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90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board   Rule Chapter 5; Medical Fees                                      Appendix V002...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                               Appendix V1035F...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
90-351 Maine Workers’ Compensation Board        Rule Chapter 5; Medical Fees                                      Appendix...
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Transcript of "Appendix V - Part I"

  1. 1. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V0001F Heart failure composite M $0.000005F Osteoarthritis composite M $0.0000100 "Anesth, salivary gland" N $0.0000102 "Anesth, repair of cleft lip" N $0.0000103 "Anesth, blepharoplasty" N $0.0000104 "Anesth, electroshock" N $0.0000120 "Anesth, ear surgery" N $0.0000124 "Anesth, ear exam" N $0.0000126 "Anesth, tympanotomy" N $0.000012F Cap bacterial assess M $0.0000140 "Anesth, procedures on eye" N $0.0000142 "Anesth, lens surgery" N $0.0000144 "Anesth, corneal transplant" N $0.0000145 "Anesth, vitreoretinal surg" N $0.0000147 "Anesth, iridectomy" N $0.0000148 "Anesth, eye exam" N $0.000014F Comp preop assess cat surg NI M $0.000015F Melan follow-up complete NI M $0.0000160 "Anesth, nose/sinus surgery" N $0.0000162 "Anesth, nose/sinus surgery" N $0.0000164 "Anesth, biopsy of nose" N $0.000016T Thermotx choroid vasc lesion T 0235 4.1331 263.25 $448.1100170 "Anesth, procedure on mouth" N $0.0000172 "Anesth, cleft palate repair" N $0.0000174 "Anesth, pharyngeal surgery" N $0.0000176 "Anesth, pharyngeal surgery" C $0.000017T Photocoagulat macular drusen T 0235 4.1331 263.25 $448.1100190 "Anesth, face/skull bone surg" N $0.0000192 "Anesth, facial bone surgery" C $0.000019T "Extracorp shock wv tx,ms nos" A $0.0000210 "Anesth, open head surgery" N $0.0000212 "Anesth, skull drainage" N $0.0000214 "Anesth, skull drainage" C $0.0000215 "Anesth, skull repair/fract" C $0.0000216 "Anesth, head vessel surgery" N $0.0000218 "Anesth, special head surgery" N $0.0000220 "Anesth, intrcrn nerve" N $0.0000222 "Anesth, head nerve surgery" N $0.000026T Measure remnant lipoproteins A $0.000027T Endoscopic epidural lysis T 0220 18.0518 1149.79 "$1,957.18 "0028T Dexa body composition study N $0.00Proposed - 07/16/2009 1
  2. 2. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V0029T Magnetic tx for incontinence A $0.0000300 "Anesth, head/neck/ptrunk" N $0.000030T Antiprothrombin antibody A $0.000031T Speculoscopy N $0.0000320 "Anesth, neck organ, 1 & over" N $0.0000322 "Anesth, biopsy of thyroid" N $0.0000326 "Anesth, larynx/trach, < 1 yr" N $0.000032T Speculoscopy w/direct sample N $0.0000350 "Anesth, neck vessel surgery" N $0.0000352 "Anesth, neck vessel surgery" N $0.0000400 "Anesth, skin, ext/per/atrunk" N $0.0000402 "Anesth, surgery of breast" N $0.0000404 "Anesth, surgery of breast" N $0.0000406 "Anesth, surgery of breast" N $0.0000410 "Anesth, correct heart rhythm" N $0.000041T Detect ur infect agnt w/cpas A $0.000042T "Ct perfusion w/contrast, cbf" N $0.000043T Co expired gas analysis A $0.0000450 "Anesth, surgery of shoulder" N $0.0000452 "Anesth, surgery of shoulder" C $0.0000454 "Anesth, collar bone biopsy" N $0.000046T "Cath lavage, mammary duct(s)" T 0021 16.1001 1025.48 "$1,745.57 "00470 "Anesth, removal of rib" N $0.0000472 "Anesth, chest wall repair" N $0.0000474 "Anesth, surgery of rib(s)" C $0.000047T "Cath lavage, mammary duct(s)" T 0021 16.1001 1025.48 "$1,745.57 "0048T Implant ventricular device C $0.000049T External circulation assist C $0.0000500 "Anesth, esophageal surgery" N $0.000050T Removal circulation assist C $0.000051T Implant total heart system C $0.0000520 "Anesth, chest procedure" N $0.0000522 "Anesth, chest lining biopsy" N $0.0000524 "Anesth, chest drainage" C $0.0000528 "Anesth, chest partition view" N $0.0000529 "Anesth, chest partition view" N $0.000052T Replace component heart syst C $0.0000530 "Anesth, pacemaker insertion" N $0.0000532 "Anesth, vascular access" N $0.0000534 "Anesth, cardioverter/defib" N $0.0000537 "Anesth, cardiac electrophys" N $0.00Proposed - 07/16/2009 2
  3. 3. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V00539 "Anesth, trach-bronch reconst" N $0.000053T Replace component heart syst C $0.0000540 "Anesth, chest surgery" C $0.0000541 "Anesth, one lung ventilation" N $0.0000542 "Anesth, release of lung" C $0.0000546 "Anesth, lung,chest wall surg" C $0.0000548 "Anesth, trachea,bronchi surg" N $0.000054T Bone surgery using computer CH D $0.0000550 "Anesth, sternal debridement" N $0.000055T Bone surgery using computer CH D $0.0000560 "Anesth, heart surg w/o pump" C $0.0000561 "Anesth, heart surg < age 1" C $0.0000562 "Anesth, heart surg w/pump" C $0.0000563 "Anesth, heart surg w/arrest" N $0.0000566 "Anesth, cabg w/o pump" N $0.000056T Bone surgery using computer CH D $0.0000580 "Anesth, heart/lung transplnt" C $0.000058T "Cryopreservation, ovary tiss" CH X 0344 0.8167 52.02 $88.550059T "Cryopreservation, oocyte" CH X 0344 0.8167 52.02 $88.5500600 "Anesth, spine, cord surgery" N $0.0000604 "Anesth, sitting procedure" C $0.000060T Electrical impedance scan B $0.000061T "Destruction of tumor, breast" B $0.0000620 "Anesth, spine, cord surgery" N $0.0000622 "Anesth, removal of nerves" C $0.0000625 Anes spine tranthor w/o vent N $0.0000626 "Anes, spine transthor w/vent" N $0.000062T Rep intradisc annulus;1 lev T 0050 29.1900 1859.23 "$3,164.78 "00630 "Anesth, spine, cord surgery" N $0.0000632 "Anesth, removal of nerves" C $0.0000634 Anesth for chemonucleolysis N $0.0000635 "Anesth, lumbar puncture" N $0.000063T Rep intradisc annulus;>1lev T 0050 29.1900 1859.23 "$3,164.78 "00640 "Anesth, spine manipulation" N $0.000064T Spectroscop eval expired gas X 0367 0.5677 36.16 $61.550065T Ocular photoscreen bilat CH D $0.000066T Ct colonography;screen E $0.0000670 "Anesth, spine, cord surgery" C $0.000067T Ct colonography;dx CH S 0332 3.0109 191.78 $326.440068T Interp/rept heart sound B $0.000069T Analysis only heart sound N $0.00Proposed - 07/16/2009 3
