5/25/2017 TEXAS MEDICAID FEE SCHEDULE - 1 of...
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5/25/2017 1 of 123 TEXAS MEDICAID FEE SCHEDULE - THERAPIES Provider Type: TOS: TOS Desc: Proc Code: Mod 1: Mod 2: Client Age Frm: Thru: Client Age Units: Non- facility/Facility Total RVUs/Base Units: Conversion Factor: Medicaid Fee: Fee Effect Date: Adjust %: Adjusted Fee for Report Date: Note Codes: Last Pricing Review Date: 1 2 3 1 2 3 CCP PROVIDER 1 MEDICAL SERVICES 92507 0 20 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016 CCP PROVIDER 1 MEDICAL SERVICES 92507 0 20 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 P2 12/15/2016 CCP PROVIDER 1 MEDICAL SERVICES 92507 21 999 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016 CCP PROVIDER 1 MEDICAL SERVICES 92507 21 999 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 P2 12/15/2016 CCP PROVIDER 1 MEDICAL SERVICES 92508 0 20 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 12/15/2016 CCP PROVIDER 1 MEDICAL SERVICES 92508 0 20 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 P2 12/15/2016 CCP PROVIDER 1 MEDICAL SERVICES 92508 21 999 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 12/15/2016 CCP PROVIDER 1 MEDICAL SERVICES 92508 21 999 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 P2 12/15/2016 CCP PROVIDER 1 MEDICAL SERVICES 92521 0 20 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016 CCP PROVIDER 1 MEDICAL SERVICES 92521 0 20 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 P2 12/15/2016 CCP PROVIDER 1 MEDICAL SERVICES 92521 21 999 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016 THERAPIES Texas Medicaid Fee Schedule Information Field Descriptions Classification assigned during provider enrollment and used to determine payable services One-character type-of-service (TOS) code assigned to each procedure code for system administration. Non-Facility pricing is for services that are rendered in places of service other than an inpatient hospital or an outpatient hospital. Facility pricing is for services that are rendered in an inpatient hospital (place of service [POS] 3), or an outpatient hospital or ambulatory surgical center (POS 5). The current relative value units (RVUs) for the procedure code, if the fee is a resource-based fee (RBF). The payable amount for RBFs is calculated by multiplying the total RVUs by the applicable conversion factor. For Anesthesia services only, this column shows the base units instead; and payment is based on the sum of the base units plus actual face-to-face time units multiplied by the applicable conversion factor. Description of the TOS. The five-digit code for services and items defined in Current Procedure Terminology or the Healthcare Common Procedure Coding System. 1st Modifier, if required for pricing determination. 2nd Modifier, if required for pricing determination. The “from age” is the beginning of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age range for the first row (0-999) is actually 0-20 years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the Texas Medicaid Provider Procedures Manual (TMPPM) for the exact age limitations. Last Pricing Review Date Mod 1 Mod 2 Facility Client Age Frm Thru Units Total RVUs/ Base Units Conversion Factor Non-facility Note Codes Note Codes Total RVUs/ Base Units Conversion Factor Medicaid Fee This fee schedule is intended to be used by a variety of provider types and provider specialties. Some procedure codes might not apply to every provider type and provider specialty designated to use the fee schedule. For detailed benefits and limitations, providers should refer to the current year’s Texas Medicaid Provider Procedures Manual and relevant issues of the Texas Medicaid Bulletin. TOS TOS Desc Proc Code Provider Type The Texas Medicaid conversion factor that is applicable for determining the amount payable when the rate is calculated by base units for anesthesia services or RVUs for other services. The Medicaid allowed amount. Medicaid rates are reviewed every two years or as necessary. This column shows the date on which the most recent review was conducted. Note code indicator. Providers should review each note code to identify specific payment explanation or limitation. See Note Codes worksheet for applicable payment explanation or limitation. A percentage reduction has been applied to the allowed fee for this service. This column does not show reductions that may have been applied using other criteria that include but are not limited to place of service, client type program, or provider specialty. Additional information about rate changes is available on the TMHP website at www.tmhp.com. The effective date of service for which the fee is payable. A percentage reduction has been applied to the allowed fee for this service. This column shows the percent by which the fee was adjusted. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx. The “through age” is the end of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age range for the first row (0-999) is actually 0-20 years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the TMPPM for exact age limitations. Medicaid rates are based on the client’s age in days, months or years. Fee Effect Date Adjust % Adjusted Fee for Report Date Medicaid Fee Fee Effect Date Adjust % Adjusted Fee for Report Date Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
Transcript of 5/25/2017 TEXAS MEDICAID FEE SCHEDULE - 1 of...
5/25/2017 1 of 123TEXAS MEDICAID FEE SCHEDULE -
THERAPIES
Provider Type:
TOS:
TOS Desc:
Proc Code:
Mod 1:
Mod 2:
Client Age
Frm:
Thru:
Client Age
Units:
Non-
facility/Facility
Total
RVUs/Base
Units:Conversion
Factor:
Medicaid Fee:
Fee Effect
Date:
Adjust %:
Adjusted Fee
for Report
Date:
Note Codes:
Last Pricing
Review Date:
1 2 3 1 2 3
CCP
PROVIDER 1
MEDICAL
SERVICES 92507 0 20 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92507 0 20 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92507 21 999 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92507 21 999 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92508 0 20 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92508 0 20 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92508 21 999 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92508 21 999 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
THERAPIES
Texas Medicaid Fee Schedule Information
Field Descriptions
Classification assigned during provider enrollment and used to determine payable services
One-character type-of-service (TOS) code assigned to each procedure code for system administration.
Non-Facility pricing is for services that are rendered in places of service other than an inpatient hospital or an outpatient hospital. Facility pricing is for services that are rendered in an inpatient hospital (place of service [POS] 3), or an outpatient hospital or ambulatory surgical center (POS 5).
The current relative value units (RVUs) for the procedure code, if the fee is a resource-based fee (RBF). The payable amount for RBFs is calculated by multiplying the total RVUs by the applicable conversion factor. For Anesthesia services only, this column shows the base units instead; and
payment is based on the sum of the base units plus actual face-to-face time units multiplied by the applicable conversion factor.
Description of the TOS.
The five-digit code for services and items defined in Current Procedure Terminology or the Healthcare Common Procedure Coding System.
1st Modifier, if required for pricing determination.
2nd Modifier, if required for pricing determination.
