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Archive Reimubursement Rates

Women's Cancer Screening Program: September 2013 - June 2014, Provider Reimbursement Schedule

The RI Department of Health Women’s Cancer Screening Program (WCSP) received our CDC Notice of Grant Award on July 1, 2013. This year, the federal budget was negatively impacted by mandated spending reductions as a result of sequestration legislation enacted by Congress.  The overall reductions in spending apply to all federal departments and agencies.  As a result, the funding recommendations for the National Breast and Cervical Cancer Early Detection Programs nationally as well as the WCSP were reduced requiring the WCSP to revise the Participating Provider Reimbursement rates. Beginning September 1, 2013, the WCSP Provider Reimbursement Rates will be revised to the RI Medicaid rates or the maximum rate allowed by the program and will remain in effect through June 30, 2014. 

The revised reimbursement rates will be effective for all procedures and office visits as of September 1, 2013 (date of service) to allow notification to WCSP Providers.  The demand for breast and cervical cancer screening, follow-up and referral for treatment for uninsured women in RI provided through the WCSP has increased over the past few years.  The revision of reimbursement rates will allow the WCSP to continue to provide services through FY 13 and remain a fiscally sound program.  Below are the revised reimbursement rates for the time period of September 1, 2013 through June 30, 2014. 

The WCSP values our partnerships with our WCSP Participating Providers that have provided critical breast and cervical cancer screening and follow-up services for 33,716 low-income uninsured women in Rhode Island since 1996 diagnosing 422 breast cancers and 34 invasive cervical cancers.  Over 2,200 women have been referred into Medicaid through the WCSP to access treatment for breast and/or cervical precancerous conditions and to access treatment for the diagnosis of breast or cervical cancer. 

  CPT CODE Reimbursement
Office Visits - Established Patients

Office Visit / Minimal / no physician

99211

$      8.05

Office Visit / Problem focused History / exam 

99212

$    20.64

Preventive Visit

99213/ 99396 / 99397

$   20.64

Office Visit / Detailed History/ Detailed Exam

99395 /99214 / 99215

$    27.00

Office Visits - New Patients

Office Visit / Problem focused History / exam

99201

$    16.72

Office Visit / Expanded problem focused history/ exam

99202

$    27.24

Preventive Visit

99385 / 99386 /  99387  

$    27.24

Office Visit / Detailed History/ Detailed Exam

99203 / 99204 / 99205

$    45.00

Diagnostic

Colposcopy of the cervix

57452

$    25.20

Colposcopy with biopsy and endocervical curettage

57454

$   42.00

Colposcopy with biopsy(s) of the cervix

57455

$   83.80

Colposcopy of the cervix with endocervical curettage (biopsy)

57456

$   79.26

Colposcopy of the cervix with loop electrode biopsy(s) of the cervix

57460 ²

$   30.00

Colposcopy of the cervix with loop electrode biopsy(s) of the cervix – Facility Fee

57460TC ²

$ 750.00

Colposcopy with loop electrode conization of the cervix

57461 ²

$   186.59

Colposcopy with loop electrode conization of the cervix – Facility Fee

57461TC ²

$ 750.00

Biopsy, single/multiple/ local ex. of lesion, with/without fulguration- sep procedure

57500

$   25.20

Endoscopy with biopsy (s) of the cervix and endocervical curettage

57505

$   25.20

Conization of cervix, with/without fulguration, with/without dilation and curettage, with/without repair; cold knife or laser

57520 ²

$  75.60

Conization of cervix – Facility Fee

57520TC ²

$ 750.00

Loop electrode excision

57522 ²

$   153.56

Loop electrode excision – Facility Fee

57522TC ²

$ 750.00

Paracervical (uterine) nerve – Anesthetic Agent

64435

$  42.00

Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without Cervical dialation, any method (separate procedure)

58100 ³

$   25.20

Endometrial sampling (biopsy) performed in conjunction with colposcopy

58110 ³

$   29.10

Pathology and Laboratory

Papillomavirus, human, amplified probe technique

87621

$  29.42

Evaluation of Aspirate

88172

$  28.48

       Technical component

88172TC

$ 9.08

       Professional component

8817226

$ 18.37

Cytopathology, smears, any other source; screening & interpretation

88160

$  17.96

         Technical component

88160TC

$ 16.10

         Professional component

8816026

$  15.27

Cytopathology, smears, any other source; prep., screening & interpretation

88161

$  19.20

         Technical component

88161TC

$  15.07

         Professional component

8816126

$  15.27

Interpretation and Report of Aspirate

88173

$ 42.31

       Technical component

88173TC

$  25.39

        Professional component

8817326

$  42.52

Screening Pap Smear Cytology

88164 / 88165

$  8.86

Screening Pap Cytology – Thin Prep – Must be reimbursed @ conventional Pap smear rate

88142 / 88143

$  16.60

Abnormal Smear (read by pathologist)                  

88141

$  7.07

Screening by automated system and manual rescreening under physician Supervision

88175

$  20.50

Pathology, Cervical/Breast Biopsy

88305

$ 39.42

          Technical component

88305TC

$  30.13

           Professional component

8830526

$  22.91

Pathology, breast, excision of lesion – surgical pathology (Global Procedure)