  4. 4. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V00700 "Anesth, abdominal wall surg" N $0.0000702 "Anesth, for liver biopsy" N $0.000070T Interp only heart sound B $0.000071T U/s leiomyomata ablate <200 CH S 0067 61.6965 3929.70 "$6,689.13 "0072T U/s leiomyomata ablate >200 CH S 0067 61.6965 3929.70 "$6,689.13 "00730 "Anesth, abdominal wall surg" N $0.000073T "Delivery, comp imrt" S 0412 5.4582 347.65 $591.7800740 "Anesth, upper gi visualize" N $0.000074T Online physician e/m CH D $0.0000750 "Anesth, repair of hernia" N $0.0000752 "Anesth, repair of hernia" N $0.0000754 "Anesth, repair of hernia" N $0.0000756 "Anesth, repair of hernia" N $0.000075T Perq stent/chest vert art C $0.000076T S&i stent/chest vert art C $0.0000770 "Anesth, blood vessel repair" N $0.000077T Cereb therm perfusion probe C $0.000078T Endovasc aort repr w/device C $0.0000790 "Anesth, surg upper abdomen" N $0.0000792 "Anesth, hemorr/excise liver" C $0.0000794 "Anesth, pancreas removal" C $0.0000796 "Anesth, for liver transplant" C $0.0000797 "Anesth, surgery for obesity" N $0.000079T Endovasc visc extnsn repr C $0.0000800 "Anesth, abdominal wall surg" N $0.0000802 "Anesth, fat layer removal" C $0.000080T Endovasc aort repr rad s&i C $0.0000810 "Anesth, low intestine scope" N $0.000081T Endovasc visc extnsn s&i C $0.0000820 "Anesth, abdominal wall surg" N $0.0000830 "Anesth, repair of hernia" N $0.0000832 "Anesth, repair of hernia" N $0.0000834 "Anesth, hernia repair< 1 yr" N $0.0000836 Anesth hernia repair preemie N $0.0000840 "Anesth, surg lower abdomen" N $0.0000842 "Anesth, amniocentesis" N $0.0000844 "Anesth, pelvis surgery" C $0.0000846 "Anesth, hysterectomy" C $0.0000848 "Anesth, pelvic organ surg" C $0.000084T Temp prostate urethral stent T 0164 2.0077 127.88 $217.6700851 "Anesth, tubal ligation" N $0.00Proposed - 07/16/2009 4
  5. 5. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V0085T Breath test heart reject X 0340 0.6310 40.19 $68.4100860 "Anesth, surgery of abdomen" N $0.0000862 "Anesth, kidney/ureter surg" N $0.0000864 "Anesth, removal of bladder" C $0.0000865 "Anesth, removal of prostate" C $0.0000866 "Anesth, removal of adrenal" C $0.0000868 "Anesth, kidney transplant" C $0.000086T L ventricle fill pressure N $0.0000870 "Anesth, bladder stone surg" N $0.0000872 Anesth kidney stone destruct N $0.0000873 Anesth kidney stone destruct N $0.000087T Sperm eval hyaluronan CH X 0344 0.8167 52.02 $88.5500880 "Anesth, abdomen vessel surg" N $0.0000882 "Anesth, major vein ligation" C $0.000088T Rf tongue base vol reduxn T 0253 16.3288 1040.05 "$1,770.37 "0089T "Actigraphy testing, 3-day" S 0218 1.1550 73.57 $125.2300902 "Anesth, anorectal surgery" N $0.0000904 "Anesth, perineal surgery" C $0.0000906 "Anesth, removal of vulva" N $0.0000908 "Anesth, removal of prostate" C $0.000090T Cervical artific disc C $0.0000910 "Anesth, bladder surgery" N $0.0000912 "Anesth, bladder tumor surg" N $0.0000914 "Anesth, removal of prostate" N $0.0000916 "Anesth, bleeding control" N $0.0000918 "Anesth, stone removal" N $0.0000920 "Anesth, genitalia surgery" N $0.0000921 "Anesth, vasectomy" N $0.0000922 "Anesth, sperm duct surgery" N $0.0000924 "Anesth, testis exploration" N $0.0000926 "Anesth, removal of testis" N $0.0000928 "Anesth, removal of testis" N $0.000092T Artific disc addl C $0.0000930 "Anesth, testis suspension" N $0.0000932 "Anesth, amputation of penis" C $0.0000934 "Anesth, penis, nodes removal" C $0.0000936 "Anesth, penis, nodes removal" C $0.0000938 "Anesth, insert penis device" N $0.000093T Cervical artific diskectomy C $0.0000940 "Anesth, vaginal procedures" N $0.0000942 "Anesth, surg on vag/urethral" N $0.00Proposed - 07/16/2009 5
  6. 6. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V00944 "Anesth, vaginal hysterectomy" C $0.0000948 "Anesth, repair of cervix" N $0.0000950 "Anesth, vaginal endoscopy" N $0.0000952 "Anesth, hysteroscope/graph" N $0.000095T Artific diskectomy addl C $0.000096T Rev cervical artific disc C $0.000098T Rev artific disc addl C $0.000099T Implant corneal ring T 0233 16.1710 1030.00 "$1,753.26 "0100T Prosth retina receive&gen T 0672 37.2078 2369.91 "$4,034.07 "0101T "Extracorp shockwv tx,hi enrg" T 0050 29.1900 1859.23 "$3,164.78 "0102T "Extracorp shockwv tx,anesth" T 0050 29.1900 1859.23 "$3,164.78 "0103T Holotranscobalamin A $0.000104T At rest cardio gas rebreathe A $0.000105T Exerc cardio gas rebreathe A $0.000106T Touch quant sensory test X 0341 0.0844 5.38 $9.150107T Vibrate quant sensory test X 0341 0.0844 5.38 $9.150108T Cool quant sensory test X 0341 0.0844 5.38 $9.150109T Heat quant sensory test X 0341 0.0844 5.38 $9.150110T Nos quant sensory test X 0341 0.0844 5.38 $9.1501112 "Anesth, bone aspirate/bx" N $0.000111T Rbc membranes fatty acids A $0.0001120 "Anesth, pelvis surgery" N $0.0001130 "Anesth, body cast procedure" N $0.0001140 "Anesth, amputation at pelvis" C $0.0001150 "Anesth, pelvic tumor surgery" C $0.000115T Med tx mngmt 15 min CH D $0.0001160 "Anesth, pelvis procedure" N $0.000116T Med tx mngmt subsqt CH D $0.0001170 "Anesth, pelvis surgery" N $0.0001173 "Anesth, fx repair, pelvis" N $0.000117T Med tx mngmt addl 15 min CH D $0.0001180 "Anesth, pelvis nerve removal" N $0.0001190 "Anesth, pelvis nerve removal" N $0.0001200 "Anesth, hip joint procedure" N $0.0001202 "Anesth, arthroscopy of hip" N $0.0001210 "Anesth, hip joint surgery" N $0.0001212 "Anesth, hip disarticulation" C $0.0001214 "Anesth, hip arthroplasty" C $0.0001215 "Anesth, revise hip repair" N $0.0001220 "Anesth, procedure on femur" N $0.0001230 "Anesth, surgery of femur" N $0.00Proposed - 07/16/2009 6