The “from age” is the beginning of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age range for the first row (0-999) is actually 0-20
years of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the Texas Medicaid Provider Procedures Manual (TMPPM) for the exact age limitations.
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
This fee schedule is intended to be used by a variety of provider types and provider specialties. Some procedure codes might not apply to every provider type and provider specialty designated to use the fee schedule. For detailed benefits and limitations, providers should refer to the current year’s Texas Medicaid
Provider Procedures Manual and relevant issues of the Texas Medicaid Bulletin.
TOS TOS DescProc
Code
Provider
Type
The Texas Medicaid conversion factor that is applicable for determining the amount payable when the rate is calculated by base units for anesthesia services or RVUs for other services.
The Medicaid allowed amount.
Medicaid rates are reviewed every two years or as necessary. This column shows the date on which the most recent review was conducted.
Note code indicator. Providers should review each note code to identify specific payment explanation or limitation. See Note Codes worksheet for applicable payment explanation or limitation.
A percentage reduction has been applied to the allowed fee for this service. This column does not show reductions that may have been applied using other criteria that include but are not limited to place of service, client type program, or provider specialty. Additional information about rate
changes is available on the TMHP website at www.tmhp.com.
The effective date of service for which the fee is payable.
A percentage reduction has been applied to the allowed fee for this service. This column shows the percent by which the fee was adjusted. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.
The “through age” is the end of an age range, if it is required for determining pricing. Some procedure codes have more than one pricing row. If the first row has a 0-999 age range, and the second row has a 21-999 age range, then the client age range for the first row (0-999) is actually 0-20 years
of age. If the first row has a 0-999 age range and the second row has a 0-20 age range, then the client age range for the first row (0-999) is actually 21-999 years of age. Refer to the TMPPM for exact age limitations.
Medicaid rates are based on the client’s age in days, months or years.
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CCP
PROVIDER 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $112.50 12/15/2016 0.00 $112.50 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $112.50 12/15/2016 0.00 $112.50 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $150.00 12/15/2016 0.00 $150.00 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $150.00 12/15/2016 0.00 $150.00 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $75.00 12/15/2016 0.00 $75.00 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $75.00 12/15/2016 0.00 $75.00 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92526 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92526 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92526 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92526 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 92610 0 999 Years 0.00 $0.0000 $193.10 12/15/2016 0.00 $193.10 P2 0.00 $0.0000 $188.56 12/15/2016 0.00 $188.56 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 3 of 123TEXAS MEDICAID FEE SCHEDULE -
THERAPIES
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CCP
PROVIDER 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 4 of 123TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CCP
PROVIDER 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CCP
PROVIDER 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
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Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CCP
PROVIDER 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 6 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $31.63 12/15/2016 0.00 $31.63 6 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $34.20 12/15/2016 0.00 $34.20 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 6 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CCP
PROVIDER 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES 97802 0 20 Years 0.98 $28.0672 $27.51 1/1/2017 0.00 $27.51 0.92 $28.0672 $25.82 1/1/2017 0.00 $25.82 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97803 0 20 Years 0.85 $28.0672 $23.86 1/1/2017 0.00 $23.86 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES 97804 0 20 Years 0.45 $28.0672 $12.63 1/1/2015 0.00 $12.63 0.43 $28.0672 $12.07 1/1/2015 0.00 $12.07 1/1/2017
CCP
PROVIDER 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES S9152 0 20 Years 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES S9152 0 20 Years 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 P2 12/15/2016
CCP
PROVIDER 1
MEDICAL
SERVICES S9152 21 999 Years 0.00 $0.0000 $169.71 12/15/2016 0.00 $169.71 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 92507 0 20 Years 0.00 $0.0000 $26.38 12/15/2016 0.00 $26.38 0.00 $0.0000 $26.38 12/15/2016 0.00 $26.38 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 92507 21 999 Years 0.00 $0.0000 $26.38 12/15/2016 0.00 $26.38 0.00 $0.0000 $26.38 12/15/2016 0.00 $26.38 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 10 of 123TEXAS MEDICAID FEE SCHEDULE -
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 11 of 123TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 12 of 123TEXAS MEDICAID FEE SCHEDULE -
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 13 of 123TEXAS MEDICAID FEE SCHEDULE -
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $27.67 12/15/2016 0.00 $27.67 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $27.67 12/15/2016 0.00 $27.67 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $27.67 12/15/2016 0.00 $27.67 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $27.67 12/15/2016 0.00 $27.67 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 14 of 123TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $28.37 12/15/2016 0.00 $28.37 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $28.37 12/15/2016 0.00 $28.37 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $28.37 12/15/2016 0.00 $28.37 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $28.37 12/15/2016 0.00 $28.37 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
DateCERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016CERTIFIED
NURSE
MIDWIFE/RE
GISTERED
NURSE/LICEN
SE 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
CHEMICAL
DEPENDENCY
TREATMENT
FACILITY
(TCADA AP 1
MEDICAL
SERVICES H0016 0 999 Years 0.00 $0.0000 $8.42 1/1/2011 0.00 $8.42 7/1/2013
CHEMICAL
DEPENDENCY
TREATMENT
FACILITY
(TCADA AP 1
MEDICAL
SERVICES H0031 0 999 Years 0.00 $0.0000 $21.06 9/1/2013 0.00 $21.06 9/1/2013
CHEMICAL
DEPENDENCY
TREATMENT
FACILITY
(TCADA AP 1
MEDICAL
SERVICES H0047 21 999 Years 0.00 $0.0000 $25.39 7/1/2013 0.00 $25.39 7/1/2013
CHEMICAL
DEPENDENCY
TREATMENT
FACILITY
(TCADA AP 9
OTHER MEDICAL
ITEMS OR
SERVICES H0050 0 20 Years 0.00 $0.0000 $26.66 7/1/2013 0.00 $26.66 7/1/2013
CHEMICAL
DEPENDENCY
TREATMENT
FACILITY
(TCADA AP 9
OTHER MEDICAL
ITEMS OR
SERVICES H0050 21 999 Years 0.00 $0.0000 $25.39 7/1/2013 0.00 $25.39 7/1/2013
CHEMICAL
DEPENDENCY
TREATMENT
FACILITY
(TCADA AP 1
MEDICAL
SERVICES H2035 0 20 Years 0.00 $0.0000 $133.75 9/1/2013 0.00 $133.75 9/1/2013
CHEMICAL
DEPENDENCY
TREATMENT
FACILITY
(TCADA AP 1
MEDICAL
SERVICES H2035 21 999 Years 0.00 $0.0000 $59.78 9/1/2013 0.00 $59.78 9/1/2013
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90901 4 20 Years 1.07 $28.0672 $30.03 7/1/2015 0.00 $30.03 0.57 $28.0672 $16.00 7/1/2015 0.00 $16.00 7/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90901 21 999 Years 1.07 $26.7305 $28.60 7/1/2015 0.00 $28.60 0.57 $26.7305 $15.24 7/1/2015 0.00 $15.24 7/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90911 4 20 Years 2.38 $28.0672 $66.80 7/1/2015 0.00 $66.80 1.26 $28.0672 $35.36 7/1/2015 0.00 $35.36 7/1/2015
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 90911 21 999 Years 2.38 $26.7305 $63.62 7/1/2015 0.00 $63.62 1.26 $26.7305 $33.68 7/1/2015 0.00 $33.68 7/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92507 0 20 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92507 21 999 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92508 0 20 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92508 21 999 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92526 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92526 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 92610 0 999 Years 0.00 $0.0000 $188.56 12/15/2016 0.00 $188.56 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 6 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $31.63 12/15/2016 0.00 $31.63 6 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $34.20 12/15/2016 0.00 $34.20 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 6 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES S9152 0 20 Years 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 12/15/2016
CLINIC/GROU
P PRACTICE 1
MEDICAL