88307

$ 67.91

          Technical component

88307TC

$ 42.52

           Professional component

8830726

$  48.71

Surgical pathology, first tissue block, with frozen section (s), single specimen

88331

$  50.16

           Technical component

88331TC

$  10.73

           Professional component

8833126

$  36.53

Each additional tissue block with frozen section (s)

88332

$  24.97

           Technical component

88332TC

$  5.57

           Professional component

8833226

$  18.16

Immunohistochemistry (including tissue immunoperoxidase, each antibody

88342

$  31.99

           Technical component

88342TC

$  19.61

           Professional component

8834226

$  26.00

Radiological/Diagnostic Procedures

Unilateral Mammogram (Global Procedure)

77055

$   47.47

                Technical Component

77055TC

$   19.20

                Professional Component

7705526

$   19.20

Unilateral, diagnostic mammogram- direct digital image, all views Global Procedure

G0206

$   63.36

                Technical Component

G0206TC

$   63.36

                Professional Component

G020626

$ 20.23

Bilateral Mammogram (Global Procedure)

77056

$  60.06

                Technical Component

77056TC

$  36.33

                Professional Component

7705626

$   29.92

Bilateral, diagnostic mammography- direct digital image, all views Global Procedure

G0204

$  78.64

                Technical Component

G0204TC

$  78.64

                Professional Component

G020426

$   24.97

Screening Mammogram (Global Procedure)

77057

$   43.96

                Technical Component²

77057TC

$   24.77

                Professional Component

7705726

$   19.20

Screening mammography, direct digital image, bilateral, all views Global Procedure

G0202

$   74.10

                Technical Component

G0202TC

$   74.10

                Professional Component

G020226

$   20.02

Consultation on x-ray examination made elsewhere, written report

7614026

$  14.86

Breast Ultrasound (Global Procedure)

76645

$   36.00

                Technical Component

76645TC

$   22.50

                Professional Component

7664526

$   15.48

Stereotactic location for breast biopsy, each lesion, radiological supervision and interpretation (Global Procedure)

77031

$  77.61

                Technical component

77031TC

$   33.85

                Professional component

7703126

$   43.76

Preoperative placement of needle location wire breast; radiological supervision and interpretation (Global Procedure)

77032

$   24.97

                Technical component

77032TC

$   9.70

                Professional component

7703226

$  15.27

Radiological examinations; surgical specimen (Global Procedure)

76098

$  13.83

                Technical component

76098TC

$  9.08

                Professional component

7609826

$   4.75

Ultrasonic guidance for needle placement (eg, biopsy aspiration, injection, localization device), imaging supervision and interpretation (Global Procedure)

76942

 

$  53.87

                Technical component

76942TC

$  62.54

                Professional component

7694226

$   19.40

Magnetic Resonance Imaging - with/out contrast, Unilateral

77058

$479.47

                Professional component

7705826

$  44.58

                Technical component

77058TC

$  429.83

Magnetic Resonance Imaging - with/out contrast, Bilateral

77059

$484.01

                Professional component

7705926

$  44.58

                Technical component

77059TC

$  439.43

Surgical

Fine Needle Aspirate – without imaging (Global Procedure)

10021 ²

$   49.33

Fine Needle Aspirate – with imaging guidance (Global Procedure)

10022 ²

$   50.77

Puncture aspiration of cyst of breast

19000 ²

$   25.20

Each additional cyst (list separately in addition to code for primary procedure)

19001²

$   8.40

Biopsy of breast; needle core (Surgical Procedure Only)

19100 ²

$   56.00

Incisional biopsy of breast (Global Procedure)

19101 ²

$  84.00

Percutaneous, needle core, using imaging guidance

19102 ²

$ 137.40

Percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance

19103 ²

$ 274.10

Excision of cyst, fibroadenoma or other benign or malignant tumor, aberrant breast tissue, duct lesion or nipple lesion (Global Procedure)

19120 ²

$ 126.00

Excision of breast lesion identified by preoperative placement of radiological marker-single lesion

19125 ²

$ 126.00

Excision of breast lesion identified by preoperative placement of radiological marker-each additional lesion

19126 ²

$ 63.00

Preoperative placement of needle localization wire, breast

19290 ²

$ 25.20

Image guided placement, metallic localization clip, percutaneous, during breast biopsy

19295 ²

$  54.08

Notes

  1. Reimbursement rates are based on the 2013 RI Medicaid Fee Schedule OR maximum payable rate allowed by the WCSP.
  2. United States citizens and qualified aliens (Permanent Resident Aliens greater than 5 years) should apply for Medical Assistance through the WCSP to cover the cost of this procedure. WCSP will provide coverage for these CPT codes only for non-qualified aliens or Permanent Resident Aliens less than 5 years needing Cone/LEEP or allowable breast biopsy CPT codes for women that do not qualify for Medicaid.
  3. Endometrial biopsy is reimbursable ONLY if performed in the initial workup of a Pap test result of Atypical Glandular Cells (AGC) or the Pap test result of a postmenopausal woman notes that endometrial cells are present.

Balance billing for covered services is not permitted by Participating Providers under contract with the WCSP.