  7. 7. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V01232 "Anesth, amputation of femur" C $0.0001234 "Anesth, radical femur surg" C $0.000123T Scleral fistulization T 0234 23.1758 1476.16 "$2,512.72 "0124T Conjunctival drug placement T 0232 5.1169 325.92 $554.7701250 "Anesth, upper leg surgery" N $0.0001260 "Anesth, upper leg veins surg" N $0.000126T Chd risk imt study CH Q 0340 0.6310 40.19 $68.4101270 "Anesth, thigh arteries surg" N $0.0001272 "Anesth, femoral artery surg" C $0.0001274 "Anesth, femoral embolectomy" C $0.000130T Chron care drug investigatn B $0.0001320 "Anesth, knee area surgery" N $0.0001340 "Anesth, knee area procedure" N $0.000135T Perq cryoablate renal tumor CH D $0.0001360 "Anesth, knee area surgery" N $0.000137T Prostate saturation sampling T 0184 11.0338 702.79 "$1,196.28 "01380 "Anesth, knee joint procedure" N $0.0001382 "Anesth, dx knee arthroscopy" N $0.0001390 "Anesth, knee area procedure" N $0.0001392 "Anesth, knee area surgery" N $0.0001400 "Anesth, knee joint surgery" N $0.0001402 "Anesth, knee arthroplasty" C $0.0001404 "Anesth, amputation at knee" C $0.000140T Exhaled breath condensate ph A $0.000141T Perq islet transplant E $0.0001420 "Anesth, knee joint casting" N $0.000142T Open islet transplant E $0.0001430 "Anesth, knee veins surgery" N $0.0001432 "Anesth, knee vessel surg" N $0.000143T Laparoscopic islet transplnt E $0.0001440 "Anesth, knee arteries surg" N $0.0001442 "Anesth, knee artery surg" C $0.0001444 "Anesth, knee artery repair" C $0.000144T CT heart wo dye; qual calc CH S 0282 1.5839 100.88 $171.730145T CT heart w/wo dye funct CH S 0383 4.7005 299.39 $509.6301462 "Anesth, lower leg procedure" N $0.0001464 "Anesth, ankle/ft arthroscopy" N $0.000146T CCTA w/wo dye CH S 0383 4.7005 299.39 $509.6301470 "Anesth, lower leg surgery" N $0.0001472 "Anesth, achilles tendon surg" N $0.0001474 "Anesth, lower leg surgery" N $0.00Proposed - 07/16/2009 7
  8. 8. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V0147T "CCTA w/wo, quan calcium" CH S 0383 4.7005 299.39 $509.6301480 "Anesth, lower leg bone surg" N $0.0001482 "Anesth, radical leg surgery" N $0.0001484 "Anesth, lower leg revision" N $0.0001486 "Anesth, ankle replacement" C $0.000148T "CCTA w/wo, strxr" CH S 0383 4.7005 299.39 $509.6301490 "Anesth, lower leg casting" N $0.000149T "CCTA w/wo, strxr quan calc" CH S 0383 4.7005 299.39 $509.6301500 "Anesth, leg arteries surg" N $0.0001502 "Anesth, lwr leg embolectomy" C $0.000150T "CCTA w/wo, disease strxr" CH S 0383 4.7005 299.39 $509.630151T CT heart funct add-on S 0282 1.5839 100.88 $171.7301520 "Anesth, lower leg vein surg" N $0.0001522 "Anesth, lower leg vein surg" N $0.000153T Tcath sensor aneurysm sac CH D $0.000154T Study sensor aneurysm sac CH D $0.000155T Lap impl gast curve electrd T 0130 34.3958 2190.81 "$3,729.19 "0156T Lap remv gast curve electrd T 0130 34.3958 2190.81 "$3,729.19 "0157T Open impl gast curve electrd C $0.000158T Open remv gast curve electrd C $0.000159T Cad breast mri N $0.000160T Tcranial magn stim tx plan S 0216 2.6846 170.99 $291.0601610 "Anesth, surgery of shoulder" N $0.000161T Tcranial magn stim tx deliv S 0216 2.6846 170.99 $291.0601620 "Anesth, shoulder procedure" N $0.0001622 Anes dx shoulder arthroscopy N $0.000162T Anal program gast neurostim S 0692 1.8376 117.04 $199.2301630 "Anesth, surgery of shoulder" N $0.0001632 "Anesth, surgery of shoulder" C $0.0001634 "Anesth, shoulder joint amput" C $0.0001636 "Anesth, forequarter amput" C $0.0001638 "Anesth, shoulder replacement" C $0.000163T Lumb artif diskectomy addl C $0.000164T Remove lumb artif disc addl C $0.0001650 "Anesth, shoulder artery surg" N $0.0001652 "Anesth, shoulder vessel surg" C $0.0001654 "Anesth, shoulder vessel surg" C $0.0001656 "Anesth, arm-leg vessel surg" C $0.000165T Revise lumb artif disc addl C $0.000166T Tcath vsd close w/o bypass C $0.0001670 "Anesth, shoulder vein surg" N $0.00Proposed - 07/16/2009 8
  9. 9. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V0167T Tcath vsd close w bypass C $0.0001680 "Anesth, shoulder casting" N $0.0001682 "Anesth, airplane cast" N $0.000168T Rhinophototx light app bilat T 0251 2.5002 159.25 $271.070169T Place stereo cath brain C $0.000170T Anorectal fistula plug rpr T 0150 30.1606 1921.05 "$3,270.01 "01710 "Anesth, elbow area surgery" N $0.0001712 "Anesth, uppr arm tendon surg" N $0.0001714 "Anesth, uppr arm tendon surg" N $0.0001716 "Anesth, biceps tendon repair" N $0.000171T Lumbar spine proces distract T 0050 29.1900 1859.23 "$3,164.78 "0172T Lumbar spine process addl T 0050 29.1900 1859.23 "$3,164.78 "01730 "Anesth, uppr arm procedure" N $0.0001732 "Anesth, dx elbow arthroscopy" N $0.000173T Iop monit io pressure N $0.0001740 "Anesth, upper arm surgery" N $0.0001742 "Anesth, humerus surgery" N $0.0001744 "Anesth, humerus repair" N $0.000174T Cad cxr with interp N $0.0001756 "Anesth, radical humerus surg" C $0.0001758 "Anesth, humeral lesion surg" N $0.000175T Cad cxr remote N $0.0001760 "Anesth, elbow replacement" N $0.000176T Aqu canal dilat w/o retent T 0673 39.7101 2529.30 "$4,305.37 "01770 "Anesth, uppr arm artery surg" N $0.0001772 "Anesth, uppr arm embolectomy" N $0.000177T Aqu canal dilat w retent T 0673 39.7101 2529.30 "$4,305.37 "01780 "Anesth, upper arm vein surg" N $0.0001782 "Anesth, uppr arm vein repair" N $0.000178T 64 lead ecg w i&r B $0.000179T 64 lead ecg w tracing X 0100 2.5547 162.72 $276.980180T 64 lead ecg w i&r only B $0.0001810 "Anesth, lower arm surgery" N $0.000181T Corneal hysteresis S 0230 0.5903 37.60 $64.0001820 "Anesth, lower arm procedure" N $0.0001829 "Anesth, dx wrist arthroscopy" N $0.000182T Hdr elect brachytherapy S 1519 1750.00 $0.0001830 "Anesth, lower arm surgery" N $0.0001832 "Anesth, wrist replacement" N $0.000183T Wound ultrasound NI T 0015 1.4595 92.96 $158.2401840 "Anesth, lwr arm artery surg" N $0.00Proposed - 07/16/2009 9