SERVICES S9152 21 999 Years 0.00 $0.0000 $169.71 12/15/2016 0.00 $169.71 0.00 $0.0000 $169.71 12/15/2016 0.00 $169.71 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92507 0 2 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92507 0 2 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92508 0 2 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92508 0 2 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $112.50 12/15/2016 0.00 $112.50 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $112.50 12/15/2016 0.00 $112.50 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $150.00 12/15/2016 0.00 $150.00 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $150.00 12/15/2016 0.00 $150.00 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $75.00 12/15/2016 0.00 $75.00 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $75.00 12/15/2016 0.00 $75.00 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92526 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92526 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92610 0 999 Years 0.00 $0.0000 $188.56 12/15/2016 0.00 $188.56 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 92610 0 999 Years 0.00 $0.0000 $193.10 12/15/2016 0.00 $193.10 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97012 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97012 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97014 0 2 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97014 0 2 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97016 0 2 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97016 0 2 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97018 0 2 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 27 of 123TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97018 0 2 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97022 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97022 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97024 0 2 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97024 0 2 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97026 0 2 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97026 0 2 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97028 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97028 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97032 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97032 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97033 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97033 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97034 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97034 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97035 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97035 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97036 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97036 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97110 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97110 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97112 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97112 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97113 0 2 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97113 0 2 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97116 0 2 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97116 0 2 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97124 0 2 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97124 0 2 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97140 0 2 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97140 0 2 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97150 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97150 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97530 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97530 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97535 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97535 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97542 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97542 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 1/1/2017
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97750 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97750 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97760 0 2 Years 0.00 $0.0000 $31.63 12/15/2016 0.00 $31.63 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97760 0 2 Years 0.00 $0.0000 $34.20 12/15/2016 0.00 $34.20 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97761 0 2 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97761 0 2 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97762 0 2 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 33 of 123TEXAS MEDICAID FEE SCHEDULE -
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES 97762 0 2 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES S9152 0 20 Years 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES S9152 0 20 Years 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 P2 12/15/2016
EARLY
CHILDHOOD
INTERVENTIO
N 1
MEDICAL
SERVICES S9152 21 999 Years 0.00 $0.0000 $169.71 12/15/2016 0.00 $169.71 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92507 0 20 Years 0.00 $0.0000 $100.34 12/15/2016 0.00 $100.34 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92507 21 999 Years 0.00 $0.0000 $100.34 12/15/2016 0.00 $100.34 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92508 0 20 Years 0.00 $0.0000 $50.68 12/15/2016 0.00 $50.68 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92508 21 999 Years 0.00 $0.0000 $50.68 12/15/2016 0.00 $50.68 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $67.90 12/15/2016 0.00 $67.90 0.00 $0.0000 $67.90 12/15/2016 0.00 $67.90 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $112.50 12/15/2016 0.00 $112.50 0.00 $0.0000 $112.50 12/15/2016 0.00 $112.50 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $84.89 12/15/2016 0.00 $84.89 0.00 $0.0000 $84.89 12/15/2016 0.00 $84.89 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $150.00 12/15/2016 0.00 $150.00 0.00 $0.0000 $150.00 12/15/2016 0.00 $150.00 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $113.18 12/15/2016 0.00 $113.18 0.00 $0.0000 $113.18 12/15/2016 0.00 $113.18 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $75.00 12/15/2016 0.00 $75.00 0.00 $0.0000 $75.00 12/15/2016 0.00 $75.00 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $56.59 12/15/2016 0.00 $56.59 0.00 $0.0000 $56.59 12/15/2016 0.00 $56.59 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92526 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92526 21 999 Years 0.00 $0.0000 $111.48 12/15/2016 0.00 $111.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92610 0 20 Years 0.00 $0.0000 $193.10 12/15/2016 0.00 $193.10 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 92610 0 999 Years 0.00 $0.0000 $113.18 12/15/2016 0.00 $113.18 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97012 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97012 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97012 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97012 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97012 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97012 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97012 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97012 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97012 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97012 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97012 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97012 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97012 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97012 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97012 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97012 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97014 AT 0 20 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97014 AT 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97014 AT GO 0 20 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97014 AT GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97014 AT GP 0 20 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97014 AT GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97014 GO 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97014 GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97014 GP 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97014 GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97014 0 20 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97014 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97014 GO 0 20 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97014 GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97014 GP 0 20 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97014 GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97016 AT 0 20 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97016 AT 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97016 AT GO 0 20 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97016 AT GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97016 AT GP 0 20 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97016 AT GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97016 GO 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97016 GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97016 GP 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97016 GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97016 0 20 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97016 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97016 GO 0 20 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97016 GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97016 GP 0 20 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97016 GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97018 AT 0 20 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97018 AT 21 999 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97018 AT GO 0 20 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97018 AT GO 21 999 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97018 AT GP 0 20 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97018 AT GP 21 999 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97018 GO 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97018 GO 21 999 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97018 GP 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97018 GP 21 999 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97018 0 20 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97018 21 999 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97018 GO 0 20 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97018 GO 21 999 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97018 GP 0 20 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97018 GP 21 999 Years 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 0.00 $0.0000 $91.08 12/15/2016 0.00 $91.08 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97022 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97022 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97022 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97022 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97022 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97022 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97022 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97022 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97022 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97022 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97022 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97022 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97022 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97022 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97022 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97022 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97024 AT 0 20 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97024 AT 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 38 of 123TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97024 AT GO 0 20 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97024 AT GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97024 AT GP 0 20 