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OHIO PART B 2016 Enrollment Package (Includes Fee Schedule) © 2016 Copyright, CGS Administrators, LLC. MEDICARE PARTICIPATING PROVIDER PROGRAM

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Page 1: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

OHIO PART B

2016 Enrollment Package(Includes Fee Schedule)

© 2016 Copyright, CGS Administrators, LLC.

MEDICARE

PARTICIPATING

PROVIDER PROGRAM

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We wish to emphasize the importance and advantages of being a Medicare participating (PAR) provider, and we are pleased that the favorable trend of participation continued into 2015 with a participation rate of 96.9 percent. As you plan for 2016 and become familiar with the coming changes, we hope that you will continue to be a PAR provider or, if you are non-participating (Non-PAR), will consider becoming a PAR provider.

It is in the interest of patients and providers to build a health care delivery system that’s better, smarter and healthier – a system that delivers better care; a system that spends health care dollars more wisely; and a system that makes our communities healthier. Next year will be the first time since 1999 that physicians will no longer have to worry about the flawed Sustainable Growth Rate (SGR) formula and potentially devastating cuts in physician payment. Bipartisan legislation passed by Congress repealing the SGR provides added momentum to the changes underway in Medicare payment to support physicians in improving care to Medicare beneficiaries. We look forward to working with providers in the coming year to achieve our common goals.

WHY BECOME A PARTICIPATING MEDICARE PROVIDER

All physicians, practitioners and suppliers – regardless of their Medicare participation status – must make their calendar year (CY) 2016 Medicare participation decision by December 31, 2015. Providers who want to maintain their current PAR status or Non-PAR status do not need to take any action during the upcoming annual participation enrollment period. To sign a participation agreement is to agree to accept assignment for all covered services that you provide to Medicare patients in CY 2016. The overwhelming majority of physicians, practitioners and suppliers have chosen to participate in Medicare. During CY 2015, 96.9 percent of all physicians and practitioners are billing under Medicare participation agreements.

If you participate and bill for services paid under the Medicare physician fee schedule (MPFS), your Medicare fee schedule amounts are 5 percent higher than if you do not participate. Your Medicare Administrative Contractor (MAC) publishes an electronic directory of providers that choose to participate.

WHAT TO DO

If you choose to be a PAR physician in CY 2016:

• Do nothing if you are currently participating, or

• If you are not currently a Medicare participant, complete the available blank agreement (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS460.pdf) and mail it (or a copy) to each MAC to which you submit Part B claims. (On the form show the name(s) and identification number(s) under which you bill.)

If you decide not to participate in CY 2016:

• Do nothing if you are currently not participating, or

• If you are currently a participant, write to each MAC to which you submit claims, advising of the termination of your participation in the participating physician program effective January 1, 2016. This written notice must be postmarked prior to January 1, 2016.

We hope you will decide to be a Medicare participant in CY 2016. Please call 1.866.276.9558 if you have any questions or need further information on participation.

ANNOUNCEMENTAbout Medicare Participation for Calendar Year 2016

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2016

The Medicare Learning Network® (MLN) has developed publications in an effort to educate Medicare providers about important Medicare enrollment information. These MLN publications also provide education to Medicare providers on how to use the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) to enroll in the Medicare Program and maintain their enrollment information. A list of publications is available at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/Medicare_Provider-Supplier_Enrollment_National_Education_Products.pdf.

To view updates and the latest information about Medicare, please visit https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/. For CGS Administrators, LLC, you may contact the following toll-free number(s) for assistance: 1.866.276.9558.

New Payment and Care Delivery Model Tests at the CMS Innovation Center:

Physicians can directly participate in health care transformation through the efforts of the CMS Innovation Center which is charged with identifying, testing, and evaluating innovative payment and service delivery models that show promise of providing better access to quality care at lower costs for beneficiaries of Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). The Innovation Center offers opportunities for innovators working in the field to share ideas, contribute to the discussion of improvements in health care, and participate in model tests.

More than 60,000 providers in all 50 states, the District of Columbia, and Puerto Rico are currently participating in over 25 Innovation Center payment and service delivery model tests, serving an estimated 2.5 million beneficiaries of Medicare, Medicaid, and CHIP. Participants include states, organizations, and a broad array of health care professionals, as well as other stakeholders in the health care community. Millions of other Americans are benefiting from Innovation Center quality improvement initiatives and the engagement of other payers in model tests.

The broad engagement of providers across the country in alternative payment and service delivery models is leading to improvement. Medicare per capita spending growth rates have reached historic lows, and hospital readmission rates have declined meaningfully. All alternative payment models and payment reforms that seek to deliver better care at lower cost share a common pathway for success. Providers, payers, and others in the health care system must make fundamental changes in their day-to-day operations that improve quality and reduce the cost of health care.

This work is aligning with the goals the Department of Health and Human Services (HHS) set in January of 2015 of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as physician value-based payment modifier (VM).

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was enacted into law in April 2015 and further facilitates the Department’s goals of paying for value. MACRA replaces the SGR with new payment policies for physicians that support delivery system reform and streamline the programs Medicare uses to reward eligible professionals for improving care. This is a major opportunity to put a broad range of physicians and other practitioners on the pathway to value and to promote the adoption of alternative payment models.

We encourage providers to join the Health Care Payment Learning and Action Network (https://innovation.cms.gov/initiatives/Health-Care-Payment-Learning-and- Action-Network/) that brings together private payers, providers, employers, state partners, consumer groups, individual consumers, and many others to accelerate the transition to alternative payment models. If you would like to join the Network, please complete the online form (http://innovationgov.force.com/hcplan).

We also encourage you to visit the CMS Innovation Center website — at http://innovation.cms.gov—for further information and for announcements of new opportunities including large scale

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2016

transformation of clinical practices to accomplish our aims of better care and better health at lower costs.

Medicare Shared Savings Program:

Currently, over 125,000 physicians participate in ACOs in the Medicare Shared Savings Program (Shared Savings Program). When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers serve, it may share in the savings it achieves for the Medicare program. In performance year 2014, we shared more than $341 million in savings with 86 ACOs.

When a Shared Savings Program ACO successfully reports required quality measures through the Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO) Web interface, Eligible professionals (EPs), (i.e. physicians and other practitioners) in the ACO will be deemed eligible to avoid the PQRS payment adjustment, regardless of whether the ACO qualifies to share in savings. In addition, EPs participating in the Shared Savings Program will have their Clinical Quality Measure (CQM) reporting requirements satisfied for the Medicare Electronic Health Record (EHR) Incentive Program if they extract the data necessary for the ACO to satisfy the quality reporting requirements for the Shared Savings Program from certified EHR technology and the EPs meet all other requirements of the Medicare EHR Incentive Program.

We encourage you to consider joining or forming an ACO under the Shared Savings Program. We also encourage physicians and other practitioners to collaborate with ACOs in your area so that together they can achieve the goals of the Shared Savings Program including successful reporting and performance on quality measures.

Please visit the Shared Savings Program Web page for more information about the program including how to apply, join or learn about ACOs in your area - http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/.

Engaging Physicians in Quality:

CMS recognizes the time and resources spent by providers and their practices to meet the requirements of various federal and state mandated quality reporting programs. As the largest payer of healthcare services in the United States, we continuously seek ways to improve healthcare quality while reducing the burden felt by providers. Several efforts have been made to meet this goal, and the needs of providers, including (as a continuation from CY 2015):

• Providers can choose quality measures that best reflect their practice and how they are reported to CMS.

• Many providers may be able to report their 2016 performance on quality measures one time during 2016 in order to avoid the 2018 PQRS negative payment adjustment, satisfy the CQM component of the Medicare EHR Incentive Program, avoid the automatic 2018 downward adjustment under the Value Modifier, and based on performance earn an incentive in 2018. Please note that this option applies to specific reporting options. Please read program requirements for more information; website URLs for each program are listed below;

• Providers and others can contribute new quality measures through open calls for measures and advocate for measures through the Measures Application Partnership (MAP). For More information about the MAP, please visit: http://www.qualityforum.org/Setting_Priorities/Partnership/Measure_Applications_Partnership.aspx.

New for CY 2016:

• For the qualified clinical data registry (QCDR) reporting mechanism, which was introduced in 2014, we increased the minimum number of non-PQRS measures that a QCDR may report for PQRS to 30 measures beginning with CY 2015 reporting. By increasing the minimum number of non-PQRS measure accepted, EPs are provided with more flexibility to meet satisfactory participation requirements and another avenue to submit measures that are meaningful to their specific specialty.

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• Knowledge levels (i.e. Beginner, Intermediate, and Advanced) were established to assist providers with reporting by providing educational resources that range from basic program awareness to reporting via an aligned reporting mechanism to meet the requirements of several quality programs. Prominent icons are used on educational materials displaying these knowledge levels.

• In addition to the traditional channels used, CMS began the use of new forums to receive stakeholder feedback including: hosting virtual office hours, which are smaller virtual sessions in which stakeholders can talk directly with CMS subject matter experts, and hosting in-person vendor summits, in which vendors who support EPs in quality reporting attended and provided insight from their perspective and areas of improvement for CMS.

• The development of the Physician Quality Reporting Programs Strategic Vision, which is a document that describes how CMS will build on its current successes in quality measurement and public reporting to advance the goals and objectives for quality improvement outlined in the CMS Quality Strategy (available here: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/Physician_Quality_Reporting_Programs_Strategic_Vision_Document.pdf)

As noted above, MACRA repeals the SGR formula for Medicare physician payments. It also establishes a new Merit-based Incentive Payment System (MIPS) for MIPS eligible professionals (MIPS EPs) under the MPFS beginning January 1, 2019. Section 101 of the MACRA sunsets payment adjustments under the current PQRS, the VM, and the EHR Incentive Programs on December 31, 2018.

Availability of the 2014 Mid-Year, Annual, and Supplemental Quality and Resource Use Reports (QRURs):

In April 2015, CMS made available the 2014 Mid-Year QRURs to all groups of physicians and physician solo practitioners nationwide, as identified by their Taxpayer Identification Number (TIN). The Mid-Year QRURs provide interim information to TINs about their performance on the three claims-based quality outcome measures and six cost measures. These measures are a subset of the measures that will be used to calculate performance under the Value Modifier and can provide physician groups and physicians insight into their potential performance under the Value Modifier. We encourage you to look at your 2015 Mid-Year QRUR when it is available in April 2016.

In September 2015, CMS made available the 2014 Annual QRURs to all groups and solo practitioners nationwide. These QRURs are also available for groups and solo practitioners that participated in the Shared Savings Program, the Pioneer ACO Model, or the Comprehensive Primary Care initiative in 2014. The 2014 Annual QRURs show how groups and solo practitioners, as identified by their TIN, performed in 2014 on the quality and cost measures used to calculate the 2016 Value Modifier. For TINs with 10 or more EPs who are subject to the 2016 Value Modifier, the QRUR shows how the Value Modifier will apply to physician payments under the MPFS for physicians who bill under the TIN in 2016. For all other TINs, the QRUR is for informational purposes only and will not affect the TINs’ payments under the Medicare MPFS in 2016.

In September 2015, CMS made available the Supplemental QRURs. These QRURs are confidential feedback reports provided to group practices with payment-standardized, risk-adjusted cost information on the management of their Medicare fee-for-service (FFS) patients based on episodes of care. The Supplemental QRURs are currently for informational purposes only and complement the per capita cost and quality information provided in the QRURs.

The Mid-Year, Annual, and Supplemental QRURs are available at https://portal.cms.gov and can be accessed by an authorized representative of the TIN using an Enterprise Identity Management (EIDM) account. Please see the How to Obtain a QRUR (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Obtain-2013-QRUR.html) website for instructions on how to set up an EIDM account and access your TIN’s QRURs. Detailed information about the QRURs is available on the 2014 QRUR (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2014-QRUR.html) website.

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2016

Medicare and Medicaid EHR Incentive Programs:

In 2015, EPs will use EHR technology certified to the 2014 Edition to meet the objectives and measures of meaningful use as modified in a recent final rule1, which includes alternate exclusions for EPs scheduled to be in Stage 1. EPs will have a 90-day EHR reporting period within CY 2015 and attest between January 4 through February 29, 2016. For more information about the EHR Incentive Programs, including the 2015 definition of meaningful use, visit http://www.cms.gov/EHRIncentivePrograms.

In order to align programs and reduce the burden on physicians and other eligible professionals, physicians may submit CQM data for both the Medicare EHR Incentive Program and the PQRS program electronically.

Physicians who fail to demonstrate meaningful use for the applicable EHR reporting period may be subject to a payment adjustment to their Medicare claims. In 2016, the result will be payment of 98% of the MPFS amount. Physicians must successfully demonstrate meaningful use every year to avoid the Medicare payment adjustments. Successful demonstration of meaningful use for an EHR reporting period in 2015 will enable physicians to avoid the payment adjustment in 2017. Physicians also have the option of filing a significant hardship exception application by July 1, 2016. Don’t wait until the last minute to meet meaningful use or file a hardship exception!

Payment Adjustments for Quality Reporting:

EPs should note that there is still time to report quality measures for 2015, which will also serve as the reporting period for the 2017 PQRS payment adjustment. The deadline is December 31, 2015. The payment adjustment for 2017, based on 2015 reporting, is negative 2.0%. The reporting requirements to avoid the 2017 PQRS payment adjustment can be found at 42 C.F.R. § 414.90, and guidance materials are available on the PQRS Web page of the CMS website.

Likewise, 2016 will also serve as the reporting period for the 2018 PQRS payment adjustment, which remains at negative 2%.

The reporting requirements to avoid the 2018 PQRS payment adjustment are detailed in the CY 2016 MPFS Final Rule. More information will be available on the PQRS Web page soon.

Please use the links below for more detailed information about CMS quality reporting programs.

PQRS Web page: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

Medicare EHR Incentive Program: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/

VM: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html

Information Related to Medicare Prescription Drug (Part D) Coverage:

Prescriber Enrollment in Medicare

Beginning June 1, 2016 physicians and EPs who write prescriptions for Part D drugs are required to be enrolled in Medicare in an approved status or have a valid record of opting out of Medicare for their prescriptions to be covered under Part D. Any physicians and EPs not in compliance with these requirements should submit their paper Medicare enrollment applications or opt-out affidavits to their Part A/B MACs or complete their Internet-based PECOS applications by January 1, 2016, or earlier, to ensure sufficient processing time. Medicare prescription drug benefit plans will validate whether the prescriber is enrolled or has opted out of Medicare as part of determining whether the drug is coverable under Part D when the beneficiary’s prescription is filled at the pharmacy. Providers may enroll by completing their Internet-based PECOS application or may enroll or opt out of Medicare by submitting to their MAC one of the following documents:

1 Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 3 and Modifications to Meaningful Use in 2015 Through 2017; Final Rule, 80 Fed. Reg. 62,762 (Oct. 16, 2015).

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ANNOUNCEMENT: About Medicare Participation for Calendar Year 2016

• A CMS-855O application (allows the physician to enroll in Medicare to order and certify services and items, and to prescribe Part D drugs; however, this option does not confer billing privileges): or

• An opt out affidavit.

If you are unsure if you are compliant with this requirement, please review the prescriber enrollment file located at https://data.cms.gov/dataset/Medicare-Individual-Provider-List/u8u9-2upx. The file identifies those providers who are currently in compliance with the prescriber enrollment requirements.

As part of the enrollment process, provider credentials and eligibility are verified. Requiring Medicare prescription drug benefit plans to validate a provider’s Medicare enrollment status improves CMS’s ability to protect the Part D program from fraud and abuse. To avoid the denial of coverage of Part D prescriptions due to your failure to enroll or opt-out, please note the following information:

• Be sure to maintain an active enrollment or opt out status with Medicare;

• If you haven’t enrolled, please do so and encourage your colleagues who are not enrolled in Medicare to enroll by January 1, 2016. The options available for enrolling or opting out are identified above. Please visit the prescriber enrollment website to obtain additional information at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Prescriber-Enrollment-Information.html.

• Interns, residents, and fellows who are prescribers of Part D drugs may enroll in Medicare to prescribe if the state licenses these prescribers. Licensure can include a provisional license or similarly- regulated credential. Otherwise, un-licensed interns, residents, and fellows must specify the teaching physician as the authorized prescriber on the prescription. Licensed residents have the option to either enroll or use the teaching physician on claims.

• Pharmacists need not enroll or opt out for their prescriptions to be covered under Part D. More information is available by visiting https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Prescriber-Enrollment-Information.html.

NPPES Taxonomy

Please check your data in the National Plan and Provider Enumeration System (NPPES) and confirm that it still correctly reflects you as a health care provider. There is increased focus on the National Provider Identifier (NPI) as a health care provider identifier for program integrity purposes. Incorrect taxonomy data in NPPES may lead to unnecessary inquiries about your credentials as it may appear to Medicare oversight authorities that you may not be lawfully prescribing Part D drugs. Comprehensive information about how the NPI rule pertains to prescribers may be obtained at: http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/Downloads/NPI-Requirements-for-Prescribers.pdf.

Prescription Drug Abuse

Prescription drug abuse is the nation’s fastest growing drug problem. Additional prescriber awareness and engagement are crucial to addressing this problem. CMS has implemented an approach to help Medicare prescription drug plans identify and manage the most egregious cases of opioid overutilization, which often involves multiple prescribers and pharmacies who are not aware of each other. If you are contacted by a prescription drug plan about the opioid use of one of your patients, please take the time to provide your feedback and expertise to help assure the safe use of these products.

Prescriber Identifiers in Research

You should be aware that CMS now allows researchers to request the release of unencrypted prescriber identifiers contained in Medicare Part D data. This change in policy now gives researchers the ability to conduct important research that involves identified prescribers, which will increase the positive contributions researchers make to the evaluation and function of the

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Part D program. This access supports CMS’s growing role as a value-based purchaser of health care, and is only granted pursuant to CMS’s policies and procedures for release of such data to researchers.

Serving Qualified Medicare Beneficiaries (QMBs):

Many Medicare beneficiaries with limited incomes and resources are also covered by their state’s Qualified Medicare Beneficiary (QMB) program. This means that the state Medicaid agency is responsible for these beneficiaries’ Medicare cost sharing. We encourage all Medicare physicians and other practitioners to serve individuals eligible for the QMB program.

We also remind all Medicare physicians and other practitioners that they may not balance bill their QMB patients for Medicare cost sharing, including deductibles, coinsurance, and copayments. Under federal law, Medicare payment plus any Medicaid payment are considered payment in full for services rendered to a beneficiary participating in the QMB program. Physicians and other practitioners may want to refresh their understanding of how their state handles QMB cost sharing claims. In most states, claims submitted to Medicare are crossed over automatically to the state Medicaid agency. States may require providers to register with their State payment system in order to receive cost sharing payments. Providers can also query their state’s Medicaid eligibility verification system to identify QMBs. More information on billing procedures for QMBs is available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1128.pdf.

We understand that the intersection between Medicare and Medicaid is complex. If you have any questions about serving QMBs, please contact [email protected].

Revalidation:

CMS has met the requirements established in section 6401(a) of the Affordable Care Act (ACA) and has mailed revalidation letters to all 1.6 million providers and suppliers by the March 23, 2015 deadline. CMS is resuming regular revalidation cycles every 3 years for Durable Medical Equipment (DME) suppliers and every 5 years for all other providers and suppliers.

When undergoing a revalidation, providers will receive requests from their respective MACs to revalidate their Medicare enrollment information. Providers can revalidate their enrollment information using the Internet-based PECOS found at https://pecos.cms.hhs.gov/pecos/login.do or the CMS-855 paper application found at http://www.cms.gov/CMSForms/CMSForms/list.asp. CMS encourages all practitioners to respond timely to revalidation requests received by their MAC. Failure to submit a complete revalidation application, including all supporting documents, may result in deactivation of your Medicare billing privileges.

Please refer to the MLN Matters Special Edition Article on this subject at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1126.pdf.

The Medicare Learning Network:

Medicare Learning Network® (MLN) educational resources provide health care professionals comprehensive, easy-to-understand information on CMS program and policy changes, regulations, and initiatives.

Publications & Multimedia

• MLN Publications come in a variety of formats on topics such as provider enrollment, preventive services, claims processing, compliance, and payment policies.

- http://go.cms.gov/MLNProducts

• MLN Matters® Articles are prepared in consultation with clinicians, billing experts, and CMS subject matter experts; they are tailored to specific provider types affected by complex program changes.

- http://go.cms.gov/MLNMattersArticles

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• Videos & Podcasts offer additional educational options in multimedia formats.

- http://go.cms.gov/mlnmultimedia

- http://go.cms.gov/MLNplaylist

Training & Events

• MLN Connects® National Provider Calls & Events cover new policies and changes to the Medicare program, and typically include Question & Answer sessions for participants.

- http://www.cms.gov/npc

• Web-Based Trainings are self-paced online courses on a broad range of Medicare and other health care-related topics.

- http://go.cms.gov/MLNTraining

Newsletter & Mailing Lists

• MLN Connects Provider eNews is a weekly newsletter for health care professionals containing CMS program and policy news, announcements, upcoming events, claim, pricer, and code information, and MLN updates.

- http://go.cms.gov/enews

• Educational Products Mailing List subscribers are e-mailed when new and revised MLN Publications are released.

- http://go.cms.gov/mlnproductslist

• MLN Matters Mailing List subscribers are e-mailed when new and revised MLN Matters Articles are released.

- http://go.cms.gov/mlnmatterslist

Continuing Education (CE) Credit

CMS is an accredited provider of IACET continuing education units (CEUs) and ACCME continuing medical education (CME) offering AMA PRA Category 1 Credits™. In addition, many professional associations offer continuing education credit for the completion of training activities designed for health care professionals including physicians, nurses, billers, coders, and other clinicians. You can find a broad range of courses that focus on staying abreast of Medicare updates, meeting professional development goals, and state license renewal requirements.

Please visit https://www.cms.gov/Outreach-and-Education/Learn/Earn-Credit/Earn-credit-page.html for more information about earning CE credit for CMS training.

For more information about MLN products and services, visit http://go.cms.gov/MLNGenInfo.

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 10Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

ANES 21.71 20.62 23.72 23.24 23.24 22.78 G0101 36.95 35.10 40.37 39.56 39.56 38.77 # G0101 27.42 26.05 29.96 29.36 29.36 28.77 G0102 18.60 17.67 20.32 19.92 19.92 19.52 # G0102 8.74 8.30 9.55 9.35 9.35 9.17 G0104 158.58 150.65 173.25 169.79 169.79 166.39 # G0104 56.36 53.54 61.57 60.34 60.34 59.13 G0105 364.79 346.55 398.53 390.56 390.56 382.75 # G0105 194.20 184.49 212.16 207.92 207.92 203.76 G0105 53 181.72 172.63 198.52 194.56 194.56 190.67 # G0105 53 97.58 92.70 106.61 104.48 104.48 102.38 G0106 199.29 189.33 217.73 213.37 213.37 209.10 G0106 TC 149.91 142.41 163.77 160.49 160.49 157.29 G0106 26 49.39 46.92 53.96 52.88 52.88 51.82 G0108 51.75 49.16 56.53 55.41 55.41 54.30 G0109 13.91 13.21 15.19 14.89 14.89 14.59 G0117 51.66 49.08 56.44 55.32 55.32 54.21 G0118 41.61 39.53 45.46 44.55 44.55 43.67 G0120 201.07 191.02 219.67 215.28 215.28 210.98 G0120 TC 149.91 142.41 163.77 160.49 160.49 157.29 G0120 26 51.16 48.60 55.89 54.77 54.77 53.68 G0121 365.15 346.89 398.92 390.94 390.94 383.12 # G0121 194.56 184.83 212.55 208.30 208.30 204.14 G0121 53 182.05 172.95 198.89 194.91 194.91 191.02 # G0121 53 97.25 92.39 106.25 104.12 104.12 102.04 G0124 31.53 29.95 34.44 33.75 33.75 33.07 G0127 21.89 20.80 23.92 23.44 23.44 22.97 # G0127 7.76 7.37 8.48 8.30 8.30 8.14 G0128 7.26 6.90 7.94 7.77 7.77 7.61 G0130 32.25 30.64 35.24 34.53 34.53 33.84 G0130 TC 21.06 20.01 23.01 22.55 22.55 22.10 G0130 26 11.19 10.63 12.22 11.98 11.98 11.74 G0141 31.53 29.95 34.44 33.75 33.75 33.07 G0166 128.17 121.76 140.02 137.22 137.22 134.47 G0168 96.80 91.96 105.75 103.64 103.64 101.57 # G0168 27.78 26.39 30.35 29.74 29.74 29.14 G0179 39.53 37.55 43.18 42.32 42.32 41.47 G0180 51.73 49.14 56.51 55.38 55.38 54.28 G0181 105.32 100.05 115.06 112.76 112.76 110.50 G0182 105.62 100.34 115.39 113.08 113.08 110.81 G0202 126.10 119.80 137.77 135.01 135.01 132.31 G0202 TC 91.40 86.83 99.85 97.85 97.85 95.90 G0202 26 34.70 32.97 37.92 37.16 37.16 36.41 G0204 154.24 146.53 168.51 165.14 165.14 161.84 G0204 TC 110.79 105.25 121.04 118.62 118.62 116.25 G0204 26 43.45 41.28 47.47 46.52 46.52 45.59 G0206 121.17 115.11 132.38 129.73 129.73 127.13 G0206 TC 86.47 82.15 94.47 92.59 92.59 90.74 G0206 26 34.70 32.97 37.92 37.16 37.16 36.41

Page 11: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 11Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

G0237 9.23 8.77 10.09 9.88 9.88 9.68 G0238 9.89 9.40 10.81 10.59 10.59 10.38 G0239 12.19 11.58 13.32 13.05 13.05 12.79 G0245 63.88 60.69 69.79 68.40 68.40 67.03 # G0245 42.84 40.70 46.81 45.87 45.87 44.95 G0246 36.90 35.06 40.32 39.51 39.51 38.72 # G0246 21.45 20.38 23.44 22.97 22.97 22.51 G0247 68.93 65.48 75.30 73.80 73.80 72.32 # G0247 23.24 22.08 25.39 24.89 24.89 24.39 G0248 103.26 98.10 112.82 110.56 110.56 108.35 G0249 103.23 98.07 112.78 110.53 110.53 108.32 G0250 9.10 8.65 9.95 9.75 9.75 9.56 G0268 51.99 49.39 56.80 55.66 55.66 54.54 # G0268 33.91 32.21 37.04 36.31 36.31 35.58 G0270 29.31 27.84 32.02 31.37 31.37 30.74 # G0270 27.01 25.66 29.51 28.92 28.92 28.35 G0271 15.55 14.77 16.99 16.64 16.64 16.31 # G0271 14.89 14.15 16.27 15.95 15.95 15.63 G0276 399.33 379.36 436.26 427.54 427.54 418.98 G0277 41.44 39.37 45.28 44.37 44.37 43.48 G0278 14.04 13.34 15.34 15.03 15.03 14.73 G0279 53.12 50.46 58.03 56.87 56.87 55.73 G0279 TC 23.34 22.17 25.50 24.99 24.99 24.50 G0279 26 29.78 28.29 32.53 31.88 31.88 31.25 G0281 13.37 12.70 14.61 14.32 14.32 14.03 G0283 13.37 12.70 14.61 14.32 14.32 14.03 G0288 34.10 32.40 37.26 36.51 36.51 35.79 G0289 87.98 83.58 96.12 94.20 94.20 92.31 G0296 27.90 26.51 30.49 29.88 29.88 29.28 # G0296 26.26 24.95 28.69 28.12 28.12 27.55 G0297 237.12 225.26 259.05 253.86 253.86 248.79 G0297 TC 186.72 177.38 203.99 199.90 199.90 195.90 G0297 26 50.41 47.89 55.07 53.97 53.97 52.89 G0329 9.08 8.63 9.92 9.73 9.73 9.53 G0339 3,160.71 3,002.67 3,453.07 3,384.01 3,384.01 3,316.34 G0340 2,322.46 2,206.34 2,537.29 2,486.54 2,486.54 2,436.82 G0341 2,170.38 2,061.86 2,371.14 2,323.71 2,323.71 2,277.24 # G0341 378.73 359.79 413.76 405.48 405.48 397.37 G0342 702.33 667.21 767.29 751.95 751.95 736.91 G0343 1,248.29 1,185.88 1,363.76 1,336.48 1,336.48 1,309.76 G0364 12.00 11.40 13.11 12.85 12.85 12.59 # G0364 8.71 8.27 9.51 9.32 9.32 9.13 C G0365 153.05 145.40 167.21 163.86 163.86 160.59 C G0365 TC 140.73 133.69 153.74 150.67 150.67 147.66 G0365 26 12.32 11.70 13.46 13.19 13.19 12.93 G0372 8.74 8.30 9.55 9.35 9.35 9.17 G0389 109.32 103.85 119.43 117.04 117.04 114.69 G0389 TC 80.23 76.22 87.65 85.91 85.91 84.19 G0389 26 29.09 27.64 31.79 31.15 31.15 30.53

Page 12: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 12Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

G0396 35.21 33.45 38.47 37.70 37.70 36.94 # G0396 33.24 31.58 36.32 35.59 35.59 34.88 G0397 70.10 66.60 76.59 75.06 75.06 73.55 # G0397 67.80 64.41 74.07 72.59 72.59 71.14 G0398 247.57 235.19 270.47 265.06 265.06 259.76 G0398 TC 148.54 141.11 162.28 159.03 159.03 155.85 G0398 26 99.03 94.08 108.19 106.03 106.03 103.91 G0399 190.46 180.94 208.08 203.92 203.92 199.84 G0399 TC 114.27 108.56 124.84 122.35 122.35 119.90 G0399 26 76.20 72.39 83.25 81.58 81.58 79.95 G0400 171.42 162.85 187.28 183.53 183.53 179.86 G0400 TC 102.85 97.71 112.37 110.12 110.12 107.92 G0400 26 68.57 65.14 74.91 73.42 73.42 71.94 G0402 161.36 153.29 176.28 172.75 172.75 169.30 # G0402 125.21 118.95 136.79 134.06 134.06 131.38 G0403 16.33 15.51 17.84 17.48 17.48 17.14 G0404 7.92 7.52 8.65 8.48 8.48 8.30 G0405 8.41 7.99 9.19 9.00 9.00 8.82 G0406 38.52 36.59 42.08 41.24 41.24 40.41 G0407 70.33 66.81 76.83 75.29 75.29 73.78 G0408 101.13 96.07 110.48 108.27 108.27 106.11 G0409 11.20 10.64 12.24 11.99 11.99 11.75 G0412 714.64 678.91 780.75 765.13 765.13 749.82 G0413 1,066.79 1,013.45 1,165.47 1,142.16 1,142.16 1,119.32 G0414 966.55 918.22 1,055.95 1,034.84 1,034.84 1,014.14 G0415 1,372.04 1,303.44 1,498.96 1,468.98 1,468.98 1,439.59 G0416 499.71 474.72 545.93 535.01 535.01 524.32 G0416 TC 345.53 328.25 377.49 369.94 369.94 362.55 G0416 26 154.18 146.47 168.44 165.07 165.07 161.77 G0420 107.83 102.44 117.81 115.45 115.45 113.14 G0421 24.89 23.65 27.20 26.66 26.66 26.13 G0422 99.81 94.82 109.04 106.86 106.86 104.72 G0423 99.81 94.82 109.04 106.86 106.86 104.72 G0424 28.49 27.07 31.13 30.51 30.51 29.90 # G0424 13.69 13.01 14.96 14.66 14.66 14.38 G0425 98.02 93.12 107.09 104.95 104.95 102.84 G0426 133.32 126.65 145.65 142.74 142.74 139.89 G0427 198.37 188.45 216.72 212.38 212.38 208.14 G0429 95.63 90.85 104.48 102.38 102.38 100.34 # G0429 70.65 67.12 77.19 75.65 75.65 74.13 G0436 14.23 13.52 15.55 15.24 15.24 14.94 # G0436 12.26 11.65 13.40 13.13 13.13 12.87 G0437 27.19 25.83 29.70 29.11 29.11 28.52 # G0437 25.54 24.26 27.90 27.34 27.34 26.78 G0438 165.96 157.66 181.31 177.69 177.69 174.13 G0439 112.15 106.54 122.52 120.07 120.07 117.67 G0442 17.32 16.45 18.92 18.54 18.54 18.17 # G0442 9.43 8.96 10.30 10.10 10.10 9.89 G0443 25.40 24.13 27.75 27.20 27.20 26.66

Page 13: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 13Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# G0443 23.42 22.25 25.59 25.08 25.08 24.58 G0444 17.32 16.45 18.92 18.54 18.54 18.17 # G0444 9.10 8.65 9.95 9.75 9.75 9.56 G0445 26.38 25.06 28.82 28.24 28.24 27.68 # G0445 23.42 22.25 25.59 25.08 25.08 24.58 G0446 25.40 24.13 27.75 27.20 27.20 26.66 # G0446 23.42 22.25 25.59 25.08 25.08 24.58 G0447 25.40 24.13 27.75 27.20 27.20 26.66 # G0447 23.42 22.25 25.59 25.08 25.08 24.58 G0451 8.24 7.83 9.00 8.82 8.82 8.65 G0452 26 18.20 17.29 19.88 19.48 19.48 19.09 G0453 32.46 30.84 35.47 34.75 34.75 34.06 G0454 9.10 8.65 9.95 9.75 9.75 9.56 G0455 124.03 117.83 135.50 132.79 132.79 130.13 # G0455 73.41 69.74 80.20 78.60 78.60 77.03 G0459 41.02 38.97 44.82 43.92 43.92 43.04 G0473 12.21 11.60 13.34 13.08 13.08 12.81 # G0473 11.55 10.97 12.62 12.36 12.36 12.12 G6001 49.77 47.28 54.37 53.28 53.28 52.21 G6001 TC 20.41 19.39 22.30 21.85 21.85 21.41 G6001 26 29.37 27.90 32.09 31.44 31.44 30.81 G6002 70.91 67.36 77.46 75.91 75.91 74.39 G6002 TC 50.97 48.42 55.68 54.57 54.57 53.48 G6002 26 19.93 18.93 21.77 21.33 21.33 20.91 G6003 172.91 164.26 188.90 185.12 185.12 181.41 G6004 133.80 127.11 146.18 143.26 143.26 140.39 G6005 133.47 126.80 145.82 142.90 142.90 140.04 G6006 133.14 126.48 145.45 142.54 142.54 139.69 G6007 278.09 264.19 303.82 297.75 297.75 291.79 G6008 185.08 175.83 202.20 198.16 198.16 194.19 G6009 183.10 173.95 200.04 196.04 196.04 192.12 G6010 182.77 173.63 199.67 195.68 195.68 191.77 G6011 297.16 282.30 324.65 318.15 318.15 311.79 G6012 243.91 231.71 266.47 261.14 261.14 255.92 G6013 244.24 232.03 266.83 261.50 261.50 256.27 G6014 244.24 232.03 266.83 261.50 261.50 256.27 G6015 318.93 302.98 348.43 341.46 341.46 334.63 G6016 317.86 301.97 347.27 340.32 340.32 333.51 G9157 97.30 92.44 106.31 104.18 104.18 102.10 G9187 42.02 39.92 45.91 44.99 44.99 44.09 P3001 31.53 29.95 34.44 33.75 33.75 33.07 Q0035 19.95 18.95 21.79 21.36 21.36 20.93 Q0035 TC 11.20 10.64 12.24 11.99 11.99 11.75 Q0035 26 8.74 8.30 9.55 9.35 9.35 9.17 Q0091 42.94 40.79 46.91 45.97 45.97 45.05 # Q0091 19.60 18.62 21.41 20.99 20.99 20.57 Q0092 23.36 22.19 25.52 25.01 25.01 24.52 R0070 132.34 125.72 144.58 141.69 141.69 138.86 R0075 132.34 125.72 144.58 141.69 141.69 138.86

Page 14: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 14Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

0100T 2,713.50 2,577.83 2,964.50 2,905.21 2,905.21 2,847.10 0159T 22.00 20.90 24.04 23.55 23.55 23.08 0159T TC 18.73 17.79 20.46 20.04 20.04 19.64 0159T 26 3.27 3.11 3.58 3.51 3.51 3.44 0171T 849.83 807.34 928.44 909.87 909.87 891.68 0172T 424.91 403.66 464.21 454.93 454.93 445.83 0191T 1,120.07 1,064.07 1,223.68 1,199.21 1,199.21 1,175.22 0249T 383.97 364.77 419.49 411.09 411.09 402.87 0295T 87.51 83.13 95.60 93.69 93.69 91.82 0296T 25.22 23.96 27.55 27.00 27.00 26.46 0297T 35.51 33.73 38.79 38.02 38.02 37.26 0298T 26.78 25.44 29.26 28.67 28.67 28.09 0308T 823.52 782.34 899.69 881.69 881.69 864.06 10021 118.90 112.96 129.90 127.31 127.31 124.76 # 10021 69.92 66.42 76.38 74.85 74.85 73.36 10022 135.55 128.77 148.09 145.12 145.12 142.22 # 10022 65.87 62.58 71.97 70.53 70.53 69.12 10030 738.39 701.47 806.69 790.56 790.56 774.74 # 10030 170.76 162.22 186.55 182.83 182.83 179.17 10035 504.39 479.17 551.05 540.03 540.03 529.23 # 10035 87.62 83.24 95.73 93.82 93.82 91.94 10036 436.60 414.77 476.99 467.44 467.44 458.09 # 10036 44.15 41.94 48.23 47.27 47.27 46.32 10040 98.67 93.74 107.80 105.65 105.65 103.53 # 10040 86.51 82.18 94.51 92.62 92.62 90.77 10060 113.05 107.40 123.51 121.04 121.04 118.62 # 10060 94.65 89.92 103.41 101.34 101.34 99.31 10061 200.28 190.27 218.81 214.43 214.43 210.14 # 10061 176.28 167.47 192.59 188.74 188.74 184.97 10080 171.04 162.49 186.86 183.13 183.13 179.47 # 10080 100.37 95.35 109.65 107.46 107.46 105.31 10081 258.41 245.49 282.31 276.67 276.67 271.14 # 10081 167.69 159.31 183.21 179.54 179.54 175.95 10120 145.29 138.03 158.73 155.56 155.56 152.44 # 10120 100.92 95.87 110.25 108.04 108.04 105.88 10121 264.51 251.28 288.97 283.19 283.19 277.53 # 10121 183.65 174.47 200.64 196.63 196.63 192.69 10140 157.03 149.18 171.56 168.13 168.13 164.77 # 10140 116.27 110.46 127.03 124.49 124.49 122.00 10160 125.38 119.11 136.98 134.24 134.24 131.56 # 10160 94.16 89.45 102.87 100.81 100.81 98.80 10180 238.50 226.58 260.57 255.36 255.36 250.25 # 10180 176.71 167.87 193.05 189.19 189.19 185.40 11000 52.51 49.88 57.36 56.21 56.21 55.09 # 11000 28.85 27.41 31.52 30.89 30.89 30.27 11001 21.01 19.96 22.95 22.49 22.49 22.05 # 11001 14.44 13.72 15.78 15.47 15.47 15.16 11004 588.03 558.63 642.42 629.58 629.58 616.99 11005 796.24 756.43 869.89 852.50 852.50 835.44

Page 15: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 15Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

11006 713.77 678.08 779.79 764.20 764.20 748.91 11008 280.06 266.06 305.97 299.85 299.85 293.86 11010 474.17 450.46 518.03 507.67 507.67 497.51 # 11010 278.60 264.67 304.37 298.29 298.29 292.32 11011 517.06 491.21 564.89 553.60 553.60 542.52 # 11011 300.46 285.44 328.26 321.69 321.69 315.26 11012 691.84 657.25 755.84 740.73 740.73 725.91 # 11012 428.57 407.14 468.21 458.85 458.85 449.67 11042 111.75 106.16 122.08 119.65 119.65 117.25 # 11042 61.46 58.39 67.15 65.80 65.80 64.49 11043 222.32 211.20 242.88 238.03 238.03 233.27 # 11043 155.92 148.12 170.34 166.93 166.93 163.60 11044 308.31 292.89 336.82 330.08 330.08 323.48 # 11044 232.71 221.07 254.23 249.15 249.15 244.17 11045 39.78 37.79 43.46 42.58 42.58 41.73 # 11045 26.31 24.99 28.74 28.16 28.16 27.60 11046 72.20 68.59 78.88 77.30 77.30 75.76 # 11046 56.43 53.61 61.65 60.42 60.42 59.21 11047 122.55 116.42 133.88 131.20 131.20 128.58 # 11047 100.53 95.50 109.83 107.63 107.63 105.48 11055 45.12 42.86 49.29 48.30 48.30 47.33 # 11055 16.20 15.39 17.70 17.34 17.34 17.00 11056 55.45 52.68 60.58 59.37 59.37 58.19 # 11056 22.91 21.76 25.02 24.52 24.52 24.02 11057 62.82 59.68 68.63 67.26 67.26 65.92 # 11057 29.95 28.45 32.72 32.06 32.06 31.42 11100 98.65 93.72 107.78 105.63 105.63 103.51 # 11100 48.69 46.26 53.20 52.13 52.13 51.08 11101 31.93 30.33 34.88 34.18 34.18 33.50 # 11101 25.03 23.78 27.35 26.80 26.80 26.25 11200 84.55 80.32 92.37 90.52 90.52 88.71 # 11200 71.40 67.83 78.00 76.44 76.44 74.91 11201 18.71 17.77 20.44 20.02 20.02 19.62 # 11201 16.74 15.90 18.29 17.92 17.92 17.56 11300 92.04 87.44 100.56 98.54 98.54 96.58 # 11300 35.17 33.41 38.42 37.65 37.65 36.90 11301 114.06 108.36 124.61 122.12 122.12 119.68 # 11301 53.58 50.90 58.54 57.36 57.36 56.21 11302 134.30 127.59 146.73 143.80 143.80 140.92 # 11302 62.98 59.83 68.80 67.42 67.42 66.08 11303 148.77 141.33 162.53 159.28 159.28 156.09 # 11303 74.49 70.77 81.39 79.75 79.75 78.15 11305 94.57 89.84 103.32 101.25 101.25 99.22 # 11305 39.68 37.70 43.36 42.49 42.49 41.64 11306 116.18 110.37 126.93 124.38 124.38 121.90 # 11306 52.09 49.49 56.91 55.78 55.78 54.66 11307 137.37 130.50 150.08 147.07 147.07 144.13 # 11307 67.03 63.68 73.23 71.77 71.77 70.33 11308 144.68 137.45 158.07 154.91 154.91 151.81

Page 16: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 16Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 11308 74.34 70.62 81.21 79.59 79.59 78.00 11310 107.82 102.43 117.79 115.44 115.44 113.13 # 11310 47.35 44.98 51.73 50.69 50.69 49.68 11311 107.19 101.83 117.10 114.76 114.76 112.46 # 11311 65.78 62.49 71.86 70.43 70.43 69.02 11312 153.22 145.56 167.39 164.05 164.05 160.77 # 11312 78.28 74.37 85.53 83.81 83.81 82.13 11313 178.16 169.25 194.64 190.75 190.75 186.93 # 11313 100.59 95.56 109.89 107.70 107.70 105.55 11400 118.03 112.13 128.95 126.37 126.37 123.84 # 11400 78.26 74.35 85.50 83.79 83.79 82.11 11401 142.64 135.51 155.84 152.72 152.72 149.66 # 11401 101.56 96.48 110.95 108.73 108.73 106.56 11402 158.70 150.77 173.39 169.91 169.91 166.52 # 11402 112.03 106.43 122.39 119.95 119.95 117.54 11403 184.74 175.50 201.83 197.79 197.79 193.83 # 11403 144.97 137.72 158.38 155.22 155.22 152.11 11404 210.04 199.54 229.47 224.88 224.88 220.39 # 11404 160.08 152.08 174.89 171.40 171.40 167.97 11406 304.77 289.53 332.96 326.30 326.30 319.78 # 11406 244.95 232.70 267.61 262.26 262.26 257.01 11420 117.07 111.22 127.90 125.35 125.35 122.84 # 11420 79.93 75.93 87.32 85.57 85.57 83.86 11421 150.46 142.94 164.38 161.09 161.09 157.87 # 11421 108.06 102.66 118.06 115.70 115.70 113.39 11422 168.63 160.20 184.23 180.55 180.55 176.94 # 11422 132.80 126.16 145.08 142.19 142.19 139.35 11423 194.94 185.19 212.97 208.71 208.71 204.54 # 11423 154.84 147.10 169.17 165.78 165.78 162.47 11424 226.00 214.70 246.91 241.97 241.97 237.13 # 11424 177.68 168.80 194.12 190.23 190.23 186.43 11426 325.29 309.03 355.38 348.28 348.28 341.31 # 11426 273.35 259.68 298.63 292.66 292.66 286.81 11440 128.66 122.23 140.56 137.76 137.76 135.00 # 11440 100.06 95.06 109.32 107.13 107.13 105.00 11441 161.23 153.17 176.15 172.63 172.63 169.18 # 11441 128.69 122.26 140.60 137.78 137.78 135.02 11442 180.81 171.77 197.54 193.58 193.58 189.70 # 11442 142.68 135.55 155.88 152.77 152.77 149.71 11443 216.60 205.77 236.64 231.90 231.90 227.26 # 11443 175.85 167.06 192.12 188.28 188.28 184.52 11444 273.05 259.40 298.31 292.34 292.34 286.50 # 11444 224.73 213.49 245.51 240.60 240.60 235.80 11446 380.70 361.67 415.92 407.61 407.61 399.45 # 11446 323.18 307.02 353.07 346.01 346.01 339.09 11450 366.64 348.31 400.56 392.54 392.54 384.69 # 11450 248.97 236.52 272.00 266.56 266.56 261.22 11451 468.46 445.04 511.80 501.56 501.56 491.53 # 11451 321.86 305.77 351.64 344.60 344.60 337.71

Page 17: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 17Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

11462 357.26 339.40 390.31 382.50 382.50 374.85 # 11462 237.29 225.43 259.24 254.06 254.06 248.98 11463 473.63 449.95 517.44 507.09 507.09 496.95 # 11463 322.77 306.63 352.62 345.58 345.58 338.66 11470 398.57 378.64 435.44 426.73 426.73 418.20 # 11470 278.27 264.36 304.01 297.93 297.93 291.97 11471 492.71 468.07 538.28 527.52 527.52 516.97 # 11471 346.11 328.80 378.12 370.55 370.55 363.15 11600 184.21 175.00 201.25 197.23 197.23 193.28 # 11600 117.48 111.61 128.35 125.79 125.79 123.27 11601 219.57 208.59 239.88 235.08 235.08 230.38 # 11601 147.26 139.90 160.89 157.67 157.67 154.51 11602 238.31 226.39 260.35 255.14 255.14 250.03 # 11602 161.73 153.64 176.69 173.16 173.16 169.69 11603 273.39 259.72 298.68 292.71 292.71 286.86 # 11603 194.18 184.47 212.14 207.90 207.90 203.73 11604 304.22 289.01 332.36 325.71 325.71 319.21 # 11604 214.16 203.45 233.97 229.29 229.29 224.70 11606 437.90 416.01 478.41 468.84 468.84 459.47 # 11606 320.23 304.22 349.85 342.86 342.86 336.01 11620 186.26 176.95 203.49 199.42 199.42 195.43 # 11620 119.21 113.25 130.24 127.64 127.64 125.09 11621 220.94 209.89 241.37 236.54 236.54 231.82 # 11621 148.63 141.20 162.38 159.14 159.14 155.95 11622 246.69 234.36 269.51 264.12 264.12 258.84 # 11622 170.11 161.60 185.84 182.13 182.13 178.48 11623 290.84 276.30 317.75 311.39 311.39 305.15 # 11623 211.30 200.74 230.85 226.24 226.24 221.72 11624 328.43 312.01 358.81 351.64 351.64 344.60 # 11624 239.69 227.71 261.87 256.63 256.63 251.51 11626 397.01 377.16 433.73 425.06 425.06 416.56 # 11626 294.79 280.05 322.06 315.62 315.62 309.30 11640 191.94 182.34 209.69 205.49 205.49 201.39 # 11640 123.24 117.08 134.64 131.95 131.95 129.32 11641 228.79 217.35 249.95 244.95 244.95 240.05 # 11641 154.84 147.10 169.17 165.78 165.78 162.47 11642 261.88 248.79 286.11 280.38 280.38 274.77 # 11642 183.00 173.85 199.93 195.93 195.93 192.00 11643 309.94 294.44 338.61 331.83 331.83 325.20 # 11643 229.41 217.94 250.63 245.62 245.62 240.71 11644 382.75 363.61 418.15 409.79 409.79 401.59 # 11644 284.47 270.25 310.79 304.58 304.58 298.48 11646 502.69 477.56 549.19 538.21 538.21 527.45 # 11646 396.20 376.39 432.85 424.19 424.19 415.70 11719 13.34 12.67 14.57 14.28 14.28 14.00 # 11719 7.76 7.37 8.48 8.30 8.30 8.14 11720 30.90 29.36 33.76 33.09 33.09 32.42 # 11720 14.80 14.06 16.17 15.85 15.85 15.53 11721 43.44 41.27 47.46 46.51 46.51 45.57

