Provider Reimbursement for Women's Cancer Screening

Reimbursement Schedule July 1, 2014 - July 1, 2015

Office Visits - Established Patients

CPT CODE Reimbursement
Office Visit / Minimal / no physician 99211 $ 16.70
Office Visit / Problem focused History / exam 99212 $ 36.27
Preventive Visit 99213/ 99396 / 99397 $ 60.48
Office Visit / Detailed History/ Detailed Exam 99395 /99214 / 99215 $ 60.48

Office Visits - New Patients

CPT CODE Reimbursement
Office Visit / Problem focused History / exam 99201 $ 35.97
Office Visit / Expanded problem focused History / exam 99202 $ 61.73
Preventive Visit 99385 / 99386 / 99387 $ 61.73
Office Visit / Detailed History/ Detailed Exam 99203 / 99204 / 99205 $ 85.50

Diagnostic

CPT CODE Reimbursement
Colposcopy of the cervix 57452 $ 78.33
Colposcopy with biopsy and endocervical curettage 57454 $ 116.17
Colposcopy with biopsy(s) of the cervix 57455 $ 94.86
Colposcopy of the cervix with endocervical curettage (biopsy) 57456 $ 88.39
Colposcopy of the cervix with loop electrode biopsy(s) of the cervix 57460 ² $ 139.61
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 $ 160.84
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 $ 64.82
Endoscopy with biopsy (s) of the cervix and endocervical curettage 57505 $ 78.10
Conization of cervix, with/without fulguration, with/without dilation and curettage, with/without repair; cold knife or laser 57520 ² $ 232.42
Conization of cervix – Facility Fee 57520TC ² $ 750.00
Loop electrode excision 57522 ² $ 207.30
Loop electrode excision – Facility Fee 57522TC ² $ 750.00
Paracervical (uterine) nerve – Anesthetic Agent 64435 $ 71.74
Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without Cervical dialation, any method (separate procedure) 58100 ³ $ 75.23
Endometrial sampling (biopsy) performed in conjunction with colposcopy 58110 ³ $ 34.93

Pathology and Laboratory

CPT CODE Reimbursement
Papillomavirus, human, amplified probe technique 87621 $ 47.87
Evaluation of Aspirate 88172 $ 45.17
    Technical component 88172TC $ 15.37
    Professional component 8817226 $ 29.80
Interpretation and Report of Aspirate 88173 $ 122.30
    Technical component 88173TC $ 63.05
    Professional component 8817326 $ 59.25
Screening Pap Smear Cytology 88164 / 88165 $ 14.42
Screening Pap Cytology – Thin Prep – Must be reimbursed @ conventional Pap smear rate 88142 / 88143 $ 27.02
Abnormal Smear (read by pathologist) 88141 $ 26.39
Screening by automated system and manual rescreening under physician Supervision 88175 $ 33.36
Pathology, Cervical/Breast Biopsy 88305 $ 58.70
    Technical component 88305TC $ 27.14
    Professional component 8830526 $ 31.56
Pathology, breast, excision of lesion – surgical pathology (Global Procedure) 88307 $ 241.30
    Technical component 88307TC $ 171.98
    Professional component 8830726 $ 69.32
Surgical pathology, first tissue block, with frozen section (s), single specimen 88331 $ 82.12
    Technical component 88331TC $ 30.46
    Professional component 8833126 $ 51.66
Each additional tissue block with frozen section (s) 88332 $ 36.22
    Technical component 88332TC $ 10.54
    Professional component 8833226 $ 25.67
Immunohistochemistry G0461 $ 73.90
    Technical component G046TC $ 48.56
    Professional component G046126 $ 25.34

