogen, initial | 6.0 |
| 9229 | subsequent | 4.0 |
| 9235 | Nitrogen washout curve (continuous) | by report |
| 9268 | Oxygen uptake, expired gas analysis rest and exercise (direct) | 5.0 |
| 9269 | rest (indirect) | 1.5 |
| 9272 | Carbon monoxide diffusing capacity | by report |
| 9275 | Pulmonary compliance | by report |
| 9277 | Carbon dioxide, expired gas determination by infrared analyzer | by report |
| ALLERGY TESTING AND TREATMENT | ||
| The following values are based on the type and number of tests performed, and must include observation and interpretation of the tests by a physician. In routine office practice, the following items may be added to fee code items 9004 or 9009F. | ||
| 9300 | Scratch or puncture tests, up to 60 tests, per 10 tests (minimum-1.0 unit) | 1.0 |
| 9301 | in excess of first 60 tests, per 20 tests | 1.0 |
| 9302 | Intradermal tests, up to total of 60 tests, per 10 tests (minimum-1.0 unit) | 1.5 |
| 9303 | in excess of first 60 tests, per 20 tests | 1.5 |
| 9304 | Patch tests, each (minimum-1.0 unit) | 0.2 |
| 9305 | Direct opththalmic tests, each (minimum-1.0 unit) | 0.4 |
| 9306 | Direct nasal tests, each (minimum-1.0 unit) | 0.4 |
| 9307 | Passive transfer tests (including cost of recipient) per 10 tests (minimum-10.0 units) | 3.0 |
| 9308 | Maximum allowable for allergy testing; reserved for allergic conditions necessitating unusually extensive testing | 22.0 |
| 9550 | Antigens-treatment sets prepared by allergist for administration by or under the supervision of another physician; solutions of increasing concentration. e.g., ragweed, dust, feathers, four vials | 4.0 |
| 9551 | five vials | 5.0 |
| 9552 | one vial or one refill | 2.0 |
| 9553 | Injection(s) of antigens prepared by allergists for own patients allow maximum of 0.5 unit plus immunization fee (code 9040) | 0.5 |
| MISCELLANEOUS | ||
| 9320 | Skin test with bacterial, viral or fungal extracts (includes reading test), e.g., brucella, tuberculin, histoplasma, coccidioidin, Frel. etc. each | 1.0 |
| 9321 | Tine test, includes injection and reading | 0.375 |
| 9323 | Exclusion test for pheochromocytoma, e.g., regitine, benzodiozane, histamine, each | 2.0 |
| 9330 | Electroencephalogram, awake, asleep (natural or induced) and activation | 7.0 |
| 9331 | at surgery | by report |
| 9332 | Electroencephalogram, interpretation and report only | 1.5 |
| 9333 | Electroencephalogram, tracing only, without interpretation and report | 5.0 |
| 9340 | Audiometric hearing screening, pure tone (air only) | 1.0 |
| 9341 | air and bone, with or without masking | 2.0 |
| 9342 | Air, bone and speech audiometry (includes reception and discrimination tests) | 3.0 |
| 9343 | Vestibular function test | 3.0 |
| 9350 | Muscle testing, manual or electrical, with report, one extremity | 1.5 |
| 9351 | four extremities and trunk | 4.0 |
| 9354 | Range of motion measurements and report, two extremities | 1.0 |
| 9358 | Electromyography, one extremity and related areas of the back | 7.0 |
| 9362 | Nerve velocity determination, each nerve (independent procedure) | 3.0 |
| (For vision testing see 5400-5411.) | ||
| 9400 | Phlebotomy, therapeutic (independent procedure) | 2.0 |
| 9404 | Intermittent positive pressure treatment, initial or subsequent | 0.6 |
| 9412 | Chemotherapy for malignant disease | by report |
| 9413 | Perfusion for malignant disease | by report |
| 9415 | Desensitization, e.g., horse serum | by report |
| 9417 | Gastric lavage, treatment, e.g., ingested poisons, etc. | 8v. |
| 9420 | Cardioversion | 10.0 |
| 9420a | Cardioversion, anesthesia fee | 3.0+T |
| Professional Dialysis Fees for Physician in Personal Attendance* | ||
| 9405 | Peritoneal dialysis (hospital) | 15.0 |
| 9407 | Patient's first hemodialysis | 20.0 |
| 9408 | See item 9405 above | |
| 9410 | Home hemodialysis | 3.0 |
| (This fee is applicable when physican participates in a training session in the home. In all other other instances, the regular home visit fee will apply.) | ||
*
For corresponding surgical prodecures see codes 2590-2592.
Footnotes
*
For corresponding surgical prodecures see codes 2590-2592.
18 CRR-NY 533.4
Current through July 31, 2021
| End of Document |
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