Page 18: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 18Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 11721 25.03 23.78 27.35 26.80 26.80 26.25 11730 95.48 90.71 104.32 102.24 102.24 100.19 # 11730 51.43 48.86 56.19 55.06 55.06 53.96 11732 34.57 32.84 37.77 37.01 37.01 36.27 # 11732 20.44 19.42 22.33 21.88 21.88 21.45 11740 47.18 44.82 51.54 50.51 50.51 49.50 # 11740 31.73 30.14 34.66 33.97 33.97 33.29 11750 172.92 164.27 188.91 185.13 185.13 181.42 # 11750 136.76 129.92 149.41 146.42 146.42 143.49 11752 314.15 298.44 343.21 336.34 336.34 329.61 # 11752 258.60 245.67 282.52 276.87 276.87 271.33 11755 128.36 121.94 140.23 137.43 137.43 134.68 # 11755 77.41 73.54 84.57 82.88 82.88 81.22 11760 186.10 176.80 203.32 199.25 199.25 195.26 # 11760 115.10 109.35 125.75 123.23 123.23 120.77 11762 270.33 256.81 295.33 289.42 289.42 283.64 # 11762 182.24 173.13 199.10 195.12 195.12 191.22 11765 159.29 151.33 174.03 170.55 170.55 167.13 # 11765 91.91 87.31 100.41 98.39 98.39 96.43 11770 268.67 255.24 293.53 287.66 287.66 281.91 # 11770 184.20 174.99 201.24 197.21 197.21 193.27 11771 557.64 529.76 609.22 597.03 597.03 585.10 # 11771 431.43 409.86 471.34 461.91 461.91 452.67 11772 676.12 642.31 738.66 723.88 723.88 709.40 # 11772 569.63 541.15 622.32 609.88 609.88 597.68 11900 53.32 50.65 58.25 57.09 57.09 55.95 # 11900 31.30 29.74 34.20 33.52 33.52 32.86 11901 67.72 64.33 73.98 72.50 72.50 71.05 # 11901 48.33 45.91 52.80 51.74 51.74 50.70 11920 163.52 155.34 178.64 175.06 175.06 171.57 # 11920 112.58 106.95 122.99 120.53 120.53 118.12 11921 190.92 181.37 208.58 204.40 204.40 200.32 # 11921 133.40 126.73 145.74 142.83 142.83 139.98 11922 58.84 55.90 64.29 63.00 63.00 61.73 # 11922 29.59 28.11 32.33 31.68 31.68 31.05 11950 71.02 67.47 77.59 76.04 76.04 74.52 # 11950 50.64 48.11 55.33 54.22 54.22 53.14 11951 94.77 90.03 103.53 101.46 101.46 99.44 # 11951 71.77 68.18 78.41 76.84 76.84 75.30 11952 127.57 121.19 139.37 136.59 136.59 133.85 # 11952 97.01 92.16 105.98 103.87 103.87 101.79 11954 153.19 145.53 167.36 164.01 164.01 160.74 # 11954 114.40 108.68 124.98 122.49 122.49 120.04 11960 928.03 881.63 1,013.87 993.60 993.60 973.73 11970 600.45 570.43 655.99 642.87 642.87 630.02 11971 448.69 426.26 490.20 480.39 480.39 470.79 # 11971 310.97 295.42 339.73 332.94 332.94 326.28 11976 138.58 131.65 151.40 148.37 148.37 145.41 # 11976 94.21 89.50 102.93 100.87 100.87 98.85

Page 19: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 19Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

11980 90.98 86.43 99.39 97.41 97.41 95.46 # 11980 56.47 53.65 61.70 60.47 60.47 59.26 11981 135.86 129.07 148.43 145.46 145.46 142.55 # 11981 82.94 78.79 90.61 88.79 88.79 87.02 11982 154.62 146.89 168.92 165.54 165.54 162.23 # 11982 100.72 95.68 110.03 107.84 107.84 105.67 11983 218.27 207.36 238.46 233.69 233.69 229.02 # 11983 174.88 166.14 191.06 187.24 187.24 183.49 12001 85.59 81.31 93.51 91.63 91.63 89.80 # 12001 44.50 42.28 48.62 47.64 47.64 46.69 12002 104.66 99.43 114.34 112.06 112.06 109.81 # 12002 58.64 55.71 64.07 62.79 62.79 61.54 12004 123.75 117.56 135.19 132.49 132.49 129.85 # 12004 73.46 69.79 80.26 78.65 78.65 77.07 12005 156.74 148.90 171.24 167.81 167.81 164.45 # 12005 95.94 91.14 104.81 102.72 102.72 100.66 12006 186.10 176.80 203.32 199.25 199.25 195.26 # 12006 117.74 111.85 128.63 126.05 126.05 123.53 12007 217.83 206.94 237.98 233.22 233.22 228.55 # 12007 148.48 141.06 162.22 158.98 158.98 155.80 12011 105.11 99.85 114.83 112.53 112.53 110.27 # 12011 55.48 52.71 60.62 59.41 59.41 58.22 12013 110.20 104.69 120.39 117.99 117.99 115.63 # 12013 58.60 55.67 64.02 62.74 62.74 61.49 12014 129.44 122.97 141.42 138.59 138.59 135.82 # 12014 75.54 71.76 82.52 80.87 80.87 79.25 12015 157.10 149.25 171.64 168.21 168.21 164.84 # 12015 94.98 90.23 103.76 101.69 101.69 99.66 12016 200.21 190.20 218.73 214.36 214.36 210.07 # 12016 129.87 123.38 141.89 139.05 139.05 136.26 12017 155.66 147.88 170.06 166.66 166.66 163.32 12018 176.47 167.65 192.80 188.95 188.95 185.16 12020 279.82 265.83 305.70 299.59 299.59 293.60 # 12020 193.05 183.40 210.91 206.69 206.69 202.56 12021 162.59 154.46 177.63 174.08 174.08 170.59 # 12021 139.58 132.60 152.49 149.44 149.44 146.45 12031 226.92 215.57 247.91 242.95 242.95 238.08 # 12031 151.00 143.45 164.97 161.67 161.67 158.44 12032 290.43 275.91 317.30 310.95 310.95 304.73 # 12032 192.48 182.86 210.29 206.08 206.08 201.96 12034 299.91 284.91 327.65 321.09 321.09 314.67 # 12034 205.25 194.99 224.24 219.75 219.75 215.36 12035 368.18 349.77 402.24 394.19 394.19 386.30 # 12035 239.01 227.06 261.12 255.90 255.90 250.78 12036 407.32 386.95 444.99 436.09 436.09 427.37 # 12036 278.47 264.55 304.23 298.15 298.15 292.18 12037 462.54 439.41 505.32 495.21 495.21 485.31 # 12037 326.14 309.83 356.30 349.17 349.17 342.19 12041 227.22 215.86 248.24 243.27 243.27 238.41

Page 20: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 20Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 12041 148.99 141.54 162.77 159.52 159.52 156.33 12042 278.18 264.27 303.91 297.83 297.83 291.87 # 12042 198.64 188.71 217.02 212.68 212.68 208.43 12044 344.60 327.37 376.48 368.94 368.94 361.56 # 12044 213.45 202.78 233.20 228.53 228.53 223.96 12045 387.98 368.58 423.87 415.39 415.39 407.09 # 12045 268.01 254.61 292.80 286.95 286.95 281.21 12046 461.36 438.29 504.03 493.95 493.95 484.07 # 12046 308.85 293.41 337.42 330.67 330.67 324.06 12047 501.12 476.06 547.47 536.52 536.52 525.79 # 12047 343.68 326.50 375.48 367.97 367.97 360.61 12051 248.08 235.68 271.03 265.62 265.62 260.30 # 12051 169.85 161.36 185.56 181.85 181.85 178.22 12052 283.37 269.20 309.58 303.39 303.39 297.32 # 12052 202.19 192.08 220.89 216.48 216.48 212.15 12053 331.72 315.13 362.40 355.15 355.15 348.05 # 12053 216.35 205.53 236.36 231.63 231.63 227.00 12054 347.28 329.92 379.41 371.82 371.82 364.38 # 12054 222.06 210.96 242.60 237.75 237.75 233.00 12055 450.95 428.40 492.66 482.80 482.80 473.14 # 12055 304.69 289.46 332.88 326.22 326.22 319.70 12056 527.05 500.70 575.81 564.29 564.29 553.01 # 12056 375.20 356.44 409.91 401.71 401.71 393.67 12057 545.94 518.64 596.44 584.51 584.51 572.82 # 12057 405.59 385.31 443.11 434.24 434.24 425.56 13100 321.31 305.24 351.03 344.01 344.01 337.13 # 13100 204.95 194.70 223.91 219.43 219.43 215.04 13101 380.18 361.17 415.35 407.04 407.04 398.90 # 13101 251.66 239.08 274.94 269.45 269.45 264.05 13102 117.63 111.75 128.51 125.95 125.95 123.43 # 13102 74.90 71.16 81.83 80.20 80.20 78.60 13120 336.55 319.72 367.68 360.33 360.33 353.12 # 13120 234.33 222.61 256.00 250.88 250.88 245.87 13121 411.09 390.54 449.12 440.14 440.14 431.34 # 13121 266.80 253.46 291.48 285.65 285.65 279.93 13122 129.11 122.65 141.05 138.23 138.23 135.47 # 13122 86.06 81.76 94.02 92.14 92.14 90.30 13131 371.05 352.50 405.38 397.27 397.27 389.32 # 13131 249.11 236.65 272.15 266.71 266.71 261.37 13132 459.69 436.71 502.22 492.18 492.18 482.33 # 13132 314.41 298.69 343.49 336.63 336.63 329.90 13133 174.31 165.59 190.43 186.62 186.62 182.88 # 13133 131.91 125.31 144.11 141.22 141.22 138.39 13151 407.62 387.24 445.33 436.43 436.43 427.70 # 13151 286.66 272.33 313.18 306.91 306.91 300.77 13152 490.53 466.00 535.90 525.18 525.18 514.68 # 13152 348.21 330.80 380.42 372.81 372.81 365.36 13153 189.11 179.65 206.60 202.47 202.47 198.42 # 13153 142.44 135.32 155.62 152.50 152.50 149.45

Page 21: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 21Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

13160 803.20 763.04 877.50 859.95 859.95 842.74 14000 602.14 572.03 657.83 644.68 644.68 631.79 # 14000 495.97 471.17 541.85 531.01 531.01 520.40 14001 777.12 738.26 849.00 832.01 832.01 815.37 # 14001 647.95 615.55 707.88 693.73 693.73 679.86 14020 674.15 640.44 736.51 721.77 721.77 707.34 # 14020 560.75 532.71 612.62 600.37 600.37 588.36 14021 846.19 803.88 924.46 905.97 905.97 887.85 # 14021 711.76 676.17 777.60 762.05 762.05 746.81 14040 740.34 703.32 808.82 792.64 792.64 776.79 # 14040 626.29 594.98 684.23 670.54 670.54 657.13 14041 917.43 871.56 1,002.29 982.25 982.25 962.61 # 14041 771.82 733.23 843.21 826.36 826.36 809.83 14060 756.87 719.03 826.88 810.35 810.35 794.14 # 14060 667.14 633.78 728.85 714.27 714.27 699.98 14061 986.33 937.01 1,077.56 1,056.01 1,056.01 1,034.89 # 14061 825.60 784.32 901.97 883.92 883.92 866.25 14301 1,050.50 997.98 1,147.68 1,124.72 1,124.72 1,102.23 # 14301 877.61 833.73 958.79 939.62 939.62 920.83 14302 223.05 211.90 243.69 238.81 238.81 234.04 14350 691.47 656.90 755.44 740.32 740.32 725.51 15002 336.85 320.01 368.01 360.65 360.65 353.44 # 15002 227.39 216.02 248.42 243.46 243.46 238.59 15003 73.42 69.75 80.21 78.61 78.61 77.04 # 15003 46.14 43.83 50.40 49.39 49.39 48.40 15004 389.84 370.35 425.90 417.38 417.38 409.03 # 15004 271.18 257.62 296.26 290.34 290.34 284.53 15005 122.16 116.05 133.46 130.79 130.79 128.18 # 15005 91.92 87.32 100.42 98.41 98.41 96.44 15040 246.20 233.89 268.97 263.59 263.59 258.32 # 15040 128.20 121.79 140.06 137.25 137.25 134.50 15050 544.94 517.69 595.34 583.44 583.44 571.77 # 15050 438.12 416.21 478.64 469.07 469.07 459.69 15100 837.50 795.63 914.97 896.68 896.68 878.75 # 15100 710.30 674.79 776.01 760.48 760.48 745.27 15101 179.89 170.90 196.54 192.60 192.60 188.75 # 15101 111.52 105.94 121.83 119.39 119.39 117.00 15110 788.93 749.48 861.90 844.66 844.66 827.77 # 15110 694.27 659.56 758.49 743.33 743.33 728.46 15111 115.66 109.88 126.36 123.83 123.83 121.36 # 15111 105.47 100.20 115.23 112.93 112.93 110.68 15115 809.30 768.84 884.17 866.48 866.48 849.15 # 15115 713.98 678.28 780.02 764.42 764.42 749.13 15116 153.54 145.86 167.74 164.38 164.38 161.09 # 15116 139.74 132.75 152.66 149.62 149.62 146.63 15120 831.48 789.91 908.40 890.23 890.23 872.42 # 15120 694.74 660.00 759.00 743.82 743.82 728.94 15121 201.83 191.74 220.50 216.10 216.10 211.77 # 15121 132.80 126.16 145.08 142.19 142.19 139.35

Page 22: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 22Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

15130 655.71 622.92 716.36 702.03 702.03 687.99 # 15130 558.74 530.80 610.42 598.21 598.21 586.25 15131 98.78 93.84 107.92 105.75 105.75 103.64 # 15131 91.22 86.66 99.66 97.67 97.67 95.71 15135 827.41 786.04 903.95 885.87 885.87 868.15 # 15135 732.42 695.80 800.17 784.16 784.16 768.48 15136 94.12 89.41 102.82 100.76 100.76 98.75 # 15136 88.53 84.10 96.72 94.78 94.78 92.89 15150 689.28 654.82 753.04 737.98 737.98 723.22 # 15150 634.72 602.98 693.43 679.56 679.56 665.97 15151 122.48 116.36 133.81 131.13 131.13 128.51 # 15151 113.93 108.23 124.46 121.98 121.98 119.54 15152 150.56 143.03 164.48 161.20 161.20 157.98 # 15152 141.69 134.61 154.80 151.71 151.71 148.67 15155 711.30 675.74 777.10 761.56 761.56 746.34 # 15155 661.67 628.59 722.88 708.42 708.42 694.26 15156 158.83 150.89 173.52 170.05 170.05 166.65 # 15156 151.27 143.71 165.27 161.97 161.97 158.72 15157 173.95 165.25 190.04 186.24 186.24 182.52 # 15157 163.43 155.26 178.55 174.97 174.97 171.48 15200 807.54 767.16 882.23 864.59 864.59 847.30 # 15200 665.88 632.59 727.48 712.93 712.93 698.67 15201 142.57 135.44 155.76 152.64 152.64 149.59 # 15201 79.13 75.17 86.45 84.72 84.72 83.03 15220 746.81 709.47 815.89 799.57 799.57 783.58 # 15220 608.11 577.70 664.36 651.07 651.07 638.05 15221 131.59 125.01 143.76 140.89 140.89 138.07 # 15221 71.77 68.18 78.41 76.84 76.84 75.30 15240 907.70 862.32 991.67 971.83 971.83 952.40 # 15240 792.01 752.41 865.27 847.96 847.96 831.00 15241 178.85 169.91 195.40 191.49 191.49 187.66 # 15241 112.13 106.52 122.50 120.05 120.05 117.65 15260 985.37 936.10 1,076.52 1,054.99 1,054.99 1,033.88 # 15260 850.94 808.39 929.65 911.05 911.05 892.84 15261 209.30 198.84 228.67 224.09 224.09 219.60 # 15261 140.60 133.57 153.61 150.54 150.54 147.52 15271 136.11 129.30 148.70 145.72 145.72 142.81 # 15271 85.17 80.91 93.05 91.18 91.18 89.36 15272 26.41 25.09 28.85 28.28 28.28 27.72 # 15272 17.54 16.66 19.16 18.78 18.78 18.40 15273 290.06 275.56 316.89 310.56 310.56 304.35 # 15273 203.95 193.75 222.81 218.36 218.36 213.99 15274 69.53 66.05 75.96 74.44 74.44 72.96 # 15274 46.52 44.19 50.82 49.81 49.81 48.81 15275 144.89 137.65 158.30 155.14 155.14 152.03 # 15275 96.24 91.43 105.14 103.04 103.04 100.98 15276 33.84 32.15 36.97 36.24 36.24 35.51 # 15276 25.29 24.03 27.63 27.08 27.08 26.54 15277 314.89 299.15 344.02 337.15 337.15 330.41

Page 23: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 23Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 15277 226.80 215.46 247.78 242.82 242.82 237.97 15278 83.01 78.86 90.69 88.87 88.87 87.09 # 15278 57.71 54.82 63.04 61.78 61.78 60.55 15570 889.22 844.76 971.47 952.04 952.04 933.00 # 15570 729.81 693.32 797.32 781.37 781.37 765.74 15572 863.63 820.45 943.52 924.65 924.65 906.15 # 15572 738.40 701.48 806.70 790.57 790.57 774.76 15574 890.97 846.42 973.38 953.91 953.91 934.84 # 15574 760.81 722.77 831.19 814.56 814.56 798.26 15576 785.24 745.98 857.88 840.72 840.72 823.91 # 15576 664.94 631.69 726.44 711.92 711.92 697.68 15600 306.90 291.56 335.29 328.59 328.59 322.02 # 15600 201.39 191.32 220.02 215.61 215.61 211.30 15610 339.21 322.25 370.59 363.18 363.18 355.91 # 15610 235.34 223.57 257.11 251.97 251.97 246.93 15620 422.49 401.37 461.58 452.34 452.34 443.29 # 15620 319.94 303.94 349.53 342.54 342.54 335.69 15630 441.97 419.87 482.85 473.19 473.19 463.73 # 15630 340.41 323.39 371.90 364.46 364.46 357.17 15650 485.73 461.44 530.66 520.04 520.04 509.65 # 15650 376.28 357.47 411.09 402.87 402.87 394.81 15731 1,105.33 1,050.06 1,207.57 1,183.42 1,183.42 1,159.75 # 15731 1,001.14 951.08 1,093.74 1,071.87 1,071.87 1,050.43 15732 1,259.06 1,196.11 1,375.53 1,348.02 1,348.02 1,321.06 # 15732 1,108.52 1,053.09 1,211.05 1,186.83 1,186.83 1,163.10 15734 1,481.62 1,407.54 1,618.67 1,586.30 1,586.30 1,554.57 # 15734 1,316.95 1,251.10 1,438.77 1,409.99 1,409.99 1,381.79 15736 1,297.52 1,232.64 1,417.54 1,389.19 1,389.19 1,361.40 # 15736 1,135.48 1,078.71 1,240.52 1,215.71 1,215.71 1,191.40 15738 1,382.66 1,313.53 1,510.56 1,480.35 1,480.35 1,450.74 # 15738 1,230.48 1,168.96 1,344.30 1,317.42 1,317.42 1,291.07 15740 992.77 943.13 1,084.60 1,062.91 1,062.91 1,041.65 # 15740 846.50 804.18 924.81 906.32 906.32 888.19 15750 911.19 865.63 995.47 975.57 975.57 956.05 15756 2,327.95 2,211.55 2,543.28 2,492.42 2,492.42 2,442.57 15757 2,301.29 2,186.23 2,514.16 2,463.89 2,463.89 2,414.61 15758 2,304.09 2,188.89 2,517.22 2,466.88 2,466.88 2,417.54 15760 831.57 789.99 908.49 890.32 890.32 872.52 # 15760 702.73 667.59 767.73 752.38 752.38 737.33 15770 663.98 630.78 725.40 710.88 710.88 696.67 15775 294.40 279.68 321.63 315.20 315.20 308.90 # 15775 224.06 212.86 244.79 239.89 239.89 235.09 15776 482.15 458.04 526.75 516.21 516.21 505.89 # 15776 355.94 338.14 388.86 381.09 381.09 373.46 15777 215.04 204.29 234.93 230.23 230.23 225.63 15780 814.98 774.23 890.36 872.56 872.56 855.12 # 15780 625.33 594.06 683.17 669.51 669.51 656.12 15781 535.33 508.56 584.84 573.15 573.15 561.68 # 15781 425.88 404.59 465.28 455.98 455.98 446.86

Page 24: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 24Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

15782 607.81 577.42 664.03 650.75 650.75 637.73 # 15782 434.92 413.17 475.15 465.65 465.65 456.33 15783 449.92 427.42 491.53 481.70 481.70 472.06 # 15783 354.61 336.88 387.41 379.66 379.66 372.07 15786 234.53 222.80 256.22 251.09 251.09 246.07 # 15786 134.61 127.88 147.06 144.12 144.12 141.23 15787 46.74 44.40 51.06 50.04 50.04 49.04 # 15787 17.48 16.61 19.10 18.72 18.72 18.34 15788 436.20 414.39 476.55 467.02 467.02 457.68 # 15788 239.32 227.35 261.45 256.22 256.22 251.09 15789 528.95 502.50 577.88 566.32 566.32 554.99 # 15789 406.36 386.04 443.95 435.07 435.07 426.36 15792 419.48 398.51 458.29 449.12 449.12 440.14 # 15792 253.82 241.13 277.30 271.76 271.76 266.32 15793 473.07 449.42 516.83 506.49 506.49 496.36 # 15793 359.01 341.06 392.22 384.38 384.38 376.69 15819 729.50 693.03 796.98 781.05 781.05 765.43 15820 544.05 516.85 594.38 582.49 582.49 570.84 # 15820 493.44 468.77 539.09 528.30 528.30 517.73 15821 586.81 557.47 641.09 628.27 628.27 615.70 # 15821 530.27 503.76 579.32 567.73 567.73 556.38 15822 429.65 408.17 469.40 460.01 460.01 450.81 # 15822 379.69 360.71 414.82 406.53 406.53 398.39 15823 586.50 557.18 640.76 627.95 627.95 615.39 # 15823 528.98 502.53 577.91 566.35 566.35 555.02 15830 1,165.45 1,107.18 1,273.26 1,247.80 1,247.80 1,222.84 15832 909.22 863.76 993.32 973.45 973.45 953.98 15833 852.02 809.42 930.83 912.21 912.21 893.98 15834 877.49 833.62 958.66 939.49 939.49 920.70 15835 919.63 873.65 1,004.70 984.61 984.61 964.92 15836 754.72 716.98 824.53 808.04 808.04 791.88 15837 788.51 749.08 861.44 844.22 844.22 827.33 # 15837 666.57 633.24 728.23 713.67 713.67 699.40 15838 567.88 539.49 620.41 608.01 608.01 595.85 15839 863.70 820.52 943.60 924.73 924.73 906.23 # 15839 731.89 695.30 799.60 783.60 783.60 767.92 15840 1,003.10 952.95 1,095.89 1,073.97 1,073.97 1,052.49 15841 1,618.28 1,537.37 1,767.98 1,732.61 1,732.61 1,697.96 15842 2,628.35 2,496.93 2,871.47 2,814.04 2,814.04 2,757.76 15845 991.02 941.47 1,082.69 1,061.04 1,061.04 1,039.82 15847 652.56 619.93 712.92 698.66 698.66 684.69 15851 94.80 90.06 103.57 101.50 101.50 99.46 # 15851 45.82 43.53 50.06 49.06 49.06 48.08 15852 47.27 44.91 51.65 50.61 50.61 49.60 15860 111.51 105.93 121.82 119.38 119.38 116.99 15920 599.06 569.11 654.48 641.39 641.39 628.57 15922 770.16 731.65 841.40 824.57 824.57 808.08 15931 684.10 649.90 747.39 732.44 732.44 717.78 15933 841.07 799.02 918.87 900.50 900.50 882.49

Page 25: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 25Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

15934 923.48 877.31 1,008.91 988.72 988.72 968.94 15935 1,086.58 1,032.25 1,187.09 1,163.35 1,163.35 1,140.09 15936 886.80 842.46 968.83 949.45 949.45 930.47 15937 1,027.52 976.14 1,122.56 1,100.11 1,100.11 1,078.11 15940 696.95 662.10 761.42 746.19 746.19 731.26 15941 890.20 845.69 972.54 953.10 953.10 934.03 15944 877.74 833.85 958.93 939.75 939.75 920.95 15945 967.31 918.94 1,056.78 1,035.64 1,035.64 1,014.93 15946 1,626.32 1,545.00 1,776.75 1,741.22 1,741.22 1,706.39 15950 585.92 556.62 640.11 627.31 627.31 614.77 15951 865.95 822.65 946.05 927.13 927.13 908.59 15952 885.81 841.52 967.75 948.39 948.39 929.43 15953 982.16 933.05 1,073.01 1,051.55 1,051.55 1,030.52 15956 1,145.55 1,088.27 1,251.51 1,226.48 1,226.48 1,201.95 15958 1,163.30 1,105.14 1,270.91 1,245.50 1,245.50 1,220.59 16000 67.00 63.65 73.20 71.74 71.74 70.30 # 16000 46.29 43.98 50.58 49.57 49.57 48.58 16020 78.25 74.34 85.49 83.78 83.78 82.10 # 16020 53.27 50.61 58.20 57.04 57.04 55.90 16025 143.17 136.01 156.41 153.28 153.28 150.21 # 16025 110.63 105.10 120.87 118.45 118.45 116.08 16030 180.24 171.23 196.91 192.98 192.98 189.12 # 16030 133.23 126.57 145.56 142.65 142.65 139.79 16035 196.74 186.90 214.94 210.63 210.63 206.43 16036 81.69 77.61 89.25 87.47 87.47 85.72 17000 64.15 60.94 70.08 68.68 68.68 67.31 # 17000 51.99 49.39 56.80 55.66 55.66 54.54 17003 5.40 5.13 5.90 5.78 5.78 5.67 # 17003 2.45 2.33 2.68 2.62 2.62 2.56 17004 144.25 137.04 157.60 154.45 154.45 151.35 # 17004 98.56 93.63 107.67 105.52 105.52 103.41 17106 330.40 313.88 360.96 353.74 353.74 346.67 # 17106 271.89 258.30 297.05 291.10 291.10 285.28 17107 420.50 399.48 459.40 450.21 450.21 441.21 # 17107 342.60 325.47 374.29 366.80 366.80 359.47 17108 621.64 590.56 679.14 665.56 665.56 652.26 # 17108 520.73 494.69 568.89 557.52 557.52 546.37 17110 105.17 99.91 114.90 112.60 112.60 110.34 # 17110 67.70 64.32 73.97 72.48 72.48 71.04 17111 125.14 118.88 136.71 133.98 133.98 131.30 # 17111 83.72 79.53 91.46 89.63 89.63 87.84 17250 75.28 71.52 82.25 80.60 80.60 78.99 # 17250 36.50 34.68 39.88 39.09 39.09 38.31 17260 91.28 86.72 99.73 97.74 97.74 95.78 # 17260 69.26 65.80 75.67 74.15 74.15 72.67 17261 137.51 130.63 150.22 147.22 147.22 144.28 # 17261 90.18 85.67 98.52 96.55 96.55 94.62 17262 168.13 159.72 183.68 180.01 180.01 176.41 # 17262 115.21 109.45 125.87 123.35 123.35 120.88

Page 26: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 26Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

17263 183.94 174.74 200.95 196.94 196.94 193.00 # 17263 128.07 121.67 139.92 137.13 137.13 134.39 17264 197.26 187.40 215.51 211.20 211.20 206.98 # 17264 136.78 129.94 149.43 146.44 146.44 143.51 17266 224.20 212.99 244.94 240.04 240.04 235.24 # 17266 160.11 152.10 174.92 171.42 171.42 167.99 17270 144.58 137.35 157.95 154.79 154.79 151.70 # 17270 98.56 93.63 107.67 105.52 105.52 103.41 17271 156.64 148.81 171.13 167.70 167.70 164.35 # 17271 109.63 104.15 119.77 117.38 117.38 115.03 17272 179.28 170.32 195.87 191.95 191.95 188.11 # 17272 127.02 120.67 138.77 136.00 136.00 133.27 17273 200.24 190.23 218.76 214.39 214.39 210.11 # 17273 143.37 136.20 156.63 153.50 153.50 150.43 17274 237.21 225.35 259.15 253.97 253.97 248.88 # 17274 175.41 166.64 191.64 187.81 187.81 184.05 17276 275.37 261.60 300.84 294.83 294.83 288.93 # 17276 210.95 200.40 230.46 225.85 225.85 221.33 17280 134.88 128.14 147.36 144.42 144.42 141.53 # 17280 89.52 85.04 97.80 95.84 95.84 93.92 17281 171.22 162.66 187.06 183.32 183.32 179.65 # 17281 123.56 117.38 134.99 132.28 132.28 129.64 17282 197.28 187.42 215.53 211.22 211.22 207.00 # 17282 143.04 135.89 156.27 153.15 153.15 150.09 17283 236.72 224.88 258.61 253.44 253.44 248.37 # 17283 178.87 169.93 195.42 191.51 191.51 187.68 17284 270.95 257.40 296.01 290.09 290.09 284.29 # 17284 208.83 198.39 228.15 223.58 223.58 219.11 17286 349.22 331.76 381.52 373.89 373.89 366.41 # 17286 280.86 266.82 306.84 300.70 300.70 294.69 17311 636.02 604.22 694.85 680.96 680.96 667.35 # 17311 379.32 360.35 414.40 406.11 406.11 397.99 17312 372.58 353.95 407.04 398.90 398.90 390.92 # 17312 201.67 191.59 220.33 215.92 215.92 211.60 17313 593.78 564.09 648.70 635.73 635.73 623.01 # 17313 340.03 323.03 371.48 364.06 364.06 356.78 17314 356.98 339.13 390.00 382.20 382.20 374.56 # 17314 187.05 177.70 204.36 200.27 200.27 196.27 17315 77.19 73.33 84.33 82.64 82.64 80.98 # 17315 53.19 50.53 58.11 56.95 56.95 55.81 17340 50.49 47.97 55.17 54.06 54.06 52.98 # 17340 48.52 46.09 53.00 51.95 51.95 50.91 17360 124.82 118.58 136.37 133.64 133.64 130.97 # 17360 97.54 92.66 106.56 104.43 104.43 102.34 19000 108.27 102.86 118.29 115.92 115.92 113.60 # 19000 44.18 41.97 48.27 47.30 47.30 46.36 19001 26.68 25.35 29.15 28.57 28.57 27.99 # 19001 22.07 20.97 24.12 23.63 23.63 23.16 19020 454.65 431.92 496.71 486.77 486.77 477.03

Page 27: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 27Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 19020 301.81 286.72 329.73 323.14 323.14 316.68 19030 159.02 151.07 173.73 170.26 170.26 166.85 # 19030 78.49 74.57 85.76 84.04 84.04 82.36 19081 658.21 625.30 719.10 704.71 704.71 690.61 # 19081 171.76 163.17 187.65 183.90 183.90 180.22 19082 540.45 513.43 590.44 578.63 578.63 567.07 # 19082 85.88 81.59 93.83 91.95 91.95 90.11 19083 636.16 604.35 695.00 681.10 681.10 667.47 # 19083 160.88 152.84 175.77 172.25 172.25 168.80 19084 519.73 493.74 567.80 556.45 556.45 545.32 # 19084 80.60 76.57 88.06 86.30 86.30 84.57 19085 973.49 924.82 1,063.54 1,042.27 1,042.27 1,021.42 # 19085 188.92 179.47 206.39 202.26 202.26 198.21 19086 767.69 729.31 838.71 821.93 821.93 805.49 # 19086 93.56 88.88 102.21 100.17 100.17 98.16 19100 145.18 137.92 158.61 155.43 155.43 152.33 # 19100 70.90 67.36 77.46 75.91 75.91 74.39 19101 330.62 314.09 361.20 353.98 353.98 346.90 # 19101 220.84 209.80 241.27 236.44 236.44 231.71 19105 2,008.28 1,907.87 2,194.05 2,150.17 2,150.17 2,107.17 # 19105 196.25 186.44 214.41 210.12 210.12 205.92 19110 469.44 445.97 512.87 502.61 502.61 492.56 # 19110 338.62 321.69 369.94 362.55 362.55 355.29 19112 439.96 417.96 480.65 471.04 471.04 461.62 # 19112 306.84 291.50 335.23 328.52 328.52 321.95 19120 484.91 460.66 529.76 519.17 519.17 508.78 # 19120 411.94 391.34 450.04 441.04 441.04 432.22 19125 538.35 511.43 588.14 576.38 576.38 564.86 # 19125 458.48 435.56 500.89 490.88 490.88 481.06 19126 164.31 156.09 179.50 175.92 175.92 172.40 19260 1,203.85 1,143.66 1,315.21 1,288.91 1,288.91 1,263.13 19271 1,622.50 1,541.38 1,772.59 1,737.13 1,737.13 1,702.39 19272 1,776.80 1,687.96 1,941.15 1,902.33 1,902.33 1,864.29 19281 229.86 218.37 251.13 246.10 246.10 241.18 # 19281 102.66 97.53 112.16 109.92 109.92 107.72 19282 159.66 151.68 174.43 170.95 170.95 167.53 # 19282 51.52 48.94 56.28 55.15 55.15 54.05 19283 257.88 244.99 281.74 276.10 276.10 270.58 # 19283 103.40 98.23 112.96 110.71 110.71 108.49 19284 192.91 183.26 210.75 206.53 206.53 202.40 # 19284 52.23 49.62 57.06 55.92 55.92 54.81 19285 485.98 461.68 530.93 520.32 520.32 509.91 # 19285 87.62 83.24 95.73 93.82 93.82 91.94 19286 424.77 403.53 464.06 454.78 454.78 445.68 # 19286 44.15 41.94 48.23 47.27 47.27 46.32 19287 811.46 770.89 886.52 868.79 868.79 851.41 # 19287 131.41 124.84 143.57 140.69 140.69 137.87 19288 651.89 619.30 712.20 697.95 697.95 683.99 # 19288 65.52 62.24 71.58 70.15 70.15 68.75

Page 28: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 28Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

19296 3,700.08 3,515.08 4,042.34 3,961.50 3,961.50 3,882.26 # 19296 213.41 202.74 233.15 228.49 228.49 223.93 19297 96.54 91.71 105.47 103.36 103.36 101.29 19298 1,001.95 951.85 1,094.63 1,072.73 1,072.73 1,051.27 # 19298 329.79 313.30 360.30 353.08 353.08 346.02 19300 508.93 483.48 556.00 544.88 544.88 533.98 # 19300 408.36 387.94 446.13 437.21 437.21 428.47 19301 654.47 621.75 715.01 700.72 700.72 686.70 19302 902.02 856.92 985.46 965.75 965.75 946.43 19303 1,014.14 963.43 1,107.94 1,085.78 1,085.78 1,064.07 19304 571.02 542.47 623.84 611.36 611.36 599.14 19305 1,130.82 1,074.28 1,235.42 1,210.71 1,210.71 1,186.49 19306 1,201.60 1,141.52 1,312.75 1,286.49 1,286.49 1,260.77 19307 1,198.86 1,138.92 1,309.76 1,283.56 1,283.56 1,257.89 19316 764.05 725.85 834.73 818.03 818.03 801.67 19318 1,094.05 1,039.35 1,195.25 1,171.34 1,171.34 1,147.92 19324 487.10 462.75 532.16 521.53 521.53 511.09 19325 632.34 600.72 690.83 677.02 677.02 663.48 19328 488.84 464.40 534.06 523.38 523.38 512.91 19330 627.00 595.65 685.00 671.30 671.30 657.88 19340 993.83 944.14 1,085.76 1,064.05 1,064.05 1,042.76 19342 912.17 866.56 996.54 976.61 976.61 957.09 19350 802.08 761.98 876.28 858.75 858.75 841.58 # 19350 665.35 632.08 726.89 712.36 712.36 698.11 19355 691.58 657.00 755.55 740.44 740.44 725.63 # 19355 571.94 543.34 624.84 612.34 612.34 600.09 19357 1,481.12 1,407.06 1,618.12 1,585.76 1,585.76 1,554.04 19361 1,566.29 1,487.98 1,711.18 1,676.95 1,676.95 1,643.42 19364 2,749.10 2,611.65 3,003.40 2,943.33 2,943.33 2,884.46 19366 1,405.67 1,335.39 1,535.70 1,504.98 1,504.98 1,474.89 19367 1,781.73 1,692.64 1,946.54 1,907.61 1,907.61 1,869.45 19368 2,195.97 2,086.17 2,399.10 2,351.12 2,351.12 2,304.09 19369 2,039.68 1,937.70 2,228.36 2,183.79 2,183.79 2,140.12 19370 677.38 643.51 740.04 725.24 725.24 710.73 19371 775.00 736.25 846.69 829.76 829.76 813.17 19380 763.76 725.57 834.41 817.72 817.72 801.37 19396 266.31 252.99 290.94 285.12 285.12 279.42 # 19396 139.77 132.78 152.70 149.64 149.64 146.65 20005 302.27 287.16 330.23 323.63 323.63 317.16 # 20005 232.92 221.27 254.46 249.37 249.37 244.38 20100 613.06 582.41 669.77 656.37 656.37 643.24 20101 431.94 410.34 471.89 462.45 462.45 453.20 # 20101 209.42 198.95 228.79 224.22 224.22 219.73 20102 474.29 450.58 518.17 507.81 507.81 497.65 # 20102 257.03 244.18 280.81 275.20 275.20 269.69 20103 563.16 535.00 615.25 602.95 602.95 590.88 # 20103 347.54 330.16 379.68 372.09 372.09 364.65 20150 903.02 857.87 986.55 966.82 966.82 947.49 20200 199.20 189.24 217.63 213.28 213.28 209.01

Page 29: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 29Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 20200 96.00 91.20 104.88 102.79 102.79 100.73 20205 279.78 265.79 305.66 299.54 299.54 293.55 # 20205 156.85 149.01 171.36 167.93 167.93 164.58 20206 224.05 212.85 244.78 239.88 239.88 235.08 # 20206 59.38 56.41 64.87 63.57 63.57 62.30 20220 161.82 153.73 176.79 173.26 173.26 169.80 # 20220 73.07 69.42 79.83 78.23 78.23 76.67 20225 498.04 473.14 544.11 533.23 533.23 522.57 # 20225 109.21 103.75 119.31 116.93 116.93 114.60 20240 154.95 147.20 169.28 165.90 165.90 162.58 20245 521.08 495.03 569.28 557.90 557.90 546.74 20250 389.45 369.98 425.48 416.97 416.97 408.63 20251 423.21 402.05 462.36 453.11 453.11 444.05 20500 101.37 96.30 110.75 108.53 108.53 106.35 # 20500 83.62 79.44 91.36 89.53 89.53 87.73 20501 112.86 107.22 123.30 120.84 120.84 118.43 # 20501 38.57 36.64 42.14 41.30 41.30 40.47 20520 196.61 186.78 214.80 210.50 210.50 206.29 # 20520 144.02 136.82 157.34 154.19 154.19 151.11 20525 460.79 437.75 503.41 493.35 493.35 483.48 # 20525 247.15 234.79 270.01 264.60 264.60 259.31 20526 75.17 71.41 82.12 80.48 80.48 78.87 # 20526 57.42 54.55 62.73 61.48 61.48 60.25 20527 81.97 77.87 89.55 87.76 87.76 86.00 # 20527 66.20 62.89 72.32 70.87 70.87 69.46 20550 57.33 54.46 62.63 61.38 61.38 60.15 # 20550 41.89 39.80 45.77 44.85 44.85 43.95 20551 58.62 55.69 64.04 62.77 62.77 61.51 # 20551 42.52 40.39 46.45 45.52 45.52 44.61 20552 53.73 51.04 58.70 57.52 57.52 56.37 # 20552 37.95 36.05 41.46 40.63 40.63 39.81 20553 61.91 58.81 67.63 66.27 66.27 64.95 # 20553 43.17 41.01 47.16 46.22 46.22 45.30 20555 329.77 313.28 360.27 353.06 353.06 346.00 20600 46.50 44.18 50.81 49.80 49.80 48.79 # 20600 35.65 33.87 38.95 38.17 38.17 37.41 20604 70.26 66.75 76.76 75.23 75.23 73.73 # 20604 46.27 43.96 50.55 49.54 49.54 48.55 20605 48.88 46.44 53.41 52.34 52.34 51.29 # 20605 37.38 35.51 40.84 40.02 40.02 39.22 20606 77.87 73.98 85.08 83.38 83.38 81.71 # 20606 52.89 50.25 57.79 56.64 56.64 55.51 20610 58.85 55.91 64.30 63.01 63.01 61.74 # 20610 46.03 43.73 50.29 49.29 49.29 48.30 20611 89.12 84.66 97.36 95.42 95.42 93.51 # 20611 61.84 58.75 67.56 66.22 66.22 64.89 20612 58.83 55.89 64.27 62.99 62.99 61.72 # 20612 41.74 39.65 45.60 44.69 44.69 43.79 20615 236.41 224.59 258.28 253.12 253.12 248.06

Page 30: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 30Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 20615 161.80 153.71 176.77 173.24 173.24 169.77 20650 201.45 191.38 220.09 215.68 215.68 211.37 # 20650 155.11 147.35 169.45 166.06 166.06 162.74 20660 249.51 237.03 272.58 267.13 267.13 261.79 20661 500.01 475.01 546.26 535.34 535.34 524.63 20662 427.73 406.34 467.29 457.94 457.94 448.79 20663 462.43 439.31 505.21 495.10 495.10 485.20 20664 875.97 832.17 957.00 937.86 937.86 919.10 20665 102.87 97.73 112.39 110.15 110.15 107.94 # 20665 89.39 84.92 97.66 95.70 95.70 93.79 20670 360.33 342.31 393.66 385.78 385.78 378.06 # 20670 144.71 137.47 158.09 154.93 154.93 151.83 20680 600.36 570.34 655.89 642.77 642.77 629.91 # 20680 420.57 399.54 459.47 450.28 450.28 441.28 20690 592.42 562.80 647.22 634.27 634.27 621.59 20692 1,113.10 1,057.45 1,216.07 1,191.75 1,191.75 1,167.91 20693 441.55 419.47 482.39 472.74 472.74 463.29 20694 414.04 393.34 452.34 443.29 443.29 434.42 # 20694 334.17 317.46 365.08 357.78 357.78 350.62 20696 1,199.41 1,139.44 1,310.36 1,284.15 1,284.15 1,258.47 20697 1,848.90 1,756.46 2,019.93 1,979.53 1,979.53 1,939.94 20802 2,417.58 2,296.70 2,641.21 2,588.39 2,588.39 2,536.61 20805 3,308.12 3,142.71 3,614.12 3,541.84 3,541.84 3,471.00 20808 4,027.62 3,826.24 4,400.18 4,312.18 4,312.18 4,225.94 20816 2,073.85 1,970.16 2,265.68 2,220.37 2,220.37 2,175.96 20822 1,784.95 1,695.70 1,950.06 1,911.06 1,911.06 1,872.83 20824 2,039.90 1,937.91 2,228.60 2,184.02 2,184.02 2,140.35 20827 1,826.71 1,735.37 1,995.68 1,955.76 1,955.76 1,916.65 20838 2,441.78 2,319.69 2,667.64 2,614.30 2,614.30 2,562.00 20900 402.40 382.28 439.62 430.82 430.82 422.21 # 20900 190.40 180.88 208.01 203.85 203.85 199.77 20902 287.30 272.94 313.88 307.60 307.60 301.45 20910 406.59 386.26 444.20 435.31 435.31 426.60 20912 476.13 452.32 520.17 509.76 509.76 499.56 20920 390.70 371.17 426.85 418.31 418.31 409.95 20922 597.26 567.40 652.51 639.46 639.46 626.67 # 20922 498.99 474.04 545.15 534.24 534.24 523.56 20924 500.52 475.49 546.81 535.88 535.88 525.16 20926 426.43 405.11 465.88 456.56 456.56 447.43 20931 115.09 109.34 125.74 123.22 123.22 120.76 20937 170.88 162.34 186.69 182.95 182.95 179.30 20938 188.83 179.39 206.30 202.17 202.17 198.12 20950 240.31 228.29 262.53 257.28 257.28 252.14 # 20950 90.76 86.22 99.15 97.18 97.18 95.23 20955 2,515.84 2,390.05 2,748.56 2,693.59 2,693.59 2,639.72 20956 2,664.42 2,531.20 2,910.88 2,852.67 2,852.67 2,795.62 20957 2,466.81 2,343.47 2,694.99 2,641.09 2,641.09 2,588.27 20962 2,131.75 2,025.16 2,328.93 2,282.36 2,282.36 2,236.72 20969 2,781.83 2,642.74 3,039.15 2,978.37 2,978.37 2,918.80

Page 31: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 31Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

20970 2,938.87 2,791.93 3,210.72 3,146.50 3,146.50 3,083.58 20972 2,385.95 2,266.65 2,606.65 2,554.52 2,554.52 2,503.42 20973 2,659.41 2,526.44 2,905.41 2,847.30 2,847.30 2,790.35 20974 73.85 70.16 80.68 79.07 79.07 77.49 # 20974 49.86 47.37 54.48 53.38 53.38 52.31 20975 178.65 169.72 195.18 191.28 191.28 187.45 20979 51.01 48.46 55.73 54.61 54.61 53.52 # 20979 32.60 30.97 35.62 34.90 34.90 34.20 20982 2,848.58 2,706.15 3,112.07 3,049.83 3,049.83 2,988.84 # 20982 386.41 367.09 422.15 413.71 413.71 405.44 20983 6,811.48 6,470.91 7,441.55 7,292.71 7,292.71 7,146.86 # 20983 410.37 389.85 448.33 439.36 439.36 430.57 20985 148.70 141.27 162.46 159.21 159.21 156.02 21010 740.20 703.19 808.67 792.50 792.50 776.65 21011 336.97 320.12 368.14 360.78 360.78 353.57 # 21011 255.12 242.36 278.71 273.14 273.14 267.67 21012 335.98 319.18 367.06 359.72 359.72 352.52 21013 505.60 480.32 552.37 541.32 541.32 530.50 # 21013 397.79 377.90 434.59 425.89 425.89 417.37 21014 517.56 491.68 565.43 554.13 554.13 543.04 21015 705.73 670.44 771.01 755.58 755.58 740.47 21016 1,021.86 970.77 1,116.39 1,094.05 1,094.05 1,072.17 21025 882.29 838.18 963.91 944.63 944.63 925.74 # 21025 752.46 714.84 822.07 805.62 805.62 789.51 21026 604.95 574.70 660.91 647.69 647.69 634.74 # 21026 494.51 469.78 540.25 529.44 529.44 518.85 21029 752.60 714.97 822.22 805.77 805.77 789.66 # 21029 632.95 601.30 691.50 677.66 677.66 664.10 21030 510.00 484.50 557.18 546.03 546.03 535.11 # 21030 415.99 395.19 454.47 445.38 445.38 436.47 21031 386.88 367.54 422.67 414.22 414.22 405.94 # 21031 293.53 278.85 320.68 314.26 314.26 307.97 21032 393.27 373.61 429.65 421.06 421.06 412.64 # 21032 291.05 276.50 317.98 311.62 311.62 305.38 21034 1,306.59 1,241.26 1,427.45 1,398.89 1,398.89 1,370.92 # 21034 1,160.65 1,102.62 1,268.01 1,242.66 1,242.66 1,217.80 21040 513.61 487.93 561.12 549.90 549.90 538.90 # 21040 416.65 395.82 455.19 446.09 446.09 437.16 21044 877.02 833.17 958.15 938.99 938.99 920.21 21045 1,231.04 1,169.49 1,344.91 1,318.02 1,318.02 1,291.66 21046 1,116.74 1,060.90 1,220.04 1,195.63 1,195.63 1,171.72 21047 1,328.23 1,261.82 1,451.09 1,422.07 1,422.07 1,393.63 21048 1,145.35 1,088.08 1,251.29 1,226.27 1,226.27 1,201.74 21049 1,219.01 1,158.06 1,331.77 1,305.14 1,305.14 1,279.03 21050 839.05 797.10 916.67 898.33 898.33 880.37 21060 794.38 754.66 867.86 850.51 850.51 833.50 21070 609.09 578.64 665.44 652.13 652.13 639.09 21073 378.50 359.58 413.52 405.25 405.25 397.14 # 21073 253.27 240.61 276.70 271.17 271.17 265.74

Page 32: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 32Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

21076 1,001.93 951.83 1,094.60 1,072.71 1,072.71 1,051.25 # 21076 849.42 806.95 927.99 909.43 909.43 891.24 21077 2,513.39 2,387.72 2,745.88 2,690.97 2,690.97 2,637.15 # 21077 2,133.76 2,027.07 2,331.13 2,284.51 2,284.51 2,238.82 21079 1,690.20 1,605.69 1,846.54 1,809.62 1,809.62 1,773.43 # 21079 1,419.69 1,348.71 1,551.02 1,520.00 1,520.00 1,489.61 21080 1,896.86 1,802.02 2,072.32 2,030.88 2,030.88 1,990.26 # 21080 1,580.66 1,501.63 1,726.87 1,692.34 1,692.34 1,658.50 21081 1,751.16 1,663.60 1,913.14 1,874.88 1,874.88 1,837.38 # 21081 1,453.70 1,381.02 1,588.17 1,556.41 1,556.41 1,525.28 21082 1,652.67 1,570.04 1,805.55 1,769.44 1,769.44 1,734.05 # 21082 1,361.79 1,293.70 1,487.76 1,458.00 1,458.00 1,428.84 21083 1,572.73 1,494.09 1,718.20 1,683.84 1,683.84 1,650.17 # 21083 1,263.76 1,200.57 1,380.66 1,353.04 1,353.04 1,325.98 21084 1,809.13 1,718.67 1,976.47 1,936.95 1,936.95 1,898.20 # 21084 1,466.31 1,392.99 1,601.94 1,569.90 1,569.90 1,538.50 21085 755.22 717.46 825.08 808.58 808.58 792.41 # 21085 575.10 546.35 628.30 615.73 615.73 603.42 21086 1,868.88 1,775.44 2,041.76 2,000.92 2,000.92 1,960.90 # 21086 1,580.63 1,501.60 1,726.84 1,692.31 1,692.31 1,658.46 21087 1,865.90 1,772.61 2,038.50 1,997.73 1,997.73 1,957.78 # 21087 1,577.31 1,498.44 1,723.21 1,688.74 1,688.74 1,654.97 21100 990.08 940.58 1,081.67 1,060.04 1,060.04 1,038.83 # 21100 493.11 468.45 538.72 527.94 527.94 517.39 21110 785.83 746.54 858.52 841.35 841.35 824.53 # 21110 663.23 630.07 724.58 710.09 710.09 695.89 21116 139.38 132.41 152.27 149.22 149.22 146.23 # 21116 44.39 42.17 48.50 47.53 47.53 46.58 21120 640.82 608.78 700.10 686.09 686.09 672.37 # 21120 512.31 486.69 559.69 548.50 548.50 537.53 21121 795.62 755.84 869.22 851.83 851.83 834.80 # 21121 669.73 636.24 731.68 717.05 717.05 702.71 21122 653.59 620.91 714.05 699.76 699.76 685.77 21123 927.26 880.90 1,013.04 992.77 992.77 972.91 21125 2,916.33 2,770.51 3,186.09 3,122.37 3,122.37 3,059.92 # 21125 783.83 744.64 856.34 839.21 839.21 822.43 21127 4,207.65 3,997.27 4,596.86 4,504.92 4,504.92 4,414.82 # 21127 894.85 850.11 977.63 958.08 958.08 938.92 21137 753.04 715.39 822.70 806.24 806.24 790.12 21138 883.38 839.21 965.09 945.79 945.79 926.88 21139 951.18 903.62 1,039.16 1,018.38 1,018.38 998.02 21141 1,343.09 1,275.94 1,467.33 1,437.98 1,437.98 1,409.22 21142 1,407.59 1,337.21 1,537.79 1,507.04 1,507.04 1,476.90 21143 1,418.12 1,347.21 1,549.29 1,518.31 1,518.31 1,487.94 21145 1,585.37 1,506.10 1,732.02 1,697.38 1,697.38 1,663.43 21146 1,554.83 1,477.09 1,698.65 1,664.68 1,664.68 1,631.39 21147 1,753.57 1,665.89 1,915.77 1,877.46 1,877.46 1,839.91 21150 1,685.00 1,600.75 1,840.86 1,804.05 1,804.05 1,767.98 21151 2,021.15 1,920.09 2,208.10 2,163.94 2,163.94 2,120.67