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97024 AT GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97024 GO 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97024 GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97024 GP 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97024 GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97024 0 20 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97024 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97024 GO 0 20 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97024 GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97024 GP 0 20 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97024 GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97026 AT 0 20 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97026 AT 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97026 AT GO 0 20 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97026 AT GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97026 AT GP 0 20 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97026 AT GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97026 GO 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97026 GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97026 GP 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97026 GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97026 0 20 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97026 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97026 GO 0 20 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97026 GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97026 GP 0 20 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97026 GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97028 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97028 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97028 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97028 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97028 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97028 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97028 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97028 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97028 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97028 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97028 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97028 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97028 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97028 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97028 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97028 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97032 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97032 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97032 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97032 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97032 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97032 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97032 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97032 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97032 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97032 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97032 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97032 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97032 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97032 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97032 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97032 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97033 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97033 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97033 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97033 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97033 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97033 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97033 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97033 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97033 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97033 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97033 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97033 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97033 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97033 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97033 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97033 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97034 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97034 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97034 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97034 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97035 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97035 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97035 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97035 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97035 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97035 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97035 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97035 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97035 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97035 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97035 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97035 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97035 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97035 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97035 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97035 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97036 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97036 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97036 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97036 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97039 AT 0 20 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97039 AT 21 999 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97039 GO 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97039 GP 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97039 0 20 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97039 21 999 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97110 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97110 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97110 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97110 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97110 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97110 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97110 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97110 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97110 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97110 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97110 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97110 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97110 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97110 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97110 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97110 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97112 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97112 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97112 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97112 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97112 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97112 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97112 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97112 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97112 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97112 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97112 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97112 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97112 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97112 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97112 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97112 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97116 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97116 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97116 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97116 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97116 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97116 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97116 GO 0 20 Years 0.00 $0.0000 $120.30 12/15/2016 0.00 $120.30 0.00 $0.0000 $120.30 12/15/2016 0.00 $120.30 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97116 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97116 GP 0 20 Years 0.00 $0.0000 $120.30 12/15/2016 0.00 $120.30 0.00 $0.0000 $120.30 12/15/2016 0.00 $120.30 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97116 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97116 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97116 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97116 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97116 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97116 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97116 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97124 AT 0 20 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97124 AT 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97124 AT GO 0 20 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97124 AT GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97124 AT GP 0 20 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97124 AT GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97124 GO 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97124 GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97124 GP 0 20 Years 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 0.00 $0.0000 $101.36 12/15/2016 0.00 $101.36 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97124 GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 46 of 123TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97124 0 20 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97124 21 999 Years 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 0.00 $0.0000 $84.79 12/15/2016 0.00 $84.79 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97124 GO 0 20 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97124 GO 21 999 Years 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 0.00 $0.0000 $85.88 12/15/2016 0.00 $85.88 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97124 GP 0 20 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97124 GP 21 999 Years 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 0.00 $0.0000 $84.24 12/15/2016 0.00 $84.