  10. 10. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V01842 "Anesth, lwr arm embolectomy" N $0.0001844 "Anesth, vascular shunt surg" N $0.000184T Exc rectal tumor endoscopic NI C $0.0001850 "Anesth, lower arm vein surg" N $0.0001852 "Anesth, lwr arm vein repair" N $0.000185T Comptr probability analysis NI N $0.0001860 "Anesth, lower arm casting" N $0.000186T Suprachoroidal drug delivery NI T 0236 18.2350 1161.46 "$1,977.04 "0187T Ophthalmic dx image anterior NI S 0230 0.5903 37.60 $64.0001905 "Anes, spine inject, x-ray/re" CH D $0.0001916 "Anesth, dx arteriography" N $0.0001920 "Anesth, catheterize heart" N $0.0001922 "Anesth, cat or MRI scan" N $0.0001924 "Anes, ther interven rad, art" N $0.0001925 "Anes, ther interven rad, car" N $0.0001926 "Anes, tx interv rad hrt/cran" N $0.0001930 "Anes, ther interven rad, vei" N $0.0001931 "Anes, ther interven rad, tip" N $0.0001932 "Anes, tx interv rad, th vein" N $0.0001933 "Anes, tx interv rad, cran v" N $0.0001935 "Anesth, perc img dx sp proc" NI N $0.0001936 "Anesth, perc img tx sp proc" NI N $0.0001951 "Anesth, burn, less 4 percent" N $0.0001952 "Anesth, burn, 4-9 percent" N $0.0001953 "Anesth, burn, each 9 percent" N $0.0001958 "Anesth, antepartum manipul" N $0.0001960 "Anesth, vaginal delivery" N $0.0001961 "Anesth, cs delivery" N $0.0001962 "Anesth, emer hysterectomy" N $0.0001963 "Anesth, cs hysterectomy" N $0.0001965 "Anesth, inc/missed ab proc" N $0.0001966 "Anesth, induced ab procedure" N $0.0001967 "Anesth/analg, vag delivery" N $0.0001968 Anes/analg cs deliver add-on N $0.0001969 Anesth/analg cs hyst add-on N $0.0001990 Support for organ donor C $0.0001991 "Anesth, nerve block/inj" N $0.0001992 "Anesth, n block/inj, prone" N $0.0001996 Hosp manage cont drug admin N $0.0001999 Unlisted anesth procedure N $0.000500F Initial prenatal care visit M $0.00Proposed - 07/16/2009 10
  11. 11. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V0501F Prenatal flow sheet M $0.000502F Subsequent prenatal care M $0.000503F Postpartum care visit M $0.000505F Hemodialysis plan docd M $0.000507F Periton dialysis plan docd M $0.000509F Urine incon plan docd M $0.000513F Elev BP plan of care docd NI M $0.000514F Care plan Hgb docd ESA pt NI M $0.000516F Anemia plan of care docd NI M $0.000517F Glaucoma plan of care docd NI M $0.000518F Fall plan of care docd NI M $0.000519F Pland chemo docd b/4 txmnt NI M $0.000520F Tissue dose done w/in 5 days NI M $0.000521F Plan of care 4 pain docd NI M $0.001000F Tobacco use assessed M $0.0010021 Fna w/o image T 0002 1.1097 70.68 $120.3110022 Fna w/image CH T 0004 4.3270 275.60 $469.131002F Assess anginal symptom/level M $0.001003F Level of activity assess M $0.0010040 Acne surgery CH T 0013 0.7930 50.51 $85.981004F Clin symp vol ovrld assess M $0.001005F Asthma symptoms evaluate M $0.0010060 Drainage of skin abscess T 0006 1.4066 89.59 $152.5010061 Drainage of skin abscess T 0006 1.4066 89.59 $152.501006F Osteoarthritis assess M $0.001007F Anti-inflm/anlgsc otc assess M $0.0010080 Drainage of pilonidal cyst T 0006 1.4066 89.59 $152.5010081 Drainage of pilonidal cyst T 0007 11.5594 736.26 "$1,253.27 "1008F Gi/renal risk assess M $0.0010120 Remove foreign body T 0006 1.4066 89.59 $152.5010121 Remove foreign body T 0021 16.1001 1025.48 "$1,745.57 "10140 Drainage of hematoma/fluid T 0007 11.5594 736.26 "$1,253.27 "1015F Copd symptoms assess M $0.0010160 Puncture drainage of lesion CH T 0006 1.4066 89.59 $152.5010180 "Complex drainage, wound" T 0008 18.3197 1166.85 "$1,986.22 "1018F Assess dyspnea not present M $0.001019F Assess dyspnea present M $0.001022F Pneumo imm status assess M $0.001026F Co-morbid condition assess M $0.001030F Influenza imm status assess M $0.001034F Current tobacco smoker M $0.00Proposed - 07/16/2009 11
  12. 12. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V1035F Smokeless tobacco user M $0.001036F Tobacco non-user M $0.001038F Persistent asthma M $0.001039F Intermittent asthma M $0.001040F DSM-IV info MDD docd M $0.001050F History of mole changes M $0.001055F Visual funct status assess M $0.001060F Doc perm/cont/parox atr fib M $0.001061F Doc lack perm+cont+parox fib M $0.001065F Ischm stroke symp lt3 hrsb/4 M $0.001066F Ischm stroke symp ge3 hrsb/4 M $0.001070F Alarm symp assessed-absent M $0.001071F Alarm symp assessed-1+ prsnt M $0.001080F Decis mkr/advncd plan docd CH D $0.001090F Pres/absn urine incon assess M $0.001091F Urine incon characterized M $0.0011000 Debride infected skin T 0013 0.7930 50.51 $85.9811001 Debride infected skin add-on CH T 0013 0.7930 50.51 $85.9811004 Debride genitalia & perineum C $0.0011005 Debride abdom wall C $0.0011006 Debride genit/per/abdom wall C $0.0011008 Remove mesh from abd wall C $0.001100F Ptfalls assess-docd ge2+/yr M $0.0011010 "Debride skin, fx" T 0019 4.3039 274.13 $466.6311011 "Debride skin/muscle, fx" T 0019 4.3039 274.13 $466.6311012 "Debride