Page 33: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 33Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

21154 2,091.78 1,987.19 2,285.27 2,239.57 2,239.57 2,194.78 21155 2,169.60 2,061.12 2,370.29 2,322.89 2,322.89 2,276.43 21159 2,520.85 2,394.81 2,754.03 2,698.95 2,698.95 2,644.97 21160 3,179.20 3,020.24 3,473.28 3,403.82 3,403.82 3,335.74 21172 1,805.70 1,715.42 1,972.73 1,933.28 1,933.28 1,894.61 21175 2,148.01 2,040.61 2,346.70 2,299.77 2,299.77 2,253.77 21179 1,447.60 1,375.22 1,581.50 1,549.88 1,549.88 1,518.89 21180 1,550.73 1,473.19 1,694.17 1,660.29 1,660.29 1,627.09 21181 734.02 697.32 801.92 785.88 785.88 770.16 21182 1,954.71 1,856.97 2,135.52 2,092.80 2,092.80 2,050.94 21183 2,314.17 2,198.46 2,528.23 2,477.66 2,477.66 2,428.11 21184 2,154.88 2,047.14 2,354.21 2,307.13 2,307.13 2,260.99 21188 1,613.31 1,532.64 1,762.54 1,727.29 1,727.29 1,692.74 21193 1,219.22 1,158.26 1,332.00 1,305.35 1,305.35 1,279.25 21194 1,441.09 1,369.04 1,574.40 1,542.91 1,542.91 1,512.05 21195 1,338.55 1,271.62 1,462.36 1,433.12 1,433.12 1,404.46 21196 1,483.69 1,409.51 1,620.94 1,588.52 1,588.52 1,556.74 21198 1,167.13 1,108.77 1,275.09 1,249.58 1,249.58 1,224.59 21199 1,076.37 1,022.55 1,175.93 1,152.42 1,152.42 1,129.37 21206 1,172.72 1,114.08 1,281.19 1,255.57 1,255.57 1,230.45 21208 1,828.16 1,736.75 1,997.26 1,957.32 1,957.32 1,918.18 # 21208 834.88 793.14 912.11 893.87 893.87 875.99 21209 794.48 754.76 867.97 850.61 850.61 833.60 # 21209 612.72 582.08 669.39 656.01 656.01 642.88 21210 2,210.92 2,100.37 2,415.43 2,367.11 2,367.11 2,319.77 # 21210 868.25 824.84 948.57 929.59 929.59 911.00 21215 3,896.62 3,701.79 4,257.06 4,171.91 4,171.91 4,088.48 # 21215 902.97 857.82 986.49 966.76 966.76 947.43 21230 713.88 678.19 779.92 764.32 764.32 749.04 21235 710.36 674.84 776.07 760.54 760.54 745.33 # 21235 563.11 534.95 615.19 602.89 602.89 590.84 21240 1,124.73 1,068.49 1,228.76 1,204.19 1,204.19 1,180.11 21242 1,029.66 978.18 1,124.91 1,102.41 1,102.41 1,080.37 21243 1,704.67 1,619.44 1,862.36 1,825.11 1,825.11 1,788.61 21244 1,061.39 1,008.32 1,159.57 1,136.37 1,136.37 1,113.65 21245 1,095.76 1,040.97 1,197.12 1,173.17 1,173.17 1,149.71 # 21245 886.39 842.07 968.38 949.01 949.01 930.04 21246 872.48 828.86 953.19 934.12 934.12 915.43 21247 1,558.07 1,480.17 1,702.20 1,668.16 1,668.16 1,634.79 21248 1,101.54 1,046.46 1,203.43 1,179.36 1,179.36 1,155.77 # 21248 910.57 865.04 994.80 974.90 974.90 955.41 21249 1,513.85 1,438.16 1,653.88 1,620.81 1,620.81 1,588.39 # 21249 1,296.92 1,232.07 1,416.88 1,388.54 1,388.54 1,360.77 21255 1,384.00 1,314.80 1,512.02 1,481.78 1,481.78 1,452.14 21256 1,194.64 1,134.91 1,305.15 1,279.04 1,279.04 1,253.47 21260 1,380.44 1,311.42 1,508.13 1,477.97 1,477.97 1,448.41 21261 2,112.25 2,006.64 2,307.64 2,261.49 2,261.49 2,216.26 21263 1,949.30 1,851.84 2,129.62 2,087.02 2,087.02 2,045.28 21267 1,547.48 1,470.11 1,690.63 1,656.82 1,656.82 1,623.69

Page 34: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 34Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

21268 1,739.40 1,652.43 1,900.29 1,862.29 1,862.29 1,825.04 21270 939.11 892.15 1,025.97 1,005.46 1,005.46 985.34 # 21270 714.29 678.58 780.37 764.76 764.76 749.47 21275 830.74 789.20 907.58 889.43 889.43 871.64 21280 555.61 527.83 607.00 594.86 594.86 582.96 21282 371.21 352.65 405.55 397.44 397.44 389.49 21295 176.56 167.73 192.89 189.04 189.04 185.25 21296 424.52 403.29 463.78 454.50 454.50 445.42 21310 125.50 119.23 137.11 134.38 134.38 131.69 # 21310 27.55 26.17 30.10 29.50 29.50 28.91 21315 267.07 253.72 291.78 285.95 285.95 280.23 # 21315 149.73 142.24 163.58 160.31 160.31 157.10 21320 248.18 235.77 271.14 265.71 265.71 260.39 # 21320 134.46 127.74 146.90 143.97 143.97 141.09 21325 461.71 438.62 504.41 494.33 494.33 484.44 21330 555.83 528.04 607.25 595.10 595.10 583.20 21335 718.97 683.02 785.47 769.76 769.76 754.37 21336 632.30 600.69 690.79 676.98 676.98 663.45 21337 392.65 373.02 428.97 420.39 420.39 411.99 # 21337 290.76 276.22 317.65 311.31 311.31 305.08 21338 706.42 671.10 771.77 756.33 756.33 741.21 21339 756.82 718.98 826.83 810.29 810.29 794.09 21340 752.29 714.68 821.88 805.45 805.45 789.34 21343 1,188.39 1,128.97 1,298.32 1,272.35 1,272.35 1,246.90 21344 1,395.67 1,325.89 1,524.77 1,494.28 1,494.28 1,464.39 21345 796.39 756.57 870.06 852.66 852.66 835.60 # 21345 650.12 617.61 710.25 696.05 696.05 682.12 21346 900.43 855.41 983.72 964.05 964.05 944.76 21347 1,122.04 1,065.94 1,225.83 1,201.31 1,201.31 1,177.29 21348 1,202.30 1,142.19 1,313.52 1,287.25 1,287.25 1,261.50 21355 420.38 399.36 459.26 450.08 450.08 441.07 # 21355 319.14 303.18 348.66 341.69 341.69 334.86 21356 489.58 465.10 534.87 524.17 524.17 513.68 # 21356 375.20 356.44 409.91 401.71 401.71 393.67 21360 534.92 508.17 584.40 572.71 572.71 561.26 21365 1,112.14 1,056.53 1,215.01 1,190.71 1,190.71 1,166.89 21366 1,159.74 1,101.75 1,267.01 1,241.68 1,241.68 1,216.85 21385 677.48 643.61 740.15 725.35 725.35 710.85 21386 689.10 654.65 752.85 737.79 737.79 723.04 21387 708.75 673.31 774.31 758.82 758.82 743.64 21390 788.04 748.64 860.94 843.72 843.72 826.85 21395 998.51 948.58 1,090.87 1,069.05 1,069.05 1,047.67 21400 186.48 177.16 203.73 199.66 199.66 195.67 # 21400 152.63 145.00 166.75 163.42 163.42 160.15 21401 429.43 407.96 469.15 459.77 459.77 450.57 # 21401 283.50 269.33 309.73 303.53 303.53 297.46 21406 516.42 490.60 564.19 552.91 552.91 541.85 21407 640.61 608.58 699.87 685.87 685.87 672.15 21408 871.77 828.18 952.41 933.36 933.36 914.70

Page 35: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 35Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

21421 737.30 700.44 805.51 789.39 789.39 773.61 # 21421 625.88 594.59 683.78 670.11 670.11 656.71 21422 669.04 635.59 730.93 716.31 716.31 701.98 21423 812.41 771.79 887.56 869.80 869.80 852.40 21431 728.70 692.27 796.11 780.18 780.18 764.58 21432 651.69 619.11 711.98 697.74 697.74 683.79 21433 1,731.98 1,645.38 1,892.19 1,854.34 1,854.34 1,817.25 21435 1,265.73 1,202.44 1,382.81 1,355.15 1,355.15 1,328.04 21436 2,087.95 1,983.55 2,281.08 2,235.46 2,235.46 2,190.75 21440 561.54 533.46 613.48 601.21 601.21 589.18 # 21440 458.01 435.11 500.38 490.37 490.37 480.56 21445 754.87 717.13 824.70 808.21 808.21 792.04 # 21445 619.13 588.17 676.40 662.87 662.87 649.61 21450 602.22 572.11 657.93 644.77 644.77 631.88 # 21450 484.88 460.64 529.74 519.14 519.14 508.76 21451 744.87 707.63 813.77 797.50 797.50 781.55 # 21451 628.85 597.41 687.02 673.28 673.28 659.81 21452 575.70 546.92 628.96 616.38 616.38 604.05 # 21452 343.00 325.85 374.73 367.23 367.23 359.88 21453 891.82 847.23 974.31 954.83 954.83 935.73 # 21453 768.23 729.82 839.29 822.50 822.50 806.06 21454 588.99 559.54 643.47 630.60 630.60 617.99 21461 2,063.64 1,960.46 2,254.53 2,209.44 2,209.44 2,165.25 # 21461 927.38 881.01 1,013.16 992.90 992.90 973.04 21462 2,193.68 2,084.00 2,396.60 2,348.67 2,348.67 2,301.69 # 21462 1,035.40 983.63 1,131.17 1,108.55 1,108.55 1,086.38 21465 956.58 908.75 1,045.06 1,024.17 1,024.17 1,003.69 21470 1,207.02 1,146.67 1,318.67 1,292.30 1,292.30 1,266.46 21480 95.05 90.30 103.85 101.76 101.76 99.73 # 21480 32.27 30.66 35.26 34.56 34.56 33.87 21485 684.72 650.48 748.05 733.09 733.09 718.43 # 21485 575.60 546.82 628.84 616.26 616.26 603.93 21490 914.97 869.22 999.60 979.62 979.62 960.02 21495 692.75 658.11 756.83 741.69 741.69 726.86 21497 715.51 679.73 781.69 766.06 766.06 750.74 # 21497 598.17 568.26 653.50 640.42 640.42 627.61 21501 441.10 419.05 481.91 472.27 472.27 462.83 # 21501 318.50 302.58 347.97 341.01 341.01 334.19 21502 531.86 505.27 581.06 569.43 569.43 558.05 21510 446.92 424.57 488.26 478.49 478.49 468.92 21550 254.22 241.51 277.74 272.18 272.18 266.74 # 21550 156.61 148.78 171.10 167.67 167.67 164.31 21552 446.65 424.32 487.97 478.20 478.20 468.64 21554 733.85 697.16 801.73 785.70 785.70 769.99 21555 404.63 384.40 442.06 433.22 433.22 424.56 # 21555 303.73 288.54 331.82 325.19 325.19 318.68 21556 528.99 502.54 577.92 566.36 566.36 555.04 21557 961.00 912.95 1,049.89 1,028.89 1,028.89 1,008.32 21558 1,355.45 1,287.68 1,480.83 1,451.22 1,451.22 1,422.19

Page 36: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 36Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

21600 554.30 526.59 605.58 593.47 593.47 581.60 21610 1,204.62 1,144.39 1,316.05 1,289.73 1,289.73 1,263.93 21615 626.45 595.13 684.40 670.71 670.71 657.31 21616 759.89 721.90 830.19 813.58 813.58 797.31 21620 504.21 479.00 550.85 539.83 539.83 529.03 21627 538.15 511.24 587.93 576.17 576.17 564.65 21630 1,217.42 1,156.55 1,330.03 1,303.43 1,303.43 1,277.36 21632 1,220.40 1,159.38 1,333.29 1,306.62 1,306.62 1,280.49 21685 1,002.30 952.19 1,095.02 1,073.12 1,073.12 1,051.66 21700 375.57 356.79 410.31 402.10 402.10 394.06 21705 561.80 533.71 613.77 601.50 601.50 589.47 21720 449.57 427.09 491.15 481.33 481.33 471.71 21725 528.85 502.41 577.77 566.21 566.21 554.89 21740 1,034.91 983.16 1,130.63 1,108.03 1,108.03 1,085.86 21742 725.78 689.49 792.91 777.06 777.06 761.52 21743 801.91 761.81 876.08 858.56 858.56 841.39 21750 691.96 657.36 755.96 740.84 740.84 726.03 21811 620.79 589.75 678.21 664.65 664.65 651.36 21812 744.73 707.49 813.61 797.34 797.34 781.39 21813 972.96 924.31 1,062.96 1,041.69 1,041.69 1,020.86 21820 136.77 129.93 149.42 146.43 146.43 143.50 # 21820 140.05 133.05 153.01 149.95 149.95 146.95 21825 541.24 514.18 591.31 579.49 579.49 567.89 21920 248.66 236.23 271.66 266.24 266.24 260.91 # 21920 158.93 150.98 173.63 170.15 170.15 166.75 21925 435.93 414.13 476.25 466.73 466.73 457.39 # 21925 351.46 333.89 383.97 376.29 376.29 368.77 21930 462.06 438.96 504.80 494.71 494.71 484.82 # 21930 362.80 344.66 396.36 388.44 388.44 380.66 21931 470.14 446.63 513.62 503.36 503.36 493.29 21932 662.99 629.84 724.32 709.83 709.83 695.64 21933 738.94 701.99 807.29 791.14 791.14 775.32 21935 1,028.68 977.25 1,123.84 1,101.37 1,101.37 1,079.34 21936 1,419.54 1,348.56 1,550.84 1,519.83 1,519.83 1,489.43 22010 953.01 905.36 1,041.16 1,020.34 1,020.34 999.94 22015 923.01 876.86 1,008.39 988.22 988.22 968.45 22100 872.38 828.76 953.07 934.01 934.01 915.33 22101 849.99 807.49 928.61 910.04 910.04 891.84 22102 788.08 748.68 860.98 843.77 843.77 826.90 22103 142.28 135.17 155.45 152.34 152.34 149.29 22110 1,051.16 998.60 1,148.39 1,125.42 1,125.42 1,102.92 22112 988.23 938.82 1,079.64 1,058.05 1,058.05 1,036.89 22114 992.09 942.49 1,083.86 1,062.19 1,062.19 1,040.95 22116 144.79 137.55 158.18 155.02 155.02 151.92 22206 2,470.65 2,347.12 2,699.19 2,645.21 2,645.21 2,592.31 22207 2,420.46 2,299.44 2,644.36 2,591.47 2,591.47 2,539.64 22208 594.16 564.45 649.12 636.13 636.13 623.42 22210 1,800.60 1,710.57 1,967.16 1,927.81 1,927.81 1,889.25 22212 1,487.82 1,413.43 1,625.44 1,592.93 1,592.93 1,561.08

Page 37: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 37Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

22214 1,493.32 1,418.65 1,631.45 1,598.82 1,598.82 1,566.84 22216 370.43 351.91 404.70 396.60 396.60 388.67 22220 1,607.72 1,527.33 1,756.43 1,721.30 1,721.30 1,686.87 22222 1,559.15 1,481.19 1,703.37 1,669.31 1,669.31 1,635.92 22224 1,589.62 1,510.14 1,736.66 1,701.93 1,701.93 1,667.89 22226 369.80 351.31 404.01 395.92 395.92 388.00 22305 186.79 177.45 204.07 199.99 199.99 195.98 # 22305 170.35 161.83 186.10 182.38 182.38 178.73 22310 303.52 288.34 331.59 324.96 324.96 318.46 # 22310 281.17 267.11 307.18 301.04 301.04 295.01 22315 872.78 829.14 953.51 934.44 934.44 915.76 # 22315 769.25 730.79 840.41 823.60 823.60 807.13 22318 1,666.41 1,583.09 1,820.55 1,784.14 1,784.14 1,748.46 22319 1,852.98 1,760.33 2,024.38 1,983.89 1,983.89 1,944.21 22325 1,447.44 1,375.07 1,581.33 1,549.71 1,549.71 1,518.71 22326 1,507.07 1,431.72 1,646.48 1,613.55 1,613.55 1,581.28 22327 1,514.64 1,438.91 1,654.75 1,621.65 1,621.65 1,589.22 22328 289.25 274.79 316.01 309.68 309.68 303.49 22505 127.44 121.07 139.23 136.45 136.45 133.72 22510 1,682.82 1,598.68 1,838.48 1,801.72 1,801.72 1,765.69 # 22510 456.83 433.99 499.09 489.11 489.11 479.32 22511 1,663.92 1,580.72 1,817.83 1,781.48 1,781.48 1,745.85 # 22511 428.73 407.29 468.38 459.01 459.01 449.83 22512 932.00 885.40 1,018.21 997.84 997.84 977.89 # 22512 213.50 202.83 233.25 228.59 228.59 224.01 22513 6,889.06 6,544.61 7,526.30 7,375.78 7,375.78 7,228.27 # 22513 543.82 516.63 594.12 582.25 582.25 570.60 22514 6,878.20 6,534.29 7,514.43 7,364.14 7,364.14 7,216.86 # 22514 506.67 481.34 553.54 542.47 542.47 531.62 22515 4,161.66 3,953.58 4,546.62 4,455.69 4,455.69 4,366.57 # 22515 230.60 219.07 251.93 246.89 246.89 241.96 22532 1,799.94 1,709.94 1,966.43 1,927.10 1,927.10 1,888.56 22533 1,665.05 1,581.80 1,819.07 1,782.68 1,782.68 1,747.03 22534 368.09 349.69 402.14 394.11 394.11 386.23 22548 2,010.19 1,909.68 2,196.13 2,152.21 2,152.21 2,109.17 22551 1,738.84 1,651.90 1,899.69 1,861.69 1,861.69 1,824.45 22552 409.97 389.47 447.89 438.93 438.93 430.16 22554 1,268.35 1,204.93 1,385.67 1,357.95 1,357.95 1,330.79 22556 1,685.91 1,601.61 1,841.85 1,805.02 1,805.02 1,768.92 22558 1,556.60 1,478.77 1,700.59 1,666.57 1,666.57 1,633.24 22585 337.22 320.36 368.41 361.04 361.04 353.82 22586 1,830.73 1,739.19 2,000.07 1,960.07 1,960.07 1,920.87 22590 1,601.40 1,521.33 1,749.53 1,714.54 1,714.54 1,680.24 22595 1,526.84 1,450.50 1,668.08 1,634.71 1,634.71 1,602.02 22600 1,300.51 1,235.48 1,420.80 1,392.39 1,392.39 1,364.53 22610 1,272.98 1,209.33 1,390.73 1,362.91 1,362.91 1,335.66 22612 1,605.74 1,525.45 1,754.27 1,719.18 1,719.18 1,684.80 22614 401.06 381.01 438.16 429.40 429.40 420.81 22630 1,586.65 1,507.32 1,733.42 1,698.75 1,698.75 1,664.77

Page 38: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 38Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

22632 329.51 313.03 359.98 352.79 352.79 345.72 22633 1,878.00 1,784.10 2,051.72 2,010.68 2,010.68 1,970.47 22634 509.13 483.67 556.22 545.10 545.10 534.20 22800 1,359.91 1,291.91 1,485.70 1,455.98 1,455.98 1,426.86 22802 2,117.74 2,011.85 2,313.63 2,267.35 2,267.35 2,222.01 22804 2,451.13 2,328.57 2,677.86 2,624.30 2,624.30 2,571.81 22808 1,857.49 1,764.62 2,029.31 1,988.73 1,988.73 1,948.95 22810 2,053.73 1,951.04 2,243.70 2,198.82 2,198.82 2,154.85 22812 2,438.73 2,316.79 2,664.31 2,611.02 2,611.02 2,558.80 22818 2,187.99 2,078.59 2,390.38 2,342.57 2,342.57 2,295.72 22819 2,822.68 2,681.55 3,083.78 3,022.11 3,022.11 2,961.66 22830 816.68 775.85 892.23 874.38 874.38 856.89 22840 779.38 740.41 851.47 834.44 834.44 817.75 22842 781.80 742.71 854.12 837.04 837.04 820.30 22843 835.24 793.48 912.50 894.25 894.25 876.37 22844 1,004.97 954.72 1,097.93 1,075.97 1,075.97 1,054.46 22845 750.64 713.11 820.08 803.68 803.68 787.60 22846 779.65 740.67 851.77 834.74 834.74 818.04 22847 845.75 803.46 923.98 905.50 905.50 887.39 22848 367.25 348.89 401.22 393.20 393.20 385.33 22849 1,314.00 1,248.30 1,435.55 1,406.83 1,406.83 1,378.69 22850 726.26 689.95 793.44 777.57 777.57 762.02 22851 417.87 396.98 456.53 447.40 447.40 438.45 22852 695.86 661.07 760.23 745.03 745.03 730.12 22855 1,119.92 1,063.92 1,223.51 1,199.04 1,199.04 1,175.06 22856 1,642.95 1,560.80 1,794.92 1,759.02 1,759.02 1,723.84 22857 1,987.67 1,888.29 2,171.53 2,128.10 2,128.10 2,085.54 22858 515.55 489.77 563.24 551.97 551.97 540.93 22861 2,038.86 1,936.92 2,227.46 2,182.91 2,182.91 2,139.25 22862 2,027.64 1,926.26 2,215.20 2,170.89 2,170.89 2,127.48 22864 2,097.82 1,992.93 2,291.87 2,246.03 2,246.03 2,201.11 22865 2,060.88 1,957.84 2,251.52 2,206.48 2,206.48 2,162.36 22900 564.95 536.70 617.21 604.87 604.87 592.77 22901 666.66 633.33 728.33 713.76 713.76 699.49 22902 428.52 407.09 468.15 458.79 458.79 449.62 # 22902 329.25 312.79 359.71 352.51 352.51 345.46 22903 438.88 416.94 479.48 469.89 469.89 460.49 22904 1,054.60 1,001.87 1,152.15 1,129.10 1,129.10 1,106.52 22905 1,339.13 1,272.17 1,463.00 1,433.74 1,433.74 1,405.07 23000 564.09 535.89 616.27 603.95 603.95 591.87 # 23000 365.56 347.28 399.37 391.38 391.38 383.55 23020 682.56 648.43 745.69 730.78 730.78 716.16 23030 425.91 404.61 465.30 456.00 456.00 446.88 # 23030 254.01 241.31 277.51 271.95 271.95 266.51 23031 408.66 388.23 446.46 437.54 437.54 428.79 # 23031 216.71 205.87 236.75 232.01 232.01 227.38 23035 670.71 637.17 732.75 718.09 718.09 703.73 23040 713.28 677.62 779.26 763.68 763.68 748.41 23044 563.60 535.42 615.73 603.42 603.42 591.35

Page 39: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 39Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

23065 211.53 200.95 231.09 226.47 226.47 221.94 # 23065 166.17 157.86 181.54 177.91 177.91 174.35 23066 536.66 509.83 586.30 574.57 574.57 563.09 # 23066 351.61 334.03 384.13 376.45 376.45 368.92 23071 418.68 397.75 457.41 448.27 448.27 439.30 23073 692.74 658.10 756.82 741.68 741.68 726.85 23075 454.94 432.19 497.02 487.08 487.08 477.34 # 23075 323.46 307.29 353.38 346.31 346.31 339.39 23076 537.21 510.35 586.90 575.16 575.16 563.66 23077 1,148.46 1,091.04 1,254.70 1,229.60 1,229.60 1,205.02 23078 1,440.91 1,368.86 1,574.19 1,542.70 1,542.70 1,511.85 23100 491.30 466.74 536.75 526.02 526.02 515.50 23101 448.59 426.16 490.08 480.29 480.29 470.68 23105 631.23 599.67 689.62 675.83 675.83 662.32 23106 485.15 460.89 530.02 519.42 519.42 509.04 23107 652.53 619.90 712.89 698.63 698.63 684.65 23120 576.49 547.67 629.82 617.23 617.23 604.89 23125 703.50 668.33 768.58 753.20 753.20 738.14 23130 602.61 572.48 658.35 645.18 645.18 632.28 23140 528.72 502.28 577.62 566.06 566.06 554.75 23145 689.19 654.73 752.94 737.89 737.89 723.13 23146 613.13 582.47 669.84 656.44 656.44 643.31 23150 650.29 617.78 710.45 696.23 696.23 682.31 23155 787.30 747.94 860.13 842.93 842.93 826.07 23156 669.58 636.10 731.52 716.89 716.89 702.55 23170 548.79 521.35 599.55 587.56 587.56 575.81 23172 559.16 531.20 610.88 598.67 598.67 586.70 23174 742.83 705.69 811.54 795.32 795.32 779.41 23180 660.90 627.86 722.04 707.60 707.60 693.44 23182 644.45 612.23 704.06 689.99 689.99 676.19 23184 727.90 691.51 795.24 779.33 779.33 763.75 23190 562.04 533.94 614.03 601.75 601.75 589.71 23195 746.67 709.34 815.74 799.42 799.42 783.44 23200 1,489.91 1,415.41 1,627.72 1,595.17 1,595.17 1,563.26 23210 1,776.28 1,687.47 1,940.59 1,901.78 1,901.78 1,863.75 23220 1,945.00 1,847.75 2,124.91 2,082.42 2,082.42 2,040.77 23330 229.92 218.42 251.18 246.16 246.16 241.24 # 23330 148.40 140.98 162.13 158.88 158.88 155.71 23333 447.45 425.08 488.84 479.07 479.07 469.49 23334 1,072.83 1,019.19 1,172.07 1,148.63 1,148.63 1,125.65 23335 1,278.58 1,214.65 1,396.85 1,368.91 1,368.91 1,341.53 23350 125.12 118.86 136.69 133.95 133.95 131.27 # 23350 51.49 48.92 56.26 55.13 55.13 54.03 23395 1,280.34 1,216.32 1,398.77 1,370.79 1,370.79 1,343.37 23397 1,137.73 1,080.84 1,242.97 1,218.10 1,218.10 1,193.75 23400 967.07 918.72 1,056.53 1,035.40 1,035.40 1,014.69 23405 619.16 588.20 676.43 662.91 662.91 649.65 23406 763.43 725.26 834.05 817.36 817.36 801.02 23410 816.22 775.41 891.72 873.89 873.89 856.41

Page 40: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 40Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

23412 846.97 804.62 925.31 906.81 906.81 888.67 23415 689.87 655.38 753.69 738.61 738.61 723.83 23420 963.04 914.89 1,052.12 1,031.08 1,031.08 1,010.46 23430 739.54 702.56 807.94 791.79 791.79 775.95 23440 750.42 712.90 819.84 803.44 803.44 787.37 23450 940.89 893.85 1,027.93 1,007.37 1,007.37 987.22 23455 996.04 946.24 1,088.18 1,066.42 1,066.42 1,045.09 23460 1,087.27 1,032.91 1,187.85 1,164.09 1,164.09 1,140.81 23462 1,057.24 1,004.38 1,155.04 1,131.93 1,131.93 1,109.29 23465 1,108.32 1,052.90 1,210.84 1,186.62 1,186.62 1,162.88 23466 1,112.20 1,056.59 1,215.08 1,190.78 1,190.78 1,166.96 23470 1,201.17 1,141.11 1,312.28 1,286.03 1,286.03 1,260.31 23472 1,456.96 1,384.11 1,591.73 1,559.89 1,559.89 1,528.70 23473 1,628.33 1,546.91 1,778.95 1,743.37 1,743.37 1,708.50 23474 1,759.86 1,671.87 1,922.65 1,884.19 1,884.19 1,846.51 23480 816.27 775.46 891.78 873.94 873.94 856.46 23485 950.76 903.22 1,038.70 1,017.93 1,017.93 997.58 23490 837.49 795.62 914.96 896.67 896.67 878.74 23491 1,008.47 958.05 1,101.76 1,079.72 1,079.72 1,058.13 23500 211.98 201.38 231.59 226.95 226.95 222.41 # 23500 215.59 204.81 235.53 230.82 230.82 226.21 23505 344.19 326.98 376.03 368.51 368.51 361.13 # 23505 326.11 309.80 356.27 349.14 349.14 342.16 23515 713.62 677.94 779.63 764.04 764.04 748.75 23520 217.93 207.03 238.08 233.32 233.32 228.65 # 23520 221.22 210.16 241.68 236.85 236.85 232.12 23525 365.46 347.19 399.27 391.29 391.29 383.47 # 23525 339.17 322.21 370.54 363.14 363.14 355.87 23530 545.48 518.21 595.94 584.03 584.03 572.34 23532 612.88 582.24 669.58 656.19 656.19 643.07 23540 218.03 207.13 238.20 233.44 233.44 228.77 # 23540 221.65 210.57 242.16 237.31 237.31 232.56 23545 329.36 312.89 359.82 352.62 352.62 345.58 # 23545 300.76 285.72 328.58 322.01 322.01 315.57 23550 557.88 529.99 609.49 597.30 597.30 585.35 23552 648.44 616.02 708.42 694.26 694.26 680.37 23570 225.40 214.13 246.25 241.33 241.33 236.50 # 23570 231.97 220.37 253.43 248.35 248.35 243.39 23575 389.10 369.65 425.10 416.60 416.60 408.26 # 23575 366.09 347.79 399.96 391.95 391.95 384.11 23585 976.79 927.95 1,067.14 1,045.80 1,045.80 1,024.88 23600 315.66 299.88 344.86 337.96 337.96 331.20 # 23600 298.24 283.33 325.83 319.31 319.31 312.93 23605 451.98 429.38 493.79 483.91 483.91 474.23 # 23605 416.15 395.34 454.64 445.54 445.54 436.63 23615 878.48 834.56 959.74 940.55 940.55 921.74 23616 1,239.38 1,177.41 1,354.02 1,326.94 1,326.94 1,300.40 23620 260.88 247.84 285.02 279.31 279.31 273.72 # 23620 248.71 236.27 271.71 266.27 266.27 260.95

Page 41: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 41Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

23625 369.11 350.65 403.25 395.19 395.19 387.29 # 23625 344.79 327.55 376.68 369.15 369.15 361.77 23630 774.51 735.78 846.15 829.22 829.22 812.64 23650 304.67 289.44 332.86 326.20 326.20 319.68 # 23650 281.01 266.96 307.00 300.86 300.86 294.85 23655 393.45 373.78 429.85 421.25 421.25 412.82 23660 574.73 545.99 627.89 615.33 615.33 603.03 23665 414.11 393.40 452.41 443.36 443.36 434.49 # 23665 387.16 367.80 422.97 414.51 414.51 406.21 23670 870.20 826.69 950.69 931.68 931.68 913.05 23675 538.35 511.43 588.14 576.38 576.38 564.86 # 23675 492.99 468.34 538.59 527.82 527.82 517.26 23680 922.79 876.65 1,008.15 987.99 987.99 968.23 23700 194.32 184.60 212.29 208.05 208.05 203.88 23800 1,022.34 971.22 1,116.90 1,094.57 1,094.57 1,072.67 23802 1,258.73 1,195.79 1,375.16 1,347.65 1,347.65 1,320.69 23900 1,387.53 1,318.15 1,515.87 1,485.56 1,485.56 1,455.84 23920 1,120.29 1,064.28 1,223.92 1,199.44 1,199.44 1,175.45 23921 461.38 438.31 504.06 493.97 493.97 484.09 23930 341.45 324.38 373.04 365.57 365.57 358.26 # 23930 214.25 203.54 234.07 229.39 229.39 224.80 23931 275.18 261.42 300.63 294.62 294.62 288.73 # 23931 156.85 149.01 171.36 167.93 167.93 164.58 23935 498.98 474.03 545.13 534.23 534.23 523.55 24000 469.97 446.47 513.44 503.17 503.17 493.11 24006 699.78 664.79 764.51 749.21 749.21 734.23 24065 247.43 235.06 270.32 264.91 264.91 259.61 # 24065 165.59 157.31 180.91 177.28 177.28 173.74 24066 605.22 574.96 661.20 647.98 647.98 635.02 # 24066 411.63 391.05 449.71 440.71 440.71 431.91 24071 404.70 384.47 442.14 433.30 433.30 424.63 24073 690.96 656.41 754.87 739.77 739.77 724.97 24075 475.38 451.61 519.35 508.97 508.97 498.79 # 24075 326.81 310.47 357.04 349.90 349.90 342.90 24076 539.37 512.40 589.26 577.47 577.47 565.93 24077 1,036.79 984.95 1,132.69 1,110.04 1,110.04 1,087.84 24079 1,326.50 1,260.18 1,449.21 1,420.23 1,420.23 1,391.82 24100 411.47 390.90 449.54 440.54 440.54 431.73 24101 493.13 468.47 538.74 527.97 527.97 517.41 24102 609.63 579.15 666.02 652.71 652.71 639.65 24105 342.81 325.67 374.52 367.03 367.03 359.70 24110 573.13 544.47 626.14 613.62 613.62 601.35 24115 732.13 695.52 799.85 783.85 783.85 768.18 24116 858.14 815.23 937.51 918.77 918.77 900.39 24120 521.83 495.74 570.10 558.70 558.70 547.53 24125 606.28 575.97 662.37 649.12 649.12 636.13 24126 643.08 610.93 702.57 688.52 688.52 674.75 24130 500.80 475.76 547.12 536.18 536.18 525.46 24134 740.59 703.56 809.09 792.91 792.91 777.06

Page 42: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 42Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

24136 618.25 587.34 675.44 661.93 661.93 648.69 24138 663.66 630.48 725.05 710.55 710.55 696.34 24140 693.69 659.01 757.86 742.70 742.70 727.85 24145 586.02 556.72 640.23 627.43 627.43 614.88 24147 612.95 582.30 669.65 656.25 656.25 643.13 24149 1,165.53 1,107.25 1,273.34 1,247.88 1,247.88 1,222.92 24150 1,558.98 1,481.03 1,703.18 1,669.12 1,669.12 1,635.74 24152 1,320.61 1,254.58 1,442.77 1,413.91 1,413.91 1,385.64 24155 839.76 797.77 917.44 899.08 899.08 881.10 24160 1,261.26 1,198.20 1,377.93 1,350.38 1,350.38 1,323.37 24164 725.13 688.87 792.20 776.35 776.35 760.83 24200 200.04 190.04 218.55 214.18 214.18 209.90 # 24200 137.92 131.02 150.67 147.66 147.66 144.70 24201 528.22 501.81 577.08 565.54 565.54 554.22 # 24201 357.30 339.44 390.36 382.55 382.55 374.90 24220 154.07 146.37 168.33 164.96 164.96 161.66 # 24220 69.60 66.12 76.04 74.52 74.52 73.03 24300 406.38 386.06 443.97 435.09 435.09 426.39 24301 743.12 705.96 811.85 795.62 795.62 779.70 24305 569.04 540.59 621.68 609.25 609.25 597.06 24310 464.97 441.72 507.98 497.82 497.82 487.86 24320 776.12 737.31 847.91 830.94 830.94 814.33 24330 712.24 676.63 778.12 762.57 762.57 747.32 24331 781.37 742.30 853.65 836.57 836.57 819.84 24332 604.80 574.56 660.74 647.53 647.53 634.58 24340 605.46 575.19 661.47 648.24 648.24 635.28 24341 736.90 700.06 805.07 788.97 788.97 773.19 24342 769.80 731.31 841.01 824.18 824.18 807.70 24343 697.18 662.32 761.67 746.43 746.43 731.50 24344 1,089.04 1,034.59 1,189.78 1,165.99 1,165.99 1,142.66 24345 694.93 660.18 759.21 744.03 744.03 729.15 24346 1,086.72 1,032.38 1,187.24 1,163.49 1,163.49 1,140.23 24357 422.34 401.22 461.40 452.18 452.18 443.14 24358 514.65 488.92 562.26 551.01 551.01 539.99 24359 652.44 619.82 712.79 698.53 698.53 684.56 24360 880.69 836.66 962.16 942.92 942.92 924.06 24361 993.52 943.84 1,085.42 1,063.70 1,063.70 1,042.43 24362 1,056.94 1,004.09 1,154.70 1,131.61 1,131.61 1,108.98 24363 1,453.66 1,380.98 1,588.13 1,556.36 1,556.36 1,525.23 24365 630.49 598.97 688.82 675.04 675.04 661.54 24366 673.55 639.87 735.85 721.13 721.13 706.71 24370 1,554.26 1,476.55 1,698.03 1,664.07 1,664.07 1,630.79 24371 1,783.53 1,694.35 1,948.50 1,909.53 1,909.53 1,871.34 24400 810.37 769.85 885.33 867.62 867.62 850.26 24410 1,053.25 1,000.59 1,150.68 1,127.67 1,127.67 1,105.12 24420 973.53 924.85 1,063.58 1,042.30 1,042.30 1,021.45 24430 1,051.64 999.06 1,148.92 1,125.94 1,125.94 1,103.43 24435 1,069.86 1,016.37 1,168.83 1,145.45 1,145.45 1,122.54 24470 563.93 535.73 616.09 603.77 603.77 591.70

Page 43: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 43Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

24495 644.93 612.68 704.58 690.49 690.49 676.68 24498 861.00 817.95 940.64 921.83 921.83 903.39 24500 346.63 329.30 378.70 371.12 371.12 363.70 # 24500 317.05 301.20 346.38 339.46 339.46 332.67 24505 486.33 462.01 531.31 520.69 520.69 510.27 # 24505 442.29 420.18 483.21 473.55 473.55 464.07 24515 869.63 826.15 950.07 931.07 931.07 912.46 24516 855.50 812.73 934.64 915.95 915.95 897.63 24530 368.68 350.25 402.79 394.74 394.74 386.85 # 24530 335.48 318.71 366.52 359.19 359.19 352.00 24535 600.82 570.78 656.40 643.26 643.26 630.40 # 24535 557.43 529.56 608.99 596.82 596.82 584.88 24538 735.47 698.70 803.51 787.44 787.44 771.70 24545 923.81 877.62 1,009.26 989.08 989.08 969.30 24546 1,034.08 982.38 1,129.74 1,107.14 1,107.14 1,085.00 24560 309.22 293.76 337.82 331.06 331.06 324.44 # 24560 278.32 264.40 304.06 297.98 297.98 292.02 24565 517.13 491.27 564.96 553.66 553.66 542.58 # 24565 477.04 453.19 521.17 510.75 510.75 500.54 24566 708.38 672.96 773.90 758.43 758.43 743.26 24575 722.50 686.38 789.34 773.55 773.55 758.08 24576 328.00 311.60 358.34 351.18 351.18 344.15 # 24576 296.11 281.30 323.50 317.02 317.02 310.68 24577 530.98 504.43 580.09 568.49 568.49 557.12 # 24577 489.57 465.09 534.85 524.16 524.16 513.67 24579 828.80 787.36 905.46 887.35 887.35 869.61 24582 794.70 754.97 868.22 850.85 850.85 833.83 24586 1,078.72 1,024.78 1,178.50 1,154.92 1,154.92 1,131.82 24587 1,076.21 1,022.40 1,175.76 1,152.24 1,152.24 1,129.20 24600 354.87 337.13 387.70 379.95 379.95 372.35 # 24600 326.60 310.27 356.81 349.67 349.67 342.68 24605 461.65 438.57 504.36 494.27 494.27 484.38 24615 706.17 670.86 771.49 756.06 756.06 740.93 24620 541.41 514.34 591.49 579.66 579.66 568.07 24635 665.17 631.91 726.70 712.16 712.16 697.91 24640 130.09 123.59 142.13 139.29 139.29 136.51 # 24640 90.65 86.12 99.04 97.06 97.06 95.12 24650 252.09 239.49 275.41 269.91 269.91 264.51 # 24650 232.37 220.75 253.86 248.79 248.79 243.81 24655 422.68 401.55 461.78 452.55 452.55 443.50 # 24655 386.85 367.51 422.64 414.18 414.18 405.90 24665 643.20 611.04 702.70 688.64 688.64 674.87 24666 725.65 689.37 792.78 776.92 776.92 761.38 24670 281.03 266.98 307.03 300.89 300.89 294.87 # 24670 255.07 242.32 278.67 273.09 273.09 267.63 24675 441.85 419.76 482.72 473.06 473.06 463.60 # 24675 405.03 384.78 442.50 433.64 433.64 424.97 24685 645.61 613.33 705.33 691.22 691.22 677.40 24800 823.72 782.53 899.91 881.91 881.91 864.27

Page 44: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 44Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

24802 974.51 925.78 1,064.65 1,043.35 1,043.35 1,022.48 24900 726.34 690.02 793.52 777.65 777.65 762.11 24920 725.76 689.47 792.89 777.03 777.03 761.50 24925 543.22 516.06 593.47 581.60 581.60 569.97 24930 764.26 726.05 834.96 818.26 818.26 801.90 24931 801.69 761.61 875.85 858.34 858.34 841.17 24935 1,108.70 1,053.27 1,211.26 1,187.03 1,187.03 1,163.29 25000 328.44 312.02 358.82 351.65 351.65 344.61 25001 334.13 317.42 365.03 357.73 357.73 350.58 25020 560.17 532.16 611.98 599.75 599.75 587.75 25023 1,084.14 1,029.93 1,184.42 1,160.73 1,160.73 1,137.51 25024 766.85 728.51 837.79 821.03 821.03 804.61 25025 1,201.32 1,141.25 1,312.44 1,286.19 1,286.19 1,260.47 25028 510.11 484.60 557.29 546.15 546.15 535.22 25031 352.32 334.70 384.91 377.21 377.21 369.67 25035 571.28 542.72 624.13 611.65 611.65 599.41 25040 555.23 527.47 606.59 594.46 594.46 582.57 25065 244.79 232.55 267.43 262.09 262.09 256.84 # 25065 160.97 152.92 175.86 172.34 172.34 168.89 25066 352.71 335.07 385.33 377.63 377.63 370.07 25071 423.40 402.23 462.56 453.32 453.32 444.26 25073 526.67 500.34 575.39 563.88 563.88 552.60 25075 462.15 439.04 504.90 494.80 494.80 484.90 # 25075 312.60 296.97 341.52 334.68 334.68 327.99 25076 510.06 484.56 557.24 546.10 546.10 535.18 25077 882.45 838.33 964.08 944.79 944.79 925.90 25078 1,163.59 1,105.41 1,271.22 1,245.80 1,245.80 1,220.87 25085 442.09 419.99 482.99 473.33 473.33 463.86 25100 338.39 321.47 369.69 362.30 362.30 355.05 25101 395.21 375.45 431.77 423.13 423.13 414.67 25105 473.86 450.17 517.70 507.35 507.35 497.20 25107 605.20 574.94 661.18 647.96 647.96 635.00 25109 529.19 502.73 578.14 566.58 566.58 555.25 25110 335.76 318.97 366.82 359.48 359.48 352.29 25111 312.96 297.31 341.91 335.06 335.06 328.36 25112 379.32 360.35 414.40 406.11 406.11 397.99 25115 748.49 711.07 817.73 801.38 801.38 785.35 25116 589.51 560.03 644.03 631.15 631.15 618.53 25118 373.76 355.07 408.33 400.17 400.17 392.16 25119 486.03 461.73 530.99 520.38 520.38 509.97 25120 488.91 464.46 534.13 523.45 523.45 512.98 25125 573.58 544.90 626.64 614.10 614.10 601.82 25126 586.72 557.38 640.99 628.16 628.16 615.61 25130 437.59 415.71 478.07 468.51 468.51 459.14 25135 545.59 518.31 596.06 584.13 584.13 572.45 25136 482.22 458.11 526.83 516.29 516.29 505.97 25145 509.91 484.41 557.07 545.93 545.93 535.01 25150 558.69 530.76 610.37 598.16 598.16 586.20 25151 576.24 547.43 629.54 616.95 616.95 604.61

Page 45: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 45Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

25170 1,480.33 1,406.31 1,617.26 1,584.91 1,584.91 1,553.21 25210 478.70 454.77 522.99 512.52 512.52 502.27 25215 608.66 578.23 664.96 651.67 651.67 638.64 25230 425.03 403.78 464.35 455.06 455.06 445.96 25240 419.71 398.72 458.53 449.36 449.36 440.38 25246 156.16 148.35 170.60 167.19 167.19 163.84 # 25246 75.96 72.16 82.98 81.33 81.33 79.71 25248 409.95 389.45 447.87 438.91 438.91 430.13 25250 515.17 489.41 562.82 551.56 551.56 540.53 25251 711.07 675.52 776.85 761.31 761.31 746.09 25259 403.39 383.22 440.70 431.89 431.89 423.26 25260 620.22 589.21 677.59 664.04 664.04 650.76 25263 611.92 581.32 668.52 655.14 655.14 642.05 25265 740.13 703.12 808.59 792.42 792.42 776.57 25270 480.90 456.86 525.39 514.88 514.88 504.59 25272 544.77 517.53 595.16 583.26 583.26 571.60 25274 655.48 622.71 716.12 701.80 701.80 687.76 25275 663.12 629.96 724.45 709.96 709.96 695.76 25280 554.67 526.94 605.98 593.86 593.86 581.98 25290 428.82 407.38 468.49 459.11 459.11 449.94 25295 515.10 489.35 562.75 551.49 551.49 540.47 25300 672.48 638.86 734.69 719.99 719.99 705.59 25301 634.98 603.23 693.71 679.85 679.85 666.25 25310 610.75 580.21 667.24 653.90 653.90 640.83 25312 707.06 671.71 772.47 757.02 757.02 741.88 25315 764.53 726.30 835.25 818.54 818.54 802.16 25316 908.80 863.36 992.86 973.00 973.00 953.55 25320 972.93 924.28 1,062.92 1,041.66 1,041.66 1,020.82 25332 833.35 791.68 910.43 892.23 892.23 874.38 25335 806.11 765.80 880.67 863.05 863.05 845.79 25337 877.37 833.50 958.53 939.35 939.35 920.56 25350 665.50 632.23 727.06 712.53 712.53 698.28 25355 746.05 708.75 815.06 798.77 798.77 782.79 25360 645.69 613.41 705.42 691.31 691.31 677.49 25365 905.90 860.61 989.70 969.91 969.91 950.51 25370 999.41 949.44 1,091.86 1,070.02 1,070.02 1,048.62 25375 947.87 900.48 1,035.55 1,014.84 1,014.84 994.54 25390 761.75 723.66 832.21 815.57 815.57 799.26 25391 991.50 941.93 1,083.22 1,061.55 1,061.55 1,040.32 25392 869.20 825.74 949.60 930.61 930.61 912.01 25393 1,125.40 1,069.13 1,229.50 1,204.91 1,204.91 1,180.82 25394 773.28 734.62 844.81 827.92 827.92 811.36 25400 796.81 756.97 870.52 853.10 853.10 836.04 25405 1,030.46 978.94 1,125.78 1,103.26 1,103.26 1,081.20 25415 957.45 909.58 1,046.02 1,025.10 1,025.10 1,004.59 25420 1,162.27 1,104.16 1,269.78 1,244.39 1,244.39 1,219.51 25425 958.33 910.41 1,046.97 1,026.03 1,026.03 1,005.51 25426 1,121.02 1,064.97 1,224.72 1,200.22 1,200.22 1,176.22 25430 724.11 687.90 791.09 775.26 775.26 759.76

Page 46: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 46Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

25431 779.56 740.58 851.67 834.64 834.64 817.94 25440 758.71 720.77 828.89 812.30 812.30 796.05 25441 925.25 878.99 1,010.84 990.62 990.62 970.81 25442 797.22 757.36 870.96 853.54 853.54 836.48 25443 775.10 736.35 846.80 829.86 829.86 813.27 25444 820.13 779.12 895.99 878.07 878.07 860.51 25445 714.46 678.74 780.55 764.95 764.95 749.65 25446 1,163.85 1,105.66 1,271.51 1,246.08 1,246.08 1,221.16 25447 817.47 776.60 893.09 875.23 875.23 857.73 25449 1,025.66 974.38 1,120.54 1,098.12 1,098.12 1,076.16 25450 515.04 489.29 562.68 551.43 551.43 540.40 25455 610.56 580.03 667.03 653.69 653.69 640.62 25490 712.70 677.07 778.63 763.06 763.06 747.80 25491 733.86 697.17 801.75 785.71 785.71 770.01 25492 898.75 853.81 981.88 962.24 962.24 943.00 25500 264.23 251.02 288.67 282.90 282.90 277.24 # 25500 243.52 231.34 266.04 260.72 260.72 255.51 25505 489.66 465.18 534.96 524.26 524.26 513.77 # 25505 450.55 428.02 492.22 482.38 482.38 472.73 25515 661.23 628.17 722.40 707.95 707.95 693.80 25520 547.13 519.77 597.74 585.78 585.78 574.06 # 25520 520.83 494.79 569.01 557.62 557.62 546.47 25525 776.35 737.53 848.16 831.20 831.20 814.57 25526 943.47 896.30 1,030.75 1,010.13 1,010.13 989.92 25530 252.55 239.92 275.91 270.39 270.39 264.98 # 25530 229.87 218.38 251.14 246.11 246.11 241.19 25535 476.66 452.83 520.75 510.34 510.34 500.12 # 25535 443.13 420.97 484.12 474.43 474.43 464.95 25545 614.15 583.44 670.96 657.54 657.54 644.38 25560 268.12 254.71 292.92 287.06 287.06 281.32 # 25560 243.47 231.30 266.00 260.67 260.67 255.46 25565 506.50 481.18 553.36 542.29 542.29 531.45 # 25565 460.81 437.77 503.44 493.36 493.36 483.49 25574 664.18 630.97 725.62 711.10 711.10 696.88 25575 892.91 848.26 975.50 955.98 955.98 936.86 25600 315.84 300.05 345.06 338.16 338.16 331.40 # 25600 299.40 284.43 327.09 320.55 320.55 314.15 25605 532.87 506.23 582.16 570.53 570.53 559.12 # 25605 502.96 477.81 549.48 538.49 538.49 527.72 25606 653.43 620.76 713.87 699.59 699.59 685.60 25607 725.60 689.32 792.72 776.86 776.86 761.32 25608 814.93 774.18 890.31 872.51 872.51 855.06 25609 1,037.30 985.44 1,133.26 1,110.59 1,110.59 1,088.38 25622 293.46 278.79 320.61 314.19 314.19 307.91 # 25622 268.48 255.06 293.32 287.45 287.45 281.70 25624 461.57 438.49 504.26 494.18 494.18 484.30 # 25624 422.78 401.64 461.89 452.65 452.65 443.60 25628 712.31 676.69 778.19 762.63 762.63 747.39 25630 295.29 280.53 322.61 316.16 316.16 309.83