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97139 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97139 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97139 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97139 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97139 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97139 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97139 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97139 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97139 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97139 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97139 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97139 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97139 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97139 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97139 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97139 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97140 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97140 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97140 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97140 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97140 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97140 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97140 GO 0 20 Years 0.00 $0.0000 $123.36 12/15/2016 0.00 $123.36 0.00 $0.0000 $123.36 12/15/2016 0.00 $123.36 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97140 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97140 GP 0 20 Years 0.00 $0.0000 $123.36 12/15/2016 0.00 $123.36 0.00 $0.0000 $123.36 12/15/2016 0.00 $123.36 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97140 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97140 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97140 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97140 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97140 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97140 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97140 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97150 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97150 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97150 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
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Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97150 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97150 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97150 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97150 GO 0 20 Years 0.00 $0.0000 $65.24 12/15/2016 0.00 $65.24 0.00 $0.0000 $65.24 12/15/2016 0.00 $65.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97150 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97150 GP 0 20 Years 0.00 $0.0000 $65.24 12/15/2016 0.00 $65.24 0.00 $0.0000 $65.24 12/15/2016 0.00 $65.24 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97150 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97150 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97150 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97150 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97150 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97150 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97150 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97161 AT 0 20 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97161 AT 21 999 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97161 0 20 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97161 21 999 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97162 AT 0 20 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97162 AT 21 999 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97162 0 20 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97162 21 999 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97163 AT 0 20 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97163 AT 21 999 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97163 0 20 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97163 21 999 Years 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 0.00 $0.0000 $85.52 1/1/2017 0.00 $85.52 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $76.97 1/1/2017 0.00 $76.97 0.00 $0.0000 $76.97 1/1/2017 0.00 $76.97 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97164 AT 0 20 Years 0.00 $0.0000 $76.97 1/1/2017 0.00 $76.97 0.00 $0.0000 $76.97 1/1/2017 0.00 $76.97 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97164 AT 21 999 Years 0.00 $0.0000 $76.97 1/1/2017 0.00 $76.97 0.00 $0.0000 $76.97 1/1/2017 0.00 $76.97 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97164 0 20 Years 0.00 $0.0000 $76.97 1/1/2017 0.00 $76.97 0.00 $0.0000 $76.97 1/1/2017 0.00 $76.97 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97164 21 999 Years 0.00 $0.0000 $76.97 1/1/2017 0.00 $76.97 0.00 $0.0000 $76.97 1/1/2017 0.00 $76.97 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97165 AT 0 20 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97165 AT 21 999 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97165 0 20 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97165 21 999 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
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RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97166 AT 0 20 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97166 AT 21 999 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97166 0 20 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97166 21 999 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97167 AT 0 20 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97167 AT 21 999 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97167 0 20 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97167 21 999 Years 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 0.00 $0.0000 $89.21 1/1/2017 0.00 $89.21 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $78.47 1/1/2017 0.00 $78.47 0.00 $0.0000 $78.47 1/1/2017 0.00 $78.47 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97168 AT 0 20 Years 0.00 $0.0000 $78.47 1/1/2017 0.00 $78.47 0.00 $0.0000 $78.47 1/1/2017 0.00 $78.47 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97168 AT 21 999 Years 0.00 $0.0000 $78.47 1/1/2017 0.00 $78.47 0.00 $0.0000 $78.47 1/1/2017 0.00 $78.47 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97168 0 20 Years 0.00 $0.0000 $78.47 1/1/2017 0.00 $78.47 0.00 $0.0000 $78.47 1/1/2017 0.00 $78.47 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97168 21 999 Years 0.00 $0.0000 $78.47 1/1/2017 0.00 $78.47 0.00 $0.0000 $78.47 1/1/2017 0.00 $78.47 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97530 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97530 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97530 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97530 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97530 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97530 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97530 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97530 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97530 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97530 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97530 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97530 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97530 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97530 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97530 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97530 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97535 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97535 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97535 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97535 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97535 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97535 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97535 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97535 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97535 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97535 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97535 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97535 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97535 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97535 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97535 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97535 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97535 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97537 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97537 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97537 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97537 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97537 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97537 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97537 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97537 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97537 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97537 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97537 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97537 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97537 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97537 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97537 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97537 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97537 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97542 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97542 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97542 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97542 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97542 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97542 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97750 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97750 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97750 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97750 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97760 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97760 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97761 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97761 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97762 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97762 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97799 AT 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97799 AT 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97799 AT GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97799 AT GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97799 AT GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97799 AT GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97799 GO 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97799 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97799 GP 0 20 Years 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 0.00 $0.0000 $130.48 12/15/2016 0.00 $130.48 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES 97799 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 55 of 123TEXAS MEDICAID FEE SCHEDULE -