Radiological/Diagnostic Procedures

CPT CODE Reimbursement
Unilateral Mammogram (Global Procedure) 77055 $ 75.27
     Technical Component 77055TC $ 45.85
     Professional Component 7705526 $ 29.42
Unilateral, diagnostic mammogram- direct digital image, all views Global Procedure G0206 $ 108.46
     Technical Component G0206TC $ 79.34
     Professional Component G020626 $ 29.12
Bilateral Mammogram (Global Procedure) 77056 $ 96.82
     Technical Component 77056TC $ 60.33
     Professional Component 7705626 $ 36.48
Bilateral, diagnostic mammography- direct digital image, all views Global Procedure G0204 $ 137.86
     Technical Component G0204TC $ 101.38
     Professional Component G020426 $ 36.48
Screening Mammogram (Global Procedure) 77057 $ 68.94
     Technical Component 77057TC $ 39.51
     Professional Component 7705726 $ 29.42
Screening mammography, direct digital image, bilateral, all views Global Procedure G0202 $ 112.99
     Technical Component G0202TC $ 83.87
     Professional Component G020226 $ 29.12
Consultation on x-ray examination made elsewhere, written report 7614026 $ 14.86
Breast Ultrasound (Global Procedure) 76645 $ 83.57
     Technical Component 76645TC $ 60.63
     Professional Component 7664526 $ 22.94
Radiological examinations; surgical specimen (Global Procedure) 76098 $ 16.10
     Technical component 76098TC $ 9.33
     Professional component 7609826 $ 6.77
Ultrasonic guidance for needle placement (eg, biopsy aspiration, injection, localization device), imaging supervision and interpretation (Global Procedure) 76942

$ 61.72
     Technical component 76942TC $ 33.78
     Professional component 7694226 $ 27.94
Magnetic Resonance Imaging - with/out contrast, Unilateral 77058 $464.74
     Technical component 77058TC $ 396.50
     Professional component 7705826 $ 68.24
Magnetic Resonance Imaging - with/out contrast, Bilateral 77059 $462.94
    Technical component 77059TC $ 394.70
    Professional component 7705926 $ 68.24

Surgical

CPT CODE Reimbursement
Fine Needle Aspirate – without imaging (Global Procedure) 10021 ² $ 59.58
Fine Needle Aspirate – with imaging guidance (Global Procedure) 10022 ² $ 55.23
Puncture aspiration of cyst of breast 19000 ² $ 36.98
Each additional cyst (list separately in addition to code for primary procedure) 19001² $ 18.20
Biopsy of breast; needle core (Surgical Procedure Only) 19100 ² $ 57.98
Incisional biopsy of breast (Global Procedure) 19101 ² $ 184.09
Breast biopsy, placement of loc device and imag of bx spec, percutaneous; stereotactic guidance; first lesion 19081 ² $ 153.04
Breast biopsy, placement of loc device and imag of bx spec, percutaneous; stereotactic guidance; each add lesion 19082 ² $ 73.03
Breast biopsy, placement of loc device and imag of bx spec, percutaneous; ultrasound guidance; first lesion 19083 ² $ 143.42
Breast biopsy, placement of loc device and imag of bx spec, percutaneous; ultrasound guidance; each add lesion 19084 ² $ 68.65
Breast biopsy, placement of loc device and imag of bx spec, percutaneous; MRI guidance; first lesion 19085 ² $ 167.45
Breast biopsy, placement of loc device and imag of bx spec, percutaneous; MRI; each add lesion 19086 ² $ 75.10
Excision of cyst, fibroadenoma or other benign or malignant tumor, aberrant breast tissue, duct lesion or nipple lesion (Global Procedure) 19120 ² $ 344.12
Excision of breast lesion identified by preoperative placement of radiological marker-single lesion 19125 ² $ 381.95
Excision of breast lesion identified by preoperative placement of radiological marker-each add lesion 19126 ² $ 134.67
Placement of breast loc device, percutaneous; mammographic guidance; first lesion 19281 $ 86.09
Placement of breast loc device, percutaneous; mammographic guidance; each add lesion 19282 $ 41.23
Placement of breast loc device, percutaneous; stereotactic guidance; first lesion 19283 $ 87.00
Placement of breast loc device, percutaneous; stereotactic guidance; each add lesion 19284 $ 41.54
Placement of breast loc device, percutaneous; ultrasound guidance; first lesion 19285 $ 73.77
Placement of breast loc device, percutaneous; ultrasound guidance; each add lesion 19286 $ 35.64
Placement of breast loc device, percutaneous; MRI guidance; first lesion 19287 $ 119.45
Placement of breast loc device, percutaneous; MRI guidance; each add lesion 19288 $ 53.32
See / Print All Rates

Notes

  1. Reimbursement rates are based on the 80% of 2014 Rhode Island Medicare 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.