Page 47: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 47Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 25630 272.61 258.98 297.83 291.87 291.87 286.03 25635 414.21 393.50 452.53 443.47 443.47 434.61 # 25635 372.14 353.53 406.56 398.43 398.43 390.46 25645 560.23 532.22 612.05 599.82 599.82 587.82 25650 310.06 294.56 338.74 331.97 331.97 325.34 # 25650 291.66 277.08 318.64 312.27 312.27 306.03 25651 475.13 451.37 519.08 508.69 508.69 498.51 25652 615.57 584.79 672.51 659.05 659.05 645.87 25660 399.49 379.52 436.45 427.72 427.72 419.16 25670 598.78 568.84 654.17 641.08 641.08 628.26 25671 521.40 495.33 569.63 558.23 558.23 547.07 25675 422.05 400.95 461.09 451.87 451.87 442.83 # 25675 386.88 367.54 422.67 414.22 414.22 405.94 25676 618.87 587.93 676.12 662.60 662.60 649.35 25680 465.03 441.78 508.05 497.88 497.88 487.92 25685 726.30 689.99 793.49 777.62 777.62 762.07 25690 467.14 443.78 510.35 500.14 500.14 490.13 25695 627.20 595.84 685.22 671.51 671.51 658.08 25800 724.11 687.90 791.09 775.26 775.26 759.76 25805 838.60 796.67 916.17 897.85 897.85 879.90 25810 858.32 815.40 937.71 918.95 918.95 900.58 25820 604.34 574.12 660.24 647.04 647.04 634.10 25825 745.38 708.11 814.33 798.04 798.04 782.08 25830 926.05 879.75 1,011.71 991.48 991.48 971.66 25900 701.12 666.06 765.97 750.65 750.65 735.64 25905 646.07 613.77 705.84 691.71 691.71 677.88 25907 576.65 547.82 629.99 617.39 617.39 605.04 25909 679.01 645.06 741.82 726.98 726.98 712.45 25915 1,175.19 1,116.43 1,283.89 1,258.22 1,258.22 1,233.05 25920 685.94 651.64 749.39 734.40 734.40 719.72 25922 567.09 538.74 619.55 607.17 607.17 595.02 25924 604.18 573.97 660.07 646.86 646.86 633.93 25927 796.31 756.49 869.96 852.56 852.56 835.51 25929 584.51 555.28 638.57 625.80 625.80 613.28 25931 653.67 620.99 714.14 699.86 699.86 685.86 26010 251.14 238.58 274.37 268.88 268.88 263.50 # 26010 134.13 127.42 146.53 143.60 143.60 140.73 26011 370.85 352.31 405.16 397.05 397.05 389.10 # 26011 181.52 172.44 198.31 194.34 194.34 190.45 26020 425.06 403.81 464.38 455.09 455.09 445.99 26025 414.54 393.81 452.88 443.82 443.82 434.94 26030 483.87 459.68 528.63 518.06 518.06 507.70 26034 528.06 501.66 576.91 565.37 565.37 554.07 26035 842.85 800.71 920.82 902.41 902.41 884.36 26037 559.79 531.80 611.57 599.33 599.33 587.35 26040 304.02 288.82 332.14 325.50 325.50 318.99 26045 460.62 437.59 503.23 493.17 493.17 483.30 26055 531.02 504.47 580.14 568.54 568.54 557.16 # 26055 301.60 286.52 329.50 322.91 322.91 316.45

Page 48: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 48Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

26060 258.45 245.53 282.36 276.71 276.71 271.18 26070 307.40 292.03 335.83 329.12 329.12 322.54 26075 325.64 309.36 355.76 348.65 348.65 341.68 26080 381.83 362.74 417.15 408.81 408.81 400.64 26100 326.40 310.08 356.59 349.46 349.46 342.47 26105 325.73 309.44 355.86 348.74 348.74 341.77 26110 313.92 298.22 342.95 336.10 336.10 329.37 26111 412.09 391.49 450.21 441.21 441.21 432.39 26113 540.48 513.46 590.48 578.67 578.67 567.10 26115 484.62 460.39 529.45 518.86 518.86 508.48 # 26115 326.52 310.19 356.72 349.59 349.59 342.60 26116 519.13 493.17 567.15 555.81 555.81 544.69 26117 740.86 703.82 809.39 793.20 793.20 777.34 26118 1,042.97 990.82 1,139.44 1,116.65 1,116.65 1,094.32 26121 588.31 558.89 642.72 629.87 629.87 617.27 26123 822.26 781.15 898.32 880.36 880.36 862.75 26125 275.78 261.99 301.29 295.26 295.26 289.36 26130 454.65 431.92 496.71 486.77 486.77 477.03 26135 540.71 513.67 590.72 578.91 578.91 567.33 26140 495.36 470.59 541.18 530.36 530.36 519.75 26145 503.19 478.03 549.73 538.74 538.74 527.97 26160 547.71 520.32 598.37 586.40 586.40 574.67 # 26160 325.52 309.24 355.63 348.52 348.52 341.55 26170 396.68 376.85 433.38 424.71 424.71 416.21 26180 433.66 411.98 473.78 464.30 464.30 455.02 26185 532.35 505.73 581.59 569.96 569.96 558.57 26200 442.37 420.25 483.29 473.63 473.63 464.15 26205 595.98 566.18 651.11 638.09 638.09 625.32 26210 433.38 411.71 473.47 464.00 464.00 454.72 26215 556.20 528.39 607.65 595.49 595.49 583.58 26230 490.81 466.27 536.21 525.48 525.48 514.97 26235 485.42 461.15 530.32 519.72 519.72 509.32 26236 433.54 411.86 473.64 464.16 464.16 454.88 26250 1,068.26 1,014.85 1,167.08 1,143.73 1,143.73 1,120.86 26260 792.88 753.24 866.23 848.91 848.91 831.93 26262 616.45 585.63 673.47 660.01 660.01 646.81 26320 339.78 322.79 371.21 363.78 363.78 356.50 26340 322.20 306.09 352.00 344.97 344.97 338.07 26341 95.49 90.72 104.33 102.25 102.25 100.20 # 26341 73.47 69.80 80.27 78.66 78.66 77.08 26350 679.34 645.37 742.18 727.33 727.33 712.78 26352 786.74 747.40 859.51 842.32 842.32 825.47 26356 854.80 812.06 933.87 915.19 915.19 896.89 26357 845.20 802.94 923.38 904.91 904.91 886.81 26358 940.87 893.83 1,027.90 1,007.34 1,007.34 987.19 26370 725.34 689.07 792.43 776.58 776.58 761.05 26372 846.94 804.59 925.28 906.78 906.78 888.64 26373 812.78 772.14 887.96 870.21 870.21 852.81 26390 811.55 770.97 886.62 868.88 868.88 851.51

Page 49: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 49Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

26392 935.06 888.31 1,021.56 1,001.12 1,001.12 981.10 26410 539.36 512.39 589.25 577.46 577.46 565.92 26412 652.69 620.06 713.07 698.81 698.81 684.84 26415 742.09 704.99 810.74 794.52 794.52 778.63 26416 704.47 669.25 769.64 754.25 754.25 739.16 26418 548.81 521.37 599.58 587.58 587.58 575.83 26420 678.14 644.23 740.86 726.05 726.05 711.53 26426 492.37 467.75 537.91 527.16 527.16 516.61 26428 724.35 688.13 791.35 775.53 775.53 760.01 26432 475.10 451.35 519.05 508.67 508.67 498.49 26433 507.19 481.83 554.10 543.02 543.02 532.16 26434 620.90 589.86 678.34 664.77 664.77 651.48 26437 596.42 566.60 651.59 638.56 638.56 625.78 26440 589.23 559.77 643.74 630.86 630.86 618.24 26442 926.44 880.12 1,012.14 991.90 991.90 972.06 26445 547.41 520.04 598.05 586.09 586.09 574.37 26449 681.77 647.68 744.83 729.94 729.94 715.35 26450 390.66 371.13 426.80 418.27 418.27 409.91 26455 384.53 365.30 420.10 411.69 411.69 403.45 26460 376.79 357.95 411.64 403.41 403.41 395.34 26471 587.40 558.03 641.73 628.90 628.90 616.32 26474 575.89 547.10 629.17 616.58 616.58 604.26 26476 552.46 524.84 603.57 591.49 591.49 579.66 26477 554.58 526.85 605.88 593.76 593.76 581.88 26478 593.95 564.25 648.89 635.92 635.92 623.20 26479 585.87 556.58 640.07 627.27 627.27 614.72 26480 717.58 681.70 783.96 768.28 768.28 752.92 26483 809.71 769.22 884.60 866.92 866.92 849.57 26485 774.10 735.40 845.71 828.79 828.79 812.22 26489 876.84 833.00 957.95 938.79 938.79 920.01 26490 757.64 719.76 827.72 811.16 811.16 794.94 26492 841.45 799.38 919.29 900.90 900.90 882.88 26494 761.29 723.23 831.71 815.09 815.09 798.78 26496 828.36 786.94 904.98 886.88 886.88 869.15 26497 839.98 797.98 917.68 899.32 899.32 881.34 26498 1,116.11 1,060.30 1,219.35 1,194.95 1,194.95 1,171.06 26499 804.02 763.82 878.39 860.82 860.82 843.61 26500 596.83 566.99 652.04 639.00 639.00 626.22 26502 668.80 635.36 730.66 716.05 716.05 701.73 26508 616.39 585.57 673.41 659.94 659.94 646.74 26510 567.51 539.13 620.00 607.60 607.60 595.45 26516 672.03 638.43 734.19 719.51 719.51 705.12 26517 796.64 756.81 870.33 852.92 852.92 835.87 26518 795.05 755.30 868.60 851.22 851.22 834.20 26520 619.58 588.60 676.89 663.35 663.35 650.08 26525 620.35 589.33 677.73 664.17 664.17 650.89 26530 527.76 501.37 576.58 565.04 565.04 553.74 26531 614.52 583.79 671.36 657.93 657.93 644.77 26535 413.63 392.95 451.89 442.85 442.85 434.00

Page 50: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 50Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

26536 680.98 646.93 743.97 729.09 729.09 714.51 26540 629.95 598.45 688.22 674.45 674.45 660.96 26541 772.33 733.71 843.77 826.90 826.90 810.36 26542 650.15 617.64 710.29 696.08 696.08 682.16 26545 662.18 629.07 723.43 708.96 708.96 694.78 26546 957.70 909.82 1,046.29 1,025.36 1,025.36 1,004.86 26548 731.41 694.84 799.07 783.08 783.08 767.42 26550 1,516.88 1,441.04 1,657.20 1,624.05 1,624.05 1,591.58 26551 2,839.57 2,697.59 3,102.23 3,040.19 3,040.19 2,979.39 26553 3,257.74 3,094.85 3,559.08 3,487.89 3,487.89 3,418.13 26554 3,304.93 3,139.68 3,610.63 3,538.42 3,538.42 3,467.65 26555 1,311.39 1,245.82 1,432.69 1,404.04 1,404.04 1,375.95 26556 3,383.89 3,214.70 3,696.91 3,622.97 3,622.97 3,550.51 26560 537.04 510.19 586.72 574.99 574.99 563.49 26561 901.80 856.71 985.22 965.52 965.52 946.21 26562 1,313.45 1,247.78 1,434.95 1,406.24 1,406.24 1,378.11 26565 649.76 617.27 709.86 695.66 695.66 681.74 26567 653.61 620.93 714.07 699.79 699.79 685.79 26568 868.05 824.65 948.35 929.38 929.38 910.80 26580 1,435.57 1,363.79 1,568.36 1,536.99 1,536.99 1,506.25 26587 906.95 861.60 990.84 971.03 971.03 951.60 26590 1,329.46 1,262.99 1,452.44 1,423.39 1,423.39 1,394.93 26591 413.49 392.82 451.74 442.70 442.70 433.85 26593 572.58 543.95 625.54 613.03 613.03 600.77 26596 730.11 693.60 797.64 781.69 781.69 766.06 26600 283.29 269.13 309.50 303.31 303.31 297.25 # 26600 267.52 254.14 292.26 286.42 286.42 280.69 26605 310.79 295.25 339.54 332.75 332.75 326.09 # 26605 284.49 270.27 310.81 304.59 304.59 298.49 26607 445.79 423.50 487.03 477.28 477.28 467.74 26608 466.43 443.11 509.58 499.39 499.39 489.41 26615 566.35 538.03 618.73 606.36 606.36 594.23 26641 357.35 339.48 390.40 382.59 382.59 374.95 # 26641 327.76 311.37 358.08 350.91 350.91 343.90 26645 410.56 390.03 448.53 439.56 439.56 430.78 # 26645 379.00 360.05 414.06 405.78 405.78 397.66 26650 466.77 443.43 509.94 499.74 499.74 489.75 26665 623.29 592.13 680.95 667.33 667.33 653.98 26670 329.40 312.93 359.87 352.67 352.67 345.62 # 26670 300.48 285.46 328.28 321.71 321.71 315.28 26675 439.50 417.53 480.16 470.56 470.56 461.15 # 26675 405.64 385.36 443.16 434.30 434.30 425.62 26676 489.44 464.97 534.72 524.02 524.02 513.54 26685 566.30 537.99 618.69 606.31 606.31 594.19 26686 616.51 585.68 673.53 660.07 660.07 646.86 26700 313.55 297.87 342.55 335.70 335.70 328.98 # 26700 295.47 280.70 322.81 316.35 316.35 310.03 26705 404.83 384.59 442.28 433.44 433.44 424.76 # 26705 372.62 353.99 407.09 398.95 398.95 390.97

Page 51: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 51Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

26706 431.38 409.81 471.28 461.85 461.85 452.62 26715 561.80 533.71 613.77 601.50 601.50 589.47 26720 190.67 181.14 208.31 204.15 204.15 200.07 # 26720 177.85 168.96 194.30 190.42 190.42 186.61 26725 326.41 310.09 356.60 349.47 349.47 342.48 # 26725 295.84 281.05 323.21 316.74 316.74 310.41 26727 458.76 435.82 501.19 491.17 491.17 481.34 26735 586.61 557.28 640.87 628.05 628.05 615.49 26740 221.70 210.62 242.21 237.37 237.37 232.62 # 26740 208.88 198.44 228.21 223.64 223.64 219.17 26742 357.75 339.86 390.84 383.02 383.02 375.36 # 26742 326.53 310.20 356.73 349.60 349.60 342.61 26746 731.78 695.19 799.47 783.48 783.48 767.81 26750 177.61 168.73 194.04 190.16 190.16 186.36 # 26750 177.94 169.04 194.40 190.51 190.51 186.70 26755 303.41 288.24 331.48 324.85 324.85 318.35 # 26755 265.61 252.33 290.18 284.37 284.37 278.68 26756 407.16 386.80 444.82 435.92 435.92 427.20 26765 490.81 466.27 536.21 525.48 525.48 514.97 26770 266.83 253.49 291.51 285.68 285.68 279.97 # 26770 248.09 235.69 271.04 265.63 265.63 260.31 26775 370.56 352.03 404.83 396.74 396.74 388.80 # 26775 337.03 320.18 368.21 360.85 360.85 353.63 26776 432.30 410.69 472.29 462.85 462.85 453.59 26785 537.43 510.56 587.14 575.40 575.40 563.89 26820 759.65 721.67 829.92 813.33 813.33 797.07 26841 697.06 662.21 761.54 746.32 746.32 731.39 26842 756.90 719.06 826.92 810.38 810.38 794.18 26843 713.10 677.45 779.07 763.49 763.49 748.21 26844 781.79 742.70 854.11 837.03 837.03 820.28 26850 663.96 630.76 725.37 710.86 710.86 696.65 26852 765.99 727.69 836.84 820.11 820.11 803.71 26860 538.36 511.44 588.16 576.39 576.39 564.87 26861 103.92 98.72 113.53 111.26 111.26 109.04 26862 697.68 662.80 762.22 746.97 746.97 732.03 26863 232.14 220.53 253.61 248.54 248.54 243.57 26910 694.46 659.74 758.70 743.53 743.53 728.66 26951 625.95 594.65 683.85 670.17 670.17 656.77 26952 619.08 588.13 676.35 662.83 662.83 649.57 26990 616.80 585.96 673.85 660.38 660.38 647.17 26991 683.75 649.56 746.99 732.06 732.06 717.42 # 26991 516.12 490.31 563.86 552.58 552.58 541.52 26992 952.00 904.40 1,040.06 1,019.26 1,019.26 998.87 27000 411.82 391.23 449.91 440.92 440.92 432.10 27001 530.54 504.01 579.61 568.02 568.02 556.66 27003 588.89 559.45 643.37 630.50 630.50 617.88 27005 717.81 681.92 784.21 768.52 768.52 753.15 27006 728.77 692.33 796.18 780.25 780.25 764.65 27025 908.97 863.52 993.05 973.19 973.19 953.73

Page 52: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 52Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27027 896.61 851.78 979.55 959.95 959.95 940.76 27030 932.50 885.88 1,018.76 998.38 998.38 978.42 27033 968.30 919.89 1,057.87 1,036.71 1,036.71 1,015.98 27035 1,146.30 1,088.99 1,252.34 1,227.29 1,227.29 1,202.75 27036 1,004.34 954.12 1,097.24 1,075.30 1,075.30 1,053.79 27040 332.27 315.66 363.01 355.75 355.75 348.63 # 27040 198.83 188.89 217.22 212.88 212.88 208.62 27041 686.44 652.12 749.94 734.94 734.94 720.25 27043 470.19 446.68 513.68 503.41 503.41 493.35 27045 749.05 711.60 818.34 801.98 801.98 785.93 27047 456.20 433.39 498.40 488.43 488.43 478.66 # 27047 359.89 341.90 393.19 385.32 385.32 377.61 27048 610.03 579.53 666.46 653.13 653.13 640.07 27049 1,354.72 1,286.98 1,480.03 1,450.43 1,450.43 1,421.42 27050 377.72 358.83 412.65 404.40 404.40 396.31 27052 569.81 541.32 622.52 610.06 610.06 597.86 27054 678.09 644.19 740.82 726.01 726.01 711.48 27057 1,011.83 961.24 1,105.43 1,083.32 1,083.32 1,061.66 27059 1,829.53 1,738.05 1,998.76 1,958.78 1,958.78 1,919.60 27060 456.92 434.07 499.18 489.20 489.20 479.41 27062 450.63 428.10 492.32 482.47 482.47 472.82 27065 504.82 479.58 551.52 540.49 540.49 529.68 27066 804.27 764.06 878.67 861.10 861.10 843.87 27067 1,019.42 968.45 1,113.72 1,091.44 1,091.44 1,069.62 27070 840.05 798.05 917.76 899.40 899.40 881.42 27071 908.82 863.38 992.89 973.03 973.03 953.57 27075 2,103.08 1,997.93 2,297.62 2,251.67 2,251.67 2,206.63 27076 2,540.59 2,413.56 2,775.59 2,720.08 2,720.08 2,665.68 27077 2,856.94 2,714.09 3,121.20 3,058.78 3,058.78 2,997.60 27078 2,070.98 1,967.43 2,262.54 2,217.29 2,217.29 2,172.95 27080 509.15 483.69 556.24 545.12 545.12 534.22 27086 278.18 264.27 303.91 297.83 297.83 291.87 # 27086 163.14 154.98 178.23 174.66 174.66 171.17 27087 622.23 591.12 679.79 666.20 666.20 652.87 27090 825.12 783.86 901.44 883.41 883.41 865.74 27091 1,599.34 1,519.37 1,747.28 1,712.33 1,712.33 1,678.08 27093 179.71 170.72 196.33 192.41 192.41 188.55 # 27093 70.59 67.06 77.12 75.58 75.58 74.07 27095 230.72 219.18 252.06 247.02 247.02 242.08 # 27095 83.14 78.98 90.83 89.01 89.01 87.23 27096 155.56 147.78 169.95 166.54 166.54 163.21 # 27096 84.56 80.33 92.38 90.53 90.53 88.72 27097 667.48 634.11 729.23 714.64 714.64 700.35 27098 662.97 629.82 724.29 709.80 709.80 695.61 27100 811.89 771.30 887.00 869.25 869.25 851.86 27105 861.42 818.35 941.10 922.28 922.28 903.83 27110 962.62 914.49 1,051.66 1,030.63 1,030.63 1,010.02 27111 894.94 850.19 977.72 958.17 958.17 939.01 27120 1,299.39 1,234.42 1,419.58 1,391.19 1,391.19 1,363.37

Page 53: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 53Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27122 1,096.44 1,041.62 1,197.86 1,173.91 1,173.91 1,150.43 27125 1,131.63 1,075.05 1,236.31 1,211.58 1,211.58 1,187.35 27130 1,357.57 1,289.69 1,483.14 1,453.49 1,453.49 1,424.41 27132 1,677.18 1,593.32 1,832.32 1,795.67 1,795.67 1,759.75 27134 1,923.79 1,827.60 2,101.74 2,059.71 2,059.71 2,018.51 27137 1,475.88 1,402.09 1,612.40 1,580.16 1,580.16 1,548.56 27138 1,533.86 1,457.17 1,675.75 1,642.23 1,642.23 1,609.39 27140 889.61 845.13 971.90 952.46 952.46 933.42 27146 1,285.52 1,221.24 1,404.43 1,376.34 1,376.34 1,348.81 27147 1,472.60 1,398.97 1,608.82 1,576.64 1,576.64 1,545.11 27151 1,590.17 1,510.66 1,737.26 1,702.52 1,702.52 1,668.47 27156 1,720.82 1,634.78 1,880.00 1,842.39 1,842.39 1,805.55 27158 1,425.93 1,354.63 1,557.82 1,526.67 1,526.67 1,496.14 27161 1,212.40 1,151.78 1,324.55 1,298.05 1,298.05 1,272.10 27165 1,372.17 1,303.56 1,499.09 1,469.11 1,469.11 1,439.73 27170 1,175.04 1,116.29 1,283.73 1,258.05 1,258.05 1,232.89 27175 663.79 630.60 725.19 710.69 710.69 696.47 27176 895.69 850.91 978.55 958.97 958.97 939.79 27177 1,111.56 1,055.98 1,214.38 1,190.09 1,190.09 1,166.28 27178 913.79 868.10 998.32 978.35 978.35 958.79 27179 972.68 924.05 1,062.66 1,041.41 1,041.41 1,020.58 27181 965.21 916.95 1,054.49 1,033.40 1,033.40 1,012.74 27185 607.21 576.85 663.38 650.11 650.11 637.10 27187 987.49 938.12 1,078.84 1,057.26 1,057.26 1,036.12 27193 464.50 441.28 507.47 497.32 497.32 487.37 # 27193 470.41 446.89 513.92 503.64 503.64 493.57 27194 702.63 667.50 767.63 752.27 752.27 737.23 27200 175.82 167.03 192.08 188.24 188.24 184.48 # 27200 183.05 173.90 199.99 195.98 195.98 192.06 27202 525.48 499.21 574.09 562.61 562.61 551.37 27220 523.63 497.45 572.07 560.63 560.63 549.41 # 27220 519.36 493.39 567.40 556.05 556.05 544.93 27222 972.57 923.94 1,062.53 1,041.28 1,041.28 1,020.45 27226 1,054.52 1,001.79 1,152.06 1,129.01 1,129.01 1,106.44 27227 1,662.03 1,578.93 1,815.77 1,779.45 1,779.45 1,743.86 27228 1,896.54 1,801.71 2,071.97 2,030.53 2,030.53 1,989.93 27230 466.44 443.12 509.59 499.40 499.40 489.41 # 27230 463.81 440.62 506.71 496.58 496.58 486.65 27232 751.94 714.34 821.49 805.06 805.06 788.96 27235 906.13 860.82 989.94 970.14 970.14 950.74 27236 1,194.78 1,135.04 1,305.30 1,279.19 1,279.19 1,253.60 27238 453.12 430.46 495.03 485.13 485.13 475.42 27240 953.15 905.49 1,041.31 1,020.49 1,020.49 1,000.07 27244 1,230.00 1,168.50 1,343.78 1,316.90 1,316.90 1,290.56 27245 1,229.65 1,168.17 1,343.40 1,316.53 1,316.53 1,290.20 27246 379.30 360.34 414.39 406.10 406.10 397.98 # 27246 381.27 362.21 416.54 408.22 408.22 400.05 27248 740.12 703.11 808.58 792.41 792.41 776.56 27250 184.07 174.87 201.10 197.08 197.08 193.13

Page 54: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 54Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27252 755.40 717.63 825.27 808.77 808.77 792.59 27253 936.92 890.07 1,023.58 1,003.11 1,003.11 983.04 27254 1,266.36 1,203.04 1,383.50 1,355.83 1,355.83 1,328.71 27256 295.06 280.31 322.36 315.91 315.91 309.59 # 27256 235.57 223.79 257.36 252.21 252.21 247.16 27257 362.91 344.76 396.47 388.54 388.54 380.77 27258 1,108.21 1,052.80 1,210.72 1,186.50 1,186.50 1,162.78 27259 1,555.00 1,477.25 1,698.84 1,664.87 1,664.87 1,631.57 27265 392.01 372.41 428.27 419.70 419.70 411.31 27266 575.99 547.19 629.27 616.69 616.69 604.36 27267 428.56 407.13 468.20 458.84 458.84 449.66 27268 526.84 500.50 575.58 564.06 564.06 552.78 27269 1,241.59 1,179.51 1,356.44 1,329.31 1,329.31 1,302.72 27275 179.24 170.28 195.82 191.90 191.90 188.06 27279 691.85 657.26 755.85 740.73 740.73 725.91 27280 1,370.50 1,301.98 1,497.28 1,467.33 1,467.33 1,437.98 27282 820.58 779.55 896.48 878.55 878.55 860.98 27284 1,564.04 1,485.84 1,708.72 1,674.54 1,674.54 1,641.05 27286 1,636.65 1,554.82 1,788.04 1,752.28 1,752.28 1,717.24 27290 1,612.43 1,531.81 1,761.58 1,726.35 1,726.35 1,691.82 27295 1,263.39 1,200.22 1,380.25 1,352.65 1,352.65 1,325.61 27301 654.49 621.77 715.04 700.73 700.73 686.71 # 27301 497.38 472.51 543.39 532.52 532.52 521.87 27303 631.45 599.88 689.86 676.06 676.06 662.54 27305 474.90 451.16 518.83 508.46 508.46 498.30 27306 350.23 332.72 382.63 374.98 374.98 367.48 27307 455.70 432.92 497.86 487.90 487.90 478.14 27310 725.29 689.03 792.38 776.54 776.54 761.01 27323 262.01 248.91 286.25 280.52 280.52 274.91 # 27323 176.23 167.42 192.53 188.68 188.68 184.91 27324 394.17 374.46 430.63 422.02 422.02 413.57 27325 540.60 513.57 590.61 578.80 578.80 567.21 27326 511.94 486.34 559.29 548.10 548.10 537.14 27327 445.17 422.91 486.35 476.62 476.62 467.08 # 27327 310.74 295.20 339.48 332.70 332.70 326.04 27328 618.47 587.55 675.68 662.17 662.17 648.92 27329 1,037.26 985.40 1,133.21 1,110.54 1,110.54 1,088.34 27330 412.24 391.63 450.37 441.37 441.37 432.54 27331 468.56 445.13 511.90 501.66 501.66 491.64 27332 633.85 602.16 692.48 678.64 678.64 665.07 27333 579.20 550.24 632.78 620.13 620.13 607.73 27334 676.75 642.91 739.35 724.56 724.56 710.07 27335 757.36 719.49 827.41 810.87 810.87 794.65 27337 417.34 396.47 455.94 446.82 446.82 437.89 27339 753.43 715.76 823.12 806.66 806.66 790.52 27340 365.45 347.18 399.26 391.28 391.28 383.46 27345 474.38 450.66 518.26 507.90 507.90 497.74 27347 522.98 496.83 571.35 559.92 559.92 548.72 27350 644.33 612.11 703.93 689.85 689.85 676.05

Page 55: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 55Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27355 595.39 565.62 650.46 637.46 637.46 624.70 27356 730.16 693.65 797.70 781.75 781.75 766.11 27357 807.62 767.24 882.33 864.69 864.69 847.39 27358 280.62 266.59 306.58 300.45 300.45 294.43 27360 843.07 800.92 921.06 902.64 902.64 884.58 27364 1,568.86 1,490.42 1,713.98 1,679.70 1,679.70 1,646.11 27365 2,077.19 1,973.33 2,269.33 2,223.94 2,223.94 2,179.46 27370 148.06 140.66 161.76 158.53 158.53 155.35 # 27370 51.10 48.55 55.83 54.72 54.72 53.62 27372 586.68 557.35 640.95 628.13 628.13 615.57 # 27372 398.68 378.75 435.56 426.86 426.86 418.32 27380 585.60 556.32 639.77 626.97 626.97 614.43 27381 788.96 749.51 861.94 844.70 844.70 827.80 27385 565.70 537.42 618.03 605.67 605.67 593.56 27386 821.15 780.09 897.10 879.16 879.16 861.58 27390 441.25 419.19 482.07 472.43 472.43 462.98 27391 570.43 541.91 623.20 610.73 610.73 598.52 27392 703.35 668.18 768.41 753.04 753.04 737.98 27393 500.34 475.32 546.62 535.68 535.68 524.96 27394 629.80 598.31 688.06 674.29 674.29 660.80 27395 873.29 829.63 954.07 935.00 935.00 916.30 27396 609.88 579.39 666.30 652.97 652.97 639.91 27397 898.07 853.17 981.15 961.53 961.53 942.30 27400 688.27 653.86 751.94 736.90 736.90 722.15 27403 634.02 602.32 692.67 678.81 678.81 665.23 27405 667.77 634.38 729.54 714.94 714.94 700.65 27407 771.61 733.03 842.98 826.13 826.13 809.60 27409 948.70 901.27 1,036.46 1,015.73 1,015.73 995.42 27412 1,653.94 1,571.24 1,806.93 1,770.79 1,770.79 1,735.37 27415 1,368.22 1,299.81 1,494.78 1,464.88 1,464.88 1,435.58 27416 975.10 926.35 1,065.30 1,043.99 1,043.99 1,023.11 27418 823.08 781.93 899.22 881.23 881.23 863.60 27420 738.33 701.41 806.62 790.49 790.49 774.67 27422 735.80 699.01 803.86 787.78 787.78 772.03 27424 742.73 705.59 811.43 795.20 795.20 779.30 27425 441.16 419.10 481.97 472.33 472.33 462.89 27427 706.00 670.70 771.31 755.88 755.88 740.76 27428 1,107.52 1,052.14 1,209.96 1,185.77 1,185.77 1,162.05 27429 1,238.63 1,176.70 1,353.21 1,326.15 1,326.15 1,299.63 27430 733.30 696.64 801.14 785.12 785.12 769.42 27435 799.20 759.24 873.13 855.67 855.67 838.56 27437 654.97 622.22 715.55 701.25 701.25 687.22 27438 835.59 793.81 912.88 894.62 894.62 876.73 27440 793.37 753.70 866.76 849.42 849.42 832.44 27441 818.13 777.22 893.80 875.93 875.93 858.42 27442 864.58 821.35 944.55 925.66 925.66 907.14 27443 802.09 761.99 876.29 858.76 858.76 841.59 27445 1,246.97 1,184.62 1,362.31 1,335.07 1,335.07 1,308.37 27446 1,159.32 1,101.35 1,266.55 1,241.22 1,241.22 1,216.39

Page 56: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 56Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27447 1,357.24 1,289.38 1,482.79 1,453.13 1,453.13 1,424.07 27448 772.26 733.65 843.70 826.83 826.83 810.29 27450 1,006.39 956.07 1,099.48 1,077.49 1,077.49 1,055.94 27454 1,299.45 1,234.48 1,419.65 1,391.26 1,391.26 1,363.43 27455 936.88 890.04 1,023.55 1,003.08 1,003.08 983.02 27457 943.61 896.43 1,030.89 1,010.28 1,010.28 990.07 27465 1,234.77 1,173.03 1,348.98 1,322.01 1,322.01 1,295.57 27466 1,175.33 1,116.56 1,284.04 1,258.36 1,258.36 1,233.20 27468 1,233.80 1,172.11 1,347.93 1,320.97 1,320.97 1,294.56 27470 1,172.35 1,113.73 1,280.79 1,255.18 1,255.18 1,230.07 27472 1,261.03 1,197.98 1,377.68 1,350.12 1,350.12 1,323.12 27475 656.32 623.50 717.03 702.68 702.68 688.63 27477 726.11 689.80 793.27 777.40 777.40 761.85 27479 789.25 749.79 862.26 845.01 845.01 828.10 27485 665.23 631.97 726.77 712.23 712.23 697.98 27486 1,406.62 1,336.29 1,536.73 1,505.99 1,505.99 1,475.88 27487 1,761.62 1,673.54 1,924.57 1,886.08 1,886.08 1,848.36 27488 1,198.26 1,138.35 1,309.10 1,282.92 1,282.92 1,257.26 27495 1,125.37 1,069.10 1,229.47 1,204.88 1,204.88 1,180.79 27496 534.41 507.69 583.84 572.17 572.17 560.73 27497 573.12 544.46 626.13 613.61 613.61 601.34 27498 639.91 607.91 699.10 685.11 685.11 671.42 27499 691.36 656.79 755.31 740.20 740.20 725.40 27500 509.89 484.40 557.06 545.92 545.92 535.00 # 27500 474.07 450.37 517.93 507.56 507.56 497.41 27501 496.72 471.88 542.66 531.81 531.81 521.17 # 27501 493.10 468.45 538.72 527.94 527.94 517.39 27502 761.87 723.78 832.35 815.70 815.70 799.38 27503 797.76 757.87 871.55 854.12 854.12 837.04 27506 1,335.65 1,268.87 1,459.20 1,430.01 1,430.01 1,401.41 27507 971.55 922.97 1,061.42 1,040.19 1,040.19 1,019.38 27508 515.08 489.33 562.73 551.47 551.47 540.44 # 27508 486.49 462.17 531.50 520.87 520.87 510.45 27509 633.55 601.87 692.15 678.30 678.30 664.73 27510 678.32 644.40 741.06 726.24 726.24 711.71 27511 997.08 947.23 1,089.31 1,067.53 1,067.53 1,046.18 27513 1,243.54 1,181.36 1,358.56 1,331.39 1,331.39 1,304.77 27514 966.72 918.38 1,056.14 1,035.01 1,035.01 1,014.31 27516 497.41 472.54 543.42 532.55 532.55 521.90 # 27516 468.81 445.37 512.18 501.93 501.93 491.89 27517 669.33 635.86 731.24 716.61 716.61 702.28 27519 890.95 846.40 973.36 953.89 953.89 934.81 27520 312.82 297.18 341.76 334.93 334.93 328.23 # 27520 286.52 272.19 313.02 306.76 306.76 300.63 27524 746.95 709.60 816.04 799.72 799.72 783.73 27530 291.82 277.23 318.81 312.44 312.44 306.20 # 27530 272.10 258.50 297.28 291.33 291.33 285.50 27532 605.06 574.81 661.03 647.81 647.81 634.85 # 27532 570.22 541.71 622.97 610.51 610.51 598.30

Page 57: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 57Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27535 896.54 851.71 979.47 959.88 959.88 940.69 27536 1,187.79 1,128.40 1,297.66 1,271.70 1,271.70 1,246.27 27538 461.00 437.95 503.64 493.57 493.57 483.70 # 27538 433.39 411.72 473.48 464.01 464.01 454.73 27540 804.31 764.09 878.70 861.13 861.13 843.90 27550 494.39 469.67 540.12 529.32 529.32 518.73 # 27550 460.54 437.51 503.14 493.07 493.07 483.21 27552 618.38 587.46 675.58 662.07 662.07 648.83 27556 873.40 829.73 954.19 935.11 935.11 916.41 27557 1,049.51 997.03 1,146.58 1,123.65 1,123.65 1,101.18 27558 1,192.11 1,132.50 1,302.38 1,276.33 1,276.33 1,250.80 27560 352.06 334.46 384.63 376.94 376.94 369.39 # 27560 326.09 309.79 356.26 349.13 349.13 342.15 27562 462.04 438.94 504.78 494.68 494.68 484.79 27566 887.54 843.16 969.63 950.25 950.25 931.24 27570 148.90 141.46 162.68 159.42 159.42 156.24 27580 1,433.95 1,362.25 1,566.59 1,535.26 1,535.26 1,504.56 27590 817.21 776.35 892.80 874.94 874.94 857.44 27591 961.31 913.24 1,050.23 1,029.23 1,029.23 1,008.64 27592 691.88 657.29 755.88 740.76 740.76 725.95 27594 509.58 484.10 556.72 545.58 545.58 534.67 27596 731.82 695.23 799.51 783.53 783.53 767.86 27598 730.14 693.63 797.67 781.72 781.72 766.08 27600 411.87 391.28 449.97 440.97 440.97 432.15 27601 440.85 418.81 481.63 471.99 471.99 462.55 27602 497.35 472.48 543.35 532.48 532.48 521.84 27603 517.42 491.55 565.28 553.98 553.98 542.90 # 27603 385.94 366.64 421.64 413.21 413.21 404.94 27604 481.64 457.56 526.19 515.67 515.67 505.36 # 27604 342.94 325.79 374.66 367.16 367.16 359.81 27605 330.48 313.96 361.05 353.83 353.83 346.76 # 27605 183.55 174.37 200.53 196.51 196.51 192.58 27606 282.00 267.90 308.09 301.92 301.92 295.88 27607 603.79 573.60 659.64 646.45 646.45 633.52 27610 646.86 614.52 706.70 692.56 692.56 678.72 27612 552.86 525.22 604.00 591.93 591.93 580.09 27613 243.98 231.78 266.55 261.21 261.21 255.99 # 27613 160.82 152.78 175.70 172.18 172.18 168.74 27614 563.83 535.64 615.99 603.67 603.67 591.59 # 27614 402.11 382.00 439.30 430.51 430.51 421.90 27615 1,024.66 973.43 1,119.44 1,097.05 1,097.05 1,075.11 27616 1,274.20 1,210.49 1,392.06 1,364.22 1,364.22 1,336.93 27618 435.75 413.96 476.05 466.53 466.53 457.21 # 27618 303.95 288.75 332.06 325.43 325.43 318.92 27619 466.64 443.31 509.81 499.61 499.61 489.61 27620 449.67 427.19 491.27 481.45 481.45 471.82 27625 582.00 552.90 635.84 623.12 623.12 610.65 27626 614.57 583.84 671.42 657.98 657.98 644.83 27630 544.77 517.53 595.16 583.26 583.26 571.60

Page 58: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 58Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 27630 362.68 344.55 396.23 388.31 388.31 380.55 27632 413.46 392.79 451.71 442.67 442.67 433.81 27634 685.68 651.40 749.11 734.13 734.13 719.44 27635 582.67 553.54 636.57 623.84 623.84 611.36 27637 743.36 706.19 812.12 795.88 795.88 779.96 27638 759.40 721.43 829.64 813.05 813.05 796.79 27640 831.09 789.54 907.97 889.81 889.81 872.02 27641 665.71 632.42 727.28 712.74 712.74 698.48 27645 1,778.23 1,689.32 1,942.72 1,903.86 1,903.86 1,865.78 27646 1,540.25 1,463.24 1,682.73 1,649.08 1,649.08 1,616.10 27647 1,030.86 979.32 1,126.22 1,103.69 1,103.69 1,081.62 27648 156.66 148.83 171.15 167.73 167.73 164.37 # 27648 53.13 50.47 58.04 56.88 56.88 55.74 27650 653.41 620.74 713.85 699.58 699.58 685.58 27652 681.65 647.57 744.71 729.81 729.81 715.22 27654 703.73 668.54 768.82 753.45 753.45 738.38 27656 613.32 582.65 670.05 656.65 656.65 643.52 # 27656 390.47 370.95 426.59 418.06 418.06 409.70 27658 369.34 350.87 403.50 395.43 395.43 387.52 27659 478.68 454.75 522.96 512.51 512.51 502.26 27664 356.67 338.84 389.67 381.87 381.87 374.23 27665 407.39 387.02 445.07 436.17 436.17 427.44 27675 483.96 459.76 528.72 518.14 518.14 507.78 27676 599.30 569.34 654.74 641.64 641.64 628.81 27680 425.77 404.48 465.15 455.85 455.85 446.73 27681 538.63 511.70 588.46 576.69 576.69 565.16 27685 648.17 615.76 708.12 693.96 693.96 680.08 # 27685 460.82 437.78 503.45 493.37 493.37 483.51 27686 553.59 525.91 604.80 592.70 592.70 580.84 27687 450.25 427.74 491.90 482.07 482.07 472.43 27690 625.17 593.91 683.00 669.33 669.33 655.95 27691 743.54 706.36 812.31 796.06 796.06 780.15 27692 105.94 100.64 115.74 113.42 113.42 111.16 27695 471.26 447.70 514.86 504.56 504.56 494.48 27696 553.71 526.02 604.92 592.83 592.83 580.97 27698 638.56 606.63 697.62 683.68 683.68 670.00 27700 593.42 563.75 648.31 635.35 635.35 622.64 27702 964.04 915.84 1,053.22 1,032.15 1,032.15 1,011.51 27703 1,108.18 1,052.77 1,210.69 1,186.47 1,186.47 1,162.74 27704 571.73 543.14 624.61 612.12 612.12 599.87 27705 755.46 717.69 825.34 808.84 808.84 792.66 27707 397.42 377.55 434.18 425.50 425.50 416.99 27709 1,165.98 1,107.68 1,273.83 1,248.36 1,248.36 1,223.39 27712 1,097.58 1,042.70 1,199.11 1,175.13 1,175.13 1,151.62 27715 1,068.01 1,014.61 1,166.80 1,143.47 1,143.47 1,120.59 27720 870.41 826.89 950.92 931.90 931.90 913.26 27722 874.45 830.73 955.34 936.24 936.24 917.52 27724 1,265.63 1,202.35 1,382.70 1,355.05 1,355.05 1,327.94 27725 1,202.75 1,142.61 1,314.00 1,287.72 1,287.72 1,261.96

Page 59: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 59Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27726 965.72 917.43 1,055.04 1,033.94 1,033.94 1,013.27 27727 1,033.56 981.88 1,129.16 1,106.58 1,106.58 1,084.45 27730 565.40 537.13 617.70 605.35 605.35 593.24 27732 401.47 381.40 438.61 429.84 429.84 421.23 27734 650.71 618.17 710.90 696.68 696.68 682.74 27740 702.73 667.59 767.73 752.38 752.38 737.33 27742 766.11 727.80 836.97 820.23 820.23 803.83 27745 750.23 712.72 819.63 803.24 803.24 787.18 27750 336.00 319.20 367.08 359.74 359.74 352.54 # 27750 309.70 294.22 338.35 331.59 331.59 324.96 27752 526.90 500.56 575.64 564.13 564.13 552.85 # 27752 488.77 464.33 533.98 523.30 523.30 512.83 27756 566.07 537.77 618.44 606.06 606.06 593.94 27758 885.95 841.65 967.90 948.54 948.54 929.57 27759 995.83 946.04 1,087.95 1,066.19 1,066.19 1,044.87 27760 323.12 306.96 353.00 345.94 345.94 339.02 # 27760 296.17 281.36 323.56 317.09 317.09 310.75 27762 464.28 441.07 507.23 497.09 497.09 487.15 # 27762 425.49 404.22 464.85 455.56 455.56 446.45 27766 604.17 573.96 660.05 646.85 646.85 633.91 27767 272.29 258.68 297.48 291.54 291.54 285.71 # 27767 273.93 260.23 299.26 293.28 293.28 287.42 27768 432.02 410.42 471.98 462.54 462.54 453.30 27769 725.46 689.19 792.57 776.72 776.72 761.19 27780 296.62 281.79 324.06 317.57 317.57 311.22 # 27780 270.98 257.43 296.04 290.12 290.12 284.31 27781 411.82 391.23 449.91 440.92 440.92 432.10 # 27781 383.23 364.07 418.68 410.31 410.31 402.10 27784 710.28 674.77 775.99 760.46 760.46 745.25 27786 306.41 291.09 334.75 328.06 328.06 321.49 # 27786 278.47 264.55 304.23 298.15 298.15 292.18 27788 410.57 390.04 448.55 439.58 439.58 430.79 # 27788 377.05 358.20 411.93 403.70 403.70 395.62 27792 647.17 614.81 707.03 692.89 692.89 679.03 27808 323.25 307.09 353.15 346.09 346.09 339.17 # 27808 291.70 277.12 318.69 312.32 312.32 306.07 27810 455.92 433.12 498.09 488.13 488.13 478.37 # 27810 416.15 395.34 454.64 445.54 445.54 436.63 27814 766.74 728.40 837.66 820.90 820.90 804.48 27816 310.20 294.69 338.89 332.12 332.12 325.47 # 27816 279.63 265.65 305.50 299.39 299.39 293.40 27818 473.22 449.56 516.99 506.66 506.66 496.52 # 27818 426.88 405.54 466.37 457.04 457.04 447.90 27822 833.50 791.83 910.60 892.39 892.39 874.54 27823 948.38 900.96 1,036.10 1,015.38 1,015.38 995.07 27824 305.50 290.23 333.76 327.09 327.09 320.55 # 27824 297.28 282.42 324.78 318.29 318.29 311.91 27825 535.09 508.34 584.59 572.90 572.90 561.44 # 27825 488.09 463.69 533.24 522.58 522.58 512.13

Page 60: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 60Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

27826 824.16 782.95 900.39 882.38 882.38 864.73 27827 1,073.09 1,019.44 1,172.36 1,148.91 1,148.91 1,125.93 27828 1,289.49 1,225.02 1,408.77 1,380.60 1,380.60 1,352.99 27829 676.21 642.40 738.76 723.98 723.98 709.50 27830 371.08 352.53 405.41 397.30 397.30 389.36 # 27830 347.09 329.74 379.20 371.62 371.62 364.19 27831 385.60 366.32 421.27 412.84 412.84 404.58 27832 750.71 713.17 820.15 803.75 803.75 787.67 27840 361.79 343.70 395.26 387.35 387.35 379.60 27842 489.66 465.18 534.96 524.26 524.26 513.77 27846 721.55 685.47 788.29 772.52 772.52 757.07 27848 807.65 767.27 882.36 864.71 864.71 847.41 27860 173.42 164.75 189.46 185.68 185.68 181.96 27870 1,028.46 977.04 1,123.60 1,101.13 1,101.13 1,079.10 27871 679.26 645.30 742.10 727.25 727.25 712.70 27880 934.91 888.16 1,021.38 1,000.96 1,000.96 980.94 27881 879.84 835.85 961.23 942.00 942.00 923.16 27882 611.82 581.23 668.41 655.05 655.05 641.95 27884 583.50 554.33 637.48 624.73 624.73 612.24 27886 666.48 633.16 728.13 713.58 713.58 699.30 27888 686.72 652.38 750.24 735.23 735.23 720.52 27889 662.55 629.42 723.83 709.35 709.35 695.16 27892 551.37 523.80 602.37 590.32 590.32 578.51 27893 598.52 568.59 653.88 640.80 640.80 627.99 27894 854.74 812.00 933.80 915.12 915.12 896.82 28001 270.38 256.86 295.39 289.48 289.48 283.69 # 28001 168.82 160.38 184.44 180.75 180.75 177.13 28002 435.76 413.97 476.07 466.54 466.54 457.22 # 28002 318.09 302.19 347.52 340.57 340.57 333.76 28003 700.02 665.02 764.77 749.48 749.48 734.49 # 28003 565.92 537.62 618.26 605.90 605.90 593.78 28005 577.12 548.26 630.50 617.88 617.88 605.52 28008 423.38 402.21 462.54 453.30 453.30 444.23 # 28008 291.25 276.69 318.19 311.83 311.83 305.60 28010 228.27 216.86 249.39 244.40 244.40 239.51 # 28010 206.57 196.24 225.68 221.17 221.17 216.74 28011 318.03 302.13 347.45 340.50 340.50 333.70 # 28011 285.49 271.22 311.90 305.67 305.67 299.55 28020 529.99 503.49 579.01 567.43 567.43 556.08 # 28020 359.41 341.44 392.66 384.80 384.80 377.11 28022 478.58 454.65 522.85 512.39 512.39 502.15 # 28022 323.11 306.95 352.99 345.93 345.93 339.01 28024 451.90 429.31 493.71 483.83 483.83 474.16 # 28024 302.68 287.55 330.68 324.07 324.07 317.58 28035 515.55 489.77 563.24 551.97 551.97 540.93 # 28035 352.20 334.59 384.78 377.09 377.09 369.54 28039 501.48 476.41 547.87 536.91 536.91 526.17 # 28039 349.96 332.46 382.33 374.68 374.68 367.18 28041 460.01 437.01 502.56 492.51 492.51 482.66

Page 61: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 61Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