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97799 0 20 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97799 21 999 Years 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 0.00 $0.0000 $109.15 12/15/2016 0.00 $109.15 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97799 GO 0 20 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97799 GO 21 999 Years 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 0.00 $0.0000 $110.56 12/15/2016 0.00 $110.56 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97799 GP 0 20 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY C
HOME HEALTH
PROCEDURE 97799 GP 21 999 Years 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 0.00 $0.0000 $108.44 12/15/2016 0.00 $108.44 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $55.17 12/15/2016 0.00 $55.17 0.00 $0.0000 $55.17 12/15/2016 0.00 $55.17 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES S9152 0 20 Years 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 12/15/2016
HOME
HEALTH
AGENCY 1
MEDICAL
SERVICES S9152 21 999 Years 0.00 $0.0000 $101.86 12/15/2016 0.00 $101.86 12/15/2016
HOME
HEALTH DME 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
HOME
HEALTH DME 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
HOME
HEALTH DME 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
HOME
HEALTH DME 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
HOME
HEALTH DME 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
HOME
HEALTH DME 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
HOME
HEALTH DME 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
HOME
HEALTH DME 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
HOME
HEALTH DME 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
HOME
HEALTH DME 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
HOME
HEALTH DME 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
HOME
HEALTH DME 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
HOME
HEALTH DME 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
HOME
HEALTH DME 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 92507 0 20 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 92507 21 999 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES S9152 0 20 Years 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 12/15/2016
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES S9152 0 20 Years 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 P2 12/15/2016
MEDICAL
SUPPLIER
(DME) 1
MEDICAL
SERVICES S9152 21 999 Years 0.00 $0.0000 $169.71 12/15/2016 0.00 $169.71 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
MH
REHABILITATI
VE SERVICES 1
MEDICAL
SERVICES H2017 18 999 Years 0.00 $0.0000 $26.93 9/1/2011 0.00 $26.93 9/1/2011
MH
REHABILITATI
VE SERVICES 1
MEDICAL
SERVICES H2017 ET 18 999 Years 0.00 $0.0000 $26.93 12/1/2014 0.00 $26.93 9/1/2011
MH
REHABILITATI
VE SERVICES 1
MEDICAL
SERVICES H2017 HQ 18 999 Years 0.00 $0.0000 $5.39 9/1/2011 0.00 $5.39 9/1/2011
MH
REHABILITATI
VE SERVICES 1
MEDICAL
SERVICES H2017 HQ TD 18 999 Years 0.00 $0.0000 $5.39 12/1/2014 0.00 $5.39 9/1/2011
MH
REHABILITATI
VE SERVICES 1
MEDICAL
SERVICES H2017 TD 18 999 Years 0.00 $0.0000 $26.93 12/1/2014 0.00 $26.93 9/1/2011
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97535 0 Y 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97535 0 Y 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97537 0 Y 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97537 0 Y 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97542 0 Y 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 6 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 6 1/1/2017
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97542 0 Y 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 1/1/2017
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97542 GO UC 0 Y 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97542 GO UC 0 Y 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
Frm Thru Units
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RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97542 GP UC 0 Y 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97542 GP UC 0 Y 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97799 0 Y 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97799 0 Y 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97799 21 Y 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
NEPHROLOGY
(HEMODIALY
SIS, RENAL
DIALYSIS) 1
MEDICAL
SERVICES 97799 21 Y 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92507 0 20 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92507 21 999 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $112.50 12/15/2016 0.00 $112.50 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $112.50 12/15/2016 0.00 $112.50 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $150.00 12/15/2016 0.00 $150.00 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $150.00 12/15/2016 0.00 $150.00 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $75.00 12/15/2016 0.00 $75.00 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $75.00 12/15/2016 0.00 $75.00 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 6 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $31.63 12/15/2016 0.00 $31.63 6 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $34.20 12/15/2016 0.00 $34.20 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 6 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 P2 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
OCCUPATION
AL
THERAPIST 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92507 0 20 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92507 21 999 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $90.00 12/15/2016 0.00 $90.00 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 66 of 123TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $112.50 12/15/2016 0.00 $112.50 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $112.50 12/15/2016 0.00 $112.50 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $150.00 12/15/2016 0.00 $150.00 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $150.00 12/15/2016 0.00 $150.00 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $75.00 12/15/2016 0.00 $75.00 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $75.00 12/15/2016 0.00 $75.00 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 6 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $31.63 12/15/2016 0.00 $31.63 6 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $34.20 12/15/2016 0.00 $34.20 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 6 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICAL
THERAPIST 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90901 4 20 Years 1.07 $28.0672 $30.03 7/1/2015 0.00 $30.03 0.57 $28.0672 $16.00 7/1/2015 0.00 $16.00 7/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90901 21 999 Years 1.07 $26.7305 $28.60 7/1/2015 0.00 $28.60 0.57 $26.7305 $15.24 7/1/2015 0.00 $15.24 7/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90911 4 20 Years 2.38 $28.0672 $66.80 7/1/2015 0.00 $66.80 1.26 $28.0672 $35.36 7/1/2015 0.00 $35.36 7/1/2015
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 90911 21 999 Years 2.38 $26.7305 $63.62 7/1/2015 0.00 $63.62 1.26 $26.7305 $33.68 7/1/2015 0.00 $33.68 7/1/2015
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92507 0 20 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92507 21 999 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92508 0 20 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92508 21 999 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92526 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92526 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 92610 0 999 Years 0.00 $0.0000 $188.56 12/15/2016 0.00 $188.56 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 73 of 123TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 6 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $31.63 12/15/2016 0.00 $31.63 6 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $34.20 12/15/2016 0.00 $34.20 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 6 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES S9152 0 20 Years 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 12/15/2016
PHYSICIAN
(D.O.) 1
MEDICAL
SERVICES S9152 21 999 Years 0.00 $0.0000 $169.71 12/15/2016 0.00 $169.71 0.00 $0.0000 $169.71 12/15/2016 0.00 $169.71 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90901 4 20 Years 1.07 $28.0672 $30.03 7/1/2015 0.00 $30.03 0.57 $28.0672 $16.00 7/1/2015 0.00 $16.00 7/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90901 21 999 Years 1.07 $26.7305 $28.60 7/1/2015 0.00 $28.60 0.57 $26.7305 $15.24 7/1/2015 0.00 $15.24 7/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90911 4 20 Years 2.38 $28.0672 $66.80 7/1/2015 0.00 $66.80 1.26 $28.0672 $35.36 7/1/2015 0.00 $35.36 7/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 90911 21 999 Years 2.38 $26.7305 $63.62 7/1/2015 0.00 $63.62 1.26 $26.7305 $33.68 7/1/2015 0.00 $33.68 7/1/2015
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92507 0 20 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92507 21 999 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92508 0 20 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92508 21 999 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92526 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92526 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 92610 0 999 Years 0.00 $0.0000 $188.56 12/15/2016 0.00 $188.56 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 77 of 123TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 79 of 123TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 80 of 123TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 6 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $31.63 12/15/2016 0.00 $31.63 6 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $34.20 12/15/2016 0.00 $34.20 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 6 12/15/2016
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES S9152 0 20 Years 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 12/15/2016
PHYSICIAN
(M.D.) 1
MEDICAL