skin/muscle/bone, fx" T 0019 4.3039 274.13 $466.631101F Pt falls assess-docd le1/yr M $0.0011040 "Debride skin, partial" T 0015 1.4595 92.96 $158.2411041 "Debride skin, full" T 0015 1.4595 92.96 $158.2411042 Debride skin/tissue T 0016 2.6604 169.45 $288.4411043 Debride tissue/muscle T 0016 2.6604 169.45 $288.4411044 Debride tissue/muscle/bone T 0682 6.8816 438.32 $746.1011055 Trim skin lesion CH T 0013 0.7930 50.51 $85.9811056 "Trim skin lesions, 2 to 4" CH T 0013 0.7930 50.51 $85.9811057 "Trim skin lesions, over 4" CH T 0015 1.4595 92.96 $158.2411100 "Biopsy, skin lesion" CH T 0013 0.7930 50.51 $85.9811101 "Biopsy, skin add-on" CH T 0013 0.7930 50.51 $85.981110F Pt lft inpt fac w/in 60 days M $0.001111F Dschrg med/current med merge M $0.001116F Auric/peri pain assessed M $0.001118F GERD symps assessed 12 month NI M $0.00Proposed - 07/16/2009 12
  13. 13. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V1119F Init. Eval for condition NI M $0.0011200 Removal of skin tags T 0013 0.7930 50.51 $85.9811201 Remove skin tags add-on T 0015 1.4595 92.96 $158.241121F Subs. Eval for condition NI M $0.001123F ACP discuss/dscn mkr docd NI M $0.001124F ACP discuss-no dscnmkr docd NI M $0.001125F Amnt Pain noted; pain prsnt NI M $0.001126F Amnt Pain noted; none prsnt NI M $0.001127F New episode for condition NI M $0.001128F Subs. episode for condition NI M $0.0011300 Shave skin lesion CH T 0013 0.7930 50.51 $85.9811301 Shave skin lesion CH T 0013 0.7930 50.51 $85.9811302 Shave skin lesion T 0013 0.7930 50.51 $85.9811303 Shave skin lesion T 0015 1.4595 92.96 $158.2411305 Shave skin lesion T 0013 0.7930 50.51 $85.9811306 Shave skin lesion T 0013 0.7930 50.51 $85.9811307 Shave skin lesion T 0013 0.7930 50.51 $85.9811308 Shave skin lesion T 0013 0.7930 50.51 $85.9811310 Shave skin lesion T 0013 0.7930 50.51 $85.9811311 Shave skin lesion T 0013 0.7930 50.51 $85.9811312 Shave skin lesion T 0013 0.7930 50.51 $85.9811313 Shave skin lesion CH T 0013 0.7930 50.51 $85.9811400 Exc tr-ext b9+marg 0.5 < cm T 0019 4.3039 274.13 $466.6311401 Exc tr-ext b9+marg 0.6-1 cm T 0019 4.3039 274.13 $466.6311402 Exc tr-ext b9+marg 1.1-2 cm T 0019 4.3039 274.13 $466.6311403 Exc tr-ext b9+marg 2.1-3 cm T 0020 8.6850 553.18 $941.6311404 Exc tr-ext b9+marg 3.1-4 cm T 0021 16.1001 1025.48 "$1,745.57 "11406 Exc tr-ext b9+marg > 4.0 cm T 0021 16.1001 1025.48 "$1,745.57 "11420 Exc h-f-nk-sp b9+marg 0.5 < T 0020 8.6850 553.18 $941.6311421 Exc h-f-nk-sp b9+marg 0.6-1 T 0020 8.6850 553.18 $941.6311422 Exc h-f-nk-sp b9+marg 1.1-2 T 0020 8.6850 553.18 $941.6311423 Exc h-f-nk-sp b9+marg 2.1-3 T 0021 16.1001 1025.48 "$1,745.57 "11424 Exc h-f-nk-sp b9+marg 3.1-4 T 0021 16.1001 1025.48 "$1,745.57 "11426 Exc h-f-nk-sp b9+marg > 4 cm T 0022 21.1098 1344.57 "$2,288.72 "11440 Exc face-mm b9+marg 0.5 < cm T 0019 4.3039 274.13 $466.6311441 Exc face-mm b9+marg 0.6-1 cm T 0019 4.3039 274.13 $466.6311442 Exc face-mm b9+marg 1.1-2 cm T 0020 8.6850 553.18 $941.6311443 Exc face-mm b9+marg 2.1-3 cm T 0020 8.6850 553.18 $941.6311444 Exc face-mm b9+marg 3.1-4 cm T 0020 8.6850 553.18 $941.6311446 Exc face-mm b9+marg > 4 cm T 0022 21.1098 1344.57 "$2,288.72 "11450 "Removal, sweat gland lesion" T 0022 21.1098 1344.57 "$2,288.72 "Proposed - 07/16/2009 13
  14. 14. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V11451 "Removal, sweat gland lesion" T 0022 21.1098 1344.57 "$2,288.72 "11462 "Removal, sweat gland lesion" T 0022 21.1098 1344.57 "$2,288.72 "11463 "Removal, sweat gland lesion" T 0022 21.1098 1344.57 "$2,288.72 "11470 "Removal, sweat gland lesion" T 0022 21.1098 1344.57 "$2,288.72 "11471 "Removal, sweat gland lesion" T 0022 21.1098 1344.57 "$2,288.72 "11600 Exc tr-ext mlg+marg 0.5 < cm T 0019 4.3039 274.13 $466.6311601 Exc tr-ext mlg+marg 0.6-1 cm T 0019 4.3039 274.13 $466.6311602 Exc tr-ext mlg+marg 1.1-2 cm T 0019 4.3039 274.13 $466.6311603 Exc tr-ext mlg+marg 2.1-3 cm T 0020 8.6850 553.18 $941.6311604 Exc tr-ext mlg+marg 3.1-4 cm T 0020 8.6850 553.18 $941.6311606 Exc tr-ext mlg+marg > 4 cm T 0021 16.1001 1025.48 "$1,745.57 "11620 Exc h-f-nk-sp mlg+marg 0.5 < T 0020 8.6850 553.18 $941.6311621 Exc h-f-nk-sp mlg+marg 0.6-1 T 0019 4.3039 274.13 $466.6311622 Exc h-f-nk-sp mlg+marg 1.1-2 T 0020 8.6850 553.18 $941.6311623 Exc h-f-nk-sp mlg+marg 2.1-3 CH T 0020 8.6850 553.18 $941.6311624 Exc h-f-nk-sp mlg+marg 3.1-4 T 0021 16.1001 1025.48 "$1,745.57 "11626 Exc h-f-nk-sp mlg+mar > 4 cm T 0022 21.1098 1344.57 "$2,288.72 "11640 Exc face-mm malig+marg 0.5 < CH T 0019 4.3039 274.13 $466.6311641 Exc face-mm malig+marg 0.6-1 CH T 0019 4.3039 274.13 $466.6311642 Exc face-mm malig+marg 1.1-2 T 0020 8.6850 553.18 $941.6311643 Exc face-mm malig+marg 2.1-3 T 0020 8.6850 553.18 $941.6311644 Exc face-mm malig+marg 3.1-4 T 0021 16.1001 1025.48 "$1,745.57 "11646 Exc face-mm mlg+marg > 4 cm T 0022 21.1098 1344.57 "$2,288.72 "11719 Trim nail(s) CH T 0013 0.7930 50.51 $85.9811720 "Debride nail, 1-5" CH T 0013 0.7930 50.51 $85.9811721 "Debride nail, 6 or more" CH T 0013 0.7930 50.51 $85.9811730 Removal of nail plate T 0013 0.7930 50.51 $85.9811732 "Remove nail plate, add-on" CH T 0013 0.7930 50.51 $85.9811740 Drain blood from under nail CH T 0012 0.2963 18.87 $32.1211750 Removal of nail bed T 0019 4.3039 274.13 $466.6311752 Remove nail bed/finger tip T 0022 21.1098 1344.57 "$2,288.72 "11755 "Biopsy, nail unit" T 0019 4.3039 274.13 $466.6311760 Repair of nail bed CH T 0134 2.1051 134.08 $228.2311762 Reconstruction of nail bed CH T 0136 15.0458 958.33 "$1,631.27 "11765 "Excision of nail fold, toe" T 0015 1.4595 92.96 $158.2411770 Removal of pilonidal lesion T 0022 21.1098 1344.57 "$2,288.72 "11771 Removal of pilonidal lesion T 0022 21.1098 1344.57 "$2,288.72 "11772 Removal of pilonidal lesion T 0022 21.1098 1344.57 "$2,288.72 "11900 Injection into skin lesions CH T 0013 0.7930 50.51 $85.9811901 Added skin lesions injection CH T 0013 0.7930 50.51 $85.9811920 Correct skin color defects CH T 0134 2.1051 134.08 $228.23Proposed - 07/16/2009 14