28043 391.54 371.96 427.75 419.20 419.20 410.81 # 28043 260.72 247.68 284.83 279.14 279.14 273.56 28045 486.95 462.60 531.99 521.35 521.35 510.92 # 28045 345.95 328.65 377.95 370.39 370.39 362.99 28046 731.66 695.08 799.34 783.36 783.36 767.69 28047 1,074.05 1,020.35 1,173.40 1,149.93 1,149.93 1,126.93 28050 416.33 395.51 454.84 445.74 445.74 436.83 # 28050 277.96 264.06 303.67 297.60 297.60 291.64 28052 438.14 416.23 478.66 469.10 469.10 459.71 # 28052 283.33 269.16 309.53 303.35 303.35 297.28 28054 382.67 363.54 418.07 409.71 409.71 401.51 # 28054 242.32 230.20 264.73 259.44 259.44 254.25 28055 374.43 355.71 409.07 400.89 400.89 392.87 28060 509.01 483.56 556.09 544.97 544.97 534.07 # 28060 354.86 337.12 387.69 379.94 379.94 372.34 28062 576.98 548.13 630.35 617.75 617.75 605.39 # 28062 406.39 386.07 443.98 435.10 435.10 426.40 28070 522.84 496.70 571.21 559.79 559.79 548.58 # 28070 353.57 335.89 386.27 378.55 378.55 370.98 28072 495.59 470.81 541.43 530.60 530.60 519.98 # 28072 329.28 312.82 359.74 352.54 352.54 345.49 28080 512.14 486.53 559.51 548.32 548.32 537.35 # 28080 361.94 343.84 395.42 387.50 387.50 379.75 28086 536.66 509.83 586.30 574.57 574.57 563.09 # 28086 358.51 340.58 391.67 383.84 383.84 376.15 28088 437.88 415.99 478.39 468.82 468.82 459.45 # 28088 280.11 266.10 306.02 299.90 299.90 293.89 28090 461.25 438.19 503.92 493.84 493.84 483.97 # 28090 306.11 290.80 334.42 327.73 327.73 321.17 28092 413.39 392.72 451.63 442.60 442.60 433.75 # 28092 266.14 252.83 290.75 284.94 284.94 279.23 28100 595.06 565.31 650.11 637.10 637.10 624.36 # 28100 409.69 389.21 447.59 438.64 438.64 429.87 28102 599.10 569.15 654.52 641.44 641.44 628.60 28103 391.27 371.71 427.47 418.92 418.92 410.54 28104 517.59 491.71 565.47 554.16 554.16 543.08 # 28104 350.94 333.39 383.40 375.73 375.73 368.22 28106 462.03 438.93 504.77 494.67 494.67 484.78 28107 548.47 521.05 599.21 587.22 587.22 575.48 # 28107 371.96 353.36 406.36 398.23 398.23 390.26 28108 431.70 410.12 471.64 462.21 462.21 452.96 # 28108 286.10 271.80 312.57 306.31 306.31 300.18 28110 452.91 430.26 494.80 484.90 484.90 475.20 # 28110 287.26 272.90 313.84 307.56 307.56 301.40 28111 484.67 460.44 529.51 518.91 518.91 508.54 # 28111 325.59 309.31 355.71 348.59 348.59 341.62 28112 479.34 455.37 523.68 513.20 513.20 502.93 # 28112 311.38 295.81 340.18 333.37 333.37 326.70 28113 580.53 551.50 634.23 621.54 621.54 609.11

Page 62: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 62Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 28113 421.45 400.38 460.44 451.23 451.23 442.20 28114 1,058.09 1,005.19 1,155.97 1,132.85 1,132.85 1,110.20 # 28114 831.96 790.36 908.91 890.73 890.73 872.92 28116 745.31 708.04 814.25 797.96 797.96 782.00 # 28116 569.14 540.68 621.78 609.35 609.35 597.16 28118 583.35 554.18 637.31 624.57 624.57 612.08 # 28118 410.79 390.25 448.79 439.82 439.82 431.02 28119 516.31 490.49 564.06 552.78 552.78 541.73 # 28119 359.20 341.24 392.43 384.58 384.58 376.89 28120 667.25 633.89 728.97 714.39 714.39 700.11 # 28120 495.67 470.89 541.52 530.69 530.69 520.08 28122 589.64 560.16 644.18 631.30 631.30 618.68 # 28122 438.12 416.21 478.64 469.07 469.07 459.69 28124 468.00 444.60 511.29 501.07 501.07 491.05 # 28124 327.65 311.27 357.96 350.80 350.80 343.78 28126 387.23 367.87 423.05 414.59 414.59 406.30 # 28126 246.55 234.22 269.35 263.97 263.97 258.69 28130 637.83 605.94 696.83 682.89 682.89 669.23 28140 591.02 561.47 645.69 632.78 632.78 620.13 # 28140 441.14 419.08 481.94 472.31 472.31 462.86 28150 419.42 398.45 458.22 449.05 449.05 440.07 # 28150 279.40 265.43 305.24 299.14 299.14 293.16 28153 402.52 382.39 439.75 430.95 430.95 422.34 # 28153 261.18 248.12 285.34 279.63 279.63 274.05 28160 412.37 391.75 450.51 441.51 441.51 432.68 # 28160 267.75 254.36 292.51 286.66 286.66 280.92 28171 852.87 810.23 931.76 913.13 913.13 894.87 28173 766.89 728.55 837.83 821.08 821.08 804.66 28175 488.62 464.19 533.82 523.15 523.15 512.68 28190 249.61 237.13 272.70 267.25 267.25 261.90 # 28190 132.93 126.28 145.22 142.31 142.31 139.47 28192 462.61 439.48 505.40 495.29 495.29 485.39 # 28192 312.73 297.09 341.65 334.82 334.82 328.13 28193 521.58 495.50 569.83 558.43 558.43 547.26 # 28193 367.10 348.75 401.06 393.05 393.05 385.18 28200 479.99 455.99 524.39 513.90 513.90 503.62 # 28200 319.26 303.30 348.80 341.81 341.81 334.98 28202 588.72 559.28 643.17 630.30 630.30 617.70 # 28202 425.69 404.41 465.07 455.77 455.77 446.65 28208 464.14 440.93 507.07 496.93 496.93 486.99 # 28208 309.00 293.55 337.58 330.83 330.83 324.22 28210 564.12 535.91 616.30 603.97 603.97 591.89 # 28210 407.01 386.66 444.66 435.77 435.77 427.05 28220 441.69 419.61 482.55 472.90 472.90 463.45 # 28220 299.70 284.72 327.43 320.88 320.88 314.47 28222 498.30 473.39 544.40 533.51 533.51 522.84 # 28222 347.76 330.37 379.93 372.32 372.32 364.87 28225 400.87 380.83 437.95 429.19 429.19 420.61 # 28225 257.24 244.38 281.04 275.41 275.41 269.91

Page 63: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 63Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

28226 592.12 562.51 646.89 633.95 633.95 621.26 # 28226 386.69 367.36 422.46 414.01 414.01 405.73 28230 426.62 405.29 466.08 456.76 456.76 447.63 # 28230 281.34 267.27 307.36 301.21 301.21 295.18 28232 378.91 359.96 413.95 405.67 405.67 397.56 # 28232 240.86 228.82 263.14 257.88 257.88 252.72 28234 399.10 379.15 436.02 427.31 427.31 418.76 # 28234 260.39 247.37 284.48 278.78 278.78 273.21 28238 661.88 628.79 723.11 708.64 708.64 694.47 # 28238 486.36 462.04 531.35 520.72 520.72 510.30 28240 433.60 411.92 473.71 464.23 464.23 454.95 # 28240 288.65 274.22 315.35 309.05 309.05 302.88 28250 572.02 543.42 624.93 612.43 612.43 600.19 # 28250 404.06 383.86 441.44 432.61 432.61 423.96 28260 677.66 643.78 740.35 725.54 725.54 711.02 # 28260 509.38 483.91 556.50 545.36 545.36 534.46 28261 971.44 922.87 1,061.30 1,040.07 1,040.07 1,019.27 # 28261 776.20 737.39 848.00 831.04 831.04 814.42 28262 1,453.62 1,380.94 1,588.08 1,556.32 1,556.32 1,525.19 # 28262 1,181.47 1,122.40 1,290.76 1,264.94 1,264.94 1,239.64 28264 985.59 936.31 1,076.76 1,055.22 1,055.22 1,034.11 # 28264 759.46 721.49 829.71 813.12 813.12 796.86 28270 482.14 458.03 526.73 516.20 516.20 505.87 # 28270 331.27 314.71 361.92 354.68 354.68 347.59 28272 386.99 367.64 422.79 414.33 414.33 406.04 # 28272 252.88 240.24 276.28 270.76 270.76 265.34 28280 508.84 483.40 555.91 544.79 544.79 533.90 # 28280 348.44 331.02 380.67 373.06 373.06 365.60 28285 525.06 498.81 573.63 562.15 562.15 550.91 # 28285 374.85 356.11 409.53 401.34 401.34 393.31 28286 444.03 421.83 485.10 475.40 475.40 465.89 # 28286 298.09 283.19 325.67 319.16 319.16 312.78 28288 593.25 563.59 648.13 635.17 635.17 622.46 # 28288 425.95 404.65 465.35 456.04 456.04 446.92 28289 721.46 685.39 788.20 772.43 772.43 756.99 # 28289 543.97 516.77 594.29 582.39 582.39 570.75 28290 578.03 549.13 631.50 618.87 618.87 606.50 # 28290 393.31 373.64 429.69 421.10 421.10 412.68 28292 776.50 737.68 848.33 831.37 831.37 814.74 # 28292 597.04 567.19 652.27 639.23 639.23 626.44 28293 1,029.32 977.85 1,124.53 1,102.03 1,102.03 1,079.99 # 28293 706.88 671.54 772.27 756.83 756.83 741.69 28294 757.37 719.50 827.43 810.88 810.88 794.66 # 28294 546.35 519.03 596.88 584.95 584.95 573.25 28296 702.22 667.11 767.18 751.84 751.84 736.79 # 28296 518.82 492.88 566.81 555.47 555.47 544.36 28297 800.66 760.63 874.72 857.23 857.23 840.09 # 28297 581.10 552.05 634.86 622.16 622.16 609.72 28298 710.80 675.26 776.55 761.01 761.01 745.80

Page 64: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 64Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 28298 504.71 479.47 551.39 540.36 540.36 529.55 28299 886.60 842.27 968.61 949.23 949.23 930.25 # 28299 677.23 643.37 739.88 725.08 725.08 710.57 28300 649.89 617.40 710.01 695.81 695.81 681.89 28302 710.42 674.90 776.14 760.61 760.61 745.40 28304 814.59 773.86 889.94 872.14 872.14 854.69 # 28304 604.89 574.65 660.85 647.63 647.63 634.69 28305 665.50 632.23 727.06 712.53 712.53 698.28 28306 602.41 572.29 658.13 644.97 644.97 632.06 # 28306 401.92 381.82 439.09 430.31 430.31 421.71 28307 668.05 634.65 729.85 715.25 715.25 700.95 # 28307 447.50 425.13 488.90 479.12 479.12 469.55 28308 554.39 526.67 605.67 593.56 593.56 581.69 # 28308 374.27 355.56 408.89 400.72 400.72 392.70 28309 904.83 859.59 988.53 968.76 968.76 949.38 28310 537.48 510.61 587.20 575.46 575.46 563.95 # 28310 356.70 338.87 389.70 381.90 381.90 374.27 28312 498.55 473.62 544.66 533.77 533.77 523.10 # 28312 317.12 301.26 346.45 339.51 339.51 332.73 28313 519.07 493.12 567.09 555.75 555.75 544.63 # 28313 356.37 338.55 389.33 381.55 381.55 373.91 28315 473.14 449.48 516.90 506.56 506.56 496.43 # 28315 323.59 307.41 353.52 346.45 346.45 339.51 28320 608.47 578.05 664.76 651.46 651.46 638.43 28322 778.18 739.27 850.16 833.15 833.15 816.49 # 28322 576.37 547.55 629.68 617.09 617.09 604.75 28340 571.21 542.65 624.05 611.57 611.57 599.33 # 28340 412.78 392.14 450.96 441.95 441.95 433.10 28341 663.87 630.68 725.28 710.78 710.78 696.57 # 28341 492.30 467.69 537.84 527.09 527.09 516.55 28344 459.45 436.48 501.95 491.91 491.91 482.08 # 28344 310.89 295.35 339.65 332.86 332.86 326.20 28345 514.66 488.93 562.27 551.02 551.02 540.01 # 28345 363.80 345.61 397.45 389.51 389.51 381.72 28360 920.62 874.59 1,005.78 985.67 985.67 965.95 28400 241.77 229.68 264.13 258.85 258.85 253.68 # 28400 222.05 210.95 242.59 237.74 237.74 232.99 28405 386.83 367.49 422.61 414.16 414.16 405.88 # 28405 352.64 335.01 385.26 377.56 377.56 370.00 28406 516.06 490.26 563.80 552.52 552.52 541.47 28415 1,101.80 1,046.71 1,203.72 1,179.65 1,179.65 1,156.05 28420 1,249.71 1,187.22 1,365.30 1,338.00 1,338.00 1,311.24 28430 230.63 219.10 251.97 246.93 246.93 241.99 # 28430 205.98 195.68 225.03 220.54 220.54 216.12 28435 311.50 295.93 340.32 333.51 333.51 326.84 # 28435 279.61 265.63 305.47 299.37 299.37 293.38 28436 440.74 418.70 481.51 471.88 471.88 462.44 28445 1,059.37 1,006.40 1,157.36 1,134.21 1,134.21 1,111.52 28446 1,208.25 1,147.84 1,320.02 1,293.61 1,293.61 1,267.74

Page 65: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 65Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

28450 210.19 199.68 229.63 225.04 225.04 220.55 # 28450 188.17 178.76 205.57 201.46 201.46 197.43 28455 283.31 269.14 309.51 303.32 303.32 297.25 # 28455 256.03 243.23 279.71 274.13 274.13 268.64 28456 311.06 295.51 339.84 333.04 333.04 326.38 28465 618.71 587.77 675.94 662.41 662.41 649.16 28470 213.18 202.52 232.90 228.24 228.24 223.68 # 28470 199.70 189.72 218.18 213.82 213.82 209.54 28475 252.07 239.47 275.39 269.88 269.88 264.49 # 28475 224.79 213.55 245.58 240.67 240.67 235.85 28476 344.45 327.23 376.31 368.79 368.79 361.42 28485 520.60 494.57 568.76 557.38 557.38 546.24 28490 140.90 133.86 153.94 150.86 150.86 147.84 # 28490 121.84 115.75 133.11 130.46 130.46 127.85 28495 173.04 164.39 189.05 185.27 185.27 181.56 # 28495 146.42 139.10 159.97 156.77 156.77 153.63 28496 423.70 402.52 462.90 453.64 453.64 444.57 # 28496 229.12 217.66 250.31 245.31 245.31 240.40 28505 656.67 623.84 717.42 703.06 703.06 689.00 # 28505 496.61 471.78 542.55 531.69 531.69 521.05 28510 120.49 114.47 131.64 129.01 129.01 126.43 # 28510 117.54 111.66 128.41 125.84 125.84 123.33 28515 157.19 149.33 171.73 168.29 168.29 164.92 # 28515 139.44 132.47 152.34 149.29 149.29 146.30 28525 555.29 527.53 606.66 594.53 594.53 582.64 # 28525 395.22 375.46 431.78 423.14 423.14 414.68 28530 112.35 106.73 122.74 120.29 120.29 117.89 # 28530 100.19 95.18 109.46 107.27 107.27 105.12 28531 336.08 319.28 367.17 359.82 359.82 352.62 # 28531 181.93 172.83 198.75 194.78 194.78 190.88 28540 202.26 192.15 220.97 216.56 216.56 212.22 # 28540 183.19 174.03 200.13 196.13 196.13 192.21 28545 284.08 269.88 310.36 304.15 304.15 298.07 # 28545 253.19 240.53 276.61 271.08 271.08 265.66 28546 540.55 513.52 590.55 578.74 578.74 567.17 # 28546 322.64 306.51 352.49 345.44 345.44 338.53 28555 867.30 823.94 947.53 928.58 928.58 910.01 # 28555 665.81 632.52 727.40 712.85 712.85 698.59 28570 215.78 204.99 235.74 231.02 231.02 226.40 # 28570 183.90 174.71 200.92 196.90 196.90 192.97 28575 356.31 338.49 389.26 381.48 381.48 373.85 # 28575 323.77 307.58 353.72 346.64 346.64 339.71 28576 384.07 364.87 419.60 411.21 411.21 402.98 28585 845.10 802.85 923.28 904.81 904.81 886.71 # 28585 669.58 636.10 731.52 716.89 716.89 702.55 28600 212.44 201.82 232.09 227.45 227.45 222.89 # 28600 183.84 174.65 200.85 196.83 196.83 192.90 28605 317.06 301.21 346.39 339.47 339.47 332.68 # 28605 286.49 272.17 313.00 306.74 306.74 300.61

Page 66: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 66Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

28606 390.61 371.08 426.74 418.21 418.21 409.85 28615 782.94 743.79 855.36 838.25 838.25 821.48 28630 153.64 145.96 167.85 164.50 164.50 161.21 # 28630 109.26 103.80 119.37 116.98 116.98 114.64 28635 170.96 162.41 186.77 183.03 183.03 179.38 # 28635 130.21 123.70 142.26 139.41 139.41 136.63 28636 277.56 263.68 303.23 297.17 297.17 291.23 # 28636 180.93 171.88 197.66 193.71 193.71 189.83 28645 647.20 614.84 707.07 692.92 692.92 679.06 # 28645 483.19 459.03 527.88 517.33 517.33 506.98 28660 113.99 108.29 124.53 122.04 122.04 119.60 # 28660 88.03 83.63 96.17 94.25 94.25 92.37 28665 151.27 143.71 165.27 161.97 161.97 158.72 # 28665 129.91 123.41 141.92 139.08 139.08 136.30 28666 185.99 176.69 203.19 199.13 199.13 195.16 28675 572.27 543.66 625.21 612.71 612.71 600.45 # 28675 407.92 387.52 445.65 436.74 436.74 428.00 28705 1,255.63 1,192.85 1,371.78 1,344.34 1,344.34 1,317.45 28715 933.30 886.64 1,019.64 999.25 999.25 979.26 28725 774.08 735.38 845.69 828.77 828.77 812.20 28730 729.29 692.83 796.75 780.82 780.82 765.20 28735 780.31 741.29 852.48 835.43 835.43 818.72 28737 688.69 654.26 752.40 737.35 737.35 722.60 28740 833.28 791.62 910.36 892.16 892.16 874.31 # 28740 620.29 589.28 677.67 664.11 664.11 650.83 28750 800.08 760.08 874.09 856.61 856.61 839.48 # 28750 588.08 558.68 642.48 629.64 629.64 617.04 28755 498.56 473.63 544.67 533.78 533.78 523.11 # 28755 328.63 312.20 359.03 351.85 351.85 344.82 28760 778.51 739.58 850.52 833.51 833.51 816.83 # 28760 575.71 546.92 628.96 616.38 616.38 604.05 28800 544.00 516.80 594.32 582.43 582.43 570.78 28805 739.45 702.48 807.85 791.69 791.69 775.86 28810 433.69 412.01 473.81 464.34 464.34 455.04 28820 557.24 529.38 608.79 596.61 596.61 584.67 # 28820 395.52 375.74 432.10 423.46 423.46 415.00 28825 530.72 504.18 579.81 568.22 568.22 556.85 # 28825 370.32 351.80 404.57 396.47 396.47 388.54 28890 315.95 300.15 345.17 338.27 338.27 331.51 # 28890 222.61 211.48 243.20 238.34 238.34 233.58 29000 279.70 265.72 305.58 299.47 299.47 293.48 # 29000 174.20 165.49 190.31 186.51 186.51 182.78 29010 230.49 218.97 251.82 246.78 246.78 241.85 # 29010 146.35 139.03 159.88 156.69 156.69 153.56 29015 276.00 262.20 301.53 295.50 295.50 289.59 # 29015 177.07 168.22 193.45 189.59 189.59 185.79 29035 188.92 179.47 206.39 202.26 202.26 198.21 # 29035 119.24 113.28 130.27 127.66 127.66 125.11 29040 219.65 208.67 239.97 235.18 235.18 230.47

Page 67: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 67Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 29040 145.04 137.79 158.46 155.28 155.28 152.18 29044 272.83 259.19 298.07 292.11 292.11 286.27 # 29044 149.90 142.41 163.77 160.49 160.49 157.29 29046 236.40 224.58 258.27 253.10 253.10 248.04 # 29046 157.51 149.63 172.07 168.64 168.64 165.27 29049 81.90 77.81 89.48 87.69 87.69 85.94 # 29049 61.85 58.76 67.57 66.22 66.22 64.89 29055 215.92 205.12 235.89 231.17 231.17 226.55 # 29055 137.69 130.81 150.43 147.42 147.42 144.47 29058 119.50 113.53 130.56 127.95 127.95 125.38 # 29058 92.22 87.61 100.75 98.74 98.74 96.76 29065 93.37 88.70 102.01 99.97 99.97 97.97 # 29065 67.73 64.34 73.99 72.51 72.51 71.06 29075 84.15 79.94 91.93 90.09 90.09 88.29 # 29075 61.47 58.40 67.16 65.81 65.81 64.50 29085 92.69 88.06 101.27 99.25 99.25 97.26 # 29085 66.72 63.38 72.89 71.43 71.43 70.00 29086 75.66 71.88 82.66 81.01 81.01 79.38 # 29086 50.35 47.83 55.00 53.90 53.90 52.82 29105 85.40 81.13 93.30 91.44 91.44 89.61 # 29105 58.78 55.84 64.22 62.93 62.93 61.67 29125 62.13 59.02 67.87 66.52 66.52 65.18 # 29125 38.80 36.86 42.39 41.54 41.54 40.71 29126 74.22 70.51 81.09 79.47 79.47 77.88 # 29126 47.93 45.53 52.36 51.31 51.31 50.29 29130 40.11 38.10 43.82 42.94 42.94 42.08 # 29130 28.61 27.18 31.26 30.64 30.64 30.03 29131 49.46 46.99 54.04 52.96 52.96 51.90 # 29131 32.70 31.07 35.73 35.02 35.02 34.32 29200 28.81 27.37 31.48 30.84 30.84 30.22 # 29200 18.29 17.38 19.99 19.58 19.58 19.19 29240 28.15 26.74 30.75 30.14 30.14 29.54 # 29240 18.62 17.69 20.34 19.94 19.94 19.54 29260 28.53 27.10 31.17 30.54 30.54 29.93 # 29260 19.66 18.68 21.48 21.06 21.06 20.63 29280 28.86 27.42 31.53 30.90 30.90 30.28 # 29280 20.32 19.30 22.20 21.75 21.75 21.31 29305 239.77 227.78 261.95 256.70 256.70 251.57 # 29305 157.93 150.03 172.53 169.08 169.08 165.70 29325 264.17 250.96 288.60 282.83 282.83 277.17 # 29325 176.74 167.90 193.09 189.22 189.22 185.44 29345 133.00 126.35 145.30 142.39 142.39 139.54 # 29345 100.13 95.12 109.39 107.20 107.20 105.06 29355 137.70 130.82 150.44 147.43 147.43 144.49 # 29355 105.82 100.53 115.61 113.30 113.30 111.03 29358 156.17 148.36 170.61 167.20 167.20 163.85 # 29358 103.58 98.40 113.16 110.89 110.89 108.68 29365 119.42 113.45 130.47 127.86 127.86 125.30 # 29365 86.88 82.54 94.92 93.02 93.02 91.16

Page 68: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 68Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

29405 79.58 75.60 86.94 85.20 85.20 83.50 # 29405 59.20 56.24 64.68 63.39 63.39 62.12 29425 76.60 72.77 83.69 82.01 82.01 80.36 # 29425 56.22 53.41 61.42 60.19 60.19 58.98 29435 113.45 107.78 123.95 121.46 121.46 119.04 # 29435 82.23 78.12 89.84 88.04 88.04 86.28 29440 42.87 40.73 46.84 45.91 45.91 44.99 # 29440 29.06 27.61 31.75 31.12 31.12 30.50 29445 132.31 125.69 144.54 141.66 141.66 138.83 # 29445 104.04 98.84 113.67 111.39 111.39 109.16 29450 141.38 134.31 154.46 151.36 151.36 148.34 # 29450 112.78 107.14 123.21 120.75 120.75 118.34 29505 80.52 76.49 87.96 86.20 86.20 84.48 # 29505 49.30 46.84 53.87 52.79 52.79 51.73 29515 69.77 66.28 76.22 74.69 74.69 73.20 # 29515 49.06 46.61 53.60 52.53 52.53 51.49 29520 30.45 28.93 33.27 32.60 32.60 31.95 # 29520 18.62 17.69 20.34 19.94 19.94 19.54 29530 28.18 26.77 30.79 30.16 30.16 29.57 # 29530 18.65 17.72 20.38 19.98 19.98 19.57 29540 25.55 24.27 27.91 27.35 27.35 26.80 # 29540 18.32 17.40 20.01 19.61 19.61 19.22 29550 18.54 17.61 20.25 19.85 19.85 19.45 # 29550 11.63 11.05 12.71 12.45 12.45 12.20 29580 51.11 48.55 55.83 54.72 54.72 53.62 # 29580 35.33 33.56 38.59 37.82 37.82 37.06 29581 58.28 55.37 63.68 62.40 62.40 61.15 # 29581 12.59 11.96 13.75 13.48 13.48 13.21 29582 66.46 63.14 72.61 71.16 71.16 69.74 # 29582 15.85 15.06 17.32 16.97 16.97 16.63 29583 41.52 39.44 45.36 44.45 44.45 43.56 # 29583 11.28 10.72 12.33 12.09 12.09 11.85 29584 66.46 63.14 72.61 71.16 71.16 69.74 # 29584 15.85 15.06 17.32 16.97 16.97 16.63 29700 60.75 57.71 66.37 65.04 65.04 63.74 # 29700 33.47 31.80 36.57 35.83 35.83 35.12 29705 65.36 62.09 71.40 69.98 69.98 68.57 # 29705 47.28 44.92 51.66 50.62 50.62 49.61 29710 119.34 113.37 130.38 127.77 127.77 125.21 # 29710 83.19 79.03 90.88 89.07 89.07 87.29 29720 82.24 78.13 89.85 88.06 88.06 86.30 # 29720 44.44 42.22 48.55 47.59 47.59 46.63 29730 63.33 60.16 69.18 67.80 67.80 66.45 # 29730 45.25 42.99 49.44 48.45 48.45 47.48 29740 97.58 92.70 106.61 104.48 104.48 102.38 # 29740 70.63 67.10 77.17 75.62 75.62 74.11 29750 87.92 83.52 96.05 94.13 94.13 92.24 # 29750 67.54 64.16 73.78 72.31 72.31 70.86 29800 505.43 480.16 552.18 541.14 541.14 530.32

Page 69: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 69Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

29804 641.53 609.45 700.87 686.85 686.85 673.11 29805 467.36 443.99 510.59 500.38 500.38 490.37 29806 1,058.16 1,005.25 1,156.04 1,132.92 1,132.92 1,110.27 29807 1,032.25 980.64 1,127.74 1,105.18 1,105.18 1,083.08 29819 581.27 552.21 635.04 622.35 622.35 609.90 29820 529.44 502.97 578.42 566.85 566.85 555.51 29821 578.37 549.45 631.87 619.23 619.23 606.84 29822 561.53 533.45 613.47 601.20 601.20 589.17 29823 613.06 582.41 669.77 656.37 656.37 643.24 29824 660.83 627.79 721.96 707.51 707.51 693.37 29825 572.39 543.77 625.34 612.82 612.82 600.56 29826 177.69 168.81 194.13 190.24 190.24 186.44 29827 1,052.28 999.67 1,149.62 1,126.63 1,126.63 1,104.10 29828 907.20 861.84 991.12 971.29 971.29 951.87 29830 448.11 425.70 489.56 479.77 479.77 470.18 29834 480.62 456.59 525.08 514.58 514.58 504.29 29835 500.97 475.92 547.31 536.36 536.36 525.63 29836 563.53 535.35 615.65 603.34 603.34 591.27 29837 517.92 492.02 565.82 554.51 554.51 543.42 29838 581.19 552.13 634.95 622.25 622.25 609.81 29840 447.44 425.07 488.83 479.06 479.06 469.48 29843 478.97 455.02 523.27 512.81 512.81 502.55 29844 489.48 465.01 534.76 524.07 524.07 513.59 29845 569.03 540.58 621.67 609.24 609.24 597.05 29846 513.87 488.18 561.41 550.18 550.18 539.18 29847 527.53 501.15 576.32 564.80 564.80 553.51 29848 503.86 478.67 550.47 539.47 539.47 528.68 29850 612.32 581.70 668.96 655.58 655.58 642.47 29851 882.34 838.22 963.95 944.68 944.68 925.78 29855 777.15 738.29 849.03 832.05 832.05 815.41 29856 994.13 944.42 1,086.08 1,064.36 1,064.36 1,043.07 29860 656.00 623.20 716.68 702.35 702.35 688.31 29861 714.92 679.17 781.05 765.43 765.43 750.12 29862 801.18 761.12 875.29 857.79 857.79 840.63 29863 801.23 761.17 875.35 857.84 857.84 840.68 29866 1,037.97 986.07 1,133.98 1,111.30 1,111.30 1,089.07 29867 1,261.38 1,198.31 1,378.06 1,350.49 1,350.49 1,323.48 29868 1,608.80 1,528.36 1,757.61 1,722.46 1,722.46 1,688.00 29870 567.62 539.24 620.13 607.73 607.73 595.57 # 29870 407.88 387.49 445.61 436.70 436.70 427.97 29871 510.10 484.60 557.29 546.15 546.15 535.22 29873 517.74 491.85 565.63 554.31 554.31 543.23 29874 533.04 506.39 582.35 570.70 570.70 559.28 29875 490.75 466.21 536.14 525.42 525.42 514.91 29876 653.78 621.09 714.25 699.97 699.97 685.98 29877 617.44 586.57 674.56 661.07 661.07 647.84 29879 657.97 625.07 718.83 704.46 704.46 690.37 29880 557.40 529.53 608.96 596.78 596.78 584.84 29881 536.79 509.95 586.44 574.71 574.71 563.22

Page 70: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 70Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

29882 696.76 661.92 761.21 745.98 745.98 731.07 29883 837.60 795.72 915.08 896.78 896.78 878.84 29884 609.73 579.24 666.13 652.81 652.81 639.76 29885 746.75 709.41 815.82 799.50 799.50 783.52 29886 632.76 601.12 691.29 677.47 677.47 663.92 29887 742.06 704.96 810.70 794.49 794.49 778.60 29888 983.68 934.50 1,074.68 1,053.18 1,053.18 1,032.11 29889 1,218.24 1,157.33 1,330.93 1,304.31 1,304.31 1,278.23 29891 672.83 639.19 735.07 720.37 720.37 705.96 29892 583.01 553.86 636.94 624.20 624.20 611.71 29893 598.27 568.36 653.61 640.54 640.54 627.73 # 29893 423.74 402.55 462.93 453.68 453.68 444.60 29894 498.58 473.65 544.70 533.81 533.81 523.14 29895 474.93 451.18 518.86 508.48 508.48 498.32 29897 504.18 478.97 550.82 539.80 539.80 529.00 29898 563.71 535.52 615.85 603.53 603.53 591.46 29899 1,033.55 981.87 1,129.15 1,106.56 1,106.56 1,084.44 29900 448.05 425.65 489.50 479.71 479.71 470.12 29901 526.52 500.19 575.22 563.72 563.72 552.45 29902 553.59 525.91 604.80 592.70 592.70 580.84 29904 634.30 602.59 692.98 679.12 679.12 665.54 29905 680.77 646.73 743.74 728.87 728.87 714.29 29906 715.59 679.81 781.78 766.14 766.14 750.82 29907 872.75 829.11 953.48 934.41 934.41 915.72 29914 991.92 942.32 1,083.67 1,061.99 1,061.99 1,040.75 29915 1,008.97 958.52 1,102.30 1,080.25 1,080.25 1,058.64 29916 1,010.29 959.78 1,103.75 1,081.67 1,081.67 1,060.04 30000 221.18 210.12 241.64 236.81 236.81 232.07 # 30000 116.33 110.51 127.09 124.55 124.55 122.05 30020 224.17 212.96 244.90 240.01 240.01 235.21 # 30020 117.35 111.48 128.20 125.64 125.64 123.13 30100 135.90 129.11 148.48 145.51 145.51 142.60 # 30100 68.19 64.78 74.50 73.00 73.00 71.54 30110 222.51 211.38 243.09 238.22 238.22 233.46 # 30110 128.50 122.08 140.39 137.59 137.59 134.84 30115 421.99 400.89 461.02 451.80 451.80 442.76 30117 836.16 794.35 913.50 895.23 895.23 877.32 # 30117 331.96 315.36 362.66 355.41 355.41 348.30 30118 757.46 719.59 827.53 810.98 810.98 794.77 30120 506.18 480.87 553.00 541.94 541.94 531.10 # 30120 430.91 409.36 470.76 461.35 461.35 452.12 30124 279.82 265.83 305.70 299.59 299.59 293.60 30125 596.90 567.06 652.12 639.08 639.08 626.30 30130 369.74 351.25 403.94 395.86 395.86 387.95 30140 426.68 405.35 466.15 456.83 456.83 447.70 30150 757.12 719.26 827.15 810.60 810.60 794.39 30160 760.38 722.36 830.71 814.10 814.10 797.81 30200 109.74 104.25 119.89 117.50 117.50 115.15 # 30200 58.79 55.85 64.23 62.94 62.94 61.69

Page 71: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 71Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

30210 144.75 137.51 158.14 154.97 154.97 151.87 # 30210 97.42 92.55 106.43 104.31 104.31 102.22 30220 290.58 276.05 317.46 311.11 311.11 304.89 # 30220 123.28 117.12 134.69 132.00 132.00 129.35 30300 178.44 169.52 194.95 191.05 191.05 187.23 # 30300 103.17 98.01 112.71 110.46 110.46 108.25 30310 200.91 190.86 219.49 215.10 215.10 210.80 30320 433.18 411.52 473.25 463.78 463.78 454.50 30400 987.36 937.99 1,078.69 1,057.11 1,057.11 1,035.98 30410 1,159.45 1,101.48 1,266.70 1,241.37 1,241.37 1,216.54 30420 1,346.49 1,279.17 1,471.05 1,441.63 1,441.63 1,412.80 30430 931.78 885.19 1,017.97 997.61 997.61 977.66 30435 1,087.20 1,032.84 1,187.77 1,164.01 1,164.01 1,140.73 30450 1,473.04 1,399.39 1,609.30 1,577.11 1,577.11 1,545.57 30460 704.82 669.58 770.02 754.62 754.62 739.53 30462 1,535.44 1,458.67 1,677.47 1,643.93 1,643.93 1,611.05 30465 964.17 915.96 1,053.35 1,032.29 1,032.29 1,011.64 30520 609.99 579.49 666.41 653.09 653.09 640.02 30540 678.80 644.86 741.59 726.75 726.75 712.22 30545 866.34 823.02 946.47 927.54 927.54 908.99 30560 257.11 244.25 280.89 275.28 275.28 269.77 # 30560 133.86 127.17 146.25 143.32 143.32 140.46 30580 639.87 607.88 699.06 685.08 685.08 671.38 # 30580 508.07 482.67 555.07 543.97 543.97 533.09 30600 575.86 547.07 629.13 616.55 616.55 604.22 # 30600 442.09 419.99 482.99 473.33 473.33 463.86 30620 607.94 577.54 664.17 650.89 650.89 637.87 30630 609.96 579.46 666.38 653.05 653.05 639.99 30801 219.37 208.40 239.66 234.86 234.86 230.17 # 30801 132.27 125.66 144.51 141.62 141.62 138.79 30802 280.38 266.36 306.31 300.18 300.18 294.18 # 30802 186.04 176.74 203.25 199.19 199.19 195.21 30901 93.06 88.41 101.67 99.64 99.64 97.65 # 30901 57.23 54.37 62.53 61.27 61.27 60.04 30903 212.51 201.88 232.16 227.52 227.52 222.96 # 30903 81.37 77.30 88.90 87.11 87.11 85.38 30905 260.96 247.91 285.10 279.39 279.39 273.80 # 30905 107.80 102.41 117.77 115.41 115.41 113.10 30906 335.50 318.73 366.54 359.21 359.21 352.03 # 30906 138.29 131.38 151.09 148.06 148.06 145.11 30915 567.04 538.69 619.49 607.11 607.11 594.96 30920 823.95 782.75 900.16 882.17 882.17 864.52 30930 120.35 114.33 131.48 128.85 128.85 126.27 31000 176.87 168.03 193.23 189.37 189.37 185.59 # 31000 103.90 98.71 113.52 111.25 111.25 109.03 31002 188.52 179.09 205.95 201.84 201.84 197.80 31020 466.08 442.78 509.20 499.01 499.01 489.03 # 31020 348.74 331.30 381.00 373.37 373.37 365.91 31030 671.57 637.99 733.69 719.01 719.01 704.64

Page 72: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 72Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 31030 519.39 493.42 567.43 556.08 556.08 544.96 31032 563.64 535.46 615.78 603.46 603.46 591.40 31040 750.42 712.90 819.84 803.44 803.44 787.37 31050 476.45 452.63 520.52 510.12 510.12 499.92 31051 631.51 599.93 689.92 676.12 676.12 662.60 31070 428.45 407.03 468.08 458.72 458.72 449.55 31075 771.73 733.14 843.11 826.25 826.25 809.73 31080 1,018.07 967.17 1,112.25 1,090.00 1,090.00 1,068.20 31081 1,449.33 1,376.86 1,583.39 1,551.72 1,551.72 1,520.68 31084 1,140.08 1,083.08 1,245.54 1,220.63 1,220.63 1,196.22 31085 1,548.10 1,470.70 1,691.31 1,657.48 1,657.48 1,624.33 31086 1,109.43 1,053.96 1,212.05 1,187.81 1,187.81 1,164.05 31087 1,069.16 1,015.70 1,168.06 1,144.70 1,144.70 1,121.80 31090 1,001.39 951.32 1,094.02 1,072.13 1,072.13 1,050.69 31200 549.40 521.93 600.22 588.21 588.21 576.45 31201 725.03 688.78 792.10 776.25 776.25 760.73 31205 872.06 828.46 952.73 933.67 933.67 915.00 31225 1,857.97 1,765.07 2,029.83 1,989.24 1,989.24 1,949.45 31230 2,067.21 1,963.85 2,258.43 2,213.26 2,213.26 2,168.99 31231 200.84 190.80 219.42 215.03 215.03 210.73 # 31231 65.10 61.85 71.13 69.70 69.70 68.31 31233 254.40 241.68 277.93 272.38 272.38 266.93 # 31233 136.73 129.89 149.37 146.38 146.38 143.45 31235 290.43 275.91 317.30 310.95 310.95 304.73 # 31235 162.24 154.13 177.25 173.71 173.71 170.23 31237 252.18 239.57 275.51 270.00 270.00 264.59 # 31237 161.79 153.70 176.76 173.22 173.22 169.76 31238 252.32 239.70 275.66 270.15 270.15 264.74 # 31238 169.49 161.02 185.17 181.47 181.47 177.84 31239 608.26 577.85 664.53 651.23 651.23 638.20 31240 161.52 153.44 176.46 172.93 172.93 169.46 31254 274.42 260.70 299.81 293.81 293.81 287.94 31255 402.72 382.58 439.97 431.17 431.17 422.54 31256 198.60 188.67 216.97 212.64 212.64 208.38 31267 319.53 303.55 349.08 342.10 342.10 335.26 31276 508.61 483.18 555.66 544.55 544.55 533.66 31287 233.20 221.54 254.77 249.68 249.68 244.69 31288 270.25 256.74 295.25 289.35 289.35 283.57 31290 1,157.65 1,099.77 1,264.74 1,239.44 1,239.44 1,214.64 31291 1,235.27 1,173.51 1,349.54 1,322.55 1,322.55 1,296.10 31292 1,000.53 950.50 1,093.08 1,071.21 1,071.21 1,049.79 31293 1,086.15 1,031.84 1,186.62 1,162.88 1,162.88 1,139.63 31294 1,242.54 1,180.41 1,357.47 1,330.32 1,330.32 1,303.71 31295 1,927.50 1,831.13 2,105.80 2,063.69 2,063.69 2,022.41 # 31295 164.77 156.53 180.01 176.41 176.41 172.88 31296 1,966.94 1,868.59 2,148.88 2,105.90 2,105.90 2,063.79 # 31296 197.64 187.76 215.92 211.60 211.60 207.37 31297 1,929.93 1,833.43 2,108.44 2,066.27 2,066.27 2,024.94 # 31297 161.28 153.22 176.20 172.68 172.68 169.23

Page 73: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 73Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

31300 1,290.02 1,225.52 1,409.35 1,381.16 1,381.16 1,353.54 31320 672.47 638.85 734.68 719.98 719.98 705.58 31360 2,105.15 1,999.89 2,299.87 2,253.87 2,253.87 2,208.79 31365 2,604.16 2,473.95 2,845.04 2,788.14 2,788.14 2,732.38 31367 2,226.75 2,115.41 2,432.72 2,384.07 2,384.07 2,336.39 31368 2,485.20 2,360.94 2,715.08 2,660.78 2,660.78 2,607.57 31370 2,094.35 1,989.63 2,288.07 2,242.32 2,242.32 2,197.47 31375 1,977.24 1,878.38 2,160.14 2,116.93 2,116.93 2,074.59 31380 1,955.85 1,858.06 2,136.77 2,094.04 2,094.04 2,052.15 31382 2,155.54 2,047.76 2,354.92 2,307.82 2,307.82 2,261.66 31390 2,901.63 2,756.55 3,170.03 3,106.63 3,106.63 3,044.50 31395 3,062.99 2,909.84 3,346.32 3,279.39 3,279.39 3,213.80 31400 968.06 919.66 1,057.61 1,036.46 1,036.46 1,015.73 31420 826.50 785.18 902.96 884.90 884.90 867.20 31500 111.46 105.89 121.77 119.34 119.34 116.94 31502 35.32 33.55 38.58 37.81 37.81 37.05 31505 80.23 76.22 87.65 85.91 85.91 84.19 # 31505 48.68 46.25 53.19 52.13 52.13 51.08 31510 204.91 194.66 223.86 219.39 219.39 214.99 # 31510 121.76 115.67 133.02 130.36 130.36 127.75 31511 206.71 196.37 225.83 221.31 221.31 216.88 # 31511 130.79 124.25 142.89 140.04 140.04 137.23 31512 199.79 189.80 218.27 213.90 213.90 209.62 # 31512 129.78 123.29 141.78 138.94 138.94 136.16 31513 132.53 125.90 144.79 141.89 141.89 139.05 31515 180.00 171.00 196.65 192.72 192.72 188.86 # 31515 105.39 100.12 115.14 112.84 112.84 110.58 31520 157.35 149.48 171.90 168.46 168.46 165.09 31525 247.69 235.31 270.61 265.19 265.19 259.89 # 31525 161.58 153.50 176.53 172.99 172.99 169.53 31526 158.75 150.81 173.43 169.96 169.96 166.55 31527 196.27 186.46 214.43 210.14 210.14 205.94 31528 145.92 138.62 159.41 156.23 156.23 153.10 31529 163.40 155.23 178.51 174.95 174.95 171.45 31530 200.23 190.22 218.75 214.38 214.38 210.09 31531 215.03 204.28 234.92 230.22 230.22 225.62 31535 191.62 182.04 209.35 205.16 205.16 201.05 31536 213.28 202.62 233.01 228.36 228.36 223.79 31540 244.77 232.53 267.41 262.06 262.06 256.82 31541 267.44 254.07 292.18 286.34 286.34 280.61 31545 367.35 348.98 401.33 393.30 393.30 385.43 31546 559.70 531.72 611.48 599.25 599.25 587.27 31560 317.53 301.65 346.90 339.96 339.96 333.17 31561 347.95 330.55 380.13 372.53 372.53 365.08 31570 333.74 317.05 364.61 357.32 357.32 350.18 # 31570 232.50 220.88 254.01 248.93 248.93 243.95 31571 253.12 240.46 276.53 271.00 271.00 265.58 31575 111.11 105.55 121.38 118.96 118.96 116.58 # 31575 76.27 72.46 83.33 81.66 81.66 80.03

Page 74: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 74Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

31576 217.85 206.96 238.00 233.24 233.24 228.57 # 31576 124.18 117.97 135.67 132.95 132.95 130.30 31577 236.30 224.49 258.16 253.00 253.00 247.94 # 31577 150.84 143.30 164.80 161.49 161.49 158.26 31578 272.71 259.07 297.93 291.97 291.97 286.13 # 31578 173.45 164.78 189.50 185.70 185.70 181.99 31579 206.02 195.72 225.08 220.58 220.58 216.17 # 31579 141.60 134.52 154.70 151.60 151.60 148.57 31580 1,203.40 1,143.23 1,314.71 1,288.43 1,288.43 1,262.65 31582 1,869.15 1,775.69 2,042.04 2,001.21 2,001.21 1,961.19 31584 1,499.51 1,424.53 1,638.21 1,605.45 1,605.45 1,573.34 31587 998.41 948.49 1,090.76 1,068.95 1,068.95 1,047.57 31588 1,127.23 1,070.87 1,231.50 1,206.87 1,206.87 1,182.73 31590 871.97 828.37 952.63 933.57 933.57 914.89 31595 752.17 714.56 821.74 805.31 805.31 789.20 31600 403.04 382.89 440.32 431.51 431.51 422.89 31601 254.59 241.86 278.14 272.57 272.57 267.12 31603 227.08 215.73 248.09 243.13 243.13 238.27 31605 187.09 177.74 204.40 200.32 200.32 196.32 31610 708.19 672.78 773.70 758.22 758.22 743.05 31611 530.40 503.88 579.46 567.87 567.87 556.51 31612 82.29 78.18 89.91 88.11 88.11 86.35 # 31612 49.42 46.95 53.99 52.91 52.91 51.85 31613 445.84 423.55 487.08 477.34 477.34 467.80 31614 743.11 705.95 811.84 795.60 795.60 779.69 31615 178.46 169.54 194.97 191.07 191.07 187.25 # 31615 128.83 122.39 140.75 137.93 137.93 135.17 31622 293.96 279.26 321.15 314.72 314.72 308.43 # 31622 145.73 138.44 159.21 156.02 156.02 152.90 31623 319.08 303.13 348.60 341.63 341.63 334.80 # 31623 147.83 140.44 161.51 158.27 158.27 155.11 31624 302.64 287.51 330.64 324.02 324.02 317.54 # 31624 149.15 141.69 162.94 159.69 159.69 156.49 31625 381.45 362.38 416.74 408.40 408.40 400.23 # 31625 171.09 162.54 186.92 183.18 183.18 179.52 31626 864.44 821.22 944.40 925.52 925.52 907.01 # 31626 213.97 203.27 233.76 229.08 229.08 224.50 31627 1,327.41 1,261.04 1,450.20 1,421.19 1,421.19 1,392.77 # 31627 98.80 93.86 107.94 105.78 105.78 103.66 31628 402.44 382.32 439.67 430.87 430.87 422.26 # 31628 190.44 180.92 208.06 203.90 203.90 199.81 31629 478.46 454.54 522.72 512.27 512.27 502.02 # 31629 201.70 191.62 220.36 215.96 215.96 211.63 31630 202.43 192.31 221.16 216.73 216.73 212.39 31631 232.99 221.34 254.54 249.45 249.45 244.46 31632 73.25 69.59 80.03 78.43 78.43 76.87 # 31632 49.91 47.41 54.52 53.43 53.43 52.36 31633 90.61 86.08 98.99 97.01 97.01 95.07 # 31633 64.32 61.10 70.27 68.86 68.86 67.48

Page 75: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 75Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

31634 1,752.15 1,664.54 1,914.22 1,875.94 1,875.94 1,838.42 # 31634 208.98 198.53 228.31 223.74 223.74 219.27 31635 338.56 321.63 369.87 362.48 362.48 355.24 # 31635 190.65 181.12 208.29 204.13 204.13 200.04 31636 224.41 213.19 245.17 240.27 240.27 235.46 31637 75.30 71.54 82.27 80.63 80.63 79.02 31638 256.26 243.45 279.97 274.37 274.37 268.88 31640 257.67 244.79 281.51 275.87 275.87 270.35 31641 261.11 248.05 285.26 279.55 279.55 273.96 31643 178.71 169.77 195.24 191.33 191.33 187.50 31645 313.08 297.43 342.04 335.20 335.20 328.50 # 31645 162.87 154.73 177.94 174.39 174.39 170.90 31646 280.45 266.43 306.39 300.27 300.27 294.26 # 31646 140.76 133.72 153.78 150.71 150.71 147.69 31647 224.05 212.85 244.78 239.88 239.88 235.08 31648 207.55 197.17 226.75 222.21 222.21 217.78 31649 70.70 67.17 77.25 75.70 75.70 74.19 31651 80.50 76.48 87.95 86.19 86.19 84.47 31652 860.03 817.03 939.58 920.79 920.79 902.38 # 31652 236.84 225.00 258.75 253.58 253.58 248.50 31653 914.88 869.14 999.51 979.52 979.52 959.93 # 31653 261.45 248.38 285.64 279.92 279.92 274.32 31654 139.22 132.26 152.10 149.05 149.05 146.07 # 31654 68.55 65.12 74.89 73.39 73.39 71.92 31660 212.22 201.61 231.85 227.22 227.22 222.67 31661 222.84 211.70 243.46 238.59 238.59 233.82 31717 250.54 238.01 273.71 268.24 268.24 262.88 # 31717 109.20 103.74 119.30 116.92 116.92 114.59 31720 52.00 49.40 56.81 55.67 55.67 54.56 31725 91.04 86.49 99.46 97.47 97.47 95.52 31730 1,161.12 1,103.06 1,268.52 1,243.15 1,243.15 1,218.29 # 31730 150.74 143.20 164.68 161.39 161.39 158.16 31750 1,389.06 1,319.61 1,517.55 1,487.20 1,487.20 1,457.46 31755 1,733.50 1,646.83 1,893.85 1,855.97 1,855.97 1,818.85 31760 1,412.62 1,341.99 1,543.29 1,512.42 1,512.42 1,482.18 31766 1,817.84 1,726.95 1,985.99 1,946.27 1,946.27 1,907.34 31770 1,363.11 1,294.95 1,489.19 1,459.41 1,459.41 1,430.22 31775 1,312.03 1,246.43 1,433.39 1,404.73 1,404.73 1,376.63 31780 1,191.66 1,132.08 1,301.89 1,275.86 1,275.86 1,250.34 31781 1,459.03 1,386.08 1,593.99 1,562.11 1,562.11 1,530.87 31785 1,094.90 1,040.16 1,196.18 1,172.26 1,172.26 1,148.82 31786 1,462.08 1,388.98 1,597.33 1,565.38 1,565.38 1,534.08 31800 724.15 687.94 791.13 775.31 775.31 759.81 31805 835.36 793.59 912.63 894.38 894.38 876.50 31820 425.73 404.44 465.11 455.80 455.80 446.68 # 31820 326.79 310.45 357.02 349.88 349.88 342.88 31825 590.56 561.03 645.18 632.28 632.28 619.63 # 31825 477.82 453.93 522.02 511.58 511.58 501.34 31830 434.70 412.97 474.92 465.42 465.42 456.11