SERVICES S9152 21 999 Years 0.00 $0.0000 $169.71 12/15/2016 0.00 $169.71 0.00 $0.0000 $169.71 12/15/2016 0.00 $169.71 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90901 4 20 Years 1.07 $28.0672 $27.63 7/1/2015 0.00 $27.63 0.57 $28.0672 $14.72 7/1/2015 0.00 $14.72 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90901 21 999 Years 1.07 $26.7305 $26.31 7/1/2015 0.00 $26.31 0.57 $26.7305 $14.02 7/1/2015 0.00 $14.02 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90911 4 20 Years 2.38 $28.0672 $61.46 7/1/2015 0.00 $61.46 1.26 $28.0672 $32.53 7/1/2015 0.00 $32.53 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 90911 21 999 Years 2.38 $26.7305 $58.53 7/1/2015 0.00 $58.53 1.26 $26.7305 $30.99 7/1/2015 0.00 $30.99 7/1/2015
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92507 0 20 Years 0.00 $0.0000 $26.38 12/15/2016 0.00 $26.38 0.00 $0.0000 $26.38 12/15/2016 0.00 $26.38 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92507 21 999 Years 0.00 $0.0000 $26.38 12/15/2016 0.00 $26.38 0.00 $0.0000 $26.38 12/15/2016 0.00 $26.38 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92508 0 20 Years 0.00 $0.0000 $10.78 12/15/2016 0.00 $10.78 0.00 $0.0000 $10.78 12/15/2016 0.00 $10.78 12/15/2016
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92508 21 999 Years 0.00 $0.0000 $10.78 12/15/2016 0.00 $10.78 0.00 $0.0000 $10.78 12/15/2016 0.00 $10.78 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $80.86 12/15/2016 0.00 $80.86 0.00 $0.0000 $80.86 12/15/2016 0.00 $80.86 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $80.86 12/15/2016 0.00 $80.86 0.00 $0.0000 $80.86 12/15/2016 0.00 $80.86 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $101.07 12/15/2016 0.00 $101.07 0.00 $0.0000 $101.07 12/15/2016 0.00 $101.07 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $101.07 12/15/2016 0.00 $101.07 0.00 $0.0000 $101.07 12/15/2016 0.00 $101.07 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $134.76 12/15/2016 0.00 $134.76 0.00 $0.0000 $134.76 12/15/2016 0.00 $134.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $134.76 12/15/2016 0.00 $134.76 0.00 $0.0000 $134.76 12/15/2016 0.00 $134.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $67.38 12/15/2016 0.00 $67.38 0.00 $0.0000 $67.38 12/15/2016 0.00 $67.38 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $67.38 12/15/2016 0.00 $67.38 0.00 $0.0000 $67.38 12/15/2016 0.00 $67.38 12/15/2016
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92526 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92526 0 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 92610 0 999 Years 0.00 $0.0000 $173.48 12/15/2016 0.00 $173.48 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
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Mod
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $27.67 12/15/2016 0.00 $27.67 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $27.67 12/15/2016 0.00 $27.67 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $27.67 12/15/2016 0.00 $27.67 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $27.67 12/15/2016 0.00 $27.67 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $21.56 12/15/2016 0.00 $21.56 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $23.31 12/15/2016 0.00 $23.31 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $28.37 12/15/2016 0.00 $28.37 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $28.37 12/15/2016 0.00 $28.37 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $28.37 12/15/2016 0.00 $28.37 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $28.37 12/15/2016 0.00 $28.37 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $94.67 1/1/2017 0.00 $94.67 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $94.67 1/1/2017 0.00 $94.67 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $94.67 1/1/2017 0.00 $94.67 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $94.67 1/1/2017 0.00 $94.67 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $94.67 1/1/2017 0.00 $94.67 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $94.67 1/1/2017 0.00 $94.67 P2 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $94.67 1/1/2017 0.00 $94.67 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $94.67 1/1/2017 0.00 $94.67 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $94.67 1/1/2017 0.00 $94.67 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $94.67 1/1/2017 0.00 $94.67 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $94.67 1/1/2017 0.00 $94.67 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 0.00 $0.0000 $89.84 1/1/2017 0.00 $89.84 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $94.67 1/1/2017 0.00 $94.67 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $80.86 1/1/2017 0.00 $80.86 9 0.00 $0.0000 $80.86 1/1/2017 0.00 $80.86 9 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $85.20 1/1/2017 0.00 $85.20 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $80.86 1/1/2017 0.00 $80.86 9 0.00 $0.0000 $80.86 1/1/2017 0.00 $80.86 9 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $85.20 1/1/2017 0.00 $85.20 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 6 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $27.76 1/1/2017 0.00 $27.76 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $30.01 1/1/2017 0.00 $30.01 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $27.76 1/1/2017 0.00 $27.76 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $30.01 1/1/2017 0.00 $30.01 P2 1/1/2017
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 0.00 $0.0000 $27.76 12/15/2016 0.00 $27.76 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $30.01 12/15/2016 0.00 $30.01 P2 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES S9152 0 20 Years 0.00 $0.0000 $159.89 12/15/2016 0.00 $159.89 0.00 $0.0000 $159.89 12/15/2016 0.00 $159.89 12/15/2016
PHYSICIAN
ASST/NURSE
PRACT/CLINI
CAL NURSE
SPEC 1
MEDICAL
SERVICES S9152 21 999 Years 0.00 $0.0000 $156.13 12/15/2016 0.00 $156.13 0.00 $0.0000 $156.13 12/15/2016 0.00 $156.13 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90901 4 20 Years 1.07 $28.0672 $30.03 7/1/2015 0.00 $30.03 0.57 $28.0672 $16.00 7/1/2015 0.00 $16.00 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90901 21 999 Years 1.07 $26.7305 $28.60 7/1/2015 0.00 $28.60 0.57 $26.7305 $15.24 7/1/2015 0.00 $15.24 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90911 4 20 Years 2.38 $28.0672 $66.80 7/1/2015 0.00 $66.80 1.26 $28.0672 $35.36 7/1/2015 0.00 $35.36 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 90911 21 999 Years 2.38 $26.7305 $63.62 7/1/2015 0.00 $63.62 1.26 $26.7305 $33.68 7/1/2015 0.00 $33.68 7/1/2015
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92507 0 20 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92507 21 999 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92508 0 20 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92508 21 999 Years 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 0.00 $0.0000 $11.72 12/15/2016 0.00 $11.72 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 0.00 $0.0000 $109.86 12/15/2016 0.00 $109.86 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 0.00 $0.0000 $146.48 12/15/2016 0.00 $146.48 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 0.00 $0.0000 $73.24 12/15/2016 0.00 $73.24 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92526 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92526 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 92610 0 999 Years 0.00 $0.0000 $188.56 12/15/2016 0.00 $188.56 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 107 of 123TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 6 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $31.63 12/15/2016 0.00 $31.63 6 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $34.20 12/15/2016 0.00 $34.20 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 108 of 123TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 6 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES S9152 0 20 Years 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 0.00 $0.0000 $173.79 12/15/2016 0.00 $173.79 12/15/2016
PHYSICIAN
GROUP
(D.O.S ONLY) 1
MEDICAL
SERVICES S9152 21 999 Years 0.00 $0.0000 $169.71 12/15/2016 0.00 $169.71 0.00 $0.0000 $169.71 12/15/2016 0.00 $169.71 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 109 of 123TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRIST 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRIST 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 111 of 123TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRIST 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 112 of 123TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRIST 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 6 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
PODIATRIST 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $31.63 12/15/2016 0.00 $31.63 6 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $34.20 12/15/2016 0.00 $34.20 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 6 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 113 of 123TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRIST 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRIST 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 114 of 123TEXAS MEDICAID FEE SCHEDULE -
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Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRY
GROUP 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 115 of 123TEXAS MEDICAID FEE SCHEDULE -
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRY
GROUP 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $35.43 12/15/2016 0.00 $35.43 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $38.32 12/15/2016 0.00 $38.32 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $23.44 12/15/2016 0.00 $23.44 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $25.34 12/15/2016 0.00 $25.34 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 116 of 123TEXAS MEDICAID FEE SCHEDULE -
THERAPIES
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRY
GROUP 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 0.00 $0.0000 $97.65 1/1/2017 0.00 $97.65 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $102.90 1/1/2017 0.00 $102.90 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 0.00 $0.0000 $87.89 1/1/2017 0.00 $87.89 9 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $92.61 1/1/2017 0.00 $92.61 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 6 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 117 of 123TEXAS MEDICAID FEE SCHEDULE -
THERAPIES
1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
PODIATRY
GROUP 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
PODIATRY
GROUP 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $31.63 12/15/2016 0.00 $31.63 6 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $34.20 12/15/2016 0.00 $34.20 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 6 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