  15. 15. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V11921 Correct skin color defects CH T 0134 2.1051 134.08 $228.2311922 Correct skin color defects CH T 0134 2.1051 134.08 $228.2311950 Therapy for contour defects CH T 0133 1.2792 81.48 $138.6911951 Therapy for contour defects CH T 0133 1.2792 81.48 $138.6911952 Therapy for contour defects CH T 0133 1.2792 81.48 $138.6911954 Therapy for contour defects CH T 0133 1.2792 81.48 $138.6911960 Insert tissue expander(s) CH T 0137 20.2069 1287.06 "$2,190.83 "11970 Replace tissue expander T 0051 42.9850 2737.89 "$4,660.43 "11971 Remove tissue expander(s) T 0022 21.1098 1344.57 "$2,288.72 "11975 Insert contraceptive cap E $0.0011976 Removal of contraceptive cap T 0019 4.3039 274.13 $466.6311977 Removal/reinsert contra cap E $0.0011980 Implant hormone pellet(s) X 0340 0.6310 40.19 $68.4111981 Insert drug implant device X 0340 0.6310 40.19 $68.4111982 Remove drug implant device X 0340 0.6310 40.19 $68.4111983 Remove/insert drug implant X 0340 0.6310 40.19 $68.4112001 Repair superficial wound(s) CH T 0133 1.2792 81.48 $138.6912002 Repair superficial wound(s) CH T 0133 1.2792 81.48 $138.6912004 Repair superficial wound(s) CH T 0133 1.2792 81.48 $138.6912005 Repair superficial wound(s) CH T 0133 1.2792 81.48 $138.6912006 Repair superficial wound(s) CH T 0133 1.2792 81.48 $138.6912007 Repair superficial wound(s) CH T 0133 1.2792 81.48 $138.6912011 Repair superficial wound(s) CH T 0133 1.2792 81.48 $138.6912013 Repair superficial wound(s) CH T 0133 1.2792 81.48 $138.6912014 Repair superficial wound(s) CH T 0133 1.2792 81.48 $138.6912015 Repair superficial wound(s) CH T 0133 1.2792 81.48 $138.6912016 Repair superficial wound(s) CH T 0133 1.2792 81.48 $138.6912017 Repair superficial wound(s) CH T 0133 1.2792 81.48 $138.6912018 Repair superficial wound(s) CH T 0133 1.2792 81.48 $138.6912020 Closure of split wound CH T 0135 4.5263 288.30 $490.7412021 Closure of split wound CH T 0135 4.5263 288.30 $490.7412031 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312032 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312034 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312035 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312036 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312037 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312041 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312042 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312044 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312045 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.23Proposed - 07/16/2009 15
  16. 16. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V12046 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312047 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312051 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312052 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312053 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312054 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312055 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312056 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2312057 Layer closure of wound(s) CH T 0134 2.1051 134.08 $228.2313100 Repair of wound or lesion CH T 0135 4.5263 288.30 $490.7413101 Repair of wound or lesion CH T 0135 4.5263 288.30 $490.7413102 Repair wound/lesion add-on CH T 0135 4.5263 288.30 $490.7413120 Repair of wound or lesion CH T 0134 2.1051 134.08 $228.2313121 Repair of wound or lesion CH T 0135 4.5263 288.30 $490.7413122 Repair wound/lesion add-on CH T 0134 2.1051 134.08 $228.2313131 Repair of wound or lesion CH T 0135 4.5263 288.30 $490.7413132 Repair of wound or lesion CH T 0135 4.5263 288.30 $490.7413133 Repair wound/lesion add-on CH T 0135 4.5263 288.30 $490.7413150 Repair of wound or lesion CH T 0135 4.5263 288.30 $490.7413151 Repair of wound or lesion CH T 0135 4.5263 288.30 $490.7413152 Repair of wound or lesion CH T 0135 4.5263 288.30 $490.7413153 Repair wound/lesion add-on CH T 0134 2.1051 134.08 $228.2313160 Late closure of wound CH T 0137 20.2069 1287.06 "$2,190.83 "14000 Skin tissue rearrangement CH T 0136 15.0458 958.33 "$1,631.27 "14001 Skin tissue rearrangement CH T 0136 15.0458 958.33 "$1,631.27 "14020 Skin tissue rearrangement CH T 0136 15.0458 958.33 "$1,631.27 "14021 Skin tissue rearrangement CH T 0136 15.0458 958.33 "$1,631.27 "14040 Skin tissue rearrangement CH T 0136 15.0458 958.33 "$1,631.27 "14041 Skin tissue rearrangement CH T 0136 15.0458 958.33 "$1,631.27 "14060 Skin tissue rearrangement CH T 0136 15.0458 958.33 "$1,631.27 "14061 Skin tissue rearrangement CH T 0136 15.0458 958.33 "$1,631.27 "14300 Skin tissue rearrangement CH T 0137 20.2069 1287.06 "$2,190.83 "14350 Skin tissue rearrangement CH T 0137 20.2069 1287.06 "$2,190.83 "15002 "Wnd prep, ch/inf, trk/arm/lg" CH T 0135 4.5263 288.30 $490.7415003 "Wnd prep, ch/inf addl 100 cm" CH T 0135 4.5263 288.30 $490.7415004 "Wnd prep ch/inf, f/n/hf/g" CH T 0135 4.5263 288.30 $490.7415005 "Wnd prep, f/n/hf/g, addl cm" CH T 0135 4.5263 288.30 $490.7415040 Harvest cultured skin graft CH T 0134 2.1051 134.08 $228.2315050 Skin pinch graft CH T 0135 4.5263 288.30 $490.7415100 "Skin splt grft, trnk/arm/leg" CH T 0137 20.2069 1287.06 "$2,190.83 "15101 "Skin splt grft t/a/l, add-on" CH T 0137 20.2069 1287.06 "$2,190.83 "Proposed - 07/16/2009 16