Page 76: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 76Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 31830 341.36 324.29 372.93 365.47 365.47 358.16 32035 724.72 688.48 791.75 775.92 775.92 760.40 32036 783.20 744.04 855.65 838.53 838.53 821.77 32096 817.34 776.47 892.94 875.08 875.08 857.58 32097 816.96 776.11 892.53 874.68 874.68 857.19 32098 774.60 735.87 846.25 829.32 829.32 812.74 32100 820.66 779.63 896.57 878.65 878.65 861.07 32110 1,484.35 1,410.13 1,621.65 1,589.22 1,589.22 1,557.43 32120 881.36 837.29 962.88 943.62 943.62 924.75 32124 938.12 891.21 1,024.89 1,004.40 1,004.40 984.31 32140 1,010.78 960.24 1,104.28 1,082.20 1,082.20 1,060.55 32141 1,552.65 1,475.02 1,696.27 1,662.35 1,662.35 1,629.10 32150 1,018.32 967.40 1,112.51 1,090.26 1,090.26 1,068.45 32151 1,016.74 965.90 1,110.79 1,088.57 1,088.57 1,066.80 32160 798.30 758.39 872.15 854.70 854.70 837.61 32200 1,149.85 1,092.36 1,256.21 1,231.09 1,231.09 1,206.47 32215 805.72 765.43 880.24 862.64 862.64 845.39 32220 1,605.69 1,525.41 1,754.22 1,719.14 1,719.14 1,684.75 32225 1,008.45 958.03 1,101.73 1,079.70 1,079.70 1,058.10 32310 922.70 876.57 1,008.06 987.90 987.90 968.14 32320 1,621.22 1,540.16 1,771.18 1,735.76 1,735.76 1,701.05 32400 147.59 140.21 161.24 158.02 158.02 154.86 # 32400 88.43 84.01 96.61 94.68 94.68 92.78 32405 426.84 405.50 466.33 457.00 457.00 447.86 # 32405 104.73 99.49 114.41 112.13 112.13 109.88 32440 1,591.86 1,512.27 1,739.11 1,704.32 1,704.32 1,670.24 32442 3,263.61 3,100.43 3,565.49 3,494.18 3,494.18 3,424.30 32445 3,613.62 3,432.94 3,947.88 3,868.92 3,868.92 3,791.54 32480 1,502.49 1,427.37 1,641.48 1,608.64 1,608.64 1,576.47 32482 1,606.99 1,526.64 1,755.64 1,720.53 1,720.53 1,686.12 32484 1,462.61 1,389.48 1,597.90 1,565.94 1,565.94 1,534.63 32486 2,401.00 2,280.95 2,623.09 2,570.63 2,570.63 2,519.21 32488 2,438.25 2,316.34 2,663.79 2,610.51 2,610.51 2,558.30 32491 1,497.42 1,422.55 1,635.93 1,603.22 1,603.22 1,571.15 32501 251.35 238.78 274.60 269.10 269.10 263.72 32503 1,839.61 1,747.63 2,009.77 1,969.58 1,969.58 1,930.19 32504 2,100.18 1,995.17 2,294.45 2,248.56 2,248.56 2,203.58 32505 945.76 898.47 1,033.24 1,012.58 1,012.58 992.32 32506 160.90 152.86 175.79 172.27 172.27 168.82 32507 160.54 152.51 175.39 171.88 171.88 168.44 32540 1,765.97 1,677.67 1,929.32 1,890.74 1,890.74 1,852.93 32550 745.58 708.30 814.55 798.25 798.25 782.29 # 32550 225.28 214.02 246.12 241.20 241.20 236.38 32551 172.79 164.15 188.77 185.00 185.00 181.30 32552 183.33 174.16 200.28 196.28 196.28 192.36 # 32552 160.00 152.00 174.80 171.30 171.30 167.88 32553 565.90 537.61 618.25 605.89 605.89 593.77 # 32553 196.79 186.95 214.99 210.69 210.69 206.48 32554 193.18 183.52 211.05 206.83 206.83 202.69

Page 77: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 77Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 32554 90.96 86.41 99.37 97.38 97.38 95.44 32555 278.37 264.45 304.12 298.03 298.03 292.08 # 32555 114.02 108.32 124.57 122.07 122.07 119.63 32556 513.17 487.51 560.64 549.42 549.42 538.43 # 32556 125.32 119.05 136.91 134.17 134.17 131.49 32557 492.45 467.83 538.00 527.24 527.24 516.70 # 32557 156.20 148.39 170.65 167.23 167.23 163.89 32560 233.96 222.26 255.60 250.48 250.48 245.47 # 32560 79.48 75.51 86.84 85.10 85.10 83.40 32561 91.61 87.03 100.08 98.08 98.08 96.12 # 32561 69.59 66.11 76.03 74.51 74.51 73.01 32562 82.65 78.52 90.30 88.49 88.49 86.72 # 32562 62.93 59.78 68.75 67.37 67.37 66.02 32601 314.28 298.57 343.36 336.49 336.49 329.76 32604 492.40 467.78 537.95 527.18 527.18 516.64 32606 471.89 448.30 515.55 505.23 505.23 495.12 32607 314.66 298.93 343.77 336.89 336.89 330.15 32608 386.12 366.81 421.83 413.39 413.39 405.12 32609 263.63 250.45 288.02 282.26 282.26 276.61 32650 673.42 639.75 735.71 721.00 721.00 706.58 32651 1,113.40 1,057.73 1,216.39 1,192.07 1,192.07 1,168.23 32652 1,691.60 1,607.02 1,848.07 1,811.11 1,811.11 1,774.89 32653 1,075.57 1,021.79 1,175.06 1,151.55 1,151.55 1,128.52 32654 1,204.71 1,144.47 1,316.14 1,289.82 1,289.82 1,264.02 32655 970.30 921.79 1,060.06 1,038.85 1,038.85 1,018.07 32656 813.72 773.03 888.98 871.21 871.21 853.78 32658 723.15 686.99 790.04 774.24 774.24 758.76 32659 740.62 703.59 809.13 792.95 792.95 777.09 32661 812.52 771.89 887.67 869.92 869.92 852.52 32662 905.28 860.02 989.02 969.24 969.24 949.85 32663 1,426.43 1,355.11 1,558.38 1,527.21 1,527.21 1,496.67 32664 864.33 821.11 944.28 925.39 925.39 906.89 32665 1,246.10 1,183.80 1,361.37 1,334.14 1,334.14 1,307.46 32666 883.19 839.03 964.88 945.59 945.59 926.68 32667 161.22 153.16 176.13 172.62 172.62 169.17 32668 160.90 152.86 175.79 172.27 172.27 168.82 32669 1,370.67 1,302.14 1,497.46 1,467.52 1,467.52 1,438.17 32670 1,631.42 1,549.85 1,782.33 1,746.68 1,746.68 1,711.74 32671 1,806.12 1,715.81 1,973.18 1,933.71 1,933.71 1,895.04 32672 1,551.49 1,473.92 1,695.01 1,661.11 1,661.11 1,627.88 32673 1,239.28 1,177.32 1,353.92 1,326.84 1,326.84 1,300.29 32674 221.42 210.35 241.90 237.06 237.06 232.32 32701 222.50 211.38 243.09 238.22 238.22 233.46 32800 958.76 910.82 1,047.44 1,026.49 1,026.49 1,005.96 32810 914.27 868.56 998.84 978.87 978.87 959.30 32815 2,851.55 2,708.97 3,115.32 3,053.01 3,053.01 2,991.94 32820 1,355.12 1,287.36 1,480.46 1,450.85 1,450.85 1,421.84 32851 3,365.04 3,196.79 3,676.31 3,602.78 3,602.78 3,530.72 32852 3,682.47 3,498.35 4,023.10 3,942.64 3,942.64 3,863.78

Page 78: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 78Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

32853 4,692.90 4,458.26 5,127.00 5,024.45 5,024.45 4,923.97 32854 4,989.68 4,740.20 5,451.23 5,342.21 5,342.21 5,235.36 32855 203.06 192.91 221.85 217.41 217.41 213.06 32856 304.58 289.35 332.75 326.09 326.09 319.57 32900 1,423.68 1,352.50 1,555.38 1,524.27 1,524.27 1,493.78 32905 1,364.66 1,296.43 1,490.89 1,461.08 1,461.08 1,431.85 32906 1,688.15 1,603.74 1,844.30 1,807.42 1,807.42 1,771.28 32940 1,255.28 1,192.52 1,371.40 1,343.97 1,343.97 1,317.10 32960 139.43 132.46 152.33 149.28 149.28 146.29 # 32960 101.30 96.24 110.68 108.47 108.47 106.29 32997 348.74 331.30 381.00 373.37 373.37 365.91 32998 2,254.08 2,141.38 2,462.59 2,413.33 2,413.33 2,365.07 # 32998 288.88 274.44 315.61 309.29 309.29 303.11 33010 122.60 116.47 133.94 131.26 131.26 128.64 33011 123.29 117.13 134.70 132.01 132.01 129.36 33015 515.10 489.35 562.75 551.49 551.49 540.47 33020 892.56 847.93 975.12 955.62 955.62 936.50 33025 810.90 770.36 885.91 868.19 868.19 850.83 33030 2,042.70 1,940.57 2,231.66 2,187.02 2,187.02 2,143.28 33031 2,522.88 2,396.74 2,756.25 2,701.13 2,701.13 2,647.10 33050 1,013.26 962.60 1,106.99 1,084.85 1,084.85 1,063.15 33120 2,142.72 2,035.58 2,340.92 2,294.10 2,294.10 2,248.22 33130 1,403.81 1,333.62 1,533.66 1,502.99 1,502.99 1,472.93 33140 1,604.62 1,524.39 1,753.05 1,717.99 1,717.99 1,683.62 33141 135.23 128.47 147.74 144.79 144.79 141.89 33202 788.34 748.92 861.26 844.03 844.03 827.15 33203 819.98 778.98 895.83 877.91 877.91 860.35 33206 466.01 442.71 509.12 498.94 498.94 488.96 33207 498.02 473.12 544.09 533.21 533.21 522.55 33208 539.37 512.40 589.26 577.47 577.47 565.93 33210 182.59 173.46 199.48 195.49 195.49 191.58 33211 186.85 177.51 204.14 200.05 200.05 196.05 33212 336.56 319.73 367.69 360.34 360.34 353.13 33213 350.99 333.44 383.46 375.79 375.79 368.26 33214 494.20 469.49 539.91 529.12 529.12 518.54 33215 312.69 297.06 341.62 334.79 334.79 328.10 33216 385.40 366.13 421.05 412.63 412.63 404.37 33217 378.38 359.46 413.38 405.11 405.11 397.00 33218 403.24 383.08 440.54 431.73 431.73 423.10 33220 404.15 383.94 441.53 432.70 432.70 424.04 33221 375.96 357.16 410.73 402.52 402.52 394.47 33222 350.11 332.60 382.49 374.84 374.84 367.34 33223 423.32 402.15 462.47 453.23 453.23 444.16 33224 523.92 497.72 572.38 560.94 560.94 549.71 33225 476.35 452.53 520.41 510.00 510.00 499.80 33226 502.19 477.08 548.64 537.67 537.67 526.92 33227 353.53 335.85 386.23 378.50 378.50 370.93 33228 368.94 350.49 403.06 395.00 395.00 387.10 33229 388.66 369.23 424.61 416.13 416.13 407.80

Page 79: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 79Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33230 400.54 380.51 437.59 428.84 428.84 420.26 33231 416.92 396.07 455.48 446.37 446.37 437.45 33233 242.81 230.67 265.27 259.97 259.97 254.77 33234 501.14 476.08 547.49 536.54 536.54 525.81 33235 652.75 620.11 713.13 698.87 698.87 684.89 33236 792.88 753.24 866.23 848.91 848.91 831.93 33237 852.58 809.95 931.44 912.81 912.81 894.56 33238 944.61 897.38 1,031.99 1,011.34 1,011.34 991.12 33240 381.76 362.67 417.07 408.73 408.73 400.56 33241 228.99 217.54 250.17 245.17 245.17 240.27 33243 1,389.92 1,320.42 1,518.48 1,488.11 1,488.11 1,458.35 33244 878.11 834.20 959.33 940.15 940.15 921.35 33249 937.52 890.64 1,024.24 1,003.75 1,003.75 983.68 33250 1,493.35 1,418.68 1,631.48 1,598.86 1,598.86 1,566.88 33251 1,654.49 1,571.77 1,807.54 1,771.38 1,771.38 1,735.95 33254 1,395.71 1,325.92 1,524.81 1,494.31 1,494.31 1,464.42 33255 1,649.48 1,567.01 1,802.06 1,766.02 1,766.02 1,730.70 33256 1,993.00 1,893.35 2,177.35 2,133.80 2,133.80 2,091.13 33257 590.29 560.78 644.90 631.99 631.99 619.36 33258 663.07 629.92 724.41 709.92 709.92 695.72 33259 856.39 813.57 935.61 916.90 916.90 898.55 33261 1,670.47 1,586.95 1,824.99 1,788.49 1,788.49 1,752.73 33262 388.39 368.97 424.32 415.83 415.83 407.51 33263 403.80 383.61 441.15 432.33 432.33 423.68 33264 420.89 399.85 459.83 450.63 450.63 441.61 33265 1,383.54 1,314.36 1,511.51 1,481.28 1,481.28 1,451.66 33266 1,883.48 1,789.31 2,057.71 2,016.55 2,016.55 1,976.22 33270 595.88 566.09 651.00 637.99 637.99 625.22 33271 501.09 476.04 547.45 536.50 536.50 525.77 33272 353.98 336.28 386.72 378.98 378.98 371.40 33273 405.62 385.34 443.14 434.27 434.27 425.59 33282 239.57 227.59 261.73 256.50 256.50 251.37 33284 211.51 200.93 231.07 226.45 226.45 221.92 33300 2,503.39 2,378.22 2,734.95 2,680.26 2,680.26 2,626.66 33305 4,198.45 3,988.53 4,586.81 4,495.07 4,495.07 4,405.17 33310 1,196.40 1,136.58 1,307.07 1,280.93 1,280.93 1,255.31 33315 1,952.14 1,854.53 2,132.71 2,090.06 2,090.06 2,048.25 33320 1,081.56 1,027.48 1,181.60 1,157.97 1,157.97 1,134.81 33321 1,250.96 1,188.41 1,366.67 1,339.34 1,339.34 1,312.55 33322 1,415.02 1,344.27 1,545.91 1,514.99 1,514.99 1,484.68 33330 1,452.00 1,379.40 1,586.31 1,554.58 1,554.58 1,523.49 33335 1,908.10 1,812.70 2,084.61 2,042.92 2,042.92 2,002.06 33361 1,389.65 1,320.17 1,518.20 1,487.84 1,487.84 1,458.07 33362 1,519.24 1,443.28 1,659.77 1,626.57 1,626.57 1,594.04 33363 1,577.79 1,498.90 1,723.74 1,689.26 1,689.26 1,655.47 33364 1,654.62 1,571.89 1,807.67 1,771.52 1,771.52 1,736.09 33365 1,822.14 1,731.03 1,990.68 1,950.87 1,950.87 1,911.85 33366 1,972.14 1,873.53 2,154.56 2,111.47 2,111.47 2,069.24 33367 640.58 608.55 699.83 685.84 685.84 672.12

Page 80: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 80Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33368 767.58 729.20 838.58 821.81 821.81 805.38 33369 1,014.48 963.76 1,108.32 1,086.15 1,086.15 1,064.43 33400 2,324.75 2,208.51 2,539.79 2,488.99 2,488.99 2,439.21 33401 1,468.87 1,395.43 1,604.74 1,572.65 1,572.65 1,541.20 33403 1,509.40 1,433.93 1,649.02 1,616.04 1,616.04 1,583.72 33404 1,795.54 1,705.76 1,961.62 1,922.39 1,922.39 1,883.94 33405 2,317.51 2,201.63 2,531.87 2,481.24 2,481.24 2,431.62 33406 2,939.78 2,792.79 3,211.71 3,147.47 3,147.47 3,084.52 33410 2,588.37 2,458.95 2,827.79 2,771.24 2,771.24 2,715.81 33411 3,431.31 3,259.74 3,748.70 3,673.73 3,673.73 3,600.26 33412 3,248.13 3,085.72 3,548.58 3,477.61 3,477.61 3,408.06 33413 3,326.49 3,160.17 3,634.20 3,561.52 3,561.52 3,490.28 33414 2,211.21 2,100.65 2,415.75 2,367.44 2,367.44 2,320.09 33415 2,067.78 1,964.39 2,259.05 2,213.87 2,213.87 2,169.59 33416 2,074.11 1,970.40 2,265.96 2,220.64 2,220.64 2,176.23 33417 1,708.53 1,623.10 1,866.57 1,829.24 1,829.24 1,792.65 33418 1,830.94 1,739.39 2,000.30 1,960.29 1,960.29 1,921.09 33419 431.89 410.30 471.85 462.40 462.40 453.16 33420 1,487.69 1,413.31 1,625.31 1,592.80 1,592.80 1,560.94 33422 1,705.39 1,620.12 1,863.14 1,825.88 1,825.88 1,789.37 33425 2,793.37 2,653.70 3,051.76 2,990.72 2,990.72 2,930.91 33426 2,431.87 2,310.28 2,656.82 2,603.68 2,603.68 2,551.61 33427 2,497.16 2,372.30 2,728.15 2,673.58 2,673.58 2,620.10 33430 2,857.12 2,714.26 3,121.40 3,058.97 3,058.97 2,997.79 33460 2,496.50 2,371.68 2,727.43 2,672.89 2,672.89 2,619.44 33463 3,159.44 3,001.47 3,451.69 3,382.66 3,382.66 3,315.00 33464 2,493.48 2,368.81 2,724.13 2,669.64 2,669.64 2,616.25 33465 2,817.48 2,676.61 3,078.10 3,016.54 3,016.54 2,956.21 33468 2,522.03 2,395.93 2,755.32 2,700.21 2,700.21 2,646.21 33470 1,317.17 1,251.31 1,439.01 1,410.22 1,410.22 1,382.01 33471 1,407.68 1,337.30 1,537.90 1,507.13 1,507.13 1,476.99 33474 2,237.62 2,125.74 2,444.60 2,395.71 2,395.71 2,347.81 33475 2,379.39 2,260.42 2,599.48 2,547.49 2,547.49 2,496.55 33476 1,558.99 1,481.04 1,703.20 1,669.13 1,669.13 1,635.75 33477 1,318.36 1,252.44 1,440.31 1,411.50 1,411.50 1,383.27 33478 1,611.10 1,530.55 1,760.13 1,724.93 1,724.93 1,690.43 33496 1,704.99 1,619.74 1,862.70 1,825.45 1,825.45 1,788.94 33500 1,596.99 1,517.14 1,744.71 1,709.82 1,709.82 1,675.62 33501 1,153.46 1,095.79 1,260.16 1,234.95 1,234.95 1,210.25 33502 1,305.12 1,239.86 1,425.84 1,397.32 1,397.32 1,369.37 33503 1,355.80 1,288.01 1,481.21 1,451.59 1,451.59 1,422.56 33504 1,500.77 1,425.73 1,639.59 1,606.80 1,606.80 1,574.67 33505 2,124.59 2,018.36 2,321.11 2,274.69 2,274.69 2,229.19 33506 2,114.08 2,008.38 2,309.64 2,263.44 2,263.44 2,218.18 33507 1,772.18 1,683.57 1,936.11 1,897.39 1,897.39 1,859.44 33508 16.55 15.72 18.08 17.72 17.72 17.37 33510 1,972.15 1,873.54 2,154.57 2,111.48 2,111.48 2,069.25 33511 2,167.59 2,059.21 2,368.09 2,320.73 2,320.73 2,274.32 33512 2,464.98 2,341.73 2,692.99 2,639.14 2,639.14 2,586.35

Page 81: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 81Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33513 2,536.61 2,409.78 2,771.25 2,715.82 2,715.82 2,661.50 33514 2,670.71 2,537.17 2,917.75 2,859.39 2,859.39 2,802.21 33516 2,789.17 2,649.71 3,047.17 2,986.23 2,986.23 2,926.51 33517 192.26 182.65 210.05 205.85 205.85 201.73 33518 422.54 401.41 461.62 452.39 452.39 443.34 33519 558.81 530.87 610.50 598.29 598.29 586.33 33521 670.10 636.60 732.09 717.45 717.45 703.10 33522 751.82 714.23 821.36 804.94 804.94 788.84 33523 854.92 812.17 934.00 915.32 915.32 897.01 33530 540.17 513.16 590.13 578.34 578.34 566.77 33533 1,907.04 1,811.69 2,083.44 2,041.78 2,041.78 2,000.94 33534 2,244.66 2,132.43 2,452.29 2,403.25 2,403.25 2,355.18 33535 2,503.72 2,378.53 2,735.31 2,680.60 2,680.60 2,626.99 33536 2,699.69 2,564.71 2,949.42 2,890.43 2,890.43 2,832.62 33542 2,684.88 2,550.64 2,933.24 2,874.57 2,874.57 2,817.09 33545 3,169.28 3,010.82 3,462.44 3,393.19 3,393.19 3,325.33 33548 3,025.81 2,874.52 3,305.70 3,239.58 3,239.58 3,174.79 33572 236.62 224.79 258.51 253.33 253.33 248.26 33600 1,761.68 1,673.60 1,924.64 1,886.15 1,886.15 1,848.43 33602 1,709.57 1,624.09 1,867.70 1,830.35 1,830.35 1,793.75 33606 1,901.82 1,806.73 2,077.74 2,036.19 2,036.19 1,995.47 33608 1,846.20 1,753.89 2,016.97 1,976.63 1,976.63 1,937.09 33610 1,820.50 1,729.48 1,988.90 1,949.12 1,949.12 1,910.14 33611 2,102.62 1,997.49 2,297.11 2,251.17 2,251.17 2,206.15 33612 2,060.51 1,957.48 2,251.10 2,206.08 2,206.08 2,161.95 33615 2,050.20 1,947.69 2,239.84 2,195.05 2,195.05 2,151.16 33617 2,222.36 2,111.24 2,427.93 2,379.37 2,379.37 2,331.79 33619 2,798.29 2,658.38 3,057.14 2,995.99 2,995.99 2,936.08 33620 1,696.13 1,611.32 1,853.02 1,815.95 1,815.95 1,779.64 33621 953.86 906.17 1,042.10 1,021.26 1,021.26 1,000.83 33622 3,719.52 3,533.54 4,063.57 3,982.30 3,982.30 3,902.65 33641 1,684.44 1,600.22 1,840.25 1,803.45 1,803.45 1,767.39 33645 1,778.02 1,689.12 1,942.49 1,903.64 1,903.64 1,865.56 33647 1,868.94 1,775.49 2,041.81 2,000.98 2,000.98 1,960.96 33660 1,805.92 1,715.62 1,972.96 1,933.51 1,933.51 1,894.83 33665 1,968.25 1,869.84 2,150.32 2,107.31 2,107.31 2,065.16 33670 2,032.12 1,930.51 2,220.09 2,175.69 2,175.69 2,132.17 33675 2,028.38 1,926.96 2,216.00 2,171.68 2,171.68 2,128.25 33676 2,182.17 2,073.06 2,384.02 2,336.34 2,336.34 2,289.62 33677 2,267.41 2,154.04 2,477.15 2,427.60 2,427.60 2,379.05 33681 1,885.31 1,791.04 2,059.70 2,018.50 2,018.50 1,978.14 33684 2,034.58 1,932.85 2,222.78 2,178.32 2,178.32 2,134.76 33688 1,939.63 1,842.65 2,119.05 2,076.67 2,076.67 2,035.13 33690 1,226.48 1,165.16 1,339.93 1,313.14 1,313.14 1,286.87 33692 2,115.87 2,010.08 2,311.59 2,265.36 2,265.36 2,220.05 33694 2,102.62 1,997.49 2,297.11 2,251.17 2,251.17 2,206.15 33697 2,114.38 2,008.66 2,309.96 2,263.76 2,263.76 2,218.49 33702 1,585.05 1,505.80 1,731.67 1,697.03 1,697.03 1,663.10 33710 2,212.40 2,101.78 2,417.05 2,368.70 2,368.70 2,321.33

Page 82: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 82Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33720 1,585.77 1,506.48 1,732.45 1,697.80 1,697.80 1,663.84 33722 1,669.34 1,585.87 1,823.75 1,787.27 1,787.27 1,751.53 33724 1,580.85 1,501.81 1,727.08 1,692.54 1,692.54 1,658.68 33726 2,091.40 1,986.83 2,284.85 2,239.15 2,239.15 2,194.37 33730 2,059.64 1,956.66 2,250.16 2,205.16 2,205.16 2,161.06 33732 1,689.15 1,604.69 1,845.39 1,808.49 1,808.49 1,772.32 33735 1,325.42 1,259.15 1,448.02 1,419.07 1,419.07 1,390.68 33736 1,439.51 1,367.53 1,572.66 1,541.21 1,541.21 1,510.39 33737 1,379.98 1,310.98 1,507.63 1,477.47 1,477.47 1,447.92 33750 1,293.63 1,228.95 1,413.29 1,385.03 1,385.03 1,357.32 33755 1,346.92 1,279.57 1,471.51 1,442.08 1,442.08 1,413.24 33762 1,368.94 1,300.49 1,495.56 1,465.65 1,465.65 1,436.34 33764 1,346.92 1,279.57 1,471.51 1,442.08 1,442.08 1,413.24 33766 1,365.83 1,297.54 1,492.17 1,462.33 1,462.33 1,433.08 33767 1,458.78 1,385.84 1,593.72 1,561.84 1,561.84 1,530.60 33768 430.27 408.76 470.07 460.67 460.67 451.46 33770 2,288.37 2,173.95 2,500.04 2,450.04 2,450.04 2,401.04 33771 2,360.66 2,242.63 2,579.02 2,527.45 2,527.45 2,476.89 33774 1,845.02 1,752.77 2,015.69 1,975.37 1,975.37 1,935.86 33775 1,984.61 1,885.38 2,168.19 2,124.82 2,124.82 2,082.33 33776 2,096.41 1,991.59 2,290.33 2,244.52 2,244.52 2,199.63 33777 2,032.87 1,931.23 2,220.91 2,176.50 2,176.50 2,132.97 33778 2,529.28 2,402.82 2,763.24 2,707.97 2,707.97 2,653.81 33779 2,518.20 2,392.29 2,751.13 2,696.11 2,696.11 2,642.18 33780 2,439.08 2,317.13 2,664.70 2,611.41 2,611.41 2,559.18 33781 2,507.26 2,381.90 2,739.19 2,684.40 2,684.40 2,630.71 33782 3,325.89 3,159.60 3,633.54 3,560.87 3,560.87 3,489.65 33783 3,780.91 3,591.86 4,130.64 4,048.02 4,048.02 3,967.06 33786 2,341.42 2,224.35 2,558.00 2,506.84 2,506.84 2,456.70 33788 1,642.88 1,560.74 1,794.85 1,758.96 1,758.96 1,723.78 33800 1,012.02 961.42 1,105.63 1,083.52 1,083.52 1,061.85 33802 1,107.95 1,052.55 1,210.43 1,186.23 1,186.23 1,162.50 33803 1,179.30 1,120.34 1,288.39 1,262.62 1,262.62 1,237.37 33813 1,316.50 1,250.68 1,438.28 1,409.52 1,409.52 1,381.33 33814 1,560.63 1,482.60 1,704.99 1,670.89 1,670.89 1,637.47 33820 991.83 942.24 1,083.58 1,061.91 1,061.91 1,040.67 33822 1,086.85 1,032.51 1,187.39 1,163.64 1,163.64 1,140.36 33824 1,206.30 1,145.99 1,317.89 1,291.53 1,291.53 1,265.70 33840 1,267.80 1,204.41 1,385.07 1,357.37 1,357.37 1,330.22 33845 1,364.86 1,296.62 1,491.11 1,461.29 1,461.29 1,432.07 33851 1,301.96 1,236.86 1,422.39 1,393.94 1,393.94 1,366.06 33852 1,432.60 1,360.97 1,565.12 1,533.81 1,533.81 1,503.14 33853 1,880.00 1,786.00 2,053.90 2,012.82 2,012.82 1,972.56 33860 3,286.17 3,121.86 3,590.14 3,518.33 3,518.33 3,447.96 33863 3,224.97 3,063.72 3,523.28 3,452.82 3,452.82 3,383.76 33864 3,298.20 3,133.29 3,603.28 3,531.21 3,531.21 3,460.59 33870 2,573.28 2,444.62 2,811.31 2,755.09 2,755.09 2,699.99 33875 2,814.73 2,673.99 3,075.09 3,013.59 3,013.59 2,953.32 33877 3,742.22 3,555.11 4,088.38 4,006.61 4,006.61 3,926.48

Page 83: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 83Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33880 1,862.74 1,769.60 2,035.04 1,994.34 1,994.34 1,954.46 33881 1,599.53 1,519.55 1,747.48 1,712.53 1,712.53 1,678.29 33883 1,156.35 1,098.53 1,263.31 1,238.04 1,238.04 1,213.28 33884 424.70 403.47 463.99 454.71 454.71 445.61 33886 998.05 948.15 1,090.37 1,068.57 1,068.57 1,047.20 33889 819.72 778.73 895.54 877.63 877.63 860.09 33891 1,010.89 960.35 1,104.40 1,082.31 1,082.31 1,060.67 33910 2,688.33 2,553.91 2,937.00 2,878.25 2,878.25 2,820.69 33915 1,308.40 1,242.98 1,429.43 1,400.84 1,400.84 1,372.82 33916 4,314.23 4,098.52 4,713.30 4,619.03 4,619.03 4,526.65 33917 1,491.98 1,417.38 1,629.99 1,597.38 1,597.38 1,565.44 33920 1,945.59 1,848.31 2,125.56 2,083.04 2,083.04 2,041.38 33922 1,422.73 1,351.59 1,554.33 1,523.24 1,523.24 1,492.78 33924 295.07 280.32 322.37 315.92 315.92 309.60 33925 1,766.19 1,677.88 1,929.56 1,890.97 1,890.97 1,853.14 33926 2,614.28 2,483.57 2,856.11 2,798.99 2,798.99 2,743.00 33933 203.06 192.91 221.85 217.41 217.41 213.06 33935 5,116.52 4,860.69 5,589.79 5,478.00 5,478.00 5,368.44 33944 203.06 192.91 221.85 217.41 217.41 213.06 33945 4,971.06 4,722.51 5,430.89 5,322.27 5,322.27 5,215.83 33946 313.48 297.81 342.48 335.63 335.63 328.91 33947 346.55 329.22 378.60 371.04 371.04 363.62 33948 247.18 234.82 270.04 264.64 264.64 259.35 33949 240.50 228.48 262.75 257.50 257.50 252.34 33951 426.91 405.56 466.39 457.07 457.07 447.93 33952 440.87 418.83 481.65 472.02 472.02 462.58 33953 476.78 452.94 520.88 510.46 510.46 500.25 33954 492.95 468.30 538.55 527.77 527.77 517.21 33955 854.52 811.79 933.56 914.88 914.88 896.59 33956 860.46 817.44 940.06 921.25 921.25 902.83 33957 189.74 180.25 207.29 203.15 203.15 199.09 33958 187.22 177.86 204.54 200.45 200.45 196.43 33959 240.90 228.86 263.19 257.92 257.92 252.76 33962 244.49 232.27 267.11 261.76 261.76 256.53 33963 481.99 457.89 526.57 516.04 516.04 505.72 33964 502.65 477.52 549.15 538.17 538.17 527.40 33965 189.74 180.25 207.29 203.15 203.15 199.09 33966 241.70 229.62 264.06 258.78 258.78 253.61 33967 265.68 252.40 290.26 284.45 284.45 278.76 33968 34.44 32.72 37.63 36.88 36.88 36.14 33969 280.51 266.48 306.45 300.32 300.32 294.32 33970 364.11 345.90 397.79 389.83 389.83 382.03 33971 721.87 685.78 788.65 772.87 772.87 757.41 33973 527.56 501.18 576.36 564.83 564.83 553.54 33974 903.40 858.23 986.96 967.23 967.23 947.89 33975 1,352.00 1,284.40 1,477.06 1,447.52 1,447.52 1,418.57 33976 1,647.64 1,565.26 1,800.05 1,764.04 1,764.04 1,728.76 33977 1,157.94 1,100.04 1,265.05 1,239.75 1,239.75 1,214.95 33978 1,370.76 1,302.22 1,497.55 1,467.61 1,467.61 1,438.26

Page 84: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 84Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

33979 2,008.65 1,908.22 2,194.45 2,150.57 2,150.57 2,107.56 33980 1,834.40 1,742.68 2,004.08 1,964.00 1,964.00 1,924.72 33981 860.17 817.16 939.73 920.94 920.94 902.52 33982 2,035.90 1,934.11 2,224.23 2,179.74 2,179.74 2,136.15 33983 2,383.23 2,264.07 2,603.68 2,551.61 2,551.61 2,500.57 33984 293.13 278.47 320.24 313.84 313.84 307.56 33985 529.30 502.84 578.27 566.70 566.70 555.36 33986 543.36 516.19 593.62 581.75 581.75 570.11 33987 214.12 203.41 233.92 229.24 229.24 224.65 33988 798.52 758.59 872.38 854.93 854.93 837.83 33989 515.68 489.90 563.39 552.12 552.12 541.08 33990 450.46 427.94 492.13 482.29 482.29 472.64 33991 656.02 623.22 716.70 702.37 702.37 688.32 33992 213.04 202.39 232.75 228.09 228.09 223.53 33993 186.96 177.61 204.25 200.17 200.17 196.17 34001 1,007.24 956.88 1,100.41 1,078.40 1,078.40 1,056.84 34051 1,010.57 960.04 1,104.05 1,081.97 1,081.97 1,060.32 34101 623.31 592.14 680.96 667.35 667.35 653.99 34111 621.26 590.20 678.73 665.16 665.16 651.85 34151 1,453.65 1,380.97 1,588.12 1,556.35 1,556.35 1,525.22 34201 1,071.79 1,018.20 1,170.93 1,147.52 1,147.52 1,124.56 34203 992.71 943.07 1,084.53 1,062.84 1,062.84 1,041.59 34401 1,494.78 1,420.04 1,633.05 1,600.39 1,600.39 1,568.38 34421 756.33 718.51 826.29 809.76 809.76 793.57 34451 1,503.58 1,428.40 1,642.66 1,609.80 1,609.80 1,577.60 34471 1,124.62 1,068.39 1,228.65 1,204.07 1,204.07 1,179.99 34490 630.15 598.64 688.44 674.67 674.67 661.18 34501 1,005.78 955.49 1,098.81 1,076.84 1,076.84 1,055.30 34502 1,578.74 1,499.80 1,724.77 1,690.27 1,690.27 1,656.46 34510 1,219.57 1,158.59 1,332.38 1,305.73 1,305.73 1,279.62 34520 1,042.34 990.22 1,138.75 1,115.98 1,115.98 1,093.66 34530 1,119.30 1,063.34 1,222.84 1,198.38 1,198.38 1,174.41 34800 1,174.07 1,115.37 1,282.68 1,257.02 1,257.02 1,231.88 34802 1,295.28 1,230.52 1,415.10 1,386.80 1,386.80 1,359.06 34803 1,339.32 1,272.35 1,463.20 1,433.94 1,433.94 1,405.25 34804 1,293.74 1,229.05 1,413.41 1,385.14 1,385.14 1,357.44 34805 1,239.65 1,177.67 1,354.32 1,327.24 1,327.24 1,300.70 34806 104.60 99.37 114.28 111.99 111.99 109.74 34808 215.88 205.09 235.85 231.14 231.14 226.52 34812 351.67 334.09 384.20 376.52 376.52 368.99 34813 247.12 234.76 269.97 264.57 264.57 259.28 34820 512.24 486.63 559.62 548.44 548.44 537.46 34825 720.54 684.51 787.19 771.44 771.44 756.01 34826 214.10 203.40 233.91 229.23 229.23 224.64 34830 1,839.97 1,747.97 2,010.17 1,969.96 1,969.96 1,930.56 34831 1,983.43 1,884.26 2,166.90 2,123.56 2,123.56 2,081.09 34832 1,969.57 1,871.09 2,151.75 2,108.72 2,108.72 2,066.55 34833 633.91 602.21 692.54 678.70 678.70 665.13 34834 283.87 269.68 310.13 303.93 303.93 297.85

Page 85: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 85Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

34841 1,199.43 1,139.46 1,310.38 1,284.17 1,284.17 1,258.49 34842 1,451.43 1,378.86 1,585.69 1,553.97 1,553.97 1,522.89 34843 1,420.02 1,349.02 1,551.37 1,520.35 1,520.35 1,489.94 34844 1,467.32 1,393.95 1,603.04 1,570.98 1,570.98 1,539.56 34845 1,199.43 1,139.46 1,310.38 1,284.17 1,284.17 1,258.49 34846 1,451.43 1,378.86 1,585.69 1,553.97 1,553.97 1,522.89 34847 1,420.02 1,349.02 1,551.37 1,520.35 1,520.35 1,489.94 34848 1,467.32 1,393.95 1,603.04 1,570.98 1,570.98 1,539.56 34900 929.98 883.48 1,016.00 995.68 995.68 975.76 35001 1,162.59 1,104.46 1,270.13 1,244.73 1,244.73 1,219.83 35002 1,183.83 1,124.64 1,293.34 1,267.47 1,267.47 1,242.13 35005 1,115.21 1,059.45 1,218.37 1,194.00 1,194.00 1,170.11 35011 1,040.75 988.71 1,137.02 1,114.28 1,114.28 1,091.99 35013 1,301.11 1,236.05 1,421.46 1,393.03 1,393.03 1,365.17 35021 1,287.76 1,223.37 1,406.88 1,378.74 1,378.74 1,351.16 35022 1,434.87 1,363.13 1,567.60 1,536.25 1,536.25 1,505.52 35045 1,027.91 976.51 1,122.99 1,100.53 1,100.53 1,078.52 35081 1,818.55 1,727.62 1,986.76 1,947.03 1,947.03 1,908.09 35082 2,284.64 2,170.41 2,495.97 2,446.05 2,446.05 2,397.13 35091 1,870.79 1,777.25 2,043.84 2,002.97 2,002.97 1,962.91 35092 2,708.83 2,573.39 2,959.40 2,900.21 2,900.21 2,842.20 35102 1,969.64 1,871.16 2,151.83 2,108.80 2,108.80 2,066.63 35103 2,340.63 2,223.60 2,557.14 2,506.00 2,506.00 2,455.88 35111 1,570.19 1,491.68 1,715.43 1,681.13 1,681.13 1,647.50 35112 1,895.87 1,801.08 2,071.24 2,029.82 2,029.82 1,989.22 35121 1,709.96 1,624.46 1,868.13 1,830.77 1,830.77 1,794.15 35122 2,211.68 2,101.10 2,416.27 2,367.94 2,367.94 2,320.59 35131 1,444.37 1,372.15 1,577.97 1,546.42 1,546.42 1,515.49 35132 1,701.78 1,616.69 1,859.19 1,822.01 1,822.01 1,785.57 35141 1,151.15 1,093.59 1,257.63 1,232.48 1,232.48 1,207.83 35142 1,376.54 1,307.71 1,503.87 1,473.79 1,473.79 1,444.32 35151 1,293.53 1,228.85 1,413.18 1,384.91 1,384.91 1,357.21 35152 1,460.71 1,387.67 1,595.82 1,563.91 1,563.91 1,532.63 35180 949.69 902.21 1,037.54 1,016.80 1,016.80 996.46 35182 1,832.44 1,740.82 2,001.94 1,961.90 1,961.90 1,922.66 35184 1,079.33 1,025.36 1,179.16 1,155.58 1,155.58 1,132.46 35188 1,172.50 1,113.88 1,280.96 1,255.34 1,255.34 1,230.24 35189 1,595.54 1,515.76 1,743.12 1,708.26 1,708.26 1,674.09 35190 785.73 746.44 858.41 841.24 841.24 824.41 35201 978.91 929.96 1,069.45 1,048.06 1,048.06 1,027.10 35206 800.44 760.42 874.48 856.99 856.99 839.86 35207 755.88 718.09 825.80 809.29 809.29 793.11 35211 1,410.40 1,339.88 1,540.86 1,510.04 1,510.04 1,479.84 35216 2,099.67 1,994.69 2,293.89 2,248.02 2,248.02 2,203.06 35221 1,500.23 1,425.22 1,639.00 1,606.23 1,606.23 1,574.11 35226 862.63 819.50 942.43 923.58 923.58 905.11 35231 1,246.62 1,184.29 1,361.93 1,334.69 1,334.69 1,308.00 35236 1,014.28 963.57 1,108.11 1,085.95 1,085.95 1,064.22 35241 1,411.28 1,340.72 1,541.83 1,511.00 1,511.00 1,480.77

Page 86: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 86Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

35246 1,614.78 1,534.04 1,764.15 1,728.86 1,728.86 1,694.28 35251 1,759.30 1,671.34 1,922.04 1,883.60 1,883.60 1,845.92 35256 1,057.33 1,004.46 1,155.13 1,132.03 1,132.03 1,109.38 35261 1,094.86 1,040.12 1,196.14 1,172.22 1,172.22 1,148.77 35266 902.09 856.99 985.54 965.83 965.83 946.51 35271 1,404.77 1,334.53 1,534.71 1,504.02 1,504.02 1,473.93 35276 1,491.45 1,416.88 1,629.41 1,596.82 1,596.82 1,564.89 35281 1,675.53 1,591.75 1,830.51 1,793.91 1,793.91 1,758.03 35286 970.30 921.79 1,060.06 1,038.85 1,038.85 1,018.07 35301 1,176.48 1,117.66 1,285.31 1,259.61 1,259.61 1,234.41 35302 1,171.37 1,112.80 1,279.72 1,254.12 1,254.12 1,229.04 35303 1,296.41 1,231.59 1,416.33 1,388.00 1,388.00 1,360.24 35304 1,337.33 1,270.46 1,461.03 1,431.81 1,431.81 1,403.17 35305 1,280.85 1,216.81 1,399.33 1,371.34 1,371.34 1,343.91 35306 478.24 454.33 522.48 512.03 512.03 501.79 35311 1,517.90 1,442.01 1,658.31 1,625.15 1,625.15 1,592.65 35321 924.80 878.56 1,010.34 990.14 990.14 970.34 35331 1,508.84 1,433.40 1,648.41 1,615.44 1,615.44 1,583.14 35341 1,423.30 1,352.14 1,554.96 1,523.87 1,523.87 1,493.39 35351 1,333.85 1,267.16 1,457.23 1,428.09 1,428.09 1,399.53 35355 1,079.34 1,025.37 1,179.18 1,155.59 1,155.59 1,132.47 35361 1,603.69 1,523.51 1,752.04 1,717.00 1,717.00 1,682.66 35363 1,814.81 1,724.07 1,982.68 1,943.03 1,943.03 1,904.17 35371 852.17 809.56 930.99 912.38 912.38 894.13 35372 1,021.88 970.79 1,116.41 1,094.08 1,094.08 1,072.19 35390 166.14 157.83 181.50 177.87 177.87 174.32 35400 155.64 147.86 170.04 166.64 166.64 163.30 35450 527.17 500.81 575.93 564.41 564.41 553.12 35452 355.76 337.97 388.67 380.89 380.89 373.28 35458 512.38 486.76 559.77 548.57 548.57 537.60 35460 326.15 309.84 356.32 349.19 349.19 342.21 35471 2,429.75 2,308.26 2,654.50 2,601.40 2,601.40 2,549.38 # 35471 539.16 512.20 589.03 577.25 577.25 565.71 35472 1,749.11 1,661.65 1,910.90 1,872.68 1,872.68 1,835.23 # 35472 367.32 348.95 401.29 393.27 393.27 385.40 35475 1,482.19 1,408.08 1,619.29 1,586.91 1,586.91 1,555.17 # 35475 342.31 325.19 373.97 366.49 366.49 359.17 35476 1,355.61 1,287.83 1,481.00 1,451.38 1,451.38 1,422.35 # 35476 275.55 261.77 301.04 295.01 295.01 289.11 35500 332.83 316.19 363.62 356.35 356.35 349.22 35501 1,556.68 1,478.85 1,700.68 1,666.66 1,666.66 1,633.32 35506 1,331.59 1,265.01 1,454.76 1,425.67 1,425.67 1,397.16 35508 1,413.18 1,342.52 1,543.90 1,513.02 1,513.02 1,482.76 35509 1,472.46 1,398.84 1,608.67 1,576.49 1,576.49 1,544.96 35510 1,285.19 1,220.93 1,404.07 1,375.99 1,375.99 1,348.47 35511 1,170.59 1,112.06 1,278.87 1,253.29 1,253.29 1,228.22 35512 1,272.63 1,209.00 1,390.35 1,362.54 1,362.54 1,335.29 35515 1,480.13 1,406.12 1,617.04 1,584.70 1,584.70 1,553.01 35516 1,275.02 1,211.27 1,392.96 1,365.10 1,365.10 1,337.80

Page 87: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 87Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

35518 1,209.79 1,149.30 1,321.70 1,295.26 1,295.26 1,269.35 35521 1,288.92 1,224.47 1,408.14 1,379.98 1,379.98 1,352.38 35522 1,258.53 1,195.60 1,374.94 1,347.44 1,347.44 1,320.50 35523 1,333.74 1,267.05 1,457.11 1,427.97 1,427.97 1,399.41 35525 1,190.83 1,131.29 1,300.98 1,274.96 1,274.96 1,249.46 35526 1,760.59 1,672.56 1,923.44 1,884.98 1,884.98 1,847.28 35531 2,107.40 2,002.03 2,302.33 2,256.29 2,256.29 2,211.16 35533 1,563.49 1,485.32 1,708.12 1,673.95 1,673.95 1,640.48 35535 2,001.07 1,901.02 2,186.17 2,142.45 2,142.45 2,099.60 35536 1,765.80 1,677.51 1,929.14 1,890.55 1,890.55 1,852.74 35537 2,282.01 2,167.91 2,493.10 2,443.23 2,443.23 2,394.37 35538 2,451.79 2,329.20 2,678.58 2,625.01 2,625.01 2,572.52 35539 2,292.34 2,177.72 2,504.38 2,454.30 2,454.30 2,405.21 35540 2,564.31 2,436.09 2,801.50 2,745.48 2,745.48 2,690.56 35556 1,460.70 1,387.67 1,595.82 1,563.91 1,563.91 1,532.63 35558 1,283.04 1,218.89 1,401.72 1,373.69 1,373.69 1,346.21 35560 1,792.41 1,702.79 1,958.21 1,919.04 1,919.04 1,880.66 35563 1,387.71 1,318.32 1,516.07 1,485.74 1,485.74 1,456.03 35565 1,379.46 1,310.49 1,507.06 1,476.92 1,476.92 1,447.38 35566 1,744.93 1,657.68 1,906.33 1,868.21 1,868.21 1,830.85 35570 1,585.52 1,506.24 1,732.18 1,697.54 1,697.54 1,663.59 35571 1,387.73 1,318.34 1,516.09 1,485.77 1,485.77 1,456.05 35572 360.18 342.17 393.50 385.63 385.63 377.91 35583 1,509.95 1,434.45 1,649.62 1,616.62 1,616.62 1,584.29 35585 1,752.92 1,665.27 1,915.06 1,876.75 1,876.75 1,839.22 35587 1,424.18 1,352.97 1,555.92 1,524.80 1,524.80 1,494.30 35600 262.30 249.19 286.57 280.84 280.84 275.23 35601 1,462.90 1,389.76 1,598.22 1,566.25 1,566.25 1,534.93 35606 1,223.64 1,162.46 1,336.83 1,310.09 1,310.09 1,283.89 35612 1,117.74 1,061.85 1,221.13 1,196.70 1,196.70 1,172.77 35616 1,152.14 1,094.53 1,258.71 1,233.54 1,233.54 1,208.87 35621 1,145.95 1,088.65 1,251.95 1,226.91 1,226.91 1,202.37 35623 1,372.82 1,304.18 1,499.81 1,469.82 1,469.82 1,440.42 35626 1,630.39 1,548.87 1,781.20 1,745.57 1,745.57 1,710.66 35631 1,931.31 1,834.74 2,109.95 2,067.76 2,067.76 2,026.40 35632 1,884.91 1,790.66 2,059.26 2,018.08 2,018.08 1,977.71 35633 2,091.82 1,987.23 2,285.31 2,239.61 2,239.61 2,194.82 35634 1,846.38 1,754.06 2,017.17 1,976.83 1,976.83 1,937.29 35636 1,673.76 1,590.07 1,828.58 1,792.01 1,792.01 1,756.17 35637 1,798.44 1,708.52 1,964.80 1,925.50 1,925.50 1,886.99 35638 1,837.29 1,745.43 2,007.24 1,967.10 1,967.10 1,927.76 35642 1,027.84 976.45 1,122.92 1,100.46 1,100.46 1,078.45 35645 1,055.13 1,002.37 1,152.73 1,129.67 1,129.67 1,107.07 35646 1,790.81 1,701.27 1,956.46 1,917.33 1,917.33 1,878.99 35647 1,622.99 1,541.84 1,773.12 1,737.65 1,737.65 1,702.90 35650 1,123.41 1,067.24 1,227.33 1,202.79 1,202.79 1,178.73 35654 1,429.20 1,357.74 1,561.40 1,530.18 1,530.18 1,499.58 35656 1,130.48 1,073.96 1,235.05 1,210.35 1,210.35 1,186.14 35661 1,130.37 1,073.85 1,234.93 1,210.23 1,210.23 1,186.02

Page 88: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 88Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