PODIATRY
GROUP 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92507 0 20 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92507 21 999 Years 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 0.00 $0.0000 $28.67 12/15/2016 0.00 $28.67 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92508 0 20 Years 0.00 $0.0000 $14.93 12/15/2016 0.00 $14.93 0.00 $0.0000 $14.93 12/15/2016 0.00 $14.93 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92508 21 999 Years 0.00 $0.0000 $14.93 12/15/2016 0.00 $14.93 0.00 $0.0000 $14.93 12/15/2016 0.00 $14.93 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92521 0 20 Years 0.00 $0.0000 $105.47 12/15/2016 0.00 $105.47 0.00 $0.0000 $105.47 12/15/2016 0.00 $105.47 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92521 21 999 Years 0.00 $0.0000 $105.47 12/15/2016 0.00 $105.47 0.00 $0.0000 $105.47 12/15/2016 0.00 $105.47 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92522 0 20 Years 0.00 $0.0000 $131.83 12/15/2016 0.00 $131.83 0.00 $0.0000 $131.83 12/15/2016 0.00 $131.83 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92522 21 999 Years 0.00 $0.0000 $131.83 12/15/2016 0.00 $131.83 0.00 $0.0000 $131.83 12/15/2016 0.00 $131.83 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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FacilityClient Age
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RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92523 0 20 Years 0.00 $0.0000 $175.77 12/15/2016 0.00 $175.77 0.00 $0.0000 $175.77 12/15/2016 0.00 $175.77 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92523 21 999 Years 0.00 $0.0000 $175.77 12/15/2016 0.00 $175.77 0.00 $0.0000 $175.77 12/15/2016 0.00 $175.77 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92524 0 20 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92524 21 999 Years 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 0.00 $0.0000 $87.89 12/15/2016 0.00 $87.89 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92526 0 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 92610 0 999 Years 0.00 $0.0000 $226.27 12/15/2016 0.00 $226.27 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97012 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97012 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97014 0 20 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97014 21 999 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97016 0 20 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97016 21 999 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97018 0 20 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97018 21 999 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97022 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97022 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97024 0 20 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97024 21 999 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97026 0 20 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97026 21 999 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97028 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97028 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97032 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97032 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97033 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97033 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97034 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97034 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97035 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97035 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97036 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97036 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97039 0 20 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97039 21 999 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97110 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97110 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97112 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97112 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97113 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97113 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97116 0 20 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97116 21 999 Years 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 0.00 $0.0000 $30.08 12/15/2016 0.00 $30.08 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97124 0 20 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97124 21 999 Years 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 0.00 $0.0000 $29.84 12/15/2016 0.00 $29.84 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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Mod
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FacilityClient Age
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Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97139 0 20 Years 0.00 $0.0000 $39.00 12/15/2016 0.00 $39.00 0.00 $0.0000 $39.00 12/15/2016 0.00 $39.00 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97139 21 999 Years 0.00 $0.0000 $39.00 12/15/2016 0.00 $39.00 0.00 $0.0000 $39.00 12/15/2016 0.00 $39.00 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97140 0 20 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97140 21 999 Years 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 0.00 $0.0000 $30.84 12/15/2016 0.00 $30.84 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97150 0 20 Years 0.00 $0.0000 $19.21 12/15/2016 0.00 $19.21 0.00 $0.0000 $19.21 12/15/2016 0.00 $19.21 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97150 21 999 Years 0.00 $0.0000 $19.21 12/15/2016 0.00 $19.21 0.00 $0.0000 $19.21 12/15/2016 0.00 $19.21 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97161 0 20 Years 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97161 21 999 Years 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97162 0 20 Years 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97162 21 999 Years 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97163 0 20 Years 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97163 21 999 Years 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97164 0 20 Years 0.00 $0.0000 $113.00 1/1/2017 0.00 $113.00 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97164 21 999 Years 0.00 $0.0000 $113.00 1/1/2017 0.00 $113.00 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97165 0 20 Years 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97165 21 999 Years 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97166 0 20 Years 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97166 21 999 Years 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97167 0 20 Years 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97167 21 999 Years 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 0.00 $0.0000 $125.55 1/1/2017 0.00 $125.55 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97168 0 20 Years 0.00 $0.0000 $113.00 1/1/2017 0.00 $113.00 0.00 $0.0000 $113.00 1/1/2017 0.00 $113.00 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97168 21 999 Years 0.00 $0.0000 $113.00 1/1/2017 0.00 $113.00 0.00 $0.0000 $113.00 1/1/2017 0.00 $113.00 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
5/25/2017 121 of 123TEXAS MEDICAID FEE SCHEDULE -
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Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97530 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97530 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97750 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97750 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97760 0 20 Years 0.00 $0.0000 $38.87 12/15/2016 0.00 $38.87 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97761 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97762 0 20 Years 0.00 $0.0000 $35.09 12/15/2016 0.00 $35.09 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97799 0 20 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES 97799 21 999 Years 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 0.00 $0.0000 $38.41 12/15/2016 0.00 $38.41 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES S8990 0 999 Years 0.00 $0.0000 $39.00 12/15/2016 0.00 $39.00 0.00 $0.0000 $39.00 12/15/2016 0.00 $39.00 12/15/2016
REHABILITATI
ON CENTERS 1
MEDICAL
SERVICES S9152 0 999 Years 0.00 $0.0000 $203.64 12/15/2016 0.00 $203.64 0.00 $0.0000 $203.64 12/15/2016 0.00 $203.64 12/15/2016
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES 97535 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 12/15/2016
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES 97537 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 12/15/2016
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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1 2 3 1 2 3
Last Pricing
Review Date
Mod
1
Mod
2
FacilityClient Age
Frm Thru Units
Total
RVUs/
Base Units
Conversion
Factor
Non-facility
Note Codes Note CodesTotal
RVUs/
Base Units
Conversion
Factor
Medicaid
Fee
TOS TOS DescProc
Code
Provider
Type Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
Medicaid
Fee
Fee Effect
Date
Adjust
%
Adjusted
Fee for
Report
Date
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 6 0.00 $0.0000 $30.17 12/15/2016 0.00 $30.17 6 1/1/2017
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES 97542 0 20 Years 0.00 $0.0000 $32.62 12/15/2016 0.00 $32.62 P2 1/1/2017
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES 97542 GO UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 0.00 $0.0000 $30.17 1/1/2017 0.00 $30.17 1/1/2017
RENAL
DIALYSIS
FACILITY 1
MEDICAL
SERVICES 97542 GP UC 0 20 Years 0.00 $0.0000 $32.62 1/1/2017 0.00 $32.62 P2 1/1/2017
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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THERAPIES
Note Code(s): 1 - In an outpatient setting, this procedure is subject to a 60% payable if diagnosis is non-emergency.
10 - Assistant surgery is payable at a percentage of surgery.
12 - CRNA/AA providers are reimbursed at 92 percent of the fee applicable to a physician for the same service.
2 - Clinical Lab Fee Schedule procedure.
3 - The calculated payable amount for anesthesia could be reduced or increased based on the modifier used.
5 - This procedure is manually reviewed to determine pricing.
5B - Procedure suspends for manual pricing and is reimbursed the lesser of the Max Fee, Invoice, or Acquisition Cost
6 - This procedure is payable only through the CCP program.
9 - The NP/CNS/PA/CNM Provider Fee Schedule reflects 100 percent of the fee applicable to a physician.
P2 - Displayed fee reflects reimbursement for the service rendered in the home setting.
Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