  17. 17. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V15110 Epidrm autogrft trnk/arm/leg CH T 0135 4.5263 288.30 $490.7415111 Epidrm autogrft t/a/l add-on CH T 0135 4.5263 288.30 $490.7415115 Epidrm a-grft face/nck/hf/g CH T 0135 4.5263 288.30 $490.7415116 Epidrm a-grft f/n/hf/g addl CH T 0135 4.5263 288.30 $490.7415120 Skn splt a-grft fac/nck/hf/g CH T 0137 20.2069 1287.06 "$2,190.83 "15121 Skn splt a-grft f/n/hf/g add CH T 0137 20.2069 1287.06 "$2,190.83 "15130 "Derm autograft, trnk/arm/leg" CH T 0136 15.0458 958.33 "$1,631.27 "15131 Derm autograft t/a/l add-on CH T 0136 15.0458 958.33 "$1,631.27 "15135 Derm autograft face/nck/hf/g CH T 0136 15.0458 958.33 "$1,631.27 "15136 "Derm autograft, f/n/hf/g add" CH T 0136 15.0458 958.33 "$1,631.27 "15150 Cult epiderm grft t/arm/leg CH T 0135 4.5263 288.30 $490.7415151 Cult epiderm grft t/a/l addl CH T 0135 4.5263 288.30 $490.7415152 Cult epiderm graft t/a/l +% CH T 0135 4.5263 288.30 $490.7415155 "Cult epiderm graft, f/n/hf/g" CH T 0135 4.5263 288.30 $490.7415156 Cult epidrm grft f/n/hfg add CH T 0135 4.5263 288.30 $490.7415157 Cult epiderm grft f/n/hfg +% CH T 0135 4.5263 288.30 $490.7415170 Acell graft trunk/arms/legs CH T 0134 2.1051 134.08 $228.2315171 Acell graft t/arm/leg add-on CH T 0134 2.1051 134.08 $228.2315175 "Acellular graft, f/n/hf/g" CH T 0135 4.5263 288.30 $490.7415176 "Acell graft, f/n/hf/g add-on" CH T 0135 4.5263 288.30 $490.7415200 "Skin full graft, trunk" CH T 0136 15.0458 958.33 "$1,631.27 "15201 Skin full graft trunk add-on CH T 0136 15.0458 958.33 "$1,631.27 "15220 Skin full graft sclp/arm/leg CH T 0136 15.0458 958.33 "$1,631.27 "15221 Skin full graft add-on CH T 0135 4.5263 288.30 $490.7415240 Skin full grft face/genit/hf CH T 0136 15.0458 958.33 "$1,631.27 "15241 Skin full graft add-on CH T 0135 4.5263 288.30 $490.7415260 Skin full graft een & lips CH T 0136 15.0458 958.33 "$1,631.27 "15261 Skin full graft add-on CH T 0136 15.0458 958.33 "$1,631.27 "15300 "Apply skinallogrft, t/arm/lg" CH T 0135 4.5263 288.30 $490.7415301 Apply sknallogrft t/a/l addl CH T 0135 4.5263 288.30 $490.7415320 Apply skin allogrft f/n/hf/g CH T 0135 4.5263 288.30 $490.7415321 Aply sknallogrft f/n/hfg add CH T 0135 4.5263 288.30 $490.7415330 Aply acell alogrft t/arm/leg CH T 0135 4.5263 288.30 $490.7415331 Aply acell grft t/a/l add-on CH T 0135 4.5263 288.30 $490.7415335 "Apply acell graft, f/n/hf/g" CH T 0135 4.5263 288.30 $490.7415336 Aply acell grft f/n/hf/g add CH T 0135 4.5263 288.30 $490.7415340 Apply cult skin substitute CH T 0134 2.1051 134.08 $228.2315341 Apply cult skin sub add-on CH T 0134 2.1051 134.08 $228.2315360 "Apply cult derm sub, t/a/l" CH T 0134 2.1051 134.08 $228.2315361 Aply cult derm sub t/a/l add CH T 0134 2.1051 134.08 $228.2315365 Apply cult derm sub f/n/hf/g CH T 0134 2.1051 134.08 $228.23Proposed - 07/16/2009 17
  18. 18. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V15366 Apply cult derm f/hf/g add CH T 0134 2.1051 134.08 $228.2315400 "Apply skin xenograft, t/a/l" CH T 0135 4.5263 288.30 $490.7415401 Apply skn xenogrft t/a/l add CH T 0135 4.5263 288.30 $490.7415420 "Apply skin xgraft, f/n/hf/g" CH T 0135 4.5263 288.30 $490.7415421 Apply skn xgrft f/n/hf/g add CH T 0135 4.5263 288.30 $490.7415430 Apply acellular xenograft CH T 0135 4.5263 288.30 $490.7415431 Apply acellular xgraft add CH T 0135 4.5263 288.30 $490.7415570 Form skin pedicle flap CH T 0137 20.2069 1287.06 "$2,190.83 "15572 Form skin pedicle flap CH T 0137 20.2069 1287.06 "$2,190.83 "15574 Form skin pedicle flap CH T 0137 20.2069 1287.06 "$2,190.83 "15576 Form skin pedicle flap CH T 0137 20.2069 1287.06 "$2,190.83 "15600 Skin graft CH T 0137 20.2069 1287.06 "$2,190.83 "15610 Skin graft CH T 0137 20.2069 1287.06 "$2,190.83 "15620 Skin graft CH T 0137 20.2069 1287.06 "$2,190.83 "15630 Skin graft CH T 0137 20.2069 1287.06 "$2,190.83 "15650 Transfer skin pedicle flap CH T 0137 20.2069 1287.06 "$2,190.83 "15731 Forehead flap w/vasc pedicle CH T 0137 20.2069 1287.06 "$2,190.83 "15732 "Muscle-skin graft, head/neck" CH T 0137 20.2069 1287.06 "$2,190.83 "15734 "Muscle-skin graft, trunk" CH T 0137 20.2069 1287.06 "$2,190.83 "15736 "Muscle-skin graft, arm" CH T 0137 20.2069 1287.06 "$2,190.83 "15738 "Muscle-skin graft, leg" CH T 0137 20.2069 1287.06 "$2,190.83 "15740 Island pedicle flap graft CH T 0136 15.0458 958.33 "$1,631.27 "15750 Neurovascular pedicle graft CH T 0137 20.2069 1287.06 "$2,190.83 "15756 Free myo/skin flap microvasc C $0.0015757 "Free skin flap, microvasc" C $0.0015758 "Free fascial flap, microvasc" C $0.0015760 Composite skin graft CH T 0137 20.2069 1287.06 "$2,190.83 "15770 Derma-fat-fascia graft CH T 0137 20.2069 1287.06 "$2,190.83 "15775 Hair transplant punch grafts CH T 0133 1.2792 81.48 $138.6915776 Hair transplant punch grafts CH T 0133 1.2792 81.48 $138.6915780 Abrasion treatment of skin T 0022 21.1098 1344.57 "$2,288.72 "15781 Abrasion treatment of skin T 0019 4.3039 274.13 $466.6315782 Abrasion treatment of skin T 0019 4.3039 274.13 $466.6315783 Abrasion treatment of skin T 0016 2.6604 169.45 $288.4415786 "Abrasion, lesion, single" T 0013 0.7930 50.51 $85.9815787 "Abrasion, lesions, add-on" T 0013 0.7930 50.51 $85.9815788 "Chemical peel, face, epiderm" CH T 0013 0.7930 50.51 $85.9815789 "Chemical peel, face, dermal" T 0015 1.4595 92.96 $158.2415792 "Chemical peel, nonfacial" CH T 0015 1.4595 92.96 $158.2415793 "Chemical peel, nonfacial" CH T 0013 0.7930 50.51 $85.9815819 "Plastic surgery, neck" CH T 0134 2.1051 134.08 $228.23Proposed - 07/16/2009 18