35663 1,308.39 1,242.97 1,429.42 1,400.83 1,400.83 1,372.81 35665 1,223.13 1,161.97 1,336.27 1,309.54 1,309.54 1,283.35 35666 1,319.95 1,253.95 1,442.04 1,413.20 1,413.20 1,384.93 35671 1,163.29 1,105.13 1,270.90 1,245.48 1,245.48 1,220.58 35681 83.56 79.38 91.29 89.46 89.46 87.66 35682 369.65 351.17 403.85 395.77 395.77 387.86 35683 431.51 409.93 471.42 461.99 461.99 452.76 35685 207.95 197.55 227.18 222.64 222.64 218.19 35686 169.01 160.56 184.64 180.95 180.95 177.33 35691 999.26 949.30 1,091.70 1,069.86 1,069.86 1,048.46 35693 847.92 805.52 926.35 907.82 907.82 889.66 35694 1,031.95 980.35 1,127.40 1,104.85 1,104.85 1,082.76 35695 1,093.40 1,038.73 1,194.54 1,170.65 1,170.65 1,147.24 35697 154.30 146.59 168.58 165.21 165.21 161.91 35700 159.84 151.85 174.63 171.13 171.13 167.70 35701 578.97 550.02 632.52 619.87 619.87 607.48 35721 469.85 446.36 513.31 503.04 503.04 492.98 35741 530.70 504.17 579.80 568.20 568.20 556.84 35761 397.22 377.36 433.96 425.28 425.28 416.77 35800 729.77 693.28 797.27 781.32 781.32 765.69 35820 2,057.58 1,954.70 2,247.91 2,202.95 2,202.95 2,158.90 35840 1,215.44 1,154.67 1,327.87 1,301.32 1,301.32 1,275.29 35860 870.68 827.15 951.22 932.20 932.20 913.56 35870 1,297.48 1,232.61 1,417.50 1,389.15 1,389.15 1,361.37 35875 617.35 586.48 674.45 660.96 660.96 647.75 35876 983.94 934.74 1,074.95 1,053.46 1,053.46 1,032.39 35879 961.44 913.37 1,050.38 1,029.37 1,029.37 1,008.78 35881 1,063.36 1,010.19 1,161.72 1,138.49 1,138.49 1,115.72 35883 1,260.64 1,197.61 1,377.25 1,349.71 1,349.71 1,322.72 35884 1,293.81 1,229.12 1,413.49 1,385.22 1,385.22 1,357.52 35901 489.59 465.11 534.88 524.18 524.18 513.69 35903 583.17 554.01 637.11 624.37 624.37 611.88 35905 1,758.51 1,670.58 1,921.17 1,882.75 1,882.75 1,845.09 35907 1,995.33 1,895.56 2,179.89 2,136.30 2,136.30 2,093.58 36002 159.02 151.07 173.73 170.26 170.26 166.85 # 36002 108.40 102.98 118.43 116.06 116.06 113.74 36005 306.57 291.24 334.93 328.23 328.23 321.67 # 36005 49.54 47.06 54.12 53.04 53.04 51.98 36010 478.23 454.32 522.47 512.01 512.01 501.78 # 36010 125.55 119.27 137.16 134.41 134.41 131.72 36011 791.43 751.86 864.64 847.34 847.34 830.39 # 36011 161.02 152.97 175.92 172.40 172.40 168.95 36012 818.24 777.33 893.93 876.05 876.05 858.52 # 36012 178.62 169.69 195.14 191.25 191.25 187.42 36013 743.55 706.37 812.33 796.08 796.08 780.16 # 36013 128.25 121.84 140.12 137.31 137.31 134.56 36014 769.15 730.69 840.29 823.49 823.49 807.02 # 36014 153.52 145.84 167.72 164.36 164.36 161.07 36015 825.12 783.86 901.44 883.41 883.41 865.74

Page 89: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 89Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 36015 175.64 166.86 191.89 188.05 188.05 184.29 36100 480.17 456.16 524.58 514.10 514.10 503.82 # 36100 159.37 151.40 174.11 170.63 170.63 167.21 36120 403.62 383.44 440.96 432.14 432.14 423.49 # 36120 103.20 98.04 112.75 110.49 110.49 108.28 36140 417.17 396.31 455.76 446.64 446.64 437.70 # 36140 105.91 100.61 115.70 113.39 113.39 111.12 36147 797.87 757.98 871.68 854.24 854.24 837.15 # 36147 190.79 181.25 208.44 204.27 204.27 200.19 36148 248.81 236.37 271.83 266.39 266.39 261.06 # 36148 50.29 47.78 54.95 53.84 53.84 52.76 36160 470.63 447.10 514.17 503.88 503.88 493.81 # 36160 126.50 120.18 138.21 135.45 135.45 132.73 36200 594.98 565.23 650.01 637.02 637.02 624.28 # 36200 157.84 149.95 172.44 168.99 168.99 165.61 36215 1,069.02 1,015.57 1,167.91 1,144.55 1,144.55 1,121.65 # 36215 240.74 228.70 263.01 257.75 257.75 252.60 36216 1,135.43 1,078.66 1,240.46 1,215.65 1,215.65 1,191.34 # 36216 282.50 268.38 308.64 302.46 302.46 296.41 36217 1,860.37 1,767.35 2,032.45 1,991.80 1,991.80 1,951.96 # 36217 335.94 319.14 367.01 359.67 359.67 352.48 36218 183.92 174.72 200.93 196.91 196.91 192.98 # 36218 54.42 51.70 59.46 58.27 58.27 57.11 36221 1,042.67 990.54 1,139.12 1,116.34 1,116.34 1,094.02 # 36221 221.29 210.23 241.76 236.93 236.93 232.20 36222 1,252.30 1,189.69 1,368.14 1,340.79 1,340.79 1,313.97 # 36222 302.73 287.59 330.73 324.12 324.12 317.63 36223 1,462.99 1,389.84 1,598.32 1,566.35 1,566.35 1,535.02 # 36223 330.67 314.14 361.26 354.04 354.04 346.96 36224 1,722.00 1,635.90 1,881.29 1,843.66 1,843.66 1,806.79 # 36224 367.82 349.43 401.84 393.81 393.81 385.93 36225 1,430.29 1,358.78 1,562.60 1,531.34 1,531.34 1,500.72 # 36225 325.91 309.61 356.05 348.93 348.93 341.95 36226 1,747.69 1,660.31 1,909.36 1,871.17 1,871.17 1,833.74 # 36226 368.86 350.42 402.98 394.92 394.92 387.02 36227 243.69 231.51 266.24 260.91 260.91 255.69 # 36227 116.49 110.67 127.27 124.73 124.73 122.23 36228 1,154.57 1,096.84 1,261.37 1,236.14 1,236.14 1,211.41 # 36228 238.20 226.29 260.23 255.02 255.02 249.92 36245 1,299.85 1,234.86 1,420.09 1,391.68 1,391.68 1,363.85 # 36245 259.24 246.28 283.22 277.55 277.55 272.00 36246 853.72 811.03 932.68 914.03 914.03 895.75 # 36246 276.56 262.73 302.14 296.10 296.10 290.18 36247 1,500.52 1,425.49 1,639.31 1,606.53 1,606.53 1,574.40 # 36247 326.79 310.45 357.02 349.88 349.88 342.88 36248 146.92 139.57 160.51 157.30 157.30 154.15 # 36248 50.95 48.40 55.66 54.54 54.54 53.45 36251 1,353.69 1,286.01 1,478.91 1,449.33 1,449.33 1,420.34 # 36251 288.76 274.32 315.47 309.15 309.15 302.97

Page 90: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 90Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

36252 1,473.19 1,399.53 1,609.46 1,577.27 1,577.27 1,545.73 # 36252 384.59 365.36 420.16 411.76 411.76 403.52 36253 2,148.31 2,040.89 2,347.02 2,300.08 2,300.08 2,254.08 # 36253 386.57 367.24 422.33 413.89 413.89 405.61 36254 2,093.20 1,988.54 2,286.82 2,241.09 2,241.09 2,196.26 # 36254 446.82 424.48 488.15 478.39 478.39 468.82 36260 634.35 602.63 693.02 679.17 679.17 665.59 36261 401.48 381.41 438.62 429.85 429.85 421.25 36262 305.91 290.61 334.20 327.52 327.52 320.97 36400 29.19 27.73 31.89 31.26 31.26 30.64 # 36400 20.31 19.29 22.18 21.74 21.74 21.30 36405 25.64 24.36 28.01 27.45 27.45 26.90 # 36405 16.44 15.62 17.96 17.61 17.61 17.25 36406 16.03 15.23 17.51 17.17 17.17 16.82 # 36406 8.47 8.05 9.26 9.07 9.07 8.89 36410 16.36 15.54 17.87 17.51 17.51 17.17 # 36410 9.46 8.99 10.34 10.13 10.13 9.92 36420 52.97 50.32 57.87 56.71 56.71 55.57 36425 40.30 38.29 44.03 43.15 43.15 42.29 36430 32.26 30.65 35.25 34.55 34.55 33.86 36440 57.53 54.65 62.85 61.59 61.59 60.36 36450 118.09 112.19 129.02 126.44 126.44 123.91 36455 128.42 122.00 140.30 137.49 137.49 134.75 36460 348.75 331.31 381.01 373.38 373.38 365.92 36470 144.11 136.90 157.44 154.28 154.28 151.20 # 36470 83.31 79.14 91.01 89.19 89.19 87.41 36471 169.66 161.18 185.36 181.65 181.65 178.02 # 36471 101.30 96.24 110.68 108.47 108.47 106.29 36475 1,458.15 1,385.24 1,593.03 1,561.17 1,561.17 1,529.95 # 36475 288.36 273.94 315.03 308.73 308.73 302.55 36476 288.99 274.54 315.72 309.41 309.41 303.22 # 36476 140.10 133.10 153.07 150.01 150.01 147.00 36478 1,148.72 1,091.28 1,254.97 1,229.87 1,229.87 1,205.27 # 36478 286.59 272.26 313.10 306.83 306.83 300.69 36479 299.40 284.43 327.09 320.55 320.55 314.15 # 36479 139.99 132.99 152.94 149.88 149.88 146.88 36481 1,930.30 1,833.79 2,108.86 2,066.68 2,066.68 2,025.35 # 36481 355.58 337.80 388.47 380.70 380.70 373.08 36500 186.06 176.76 203.27 199.20 199.20 195.22 36510 88.27 83.86 96.44 94.51 94.51 92.62 # 36510 56.06 53.26 61.25 60.02 60.02 58.82 36511 93.85 89.16 102.53 100.49 100.49 98.47 36512 94.50 89.78 103.25 101.18 101.18 99.15 36513 97.81 92.92 106.86 104.72 104.72 102.63 36514 509.11 483.65 556.20 545.08 545.08 534.18 # 36514 93.65 88.97 102.32 100.27 100.27 98.27 36515 1,936.06 1,839.26 2,115.15 2,072.84 2,072.84 2,031.38 # 36515 88.86 84.42 97.08 95.14 95.14 93.24 36516 1,949.21 1,851.75 2,129.51 2,086.93 2,086.93 2,045.19

Page 91: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 91Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 36516 70.45 66.93 76.97 75.43 75.43 73.92 36522 1,312.73 1,247.09 1,434.15 1,405.47 1,405.47 1,377.37 # 36522 101.53 96.45 110.92 108.70 108.70 106.52 36555 249.38 236.91 272.45 267.00 267.00 261.66 # 36555 120.54 114.51 131.69 129.05 129.05 126.48 36556 227.02 215.67 248.02 243.06 243.06 238.20 # 36556 122.83 116.69 134.19 131.51 131.51 128.88 36557 963.31 915.14 1,052.41 1,031.37 1,031.37 1,010.74 # 36557 332.23 315.62 362.96 355.71 355.71 348.59 36558 749.60 712.12 818.94 802.56 802.56 786.51 # 36558 280.24 266.23 306.16 300.05 300.05 294.04 36560 1,283.16 1,219.00 1,401.85 1,373.81 1,373.81 1,346.34 # 36560 394.40 374.68 430.88 422.27 422.27 413.83 36561 1,122.66 1,066.53 1,226.51 1,201.98 1,201.98 1,177.95 # 36561 358.79 340.85 391.98 384.13 384.13 376.45 36563 1,268.25 1,204.84 1,385.57 1,357.85 1,357.85 1,330.70 # 36563 387.38 368.01 423.21 414.75 414.75 406.46 36565 934.74 888.00 1,021.20 1,000.78 1,000.78 980.77 # 36565 355.93 338.13 388.85 381.08 381.08 373.45 36566 5,121.26 4,865.20 5,594.98 5,483.09 5,483.09 5,373.42 # 36566 390.84 371.30 427.00 418.45 418.45 410.08 36568 288.10 273.70 314.76 308.46 308.46 302.30 # 36568 98.45 93.53 107.56 105.41 105.41 103.30 36569 240.12 228.11 262.33 257.08 257.08 251.94 # 36569 92.87 88.23 101.46 99.44 99.44 97.45 36570 1,102.00 1,046.90 1,203.94 1,179.85 1,179.85 1,156.26 # 36570 313.82 298.13 342.85 336.00 336.00 329.28 36571 1,240.52 1,178.49 1,355.26 1,328.16 1,328.16 1,301.59 # 36571 327.10 310.75 357.36 350.22 350.22 343.22 36575 158.33 150.41 172.97 169.51 169.51 166.12 # 36575 35.73 33.94 39.03 38.25 38.25 37.48 36576 376.34 357.52 411.15 402.93 402.93 394.86 # 36576 200.17 190.16 218.68 214.31 214.31 210.02 36578 499.31 474.34 545.49 534.58 534.58 523.88 # 36578 218.28 207.37 238.48 233.70 233.70 229.03 36580 205.73 195.44 224.76 220.26 220.26 215.86 # 36580 68.01 64.61 74.30 72.82 72.82 71.36 36581 732.15 695.54 799.87 783.87 783.87 768.20 # 36581 198.69 188.76 217.07 212.73 212.73 208.47 36582 1,050.22 997.71 1,147.37 1,124.42 1,124.42 1,101.93 # 36582 310.36 294.84 339.07 332.28 332.28 325.63 36583 1,299.87 1,234.88 1,420.11 1,391.71 1,391.71 1,363.88 # 36583 342.75 325.61 374.45 366.97 366.97 359.63 36584 195.77 185.98 213.88 209.60 209.60 205.40 # 36584 67.25 63.89 73.47 72.00 72.00 70.56 36585 1,095.35 1,040.58 1,196.67 1,172.74 1,172.74 1,149.28 # 36585 287.77 273.38 314.39 308.10 308.10 301.93 36589 163.05 154.90 178.14 174.57 174.57 171.07 # 36589 138.72 131.78 151.55 148.51 148.51 145.54

Page 92: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 92Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

36590 287.92 273.52 314.55 308.26 308.26 302.09 # 36590 207.07 196.72 226.23 221.71 221.71 217.27 36591 21.72 20.63 23.72 23.25 23.25 22.79 36592 24.35 23.13 26.60 26.07 26.07 25.55 36593 28.98 27.53 31.66 31.03 31.03 30.41 36595 560.49 532.47 612.34 600.09 600.09 588.09 # 36595 187.43 178.06 204.77 200.68 200.68 196.66 36596 127.37 121.00 139.15 136.37 136.37 133.64 # 36596 45.20 42.94 49.38 48.39 48.39 47.43 36597 123.19 117.03 134.58 131.89 131.89 129.26 # 36597 62.38 59.26 68.15 66.78 66.78 65.45 36598 105.90 100.61 115.70 113.39 113.39 111.12 # 36598 37.53 35.65 41.00 40.18 40.18 39.38 36600 30.60 29.07 33.43 32.76 32.76 32.11 # 36600 15.81 15.02 17.27 16.93 16.93 16.59 36620 51.96 49.36 56.76 55.63 55.63 54.51 36625 106.40 101.08 116.24 113.92 113.92 111.64 36640 119.00 113.05 130.01 127.41 127.41 124.86 36660 65.21 61.95 71.24 69.82 69.82 68.43 36680 59.55 56.57 65.06 63.76 63.76 62.48 36800 126.13 119.82 137.79 135.03 135.03 132.33 36810 220.63 209.60 241.04 236.22 236.22 231.50 36815 149.68 142.20 163.53 160.26 160.26 157.06 36818 717.91 682.01 784.31 768.63 768.63 753.25 36819 759.57 721.59 829.83 813.23 813.23 796.97 36820 756.85 719.01 826.86 810.32 810.32 794.12 36821 687.88 653.49 751.51 736.48 736.48 721.75 36823 1,370.06 1,301.56 1,496.79 1,466.86 1,466.86 1,437.52 36825 828.76 787.32 905.42 887.31 887.31 869.56 36830 692.29 657.68 756.33 741.21 741.21 726.39 36831 639.37 607.40 698.51 684.54 684.54 670.85 36832 784.65 745.42 857.23 840.09 840.09 823.29 36833 841.47 799.40 919.31 900.92 900.92 882.90 36835 501.56 476.48 547.95 536.99 536.99 526.25 36838 1,189.43 1,129.96 1,299.45 1,273.46 1,273.46 1,247.99 36860 201.60 191.52 220.25 215.84 215.84 211.53 # 36860 111.21 105.65 121.50 119.07 119.07 116.69 36861 135.39 128.62 147.91 144.96 144.96 142.06 36870 1,737.07 1,650.22 1,897.75 1,859.80 1,859.80 1,822.61 # 36870 304.01 288.81 332.13 325.48 325.48 318.98 37140 2,338.49 2,221.57 2,554.81 2,503.71 2,503.71 2,453.64 37145 2,187.81 2,078.42 2,390.18 2,342.38 2,342.38 2,295.53 37160 2,247.26 2,134.90 2,455.14 2,406.03 2,406.03 2,357.91 37180 2,071.66 1,968.08 2,263.29 2,218.03 2,218.03 2,173.67 37181 2,366.29 2,247.98 2,585.18 2,533.47 2,533.47 2,482.80 37182 850.85 808.31 929.56 910.96 910.96 892.75 37183 5,565.96 5,287.66 6,080.81 5,959.20 5,959.20 5,840.01 # 37183 401.68 381.60 438.84 430.07 430.07 421.46 37184 2,165.63 2,057.35 2,365.95 2,318.63 2,318.63 2,272.26

Page 93: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 93Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 37184 473.24 449.58 517.02 506.68 506.68 496.55 37185 689.25 654.79 753.01 737.94 737.94 723.19 # 37185 173.22 164.56 189.24 185.46 185.46 181.75 37186 1,310.47 1,244.95 1,431.69 1,403.06 1,403.06 1,375.00 # 37186 257.37 244.50 281.18 275.55 275.55 270.04 37187 1,962.05 1,863.95 2,143.54 2,100.67 2,100.67 2,058.66 # 37187 418.88 397.94 457.63 448.48 448.48 439.51 37188 1,685.39 1,601.12 1,841.29 1,804.47 1,804.47 1,768.38 # 37188 300.65 285.62 328.46 321.90 321.90 315.46 37191 2,482.42 2,358.30 2,712.05 2,657.80 2,657.80 2,604.65 # 37191 244.75 232.51 267.39 262.04 262.04 256.80 37192 1,478.43 1,404.51 1,615.19 1,582.88 1,582.88 1,551.22 # 37192 378.00 359.10 412.97 404.71 404.71 396.61 37193 1,525.47 1,449.20 1,666.58 1,633.25 1,633.25 1,600.59 # 37193 375.73 356.94 410.48 402.27 402.27 394.22 37195 131.60 125.02 143.77 140.90 140.90 138.08 37197 1,446.98 1,374.63 1,580.82 1,549.21 1,549.21 1,518.23 # 37197 324.86 308.62 354.91 347.82 347.82 340.86 37200 224.79 213.55 245.58 240.67 240.67 235.85 37211 411.40 390.83 449.45 440.46 440.46 431.65 37212 361.73 343.64 395.19 387.29 387.29 379.53 37213 253.92 241.22 277.40 271.86 271.86 266.42 37214 139.28 132.32 152.17 149.12 149.12 146.14 37215 1,030.98 979.43 1,126.34 1,103.82 1,103.82 1,081.74 37217 1,130.23 1,073.72 1,234.78 1,210.09 1,210.09 1,185.89 37218 843.02 800.87 921.00 902.58 902.58 884.52 37220 2,990.04 2,840.54 3,266.62 3,201.29 3,201.29 3,137.27 # 37220 430.25 408.74 470.05 460.66 460.66 451.44 37221 4,400.93 4,180.88 4,808.01 4,711.85 4,711.85 4,617.61 # 37221 528.71 502.27 577.61 566.05 566.05 554.74 37222 845.02 802.77 923.19 904.72 904.72 886.63 # 37222 194.23 184.52 212.20 207.95 207.95 203.79 37223 2,442.91 2,320.76 2,668.87 2,615.49 2,615.49 2,563.18 # 37223 222.65 211.52 243.25 238.38 238.38 233.61 37224 3,624.53 3,443.30 3,959.80 3,880.59 3,880.59 3,802.98 # 37224 473.44 449.77 517.24 506.89 506.89 496.74 37225 10,364.57 9,846.34 11,323.29 11,096.82 11,096.82 10,874.88 # 37225 641.79 609.70 701.16 687.14 687.14 673.39 37226 8,526.08 8,099.78 9,314.75 9,128.45 9,128.45 8,945.87 # 37226 556.49 528.67 607.97 595.82 595.82 583.90 37227 13,992.17 13,292.56 15,286.44 14,980.72 14,980.72 14,681.11 # 37227 771.86 733.27 843.26 826.39 826.39 809.86 37228 5,143.94 4,886.74 5,619.75 5,507.36 5,507.36 5,397.21 # 37228 578.53 549.60 632.04 619.40 619.40 607.02 37229 10,225.13 9,713.87 11,170.95 10,947.53 10,947.53 10,728.58 # 37229 748.52 711.09 817.75 801.40 801.40 785.37 37230 7,827.20 7,435.84 8,551.22 8,380.19 8,380.19 8,212.59 # 37230 737.16 700.30 805.35 789.23 789.23 773.44 37231 12,572.95 11,944.30 13,735.95 13,461.22 13,461.22 13,192.00

Page 94: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 94Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 37231 801.81 761.72 875.98 858.46 858.46 841.29 37232 1,150.92 1,093.37 1,257.38 1,232.23 1,232.23 1,207.58 # 37232 210.22 199.71 229.67 225.08 225.08 220.58 37233 1,396.38 1,326.56 1,525.54 1,495.03 1,495.03 1,465.13 # 37233 342.30 325.19 373.97 366.49 366.49 359.17 37234 3,653.32 3,470.65 3,991.25 3,911.43 3,911.43 3,833.20 # 37234 294.51 279.78 321.75 315.31 315.31 309.01 37235 3,854.44 3,661.72 4,210.98 4,126.76 4,126.76 4,044.23 # 37235 418.71 397.77 457.44 448.28 448.28 439.31 37236 3,888.34 3,693.92 4,248.01 4,163.05 4,163.05 4,079.79 # 37236 467.73 444.34 510.99 500.77 500.77 490.75 37237 2,321.13 2,205.07 2,535.83 2,485.12 2,485.12 2,435.41 # 37237 220.84 209.80 241.27 236.44 236.44 231.71 37238 3,955.11 3,757.35 4,320.95 4,234.53 4,234.53 4,149.84 # 37238 323.82 307.63 353.77 346.70 346.70 339.77 37239 1,913.68 1,818.00 2,090.70 2,048.89 2,048.89 2,007.91 # 37239 154.57 146.84 168.87 165.49 165.49 162.17 37241 4,505.21 4,279.95 4,921.94 4,823.50 4,823.50 4,727.03 # 37241 464.05 440.85 506.98 496.83 496.83 486.90 37242 7,220.16 6,859.15 7,888.02 7,730.27 7,730.27 7,575.66 # 37242 507.46 482.09 554.40 543.32 543.32 532.45 37243 9,166.29 8,707.98 10,014.18 9,813.89 9,813.89 9,617.61 # 37243 598.50 568.58 653.87 640.79 640.79 627.98 37244 6,404.72 6,084.48 6,997.15 6,857.21 6,857.21 6,720.06 # 37244 700.75 665.71 765.57 750.26 750.26 735.25 37252 1,315.18 1,249.42 1,436.83 1,408.09 1,408.09 1,379.93 # 37252 95.10 90.35 103.90 101.82 101.82 99.79 37253 208.57 198.14 227.86 223.31 223.31 218.85 # 37253 76.11 72.30 83.15 81.48 81.48 79.84 37500 773.13 734.47 844.64 827.75 827.75 811.19 37565 736.99 700.14 805.16 789.06 789.06 773.28 37600 724.57 688.34 791.59 775.76 775.76 760.24 37605 820.26 779.25 896.14 878.22 878.22 860.66 37606 587.78 558.39 642.15 629.30 629.30 616.72 37607 386.07 366.77 421.79 413.34 413.34 405.08 37609 303.83 288.64 331.94 325.30 325.30 318.79 # 37609 208.84 198.40 228.16 223.59 223.59 219.12 37615 514.55 488.82 562.14 550.90 550.90 539.88 37616 1,122.89 1,066.75 1,226.76 1,202.23 1,202.23 1,178.19 37617 1,366.98 1,298.63 1,493.42 1,463.56 1,463.56 1,434.29 37618 390.44 370.92 426.56 418.03 418.03 409.66 37619 1,680.81 1,596.77 1,836.29 1,799.55 1,799.55 1,763.56 37650 520.28 494.27 568.41 557.04 557.04 545.89 37660 1,198.60 1,138.67 1,309.47 1,283.29 1,283.29 1,257.62 37700 254.50 241.78 278.05 272.48 272.48 267.03 37718 447.78 425.39 489.20 479.41 479.41 469.82 37722 493.21 468.55 538.83 528.06 528.06 517.50 37735 702.02 666.92 766.96 751.62 751.62 736.59 37760 634.24 602.53 692.91 679.05 679.05 665.47

Page 95: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 95Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

37761 565.54 537.26 617.85 605.49 605.49 593.38 37765 647.82 615.43 707.74 693.59 693.59 679.72 # 37765 460.79 437.75 503.41 493.35 493.35 483.48 37766 772.26 733.65 843.70 826.83 826.83 810.29 # 37766 563.87 535.68 616.03 603.72 603.72 591.64 37780 259.51 246.53 283.51 277.84 277.84 272.29 37785 352.47 334.85 385.08 377.37 377.37 369.83 # 37785 266.69 253.36 291.36 285.53 285.53 279.82 37788 1,299.94 1,234.94 1,420.18 1,391.78 1,391.78 1,363.95 37790 504.59 479.36 551.26 540.24 540.24 529.43 38100 1,170.43 1,111.91 1,278.70 1,253.12 1,253.12 1,228.06 38101 1,173.40 1,114.73 1,281.94 1,256.31 1,256.31 1,231.18 38102 267.45 254.08 292.19 286.35 286.35 280.62 38115 1,285.04 1,220.79 1,403.91 1,375.83 1,375.83 1,348.31 38120 1,065.12 1,011.86 1,163.64 1,140.36 1,140.36 1,117.56 38200 119.13 113.17 130.15 127.55 127.55 124.99 38205 82.90 78.76 90.57 88.76 88.76 86.99 38206 83.23 79.07 90.93 89.11 89.11 87.33 38220 157.37 149.50 171.93 168.49 168.49 165.12 # 38220 61.72 58.63 67.42 66.08 66.08 64.76 38221 160.72 152.68 175.58 172.07 172.07 168.64 # 38221 74.93 71.18 81.86 80.22 80.22 78.61 38230 199.46 189.49 217.91 213.56 213.56 209.29 38232 198.81 188.87 217.20 212.85 212.85 208.60 38240 223.79 212.60 244.49 239.60 239.60 234.81 38241 167.74 159.35 183.25 179.58 179.58 176.00 38242 117.64 111.76 128.52 125.95 125.95 123.43 38243 117.37 111.50 128.23 125.66 125.66 123.14 38300 268.18 254.77 292.99 287.12 287.12 281.38 # 38300 183.38 174.21 200.34 196.34 196.34 192.42 38305 476.02 452.22 520.05 509.66 509.66 499.47 38308 448.21 425.80 489.67 479.87 479.87 470.27 38380 569.18 540.72 621.83 609.40 609.40 597.21 38381 812.81 772.17 888.00 870.24 870.24 852.84 38382 624.69 593.46 682.48 668.83 668.83 655.45 38500 326.40 310.08 356.59 349.46 349.46 342.47 # 38500 255.07 242.32 278.67 273.09 273.09 267.63 38505 122.63 116.50 133.98 131.30 131.30 128.67 # 38505 71.35 67.78 77.95 76.38 76.38 74.85 38510 515.04 489.29 562.68 551.43 551.43 540.40 # 38510 423.67 402.49 462.86 453.61 453.61 444.53 38520 465.76 442.47 508.84 498.66 498.66 488.69 38525 438.17 416.26 478.70 469.12 469.12 459.74 38530 551.60 524.02 602.62 590.57 590.57 578.76 38542 520.10 494.10 568.22 556.85 556.85 545.72 38550 506.30 480.99 553.14 542.08 542.08 531.23 38555 1,010.94 960.39 1,104.45 1,082.36 1,082.36 1,060.71 38562 704.18 668.97 769.32 753.93 753.93 738.85 38564 709.35 673.88 774.96 759.46 759.46 744.27

Page 96: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 96Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

38570 506.70 481.37 553.58 542.50 542.50 531.66 38571 671.83 638.24 733.98 719.30 719.30 704.92 38572 937.57 890.69 1,024.29 1,003.81 1,003.81 983.73 38700 810.05 769.55 884.98 867.28 867.28 849.94 38720 1,355.92 1,288.12 1,481.34 1,451.71 1,451.71 1,422.68 38724 1,465.27 1,392.01 1,600.81 1,568.80 1,568.80 1,537.42 38740 698.59 663.66 763.21 747.95 747.95 732.99 38745 883.07 838.92 964.76 945.46 945.46 926.56 38746 220.73 209.69 241.14 236.33 236.33 231.60 38747 272.45 258.83 297.65 291.70 291.70 285.87 38760 848.39 805.97 926.87 908.33 908.33 890.16 38765 1,304.97 1,239.72 1,425.68 1,397.17 1,397.17 1,369.22 38770 812.50 771.88 887.66 869.91 869.91 852.51 38780 1,029.98 978.48 1,125.25 1,102.75 1,102.75 1,080.69 38790 83.26 79.10 90.97 89.15 89.15 87.37 38792 39.51 37.53 43.16 42.30 42.30 41.45 38794 298.67 283.74 326.30 319.78 319.78 313.39 38900 140.75 133.71 153.77 150.70 150.70 147.68 39000 501.00 475.95 547.34 536.39 536.39 525.67 39010 798.56 758.63 872.42 854.98 854.98 837.88 39200 895.49 850.72 978.33 958.77 958.77 939.60 39220 1,156.04 1,098.24 1,262.98 1,237.72 1,237.72 1,212.96 39401 316.89 301.05 346.21 339.28 339.28 332.50 39402 414.41 393.69 452.74 443.69 443.69 434.82 39501 857.74 814.85 937.08 918.33 918.33 899.97 39503 6,251.05 5,938.50 6,829.28 6,692.69 6,692.69 6,558.84 39540 876.66 832.83 957.75 938.60 938.60 919.83 39541 956.09 908.29 1,044.53 1,023.64 1,023.64 1,003.17 39545 905.13 859.87 988.85 969.07 969.07 949.69 39560 804.92 764.67 879.37 861.79 861.79 844.55 39561 1,251.34 1,188.77 1,367.09 1,339.74 1,339.74 1,312.94 40490 124.99 118.74 136.55 133.83 133.83 131.15 # 40490 73.72 70.03 80.53 78.92 78.92 77.35 40500 494.22 469.51 539.94 529.14 529.14 518.56 # 40500 362.42 344.30 395.95 388.02 388.02 380.26 40510 475.72 451.93 519.72 509.32 509.32 499.13 # 40510 357.06 339.21 390.09 382.29 382.29 374.65 40520 480.23 456.22 524.65 514.17 514.17 503.88 # 40520 358.62 340.69 391.79 383.96 383.96 376.28 40525 551.89 524.30 602.95 590.88 590.88 579.06 40527 620.65 589.62 678.06 664.50 664.50 651.21 40530 530.44 503.92 579.51 567.92 567.92 556.55 # 40530 403.90 383.71 441.27 432.45 432.45 423.80 40650 430.39 408.87 470.20 460.79 460.79 451.58 # 40650 297.93 283.03 325.48 318.98 318.98 312.59 40652 476.03 452.23 520.06 509.67 509.67 499.48 # 40652 349.81 332.32 382.17 374.52 374.52 367.03 40654 557.55 529.67 609.12 596.94 596.94 585.01 # 40654 423.44 402.27 462.61 453.35 453.35 444.29

Page 97: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 97Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

40700 909.24 863.78 993.35 973.48 973.48 954.01 40701 1,023.91 972.71 1,118.62 1,096.25 1,096.25 1,074.32 40702 857.20 814.34 936.49 917.76 917.76 899.40 40720 1,021.57 970.49 1,116.06 1,093.74 1,093.74 1,071.87 40761 1,081.58 1,027.50 1,181.63 1,157.99 1,157.99 1,134.83 40800 207.93 197.53 227.16 222.62 222.62 218.17 # 40800 131.35 124.78 143.50 140.62 140.62 137.80 40801 311.95 296.35 340.80 333.98 333.98 327.30 # 40801 223.86 212.67 244.57 239.68 239.68 234.89 40804 186.75 177.41 204.02 199.94 199.94 195.94 # 40804 117.07 111.22 127.90 125.35 125.35 122.84 40805 360.53 342.50 393.88 386.00 386.00 378.28 # 40805 222.82 211.68 243.43 238.57 238.57 233.80 40806 109.13 103.67 119.22 116.84 116.84 114.51 # 40806 31.89 30.30 34.85 34.14 34.14 33.47 40808 182.53 173.40 199.41 195.42 195.42 191.51 # 40808 108.24 102.83 118.25 115.89 115.89 113.56 40810 202.75 192.61 221.50 217.07 217.07 212.73 # 40810 127.81 121.42 139.63 136.84 136.84 134.10 40812 285.41 271.14 311.81 305.58 305.58 299.47 # 40812 199.30 189.34 217.74 213.38 213.38 209.12 40814 382.65 363.52 418.05 409.69 409.69 401.50 # 40814 307.38 292.01 335.81 329.10 329.10 322.52 40816 399.87 379.88 436.86 428.12 428.12 419.55 # 40816 319.34 303.37 348.88 341.90 341.90 335.05 40818 352.42 334.80 385.02 377.32 377.32 369.77 # 40818 271.56 257.98 296.68 290.74 290.74 284.92 40819 312.88 297.24 341.83 335.00 335.00 328.29 # 40819 241.23 229.17 263.55 258.28 258.28 253.12 40820 259.20 246.24 283.18 277.52 277.52 271.96 # 40820 170.79 162.25 186.59 182.86 182.86 179.20 40830 260.44 247.42 284.53 278.84 278.84 273.26 # 40830 165.12 156.86 180.39 176.78 176.78 173.25 40831 331.72 315.13 362.40 355.15 355.15 348.05 # 40831 225.22 213.96 246.05 241.13 241.13 236.31 40840 806.81 766.47 881.44 863.81 863.81 846.54 # 40840 634.58 602.85 693.28 679.41 679.41 665.82 40842 776.57 737.74 848.40 831.44 831.44 814.81 # 40842 608.95 578.50 665.28 651.97 651.97 638.93 40843 1,078.68 1,024.75 1,178.46 1,154.90 1,154.90 1,131.80 # 40843 860.10 817.10 939.67 920.87 920.87 902.45 40844 1,297.45 1,232.58 1,417.47 1,389.12 1,389.12 1,361.34 # 40844 1,061.46 1,008.39 1,159.65 1,136.45 1,136.45 1,113.73 40845 1,459.31 1,386.34 1,594.29 1,562.40 1,562.40 1,531.16 # 40845 1,238.11 1,176.20 1,352.63 1,325.58 1,325.58 1,299.07 41000 160.32 152.30 175.15 171.64 171.64 168.21 # 41000 112.99 107.34 123.44 120.97 120.97 118.55 41005 222.27 211.16 242.83 237.98 237.98 233.22 # 41005 124.98 118.73 136.54 133.81 133.81 131.13

Page 98: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 98Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

41006 354.60 336.87 387.40 379.65 379.65 372.06 # 41006 254.02 241.32 277.52 271.96 271.96 266.52 41007 346.52 329.19 378.57 371.00 371.00 363.58 # 41007 244.63 232.40 267.26 261.91 261.91 256.68 41008 375.87 357.08 410.64 402.43 402.43 394.38 # 41008 272.66 259.03 297.88 291.93 291.93 286.09 41009 399.06 379.11 435.98 427.26 427.26 418.72 # 41009 295.53 280.75 322.86 316.41 316.41 310.09 41010 197.94 188.04 216.25 211.92 211.92 207.68 # 41010 107.88 102.49 117.86 115.51 115.51 113.19 41015 448.35 425.93 489.82 480.02 480.02 470.42 # 41015 352.70 335.07 385.33 377.63 377.63 370.07 41016 438.48 416.56 479.04 469.46 469.46 460.08 # 41016 354.67 336.94 387.48 379.73 379.73 372.14 41017 442.46 420.34 483.39 473.72 473.72 464.24 # 41017 356.34 338.52 389.30 381.51 381.51 373.89 41018 504.44 479.22 551.10 540.09 540.09 529.29 # 41018 417.67 396.79 456.31 447.18 447.18 438.23 41019 472.52 448.89 516.22 505.90 505.90 495.78 41100 165.81 157.52 181.15 177.53 177.53 173.97 # 41100 108.62 103.19 118.67 116.30 116.30 113.98 41105 168.62 160.19 184.22 180.54 180.54 176.93 # 41105 112.41 106.79 122.81 120.35 120.35 117.94 41108 145.68 138.40 159.16 155.97 155.97 152.86 # 41108 91.12 86.56 99.54 97.55 97.55 95.60 41110 208.65 198.22 227.95 223.40 223.40 218.93 # 41110 132.07 125.47 144.29 141.40 141.40 138.58 41112 331.30 314.74 361.95 354.72 354.72 347.62 # 41112 254.39 241.67 277.92 272.37 272.37 266.92 41113 363.10 344.95 396.69 388.76 388.76 380.98 # 41113 282.25 268.14 308.36 302.20 302.20 296.15 41114 640.95 608.90 700.24 686.23 686.23 672.51 41115 243.70 231.52 266.25 260.92 260.92 255.70 # 41115 153.64 145.96 167.85 164.50 164.50 161.21 41116 326.94 310.59 357.18 350.04 350.04 343.03 # 41116 221.43 210.36 241.91 237.07 237.07 232.33 41120 1,081.06 1,027.01 1,181.06 1,157.44 1,157.44 1,134.29 41130 1,336.28 1,269.47 1,459.89 1,430.69 1,430.69 1,402.08 41135 2,204.45 2,094.23 2,408.36 2,360.20 2,360.20 2,313.00 41140 2,220.51 2,109.48 2,425.90 2,377.38 2,377.38 2,329.83 41145 2,823.70 2,682.52 3,084.90 3,023.20 3,023.20 2,962.73 41150 2,236.25 2,124.44 2,443.11 2,394.24 2,394.24 2,346.36 41153 2,438.25 2,316.34 2,663.79 2,610.51 2,610.51 2,558.30 41155 3,063.53 2,910.35 3,346.90 3,279.96 3,279.96 3,214.37 41250 262.20 249.09 286.45 280.73 280.73 275.11 # 41250 153.73 146.04 167.95 164.59 164.59 161.30 41251 286.53 272.20 313.03 306.77 306.77 300.63 # 41251 183.32 174.15 200.27 196.27 196.27 192.35 41252 311.18 295.62 339.96 333.17 333.17 326.51

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 99Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 41252 212.24 201.63 231.87 227.24 227.24 222.70 41500 410.43 389.91 448.40 439.43 439.43 430.64 41510 418.18 397.27 456.86 447.72 447.72 438.76 41512 662.42 629.30 723.70 709.22 709.22 695.04 41520 350.11 332.60 382.49 374.84 374.84 367.34 # 41520 259.73 246.74 283.75 278.08 278.08 272.52 41530 952.99 905.34 1,041.14 1,020.31 1,020.31 999.91# 41530 374.51 355.78 409.15 400.96 400.96 392.94 41800 263.87 250.68 288.28 282.52 282.52 276.87 # 41800 145.55 138.27 159.01 155.83 155.83 152.71 41805 252.35 239.73 275.69 270.18 270.18 264.78 # 41805 173.47 164.80 189.52 185.73 185.73 182.01 41806 350.65 333.12 383.09 375.43 375.43 367.92 # 41806 261.91 248.81 286.13 280.40 280.40 274.79 41822 290.19 275.68 317.03 310.70 310.70 304.49 # 41822 185.01 175.76 202.12 198.08 198.08 194.12 41823 425.28 404.02 464.62 455.33 455.33 446.22 # 41823 326.68 310.35 356.90 349.76 349.76 342.77 41825 208.21 197.80 227.47 222.92 222.92 218.45 # 41825 123.08 116.93 134.47 131.78 131.78 129.15 41826 311.85 296.26 340.70 333.88 333.88 327.20 # 41826 214.56 203.83 234.40 229.71 229.71 225.12 41827 437.24 415.38 477.69 468.13 468.13 458.77 # 41827 310.70 295.17 339.45 332.66 332.66 326.00 41828 308.46 293.04 337.00 330.26 330.26 323.66 # 41828 217.08 206.23 237.16 232.43 232.43 227.78 41830 391.67 372.09 427.90 419.35 419.35 410.96 # 41830 288.46 274.04 315.15 308.84 308.84 302.67 41872 362.75 344.61 396.30 388.38 388.38 380.62 # 41872 258.89 245.95 282.84 277.18 277.18 271.64 41874 373.68 355.00 408.25 400.09 400.09 392.08 # 41874 259.63 246.65 283.65 277.98 277.98 272.42 42000 156.45 148.63 170.92 167.51 167.51 164.16 # 42000 104.19 98.98 113.83 111.55 111.55 109.32 42100 148.52 141.09 162.25 159.01 159.01 155.83 # 42100 110.39 104.87 120.60 118.19 118.19 115.82 42104 212.73 202.09 232.40 227.76 227.76 223.20 # 42104 140.09 133.09 153.05 149.99 149.99 146.99 42106 270.53 257.00 295.55 289.64 289.64 283.84 # 42106 180.14 171.13 196.80 192.87 192.87 189.01 42107 459.02 436.07 501.48 491.45 491.45 481.62 # 42107 350.22 332.71 382.62 374.97 374.97 367.47 42120 1,022.64 971.51 1,117.24 1,094.89 1,094.89 1,073.00 42140 248.23 235.82 271.19 265.77 265.77 260.45 # 42140 154.56 146.83 168.85 165.47 165.47 162.16 42145 706.63 671.30 772.00 756.55 756.55 741.42 42160 228.70 217.27 249.86 244.86 244.86 239.96 # 42160 147.85 140.46 161.53 158.30 158.30 155.14 42180 242.17 230.06 264.57 259.28 259.28 254.09

Page 100: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 100Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 42180 185.31 176.04 202.45 198.40 198.40 194.43 42182 319.23 303.27 348.76 341.78 341.78 334.95 # 42182 258.42 245.50 282.33 276.68 276.68 271.15 42200 855.80 813.01 934.96 916.26 916.26 897.94 42205 893.73 849.04 976.40 956.87 956.87 937.73 42210 997.41 947.54 1,089.67 1,067.88 1,067.88 1,046.52 42215 658.44 625.52 719.35 704.96 704.96 690.86 42220 499.59 474.61 545.80 534.89 534.89 524.19 42225 873.90 830.21 954.74 935.65 935.65 916.94 42226 894.94 850.19 977.72 958.17 958.17 939.01 42227 849.29 806.83 927.85 909.29 909.29 891.11 42235 730.24 693.73 797.79 781.84 781.84 766.20 42260 812.68 772.05 887.86 870.10 870.10 852.70 # 42260 670.36 636.84 732.37 717.72 717.72 703.36 42280 164.15 155.94 179.33 175.74 175.74 172.22 # 42280 111.56 105.98 121.88 119.44 119.44 117.05 42281 202.82 192.68 221.58 217.15 217.15 212.81 # 42281 151.54 143.96 165.55 162.24 162.24 159.00 42300 207.09 196.74 226.25 221.73 221.73 217.29 # 42300 153.18 145.52 167.35 164.00 164.00 160.72 42305 434.29 412.58 474.47 464.98 464.98 455.68 42310 159.17 151.21 173.89 170.42 170.42 167.01 # 42310 124.00 117.80 135.47 132.76 132.76 130.10 42320 246.94 234.59 269.78 264.39 264.39 259.10 # 42320 176.27 167.46 192.58 188.73 188.73 184.95 42330 229.71 218.22 250.95 245.94 245.94 241.02 # 42330 165.95 157.65 181.30 177.68 177.68 174.12 42335 370.30 351.79 404.56 396.46 396.46 388.54 # 42335 259.21 246.25 283.19 277.53 277.53 271.98 42340 459.41 436.44 501.91 491.87 491.87 482.03 # 42340 337.46 320.59 368.68 361.31 361.31 354.09 42400 103.44 98.27 113.01 110.75 110.75 108.53 # 42400 55.12 52.36 60.21 59.01 59.01 57.82 42405 296.09 281.29 323.48 317.01 317.01 310.67 # 42405 227.72 216.33 248.78 243.80 243.80 238.92 42408 447.37 425.00 488.75 478.98 478.98 469.40 # 42408 327.73 311.34 358.04 350.88 350.88 343.86 42409 327.48 311.11 357.78 350.62 350.62 343.61 # 42409 221.97 210.87 242.50 237.65 237.65 232.90 42410 626.85 595.51 684.84 671.14 671.14 657.72 42415 1,065.93 1,012.63 1,164.52 1,141.24 1,141.24 1,118.41 42420 1,198.10 1,138.20 1,308.93 1,282.76 1,282.76 1,257.10 42425 843.14 800.98 921.13 902.70 902.70 884.65 42426 1,363.72 1,295.53 1,489.86 1,460.06 1,460.06 1,430.86 42440 414.59 393.86 452.94 443.88 443.88 435.00 42450 447.71 425.32 489.12 479.33 479.33 469.74 # 42450 359.30 341.34 392.54 384.69 384.69 376.99 42500 429.55 408.07 469.28 459.90 459.90 450.70 # 42500 343.43 326.26 375.20 367.69 367.69 360.34

Page 101: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 101Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

42505 552.21 524.60 603.29 591.23 591.23 579.40 # 42505 455.90 433.11 498.08 488.12 488.12 478.35 42507 514.69 488.96 562.30 551.06 551.06 540.04 42509 847.32 804.95 925.69 907.18 907.18 889.03 42510 643.25 611.09 702.75 688.70 688.70 674.92 42550 131.17 124.61 143.30 140.44 140.44 137.63 # 42550 64.11 60.90 70.04 68.63 68.63 67.26 42600 473.61 449.93 517.42 507.07 507.07 496.93 # 42600 349.70 332.22 382.05 374.42 374.42 366.93 42650 82.43 78.31 90.06 88.25 88.25 86.49 # 42650 58.76 55.82 64.19 62.91 62.91 61.65 42660 126.50 120.18 138.21 135.45 135.45 132.73 # 42660 90.02 85.52 98.35 96.38 96.38 94.45 42665 303.95 288.75 332.06 325.43 325.43 318.92 # 42665 205.02 194.77 223.99 219.50 219.50 215.11 42700 186.65 177.32 203.92 199.84 199.84 195.83 # 42700 135.38 128.61 147.90 144.95 144.95 142.05 42720 454.89 432.15 496.97 487.04 487.04 477.30 # 42720 396.71 376.87 433.40 424.73 424.73 416.23 42725 824.52 783.29 900.78 882.76 882.76 865.11 42800 156.31 148.49 170.76 167.35 167.35 164.00 # 42800 111.94 106.34 122.29 119.84 119.84 117.45 42804 190.99 181.44 208.66 204.48 204.48 200.39 # 42804 112.76 107.12 123.19 120.73 120.73 118.31 42806 215.13 204.37 235.03 230.32 230.32 225.71 # 42806 131.97 125.37 144.18 141.29 141.29 138.46 42808 224.74 213.50 245.53 240.61 240.61 235.81 # 42808 163.28 155.12 178.39 174.82 174.82 171.33 42809 199.12 189.16 217.53 213.19 213.19 208.92 # 42809 123.20 117.04 134.60 131.91 131.91 129.27 42810 381.34 362.27 416.61 408.27 408.27 400.11 # 42810 287.99 273.59 314.63 308.34 308.34 302.17 42815 559.49 531.52 611.25 599.02 599.02 587.04 42820 291.77 277.18 318.76 312.39 312.39 306.14 42821 302.75 287.61 330.75 324.14 324.14 317.65 42825 262.46 249.34 286.74 281.00 281.00 275.38 42826 252.07 239.47 275.39 269.88 269.88 264.49 42830 207.00 196.65 226.15 221.63 221.63 217.20 42831 223.65 212.47 244.34 239.45 239.45 234.67 42835 191.96 182.36 209.71 205.52 205.52 201.41 42836 241.24 229.18 263.56 258.29 258.29 253.13 42842 1,022.14 971.03 1,116.68 1,094.35 1,094.35 1,072.47 42844 1,404.02 1,333.82 1,533.89 1,503.21 1,503.21 1,473.15 42845 2,274.19 2,160.48 2,484.55 2,434.86 2,434.86 2,386.16 42860 187.76 178.37 205.13 201.02 201.02 197.00 42870 597.14 567.28 652.37 639.32 639.32 626.53 42890 1,451.28 1,378.72 1,585.53 1,553.82 1,553.82 1,522.75 42892 1,919.83 1,823.84 2,097.42 2,055.46 2,055.46 2,014.35 42894 2,415.15 2,294.39 2,638.55 2,585.78 2,585.78 2,534.06

Page 102: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 102Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