  19. 19. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V15820 Revision of lower eyelid CH T 0137 20.2069 1287.06 "$2,190.83 "15821 Revision of lower eyelid CH T 0137 20.2069 1287.06 "$2,190.83 "15822 Revision of upper eyelid CH T 0137 20.2069 1287.06 "$2,190.83 "15823 Revision of upper eyelid CH T 0137 20.2069 1287.06 "$2,190.83 "15824 Removal of forehead wrinkles CH T 0137 20.2069 1287.06 "$2,190.83 "15825 Removal of neck wrinkles CH T 0137 20.2069 1287.06 "$2,190.83 "15826 Removal of brow wrinkles CH T 0137 20.2069 1287.06 "$2,190.83 "15828 Removal of face wrinkles CH T 0137 20.2069 1287.06 "$2,190.83 "15829 Removal of skin wrinkles CH T 0137 20.2069 1287.06 "$2,190.83 "15830 Exc skin abd T 0022 21.1098 1344.57 "$2,288.72 "15832 Excise excessive skin tissue T 0022 21.1098 1344.57 "$2,288.72 "15833 Excise excessive skin tissue T 0022 21.1098 1344.57 "$2,288.72 "15834 Excise excessive skin tissue T 0022 21.1098 1344.57 "$2,288.72 "15835 Excise excessive skin tissue CH T 0022 21.1098 1344.57 "$2,288.72 "15836 Excise excessive skin tissue T 0021 16.1001 1025.48 "$1,745.57 "15837 Excise excessive skin tissue T 0021 16.1001 1025.48 "$1,745.57 "15838 Excise excessive skin tissue T 0021 16.1001 1025.48 "$1,745.57 "15839 Excise excessive skin tissue T 0021 16.1001 1025.48 "$1,745.57 "15840 Graft for face nerve palsy CH T 0137 20.2069 1287.06 "$2,190.83 "15841 Graft for face nerve palsy CH T 0137 20.2069 1287.06 "$2,190.83 "15842 Flap for face nerve palsy CH T 0137 20.2069 1287.06 "$2,190.83 "15845 "Skin and muscle repair, face" CH T 0137 20.2069 1287.06 "$2,190.83 "15847 Exc skin abd add-on T 0022 21.1098 1344.57 "$2,288.72 "15850 Removal of sutures T 0016 2.6604 169.45 $288.4415851 Removal of sutures T 0016 2.6604 169.45 $288.4415852 Dressing change not for burn X 0340 0.6310 40.19 $68.4115860 Test for blood flow in graft X 0340 0.6310 40.19 $68.4115876 Suction assisted lipectomy CH T 0137 20.2069 1287.06 "$2,190.83 "15877 Suction assisted lipectomy CH T 0137 20.2069 1287.06 "$2,190.83 "15878 Suction assisted lipectomy CH T 0137 20.2069 1287.06 "$2,190.83 "15879 Suction assisted lipectomy CH T 0137 20.2069 1287.06 "$2,190.83 "15920 Removal of tail bone ulcer T 0019 4.3039 274.13 $466.6315922 Removal of tail bone ulcer CH T 0137 20.2069 1287.06 "$2,190.83 "15931 Remove sacrum pressure sore T 0022 21.1098 1344.57 "$2,288.72 "15933 Remove sacrum pressure sore T 0022 21.1098 1344.57 "$2,288.72 "15934 Remove sacrum pressure sore CH T 0137 20.2069 1287.06 "$2,190.83 "15935 Remove sacrum pressure sore CH T 0137 20.2069 1287.06 "$2,190.83 "15936 Remove sacrum pressure sore CH T 0136 15.0458 958.33 "$1,631.27 "15937 Remove sacrum pressure sore CH T 0137 20.2069 1287.06 "$2,190.83 "15940 Remove hip pressure sore T 0022 21.1098 1344.57 "$2,288.72 "15941 Remove hip pressure sore T 0022 21.1098 1344.57 "$2,288.72 "Proposed - 07/16/2009 19
  20. 20. 90-351 Maine Workers’ Compensation Board Rule Chapter 5; Medical Fees Appendix V15944 Remove hip pressure sore CH T 0137 20.2069 1287.06 "$2,190.83 "15945 Remove hip pressure sore CH T 0137 20.2069 1287.06 "$2,190.83 "15946 Remove hip pressure sore CH T 0137 20.2069 1287.06 "$2,190.83 "15950 Remove thigh pressure sore T 0022 21.1098 1344.57 "$2,288.72 "15951 Remove thigh pressure sore T 0022 21.1098 1344.57 "$2,288.72 "15952 Remove thigh pressure sore CH T 0136 15.0458 958.33 "$1,631.27 "15953 Remove thigh pressure sore CH T 0136 15.0458 958.33 "$1,631.27 "15956 Remove thigh pressure sore CH T 0136 15.0458 958.33 "$1,631.27 "15958 Remove thigh pressure sore CH T 0136 15.0458 958.33 "$1,631.27 "15999 Removal of pressure sore T 0019 4.3039 274.13 $466.6316000 Initial treatment of burn(s) CH T 0013 0.7930 50.51 $85.9816020 "Dress/debrid p-thick burn, s" CH T 0015 1.4595 92.96 $158.2416025 "Dress/debrid p-thick burn, m" CH T 0016 2.6604 169.45 $288.4416030 "Dress/debrid p-thick burn, l" CH T 0016 2.6604 169.45 $288.4416035 "Incision of burn scab, initi" T 0016 2.6604 169.45 $288.4416036 Escharotomy; addl incision C $0.0017000 Destruct premalg lesion CH T 0013 0.7930 50.51 $85.9817003 "Destruct premalg les, 2-14" CH T 0012 0.2963 18.87 $32.1217004 Destroy premlg lesions 15+ CH T 0016 2.6604 169.45 $288.4417106 Destruction of skin lesions CH T 0016 2.6604 169.45 $288.4417107 Destruction of skin lesions CH T 0016 2.6604 169.45 $288.4417108 Destruction of skin lesions CH T 0016 2.6604 169.45 $288.4417110 "Destruct b9 lesion, 1-14" CH T 0013 0.7930 50.51 $85.9817111 "Destruct lesion, 15 or more" CH T 0015 1.4595 92.96 $158.2417250 "Chemical cautery, tissue" CH T 0015 1.4595 92.96 $158.2417260 Destruction of skin lesions T 0015 1.4595 92.96 $158.2417261 Destruction of skin lesions T 0015 1.4595 92.96 $158.2417262 Destruction of skin lesions T 0015 1.4595 92.96 $158.2417263 Destruction of skin lesions T 0015 1.4595 92.96 $158.2417264 Destruction of skin lesions T 0015 1.4595 92.96 $158.2417266 Destruction of skin lesions T 0016 2.6604 169.45 $288.4417270 Destruction of skin lesions T 0015 1.4595 92.96 $158.2417271 Destruction of skin lesions CH T 0015 1.4595 92.96 $158.2417272 Destruction of skin lesions T 0015 1.4595 92.96 $158.2417273 Destruction of skin lesions CH T 0016 2.6604 169.45 $288.4417274 Destruction of skin lesions T 0016 2.6604 169.45 $288.4417276 Destruction of skin lesions T 0016 2.6604 169.45 $288.4417280 Destruction of skin lesions T 0015 1.4595 92.96 $158.2417281 Destruction of skin lesions CH T 0016 2.6604 169.45 $288.4417282 Destruction of skin lesions CH T 0016 2.6604 169.45 $288.4417283 Destruction of skin lesions CH T 0016 2.6604 169.45 $288.44Proposed - 07/16/2009 20
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