42900 340.31 323.29 371.78 364.34 364.34 357.05 42950 819.00 778.05 894.76 876.86 876.86 859.33 42953 984.41 935.19 1,075.47 1,053.96 1,053.96 1,032.88 42955 774.31 735.59 845.93 829.01 829.01 812.43 42960 170.63 162.10 186.42 182.69 182.69 179.03 42961 424.85 403.61 464.15 454.87 454.87 445.77 42962 520.58 494.55 568.73 557.36 557.36 546.22 42970 404.57 384.34 441.99 433.15 433.15 424.49 42971 458.86 435.92 501.31 491.28 491.28 481.46 42972 514.35 488.63 561.92 550.69 550.69 539.67 43020 533.42 506.75 582.76 571.11 571.11 559.69 43030 522.83 496.69 571.19 559.77 559.77 548.57 43045 1,326.60 1,260.27 1,449.31 1,420.32 1,420.32 1,391.91 43100 628.46 597.04 686.60 672.87 672.87 659.41 43101 1,033.21 981.55 1,128.78 1,106.21 1,106.21 1,084.08 43107 2,601.61 2,471.53 2,842.26 2,785.42 2,785.42 2,729.71 43108 4,677.96 4,444.06 5,110.67 5,008.46 5,008.46 4,908.29 43112 2,749.88 2,612.39 3,004.25 2,944.16 2,944.16 2,885.28 43113 4,625.28 4,394.02 5,053.12 4,952.06 4,952.06 4,853.02 43116 5,135.87 4,879.08 5,610.94 5,498.73 5,498.73 5,388.75 43117 2,519.46 2,393.49 2,752.51 2,697.46 2,697.46 2,643.52 43118 3,772.73 3,584.09 4,121.70 4,039.27 4,039.27 3,958.48 43121 2,935.05 2,788.30 3,206.55 3,142.41 3,142.41 3,079.56 43122 2,613.23 2,482.57 2,854.96 2,797.86 2,797.86 2,741.90 43123 4,821.54 4,580.46 5,267.53 5,162.18 5,162.18 5,058.93 43124 3,911.68 3,716.10 4,273.52 4,188.05 4,188.05 4,104.28 43130 794.62 754.89 868.12 850.76 850.76 833.74 43135 1,514.31 1,438.59 1,654.38 1,621.29 1,621.29 1,588.86 43180 555.57 527.79 606.96 594.81 594.81 582.92 43191 155.55 147.77 169.94 166.53 166.53 163.20 43192 171.96 163.36 187.86 184.10 184.10 180.42 43193 171.36 162.79 187.21 183.46 183.46 179.79 43194 196.61 186.78 214.80 210.50 210.50 206.29 43195 186.40 177.08 203.64 199.57 199.57 195.58 43196 199.75 189.76 218.22 213.85 213.85 209.58 43197 182.90 173.76 199.82 195.82 195.82 191.90 # 43197 84.29 80.08 92.09 90.25 90.25 88.45 43198 203.63 193.45 222.47 218.02 218.02 213.66 # 43198 101.08 96.03 110.43 108.23 108.23 106.06 43200 259.48 246.51 283.49 277.82 277.82 272.26 # 43200 94.81 90.07 103.58 101.51 101.51 99.48 43201 264.39 251.17 288.85 283.07 283.07 277.41 # 43201 110.56 105.03 120.78 118.37 118.37 116.00 43202 344.94 327.69 376.84 369.31 369.31 361.93 # 43202 110.59 105.06 120.82 118.40 118.40 116.04 43204 143.38 136.21 156.64 153.51 153.51 150.44 43205 149.35 141.88 163.16 159.90 159.90 156.70 43206 316.89 301.05 346.21 339.28 339.28 332.50 # 43206 143.02 135.87 156.25 153.12 153.12 150.06

Page 103: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 103Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

43210 432.98 411.33 473.03 463.57 463.57 454.30 43211 246.51 234.18 269.31 263.93 263.93 258.65 43212 200.22 190.21 218.74 214.37 214.37 210.08 43213 1,157.78 1,099.89 1,264.87 1,239.57 1,239.57 1,214.78 # 43213 269.68 256.20 294.63 288.74 288.74 282.97 43214 201.52 191.44 220.16 215.75 215.75 211.44 43215 400.02 380.02 437.02 428.28 428.28 419.72 # 43215 150.55 143.02 164.47 161.18 161.18 157.96 43216 394.41 374.69 430.89 422.28 422.28 413.84 # 43216 141.98 134.88 155.11 152.01 152.01 148.97 43217 427.12 405.76 466.62 457.29 457.29 448.14 # 43217 169.76 161.27 185.46 181.75 181.75 178.11 43220 1,063.69 1,010.51 1,162.09 1,138.85 1,138.85 1,116.06 # 43220 125.95 119.65 137.60 134.85 134.85 132.15 43226 363.47 345.30 397.10 389.15 389.15 381.36 # 43226 138.98 132.03 151.83 148.80 148.80 145.82 43227 658.37 625.45 719.27 704.88 704.88 690.78 # 43227 174.55 165.82 190.69 186.88 186.88 183.14 43229 685.66 651.38 749.09 734.10 734.10 719.42 # 43229 207.42 197.05 226.61 222.08 222.08 217.64 43231 383.88 364.69 419.39 411.01 411.01 402.79 # 43231 169.25 160.79 184.91 181.21 181.21 177.58 43232 458.70 435.77 501.14 491.11 491.11 481.29 # 43232 208.24 197.83 227.50 222.95 222.95 218.49 43233 238.62 226.69 260.69 255.48 255.48 250.38 43235 297.79 282.90 325.34 318.83 318.83 312.46 # 43235 130.49 123.97 142.57 139.71 139.71 136.92 43236 369.75 351.26 403.95 395.86 395.86 387.95 # 43236 147.23 139.87 160.85 157.63 157.63 154.48 43237 205.64 195.36 224.66 220.17 220.17 215.76 43238 243.73 231.54 266.27 260.95 260.95 255.73 43239 378.98 360.03 414.03 405.75 405.75 397.64 # 43239 147.26 139.90 160.89 157.67 157.67 154.51 43240 408.04 387.64 445.79 436.87 436.87 428.13 43241 151.22 143.66 165.21 161.91 161.91 158.67 43242 275.15 261.39 300.60 294.58 294.58 288.70 43243 248.41 235.99 271.39 265.96 265.96 260.64 43244 256.98 244.13 280.75 275.14 275.14 269.64 43245 583.19 554.03 637.13 624.39 624.39 611.90 # 43245 185.48 176.21 202.64 198.59 198.59 194.63 43246 210.45 199.93 229.92 225.32 225.32 220.81 43247 399.14 379.18 436.06 427.34 427.34 418.80 # 43247 186.81 177.47 204.09 200.01 200.01 196.01 43248 391.16 371.60 427.34 418.80 418.80 410.42 # 43248 175.54 166.76 191.77 187.93 187.93 184.17 43249 1,010.30 959.79 1,103.76 1,081.68 1,081.68 1,060.05 # 43249 162.29 154.18 177.31 173.77 173.77 170.29 43250 435.59 413.81 475.88 466.36 466.36 457.03 # 43250 179.55 170.57 196.16 192.23 192.23 188.39

Page 104: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 104Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

43251 477.19 453.33 521.33 510.90 510.90 500.68 # 43251 206.35 196.03 225.43 220.93 220.93 216.51 43252 352.96 335.31 385.61 377.89 377.89 370.33 # 43252 177.44 168.57 193.86 189.98 189.98 186.19 43253 274.47 260.75 299.86 293.87 293.87 287.99 43254 282.90 268.76 309.07 302.89 302.89 296.83 43255 692.71 658.07 756.78 741.65 741.65 726.81 # 43255 210.86 200.32 230.37 225.76 225.76 221.24 43257 244.09 231.89 266.67 261.34 261.34 256.12 43259 237.06 225.21 258.99 253.82 253.82 248.75 43260 336.01 319.21 367.09 359.75 359.75 352.56 43261 352.80 335.16 385.43 377.73 377.73 370.17 43262 372.01 353.41 406.42 398.29 398.29 390.32 43263 372.37 353.75 406.81 398.68 398.68 390.71 43264 378.99 360.04 414.05 405.77 405.77 397.65 43265 449.99 427.49 491.61 481.78 481.78 472.14 43266 237.33 225.46 259.28 254.09 254.09 249.01 43270 715.07 679.32 781.22 765.59 765.59 750.28 # 43270 243.73 231.54 266.27 260.95 260.95 255.73 43273 122.72 116.58 134.07 131.39 131.39 128.77 43274 480.39 456.37 524.83 514.33 514.33 504.05 43275 391.94 372.34 428.19 419.62 419.62 411.23 43276 500.31 475.29 546.58 535.65 535.65 524.93 43277 394.03 374.33 430.48 421.87 421.87 413.43 43278 449.63 427.15 491.22 481.40 481.40 471.78 43279 1,313.49 1,247.82 1,434.99 1,406.29 1,406.29 1,378.16 43280 1,096.70 1,041.87 1,198.15 1,174.18 1,174.18 1,150.70 43281 1,570.12 1,491.61 1,715.35 1,681.05 1,681.05 1,647.42 43282 1,765.62 1,677.34 1,928.94 1,890.36 1,890.36 1,852.55 43283 162.39 154.27 177.41 173.86 173.86 170.38 43300 620.02 589.02 677.37 663.83 663.83 650.56 43305 1,109.05 1,053.60 1,211.64 1,187.41 1,187.41 1,163.66 43310 1,517.44 1,441.57 1,657.81 1,624.65 1,624.65 1,592.16 43312 1,651.63 1,569.05 1,804.41 1,768.32 1,768.32 1,732.96 43313 2,743.50 2,606.33 2,997.28 2,937.33 2,937.33 2,878.59 43314 3,137.31 2,980.44 3,427.51 3,358.95 3,358.95 3,291.77 43320 1,412.37 1,341.75 1,543.01 1,512.16 1,512.16 1,481.91 43325 1,359.11 1,291.15 1,484.82 1,455.13 1,455.13 1,426.02 43327 830.63 789.10 907.47 889.32 889.32 871.53 43328 1,156.61 1,098.78 1,263.60 1,238.32 1,238.32 1,213.55 43330 1,347.31 1,279.94 1,471.93 1,442.49 1,442.49 1,413.64 43331 1,368.26 1,299.85 1,494.83 1,464.93 1,464.93 1,435.63 43332 1,178.74 1,119.80 1,287.77 1,262.01 1,262.01 1,236.77 43333 1,284.94 1,220.69 1,403.79 1,375.72 1,375.72 1,348.20 43334 1,277.59 1,213.71 1,395.77 1,367.86 1,367.86 1,340.50 43335 1,370.37 1,301.85 1,497.13 1,467.18 1,467.18 1,437.83 43336 1,537.82 1,460.93 1,680.07 1,646.47 1,646.47 1,613.54 43337 1,657.60 1,574.72 1,810.93 1,774.71 1,774.71 1,739.23 43338 119.31 113.34 130.34 127.73 127.73 125.18

Page 105: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 105Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

43340 1,383.72 1,314.53 1,511.71 1,481.48 1,481.48 1,451.85 43341 1,431.96 1,360.36 1,564.41 1,533.12 1,533.12 1,502.46 43351 1,308.77 1,243.33 1,429.83 1,401.23 1,401.23 1,373.20 43352 1,086.68 1,032.35 1,187.20 1,163.46 1,163.46 1,140.19 43360 2,404.51 2,284.28 2,626.92 2,574.38 2,574.38 2,522.89 43361 2,607.41 2,477.04 2,848.60 2,791.63 2,791.63 2,735.79 43400 1,500.73 1,425.69 1,639.54 1,606.76 1,606.76 1,574.63 43401 1,583.07 1,503.92 1,729.51 1,694.92 1,694.92 1,661.01 43405 1,485.35 1,411.08 1,622.74 1,590.29 1,590.29 1,558.48 43410 1,062.48 1,009.36 1,160.76 1,137.55 1,137.55 1,114.80 43415 2,622.40 2,491.28 2,864.97 2,807.67 2,807.67 2,751.51 43420 1,026.29 974.98 1,121.23 1,098.80 1,098.80 1,076.83 43425 1,465.42 1,392.15 1,600.97 1,568.96 1,568.96 1,537.57 43450 202.07 191.97 220.77 216.35 216.35 212.03 # 43450 86.05 81.75 94.01 92.14 92.14 90.30 43453 907.51 862.13 991.45 971.62 971.62 952.19 # 43453 92.70 88.07 101.28 99.26 99.26 97.27 43460 217.87 206.98 238.03 233.27 233.27 228.60 43496 2,234.21 2,122.50 2,440.88 2,392.06 2,392.06 2,344.22 43500 792.11 752.50 865.38 848.07 848.07 831.11 43501 1,362.81 1,294.67 1,488.87 1,459.10 1,459.10 1,429.91 43502 1,544.04 1,466.84 1,686.87 1,653.13 1,653.13 1,620.06 43510 952.95 905.30 1,041.10 1,020.27 1,020.27 999.87 43520 695.36 660.59 759.68 744.49 744.49 729.59 43605 845.60 803.32 923.82 905.34 905.34 887.24 43610 992.38 942.76 1,084.17 1,062.49 1,062.49 1,041.23 43611 1,238.95 1,177.00 1,353.55 1,326.48 1,326.48 1,299.95 43620 1,987.61 1,888.23 2,171.46 2,128.04 2,128.04 2,085.48 43621 2,309.05 2,193.60 2,522.64 2,472.19 2,472.19 2,422.75 43622 2,355.14 2,237.38 2,572.99 2,521.52 2,521.52 2,471.10 43631 1,469.92 1,396.42 1,605.88 1,573.76 1,573.76 1,542.29 43632 2,065.13 1,961.87 2,256.15 2,211.02 2,211.02 2,166.81 43633 1,950.76 1,853.22 2,131.20 2,088.58 2,088.58 2,046.82 43634 2,149.77 2,042.28 2,348.62 2,301.64 2,301.64 2,255.61 43635 114.84 109.10 125.47 122.96 122.96 120.50 43640 1,193.93 1,134.23 1,304.36 1,278.28 1,278.28 1,252.72 43641 1,202.49 1,142.37 1,313.73 1,287.45 1,287.45 1,261.70 43644 1,758.23 1,670.32 1,920.87 1,882.45 1,882.45 1,844.80 43645 1,879.74 1,785.75 2,053.61 2,012.55 2,012.55 1,972.30 43647 295.90 281.11 323.28 316.81 316.81 310.48 43648 295.90 281.11 323.28 316.81 316.81 310.48 43651 657.10 624.25 717.89 703.54 703.54 689.46 43652 773.24 734.58 844.77 827.87 827.87 811.31 43653 575.61 546.83 628.85 616.27 616.27 603.95 43752 41.38 39.31 45.21 44.30 44.30 43.41 43753 22.19 21.08 24.24 23.76 23.76 23.29 43754 100.66 95.63 109.97 107.78 107.78 105.63 # 43754 32.63 31.00 35.65 34.94 34.94 34.24 43755 134.77 128.03 147.23 144.29 144.29 141.40

Page 106: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 106Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 43755 61.80 58.71 67.52 66.17 66.17 64.85 43756 194.48 184.76 212.47 208.22 208.22 204.06 # 43756 51.17 48.61 55.90 54.79 54.79 53.69 43757 275.29 261.53 300.76 294.75 294.75 288.85 # 43757 78.08 74.18 85.31 83.61 83.61 81.94 43760 457.89 435.00 500.25 490.25 490.25 480.44 # 43760 47.69 45.31 52.11 51.06 51.06 50.04 43761 116.57 110.74 127.35 124.81 124.81 122.31 # 43761 104.08 98.88 113.71 111.44 111.44 109.20 43770 1,131.25 1,074.69 1,235.89 1,211.18 1,211.18 1,186.96 43771 1,288.49 1,224.07 1,407.68 1,379.53 1,379.53 1,351.94 43772 960.43 912.41 1,049.27 1,028.28 1,028.28 1,007.72 43773 1,283.84 1,219.65 1,402.60 1,374.55 1,374.55 1,347.05 43774 970.96 922.41 1,060.77 1,039.55 1,039.55 1,018.76 43775 1,123.77 1,067.58 1,227.72 1,203.16 1,203.16 1,179.11 43800 940.85 893.81 1,027.88 1,007.32 1,007.32 987.17 43810 1,030.25 978.74 1,125.55 1,103.05 1,103.05 1,080.99 43820 1,359.34 1,291.37 1,485.08 1,455.37 1,455.37 1,426.26 43825 1,322.98 1,256.83 1,445.35 1,416.44 1,416.44 1,388.12 43830 704.86 669.62 770.06 754.66 754.66 739.58 43831 585.28 556.02 639.42 626.64 626.64 614.10 43832 1,053.29 1,000.63 1,150.72 1,127.71 1,127.71 1,105.16 43840 1,377.15 1,308.29 1,504.53 1,474.44 1,474.44 1,444.95 43843 1,294.56 1,229.83 1,414.30 1,386.01 1,386.01 1,358.30 43845 1,992.56 1,892.93 2,176.87 2,133.33 2,133.33 2,090.67 43846 1,636.01 1,554.21 1,787.34 1,751.60 1,751.60 1,716.57 43847 1,799.53 1,709.55 1,965.98 1,926.66 1,926.66 1,888.13 43848 1,953.21 1,855.55 2,133.88 2,091.21 2,091.21 2,049.38 43850 1,644.86 1,562.62 1,797.01 1,761.08 1,761.08 1,725.85 43855 1,668.43 1,585.01 1,822.76 1,786.31 1,786.31 1,750.58 43860 1,659.32 1,576.35 1,812.80 1,776.54 1,776.54 1,741.01 43865 1,728.12 1,641.71 1,887.97 1,850.21 1,850.21 1,813.21 43870 718.75 682.81 785.23 769.52 769.52 754.14 43880 1,621.31 1,540.24 1,771.28 1,735.86 1,735.86 1,701.14 43881 594.81 565.07 649.83 636.84 636.84 624.09 43882 594.81 565.07 649.83 636.84 636.84 624.09 43886 360.38 342.36 393.71 385.84 385.84 378.12 43887 323.12 306.96 353.00 345.94 345.94 339.02 43888 458.82 435.88 501.26 491.23 491.23 481.41 44005 1,108.60 1,053.17 1,211.15 1,186.93 1,186.93 1,163.19 44010 872.29 828.68 952.98 933.93 933.93 915.25 44015 145.43 138.16 158.88 155.71 155.71 152.59 44020 986.99 937.64 1,078.29 1,056.72 1,056.72 1,035.59 44021 986.68 937.35 1,077.95 1,056.39 1,056.39 1,035.26 44025 998.25 948.34 1,090.59 1,068.78 1,068.78 1,047.40 44050 947.69 900.31 1,035.36 1,014.65 1,014.65 994.35 44055 1,513.55 1,437.87 1,653.55 1,620.48 1,620.48 1,588.07 44100 110.49 104.97 120.72 118.30 118.30 115.93 44110 862.02 818.92 941.76 922.92 922.92 904.46

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 107Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

44111 996.97 947.12 1,089.19 1,067.41 1,067.41 1,046.06 44120 1,240.90 1,178.86 1,355.69 1,328.57 1,328.57 1,302.00 44121 247.50 235.13 270.40 264.99 264.99 259.69 44125 1,197.62 1,137.74 1,308.40 1,282.24 1,282.24 1,256.59 44126 2,504.70 2,379.47 2,736.39 2,681.66 2,681.66 2,628.03 44127 2,877.74 2,733.85 3,143.93 3,081.05 3,081.05 3,019.43 44128 249.96 237.46 273.08 267.62 267.62 262.27 44130 1,330.40 1,263.88 1,453.46 1,424.39 1,424.39 1,395.90 44139 123.92 117.72 135.38 132.68 132.68 130.02 44140 1,359.44 1,291.47 1,485.19 1,455.49 1,455.49 1,426.38 44141 1,847.88 1,755.49 2,018.81 1,978.44 1,978.44 1,938.87 44143 1,686.87 1,602.53 1,842.91 1,806.05 1,806.05 1,769.93 44144 1,795.94 1,706.14 1,962.06 1,922.82 1,922.82 1,884.37 44145 1,682.16 1,598.05 1,837.76 1,801.00 1,801.00 1,764.99 44146 2,144.30 2,037.09 2,342.65 2,295.80 2,295.80 2,249.88 44147 1,974.71 1,875.97 2,157.37 2,114.22 2,114.22 2,071.93 44150 1,889.98 1,795.48 2,064.80 2,023.51 2,023.51 1,983.04 44151 2,164.45 2,056.23 2,364.66 2,317.38 2,317.38 2,271.03 44155 2,105.84 2,000.55 2,300.63 2,254.62 2,254.62 2,209.53 44156 2,324.51 2,208.28 2,539.52 2,488.73 2,488.73 2,438.95 44157 2,179.02 2,070.07 2,380.58 2,332.97 2,332.97 2,286.32 44158 2,150.69 2,043.16 2,349.63 2,302.65 2,302.65 2,256.59 44160 1,258.25 1,195.34 1,374.64 1,347.14 1,347.14 1,320.20 44180 929.79 883.30 1,015.80 995.47 995.47 975.57 44186 658.98 626.03 719.93 705.54 705.54 691.43 44187 1,114.02 1,058.32 1,217.07 1,192.72 1,192.72 1,168.87 44188 1,236.56 1,174.73 1,350.94 1,323.93 1,323.93 1,297.45 44202 1,406.37 1,336.05 1,536.46 1,505.73 1,505.73 1,475.61 44203 246.43 234.11 269.23 263.84 263.84 258.57 44204 1,560.39 1,482.37 1,704.73 1,670.63 1,670.63 1,637.22 44205 1,356.76 1,288.92 1,482.26 1,452.61 1,452.61 1,423.56 44206 1,778.30 1,689.39 1,942.80 1,903.94 1,903.94 1,865.86 44207 1,847.93 1,755.53 2,018.86 1,978.48 1,978.48 1,938.91 44208 2,013.43 1,912.76 2,199.67 2,155.68 2,155.68 2,112.56 44210 1,802.36 1,712.24 1,969.08 1,929.70 1,929.70 1,891.11 44211 2,207.60 2,097.22 2,411.80 2,363.57 2,363.57 2,316.30 44212 2,069.76 1,966.27 2,261.21 2,215.98 2,215.98 2,171.66 44213 192.00 182.40 209.76 205.56 205.56 201.46 44227 1,692.26 1,607.65 1,848.80 1,811.83 1,811.83 1,775.59 44300 851.66 809.08 930.44 911.84 911.84 893.60 44310 1,057.05 1,004.20 1,154.83 1,131.74 1,131.74 1,109.11 44312 593.66 563.98 648.58 635.61 635.61 622.90 44314 1,013.63 962.95 1,107.39 1,085.24 1,085.24 1,063.54 44316 1,435.59 1,363.81 1,568.38 1,537.01 1,537.01 1,506.27 44320 1,215.51 1,154.73 1,327.94 1,301.39 1,301.39 1,275.36 44322 999.24 949.28 1,091.67 1,069.83 1,069.83 1,048.43 44340 628.08 596.68 686.18 672.46 672.46 659.02 44345 1,062.70 1,009.57 1,161.01 1,137.79 1,137.79 1,115.03 44346 1,196.35 1,136.53 1,307.01 1,280.87 1,280.87 1,255.25

Page 108: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 108Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

44360 152.12 144.51 166.19 162.86 162.86 159.61 44361 167.85 159.46 183.38 179.71 179.71 176.11 44363 201.49 191.42 220.13 215.73 215.73 211.42 44364 214.35 203.63 234.17 229.49 229.49 224.91 44365 188.45 179.03 205.88 201.77 201.77 197.73 44366 251.73 239.14 275.01 269.51 269.51 264.12 44369 257.34 244.47 281.14 275.52 275.52 270.01 44370 278.78 264.84 304.57 298.47 298.47 292.50 44372 251.56 238.98 274.83 269.33 269.33 263.95 44373 202.23 192.12 220.94 216.52 216.52 212.19 44376 296.67 281.84 324.12 317.63 317.63 311.28 44377 313.02 297.37 341.98 335.13 335.13 328.43 44378 400.32 380.30 437.35 428.59 428.59 420.03 44379 425.50 404.23 464.86 455.57 455.57 446.46 44380 208.95 198.50 228.28 223.71 223.71 219.24 # 44380 62.69 59.56 68.49 67.13 67.13 65.78 44381 937.44 890.57 1,024.16 1,003.67 1,003.67 983.60 # 44381 91.74 87.15 100.22 98.22 98.22 96.26 44382 302.30 287.19 330.27 323.67 323.67 317.19 # 44382 79.78 75.79 87.16 85.41 85.41 83.70 44384 160.47 152.45 175.32 171.81 171.81 168.37 44385 231.09 219.54 252.47 247.42 247.42 242.48 # 44385 77.93 74.03 85.13 83.43 83.43 81.77 44386 324.44 308.22 354.45 347.37 347.37 340.42 # 44386 95.68 90.90 104.54 102.44 102.44 100.40 44388 339.16 322.20 370.53 363.12 363.12 355.86 # 44388 165.28 157.02 180.57 176.96 176.96 173.42 44388 53 168.33 159.91 183.90 180.22 180.22 176.62 # 44388 53 81.56 77.48 89.10 87.32 87.32 85.57 44389 425.82 404.53 465.21 455.91 455.91 446.79 # 44389 181.28 172.22 198.05 194.10 194.10 190.21 44390 427.42 406.05 466.96 457.62 457.62 448.47 # 44390 221.00 209.95 241.44 236.61 236.61 231.89 44391 729.46 692.99 796.94 781.00 781.00 765.38 # 44391 241.70 229.62 264.06 258.78 258.78 253.61 44392 402.94 382.79 440.21 431.40 431.40 422.77 # 44392 208.69 198.26 228.00 223.43 223.43 218.96 44394 453.19 430.53 495.11 485.21 485.21 475.50 # 44394 236.91 225.06 258.82 253.64 253.64 248.57 44401 3,051.87 2,899.28 3,334.17 3,267.48 3,267.48 3,202.13 # 44401 253.79 241.10 277.27 271.72 271.72 266.28 44402 274.70 260.97 300.12 294.11 294.11 288.24 44403 315.72 299.93 344.92 338.02 338.02 331.26 44404 408.48 388.06 446.27 437.35 437.35 428.59 # 44404 181.69 172.61 198.50 194.53 194.53 190.65 44405 582.07 552.97 635.92 623.20 623.20 610.73 # 44405 193.24 183.58 211.12 206.90 206.90 202.76 44406 240.84 228.80 263.12 257.85 257.85 252.70 44407 288.44 274.02 315.12 308.82 308.82 302.65

Page 109: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 109Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

44408 243.29 231.13 265.80 260.49 260.49 255.28 44500 24.88 23.64 27.19 26.65 26.65 26.12 44602 1,435.49 1,363.72 1,568.28 1,536.92 1,536.92 1,506.18 44603 1,644.95 1,562.70 1,797.11 1,761.17 1,761.17 1,725.94 44604 1,072.75 1,019.11 1,171.98 1,148.54 1,148.54 1,125.57 44605 1,323.28 1,257.12 1,445.69 1,416.78 1,416.78 1,388.44 44615 1,090.83 1,036.29 1,191.73 1,167.89 1,167.89 1,144.54 44620 878.32 834.40 959.56 940.37 940.37 921.56 44625 1,029.55 978.07 1,124.78 1,102.29 1,102.29 1,080.24 44626 1,628.64 1,547.21 1,779.29 1,743.71 1,743.71 1,708.83 44640 1,423.10 1,351.95 1,554.74 1,523.65 1,523.65 1,493.17 44650 1,471.57 1,397.99 1,607.69 1,575.53 1,575.53 1,544.02 44660 1,348.01 1,280.61 1,472.70 1,443.25 1,443.25 1,414.39 44661 1,574.30 1,495.59 1,719.93 1,685.53 1,685.53 1,651.83 44680 1,080.36 1,026.34 1,180.29 1,156.68 1,156.68 1,133.54 44700 1,032.23 980.62 1,127.71 1,105.16 1,105.16 1,083.06 44701 171.98 163.38 187.89 184.13 184.13 180.45 44720 281.23 267.17 307.25 301.10 301.10 295.08 44721 393.60 373.92 430.01 421.41 421.41 412.98 44800 769.70 731.22 840.90 824.09 824.09 807.61 44820 848.27 805.86 926.74 908.20 908.20 890.04 44850 759.27 721.31 829.51 812.91 812.91 796.65 44900 780.61 741.58 852.82 835.76 835.76 819.05 44950 650.50 617.98 710.68 696.46 696.46 682.54 44955 85.60 81.32 93.52 91.64 91.64 89.82 44960 885.32 841.05 967.21 947.86 947.86 928.91 44970 606.33 576.01 662.41 649.16 649.16 636.18 45000 423.34 402.17 462.50 453.25 453.25 444.19 45005 265.13 251.87 289.65 283.85 283.85 278.17 # 45005 160.28 152.27 175.11 171.60 171.60 168.18 45020 572.98 544.33 625.98 613.46 613.46 601.19 45100 297.94 283.04 325.50 318.99 318.99 312.60 45108 366.33 348.01 400.21 392.21 392.21 384.36 45110 1,866.54 1,773.21 2,039.19 1,998.41 1,998.41 1,958.45 45111 1,097.29 1,042.43 1,198.79 1,174.82 1,174.82 1,151.32 45112 1,903.72 1,808.53 2,079.81 2,038.21 2,038.21 1,997.45 45113 1,913.32 1,817.65 2,090.30 2,048.50 2,048.50 2,007.52 45114 1,843.47 1,751.30 2,014.00 1,973.71 1,973.71 1,934.23 45116 1,667.38 1,584.01 1,821.61 1,785.18 1,785.18 1,749.47 45119 1,969.08 1,870.63 2,151.22 2,108.20 2,108.20 2,066.04 45120 1,518.85 1,442.91 1,659.35 1,626.16 1,626.16 1,593.64 45121 1,760.31 1,672.29 1,923.13 1,884.67 1,884.67 1,846.97 45123 1,130.40 1,073.88 1,234.96 1,210.26 1,210.26 1,186.05 45126 2,828.57 2,687.14 3,090.21 3,028.41 3,028.41 2,967.84 45130 1,097.99 1,043.09 1,199.55 1,175.56 1,175.56 1,152.06 45135 1,384.62 1,315.39 1,512.70 1,482.44 1,482.44 1,452.80 45136 1,825.72 1,734.43 1,994.59 1,954.70 1,954.70 1,915.61 45150 389.88 370.39 425.95 417.43 417.43 409.08 45160 1,031.65 980.07 1,127.08 1,104.54 1,104.54 1,082.45

Page 110: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 110Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

45171 599.50 569.53 654.96 641.86 641.86 629.03 45172 810.42 769.90 885.39 867.68 867.68 850.32 45190 694.57 659.84 758.82 743.64 743.64 728.77 45300 117.74 111.85 128.63 126.05 126.05 123.53 # 45300 53.97 51.27 58.96 57.78 57.78 56.63 45303 901.80 856.71 985.22 965.52 965.52 946.21 # 45303 92.91 88.26 101.50 99.46 99.46 97.47 45305 187.04 177.69 204.34 200.26 200.26 196.26 # 45305 79.23 75.27 86.56 84.82 84.82 83.12 45307 225.00 213.75 245.81 240.90 240.90 236.08 # 45307 107.33 101.96 117.25 114.91 114.91 112.61 45308 207.11 196.75 226.26 221.74 221.74 217.30 # 45308 89.77 85.28 98.07 96.11 96.11 94.19 45309 217.02 206.17 237.10 232.36 232.36 227.71 # 45309 95.73 90.94 104.58 102.49 102.49 100.44 45315 217.36 206.49 237.46 232.71 232.71 228.06 # 45315 105.28 100.02 115.02 112.72 112.72 110.47 45317 234.54 222.81 256.23 251.10 251.10 246.08 # 45317 118.51 112.58 129.47 126.88 126.88 124.34 45320 234.46 222.74 256.15 251.03 251.03 246.01 # 45320 111.53 105.95 121.84 119.40 119.40 117.01 45321 108.30 102.89 118.32 115.95 115.95 113.63 45327 123.46 117.29 134.88 132.18 132.18 129.54 45330 158.58 150.65 173.25 169.79 169.79 166.39 # 45330 56.36 53.54 61.57 60.34 60.34 59.13 45331 242.70 230.57 265.16 259.85 259.85 254.66 # 45331 72.77 69.13 79.50 77.91 77.91 76.36 45332 296.11 281.30 323.50 317.02 317.02 310.68 # 45332 112.71 107.07 123.13 120.67 120.67 118.25 45333 330.91 314.36 361.51 354.28 354.28 347.20 # 45333 100.83 95.79 110.16 107.95 107.95 105.79 45334 575.21 546.45 628.42 615.85 615.85 603.53 # 45334 125.57 119.29 137.18 134.44 134.44 131.74 45335 273.30 259.64 298.59 292.62 292.62 286.76 # 45335 72.80 69.16 79.53 77.95 77.95 76.38 45337 123.34 117.17 134.75 132.05 132.05 129.41 45338 309.84 294.35 338.50 331.73 331.73 325.09 # 45338 128.07 121.67 139.92 137.13 137.13 134.39 45340 461.37 438.30 504.05 493.96 493.96 484.08 # 45340 84.37 80.15 92.17 90.33 90.33 88.53 45341 131.87 125.28 144.07 141.19 141.19 138.36 45342 179.03 170.08 195.59 191.68 191.68 187.85 45346 2,916.82 2,770.98 3,186.63 3,122.89 3,122.89 3,060.44 # 45346 169.36 160.89 185.02 181.32 181.32 177.70 45347 163.45 155.28 178.57 175.00 175.00 171.50 45349 208.28 197.87 227.55 223.00 223.00 218.53 45350 550.22 522.71 601.12 589.10 589.10 577.31 # 45350 107.82 102.43 117.79 115.44 115.44 113.13 45378 365.15 346.89 398.92 390.94 390.94 383.12

Page 111: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 111Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 45378 194.56 184.83 212.55 208.30 208.30 204.14 45378 53 182.41 173.29 199.28 195.29 195.29 191.38 # 45378 53 97.28 92.42 106.28 104.16 104.16 102.07 45379 460.85 437.81 503.48 493.41 493.41 483.54 # 45379 250.49 237.97 273.67 268.19 268.19 262.83 45380 449.54 427.06 491.12 481.30 481.30 471.67 # 45380 210.91 200.36 230.41 225.80 225.80 221.28 45381 432.75 411.11 472.78 463.32 463.32 454.05 # 45381 210.89 200.35 230.40 225.79 225.79 221.27 45382 755.84 718.05 825.76 809.24 809.24 793.06 # 45382 271.36 257.79 296.46 290.52 290.52 284.72 45384 494.14 469.43 539.84 529.05 529.05 518.47 # 45384 239.41 227.44 261.56 256.32 256.32 251.19 45385 474.24 450.53 518.11 507.75 507.75 497.59 # 45385 266.52 253.19 291.17 285.35 285.35 279.65 45386 624.19 592.98 681.93 668.29 668.29 654.93 # 45386 222.54 211.41 243.12 238.26 238.26 233.50 45388 3,070.98 2,917.43 3,355.04 3,287.94 3,287.94 3,222.19 # 45388 283.09 268.94 309.28 303.09 303.09 297.03 45389 302.96 287.81 330.98 324.36 324.36 317.87 45390 346.17 328.86 378.19 370.62 370.62 363.20 45391 269.63 256.15 294.57 288.68 288.68 282.91 45392 317.53 301.65 346.90 339.96 339.96 333.17 45393 265.03 251.78 289.55 283.75 283.75 278.08 45395 1,997.77 1,897.88 2,182.56 2,138.91 2,138.91 2,096.13 45397 2,176.67 2,067.84 2,378.02 2,330.45 2,330.45 2,283.84 45398 697.73 662.84 762.27 747.02 747.02 732.08 # 45398 246.45 234.13 269.25 263.87 263.87 258.59 45400 1,151.24 1,093.68 1,257.73 1,232.58 1,232.58 1,207.93 45402 1,537.61 1,460.73 1,679.84 1,646.25 1,646.25 1,613.32 45500 520.04 494.04 568.15 556.78 556.78 545.65 45505 591.93 562.33 646.68 633.74 633.74 621.07 45520 148.72 141.28 162.47 159.22 159.22 156.03 # 45520 39.93 37.93 43.62 42.75 42.75 41.89 45540 1,069.48 1,016.01 1,168.41 1,145.04 1,145.04 1,122.15 45541 949.15 901.69 1,036.94 1,016.21 1,016.21 995.89 45550 1,473.97 1,400.27 1,610.31 1,578.10 1,578.10 1,546.53 45560 688.89 654.45 752.62 737.56 737.56 722.81 45562 1,128.45 1,072.03 1,232.83 1,208.18 1,208.18 1,184.02 45563 1,666.29 1,582.98 1,820.43 1,784.02 1,784.02 1,748.33 45800 1,213.79 1,153.10 1,326.07 1,299.55 1,299.55 1,273.56 45805 1,478.32 1,404.40 1,615.06 1,582.76 1,582.76 1,551.10 45820 1,200.34 1,140.32 1,311.37 1,285.14 1,285.14 1,259.43 45825 1,395.52 1,325.74 1,524.60 1,494.11 1,494.11 1,464.24 45900 202.97 192.82 221.74 217.30 217.30 212.96 45905 168.83 160.39 184.45 180.76 180.76 177.15 45910 194.10 184.40 212.06 207.82 207.82 203.67 45915 322.30 306.19 352.12 345.08 345.08 338.18 # 45915 225.34 214.07 246.18 241.26 241.26 236.43

Page 112: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 112Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

45990 108.42 103.00 118.45 116.08 116.08 113.76 46020 270.68 257.15 295.72 289.81 289.81 284.02 # 46020 232.56 220.93 254.07 248.99 248.99 244.01 46030 135.13 128.37 147.63 144.67 144.67 141.77 # 46030 89.77 85.28 98.07 96.11 96.11 94.19 46040 522.67 496.54 571.02 559.60 559.60 548.41 # 46040 411.58 391.00 449.65 440.66 440.66 431.85 46045 431.75 410.16 471.68 462.25 462.25 453.01 46050 192.92 183.27 210.76 206.54 206.54 202.41 # 46050 96.29 91.48 105.20 103.10 103.10 101.04 46060 473.67 449.99 517.49 507.14 507.14 497.00 46070 223.84 212.65 244.55 239.66 239.66 234.86 46080 241.83 229.74 264.20 258.92 258.92 253.75 # 46080 159.99 151.99 174.79 171.29 171.29 167.87 46083 169.90 161.41 185.62 181.91 181.91 178.27 # 46083 105.48 100.21 115.24 112.94 112.94 110.69 46200 430.10 408.60 469.89 460.49 460.49 451.28 # 46200 319.99 303.99 349.59 342.60 342.60 335.74 46220 198.83 188.89 217.22 212.88 212.88 208.62 # 46220 117.97 112.07 128.88 126.30 126.30 123.77 46221 259.37 246.40 283.36 277.69 277.69 272.14 # 46221 187.71 178.32 205.07 200.96 200.96 196.95 46230 265.35 252.08 289.89 284.10 284.10 278.42 # 46230 172.34 163.72 188.28 184.52 184.52 180.83 46250 451.00 428.45 492.72 482.86 482.86 473.20 # 46250 313.94 298.24 342.98 336.12 336.12 329.39 46255 493.87 469.18 539.56 528.77 528.77 518.19 # 46255 352.86 335.22 385.50 377.80 377.80 370.24 46257 419.62 398.64 458.44 449.27 449.27 440.29 46258 465.75 442.46 508.83 498.65 498.65 488.68 46260 474.39 450.67 518.27 507.91 507.91 497.75 46261 521.65 495.57 569.91 558.51 558.51 547.34 46262 550.05 522.55 600.93 588.92 588.92 577.14 46270 495.45 470.68 541.28 530.46 530.46 519.85 # 46270 388.62 369.19 424.57 416.08 416.08 407.76 46275 524.11 497.90 572.59 561.13 561.13 549.91 # 46275 410.06 389.56 447.99 439.04 439.04 430.25 46280 466.26 442.95 509.39 499.20 499.20 489.22 46285 519.43 493.46 567.48 556.13 556.13 545.01 # 46285 408.66 388.23 446.46 437.54 437.54 428.79 46288 548.06 520.66 598.76 586.79 586.79 575.06 46320 177.85 168.96 194.30 190.42 190.42 186.61 # 46320 110.47 104.95 120.69 118.28 118.28 115.91 46500 187.21 177.85 204.53 200.43 200.43 196.42 # 46500 121.14 115.08 132.34 129.70 129.70 127.10 46505 279.43 265.46 305.28 299.17 299.17 293.19 # 46505 237.03 225.18 258.96 253.78 253.78 248.71 46600 84.68 80.45 92.52 90.67 90.67 88.85 # 46600 40.64 38.61 44.40 43.52 43.52 42.64

Page 113: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 113Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

46601 133.21 126.55 145.53 142.62 142.62 139.77 # 46601 93.76 89.07 102.43 100.38 100.38 98.37 46604 581.31 552.24 635.08 622.38 622.38 609.94 # 46604 66.59 63.26 72.75 71.29 71.29 69.86 46606 215.40 204.63 235.32 230.62 230.62 226.01 # 46606 76.37 72.55 83.43 81.77 81.77 80.13 46607 186.48 177.16 203.73 199.66 199.66 195.67 # 46607 126.66 120.33 138.38 135.61 135.61 132.89 46608 221.75 210.66 242.26 237.42 237.42 232.67 # 46608 81.40 77.33 88.93 87.15 87.15 85.40 46610 216.13 205.32 236.12 231.39 231.39 226.77 # 46610 81.37 77.30 88.90 87.11 87.11 85.38 46611 169.08 160.63 184.72 181.03 181.03 177.41 # 46611 81.65 77.57 89.21 87.42 87.42 85.68 46612 246.52 234.19 269.32 263.94 263.94 258.66 # 46612 94.01 89.31 102.71 100.65 100.65 98.64 46614 123.66 117.48 135.10 132.40 132.40 129.75 # 46614 64.83 61.59 70.83 69.41 69.41 68.02 46615 140.24 133.23 153.21 150.16 150.16 147.15 # 46615 93.24 88.58 101.87 99.83 99.83 97.83 46700 653.29 620.63 713.72 699.45 699.45 685.47 46705 499.17 474.21 545.34 534.44 534.44 523.76 46706 165.21 156.95 180.49 176.88 176.88 173.34 46707 473.94 450.24 517.78 507.43 507.43 497.28 46710 1,056.36 1,003.54 1,154.07 1,130.99 1,130.99 1,108.37 46712 2,155.26 2,047.50 2,354.63 2,307.53 2,307.53 2,261.38 46715 542.08 514.98 592.23 580.38 580.38 568.78 46716 1,109.40 1,053.93 1,212.02 1,187.78 1,187.78 1,164.02 46730 1,831.10 1,739.55 2,000.48 1,960.47 1,960.47 1,921.26 46735 2,123.03 2,016.88 2,319.41 2,273.02 2,273.02 2,227.56 46740 2,166.48 2,058.16 2,366.88 2,319.55 2,319.55 2,273.16 46742 2,453.15 2,330.49 2,680.06 2,626.46 2,626.46 2,573.93 46744 3,573.76 3,395.07 3,904.33 3,826.25 3,826.25 3,749.72 46746 3,687.42 3,503.05 4,028.51 3,947.94 3,947.94 3,868.98 46748 4,005.95 3,805.65 4,376.50 4,288.97 4,288.97 4,203.19 46750 755.09 717.34 824.94 808.44 808.44 792.27 46751 596.05 566.25 651.19 638.17 638.17 625.40 46753 612.38 581.76 669.02 655.64 655.64 642.53 46754 284.72 270.48 311.05 304.83 304.83 298.74 # 46754 225.23 213.97 246.07 241.14 241.14 236.33 46760 1,092.86 1,038.22 1,193.95 1,170.08 1,170.08 1,146.68 46761 926.65 880.32 1,012.37 992.12 992.12 972.28 46762 927.82 881.43 1,013.64 993.37 993.37 973.50 46900 233.48 221.81 255.08 249.98 249.98 244.97 # 46900 136.19 129.38 148.79 145.81 145.81 142.89 46910 247.12 234.76 269.97 264.57 264.57 259.28 # 46910 133.39 126.72 145.73 142.82 142.82 139.97 46916 221.26 210.20 241.73 236.90 236.90 232.16 # 46916 141.72 134.63 154.82 151.73 151.73 148.70

Page 114: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 114Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

46917 427.35 405.98 466.88 457.54 457.54 448.39 # 46917 130.88 124.34 142.99 140.13 140.13 137.32 46922 256.73 243.89 280.47 274.86 274.86 269.36 # 46922 134.79 128.05 147.26 144.31 144.31 141.43 46924 508.10 482.70 555.11 544.01 544.01 533.13 # 46924 183.36 174.19 200.32 196.32 196.32 192.40 46930 197.93 188.03 216.23 211.91 211.91 207.67 # 46930 144.02 136.82 157.34 154.19 154.19 151.11 46940 222.22 211.11 242.78 237.92 237.92 233.16 # 46940 146.62 139.29 160.18 156.98 156.98 153.84 46942 209.41 198.94 228.78 224.20 224.20 219.72 # 46942 131.18 124.62 143.31 140.45 140.45 137.64 46945 297.52 282.64 325.04 318.54 318.54 312.17 # 46945 220.93 209.88 241.36 236.53 236.53 231.81 46946 303.48 288.31 331.56 324.92 324.92 318.42 # 46946 221.97 210.87 242.50 237.65 237.65 232.90 46947 382.44 363.32 417.82 409.46 409.46 401.27 47000 345.56 328.28 377.52 369.97 369.97 362.57 # 47000 103.98 98.78 113.60 111.32 111.32 109.09 47001 106.05 100.75 115.86 113.55 113.55 111.29 47010 1,216.31 1,155.49 1,328.81 1,302.24 1,302.24 1,276.19 47015 1,156.17 1,098.36 1,263.11 1,237.85 1,237.85 1,213.09 47100 849.70 807.22 928.30 909.74 909.74 891.55 47120 2,360.77 2,242.73 2,579.14 2,527.56 2,527.56 2,477.01 47122 3,490.85 3,316.31 3,813.76 3,737.48 3,737.48 3,662.73 47125 3,120.21 2,964.20 3,408.83 3,340.66 3,340.66 3,273.84 47130 3,352.34 3,184.72 3,662.43 3,589.18 3,589.18 3,517.40 47135 5,444.01 5,171.81 5,947.58 5,828.63 5,828.63 5,712.05 47140 3,621.75 3,440.66 3,956.76 3,877.63 3,877.63 3,800.07 47141 4,330.78 4,114.24 4,731.38 4,636.75 4,636.75 4,544.02 47142 4,777.04 4,538.19 5,218.92 5,114.54 5,114.54 5,012.25 47143 332.95 316.30 363.75 356.47 356.47 349.34 47144 332.95 316.30 363.75 356.47 356.47 349.34 47145 332.95 316.30 363.75 356.47 356.47 349.34 47146 336.42 319.60 367.54 360.19 360.19 352.99 47147 391.49 371.92 427.71 419.15 419.15 410.77 47300 1,142.81 1,085.67 1,248.52 1,223.55 1,223.55 1,199.08 47350 1,385.58 1,316.30 1,513.75 1,483.47 1,483.47 1,453.80 47360 1,884.26 1,790.05 2,058.56 2,017.39 2,017.39 1,977.05 47361 3,069.05 2,915.60 3,352.94 3,285.88 3,285.88 3,220.16 47362 1,466.20 1,392.89 1,601.82 1,569.78 1,569.78 1,538.39 47370 1,263.18 1,200.02 1,380.02 1,352.42 1,352.42 1,325.38 47371 1,140.72 1,083.68 1,246.23 1,221.31 1,221.31 1,196.89 47380 1,461.65 1,388.57 1,596.86 1,564.92 1,564.92 1,533.62 47381 1,349.54 1,282.06 1,474.37 1,444.88 1,444.88 1,415.98 47382 4,736.65 4,499.82 5,174.79 5,071.29 5,071.29 4,969.86 # 47382 782.92 743.77 855.34 838.22 838.22 821.46 47383 7,078.91 6,724.96 7,733.70 7,579.03 7,579.03 7,427.45 # 47383 497.36 472.49 543.36 532.50 532.50 521.85

Page 115: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 115Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

47400 2,181.71 2,072.62 2,383.51 2,335.85 2,335.85 2,289.13 47420 1,357.96 1,290.06 1,483.57 1,453.90 1,453.90 1,424.82 47425 1,370.12 1,301.61 1,496.85 1,466.92 1,466.92 1,437.58 47460 1,267.57 1,204.19 1,384.82 1,357.13 1,357.13 1,329.99 47480 880.41 836.39 961.85 942.61 942.61 923.76 47490 330.64 314.11 361.23 354.00 354.00 346.92 47531 353.82 336.13 386.55 378.82 378.82 371.24 # 47531 97.12 92.26 106.10 103.97 103.97 101.89 47532 779.82 740.83 851.95 834.91 834.91 818.21 # 47532 219.74 208.75 240.06 235.27 235.27 230.56 47533 1,269.51 1,206.03 1,386.93 1,359.20 1,359.20 1,332.01 # 47533 311.39 295.82 340.19 333.39 333.39 326.72 47534 1,566.64 1,488.31 1,711.56 1,677.32 1,677.32 1,643.78 # 47534 413.29 392.63 451.52 442.50 442.50 433.64 47535 1,048.15 995.74 1,145.10 1,122.20 1,122.20 1,099.76 # 47535 237.62 225.74 259.60 254.41 254.41 249.33 47536 771.70 733.12 843.09 826.23 826.23 809.70 # 47536 149.83 142.34 163.69 160.41 160.41 157.21 47537 383.02 363.87 418.45 410.08 410.08 401.88 # 47537 101.01 95.96 110.35 108.15 108.15 105.98 47538 4,229.07 4,017.62 4,620.26 4,527.86 4,527.86 4,437.30 # 47538 334.83 318.09 365.80 358.49 358.49 351.33 47539 4,627.16 4,395.80 5,055.17 4,954.06 4,954.06 4,854.98 # 47539 452.88 430.24 494.78 484.89 484.89 475.19 47540 4,815.12 4,574.36 5,260.51 5,155.30 5,155.30 5,052.19 # 47540 540.59 513.56 590.59 578.78 578.78 567.20 47541 1,121.75 1,065.66 1,225.51 1,201.00 1,201.00 1,176.98 # 47541 287.88 273.49 314.51 308.22 308.22 302.06 47542 492.09 467.49 537.61 526.86 526.86 516.33 # 47542 136.45 129.63 149.07 146.10 146.10 143.18 47543 1,250.11 1,187.60 1,365.74 1,338.43 1,338.43 1,311.66 # 47543 171.37 162.80 187.22 183.47 183.47 179.80 47544 776.95 738.10 848.82 831.84 831.84 815.20 # 47544 219.50 208.53 239.81 235.01 235.01 230.31 47550 169.23 160.77 184.89 181.18 181.18 177.56 47552 316.34 300.52 345.60 338.69 338.69 331.91 47553 313.30 297.64 342.29 335.44 335.44 328.74 47554 485.89 461.60 530.84 520.23 520.23 509.82 47555 374.97 356.22 409.65 401.47 401.47 393.44 47556 426.47 405.15 465.92 456.61 456.61 447.48 47562 663.87 630.68 725.28 710.78 710.78 696.57 47563 721.71 685.62 788.46 772.70 772.70 757.24 47564 1,125.36 1,069.09 1,229.45 1,204.87 1,204.87 1,180.77 47570 774.15 735.44 845.76 828.84 828.84 812.27 47600 1,079.69 1,025.71 1,179.57 1,155.98 1,155.98 1,132.87 47605 1,137.22 1,080.36 1,242.41 1,217.56 1,217.56 1,193.22 47610 1,270.85 1,207.31 1,388.41 1,360.63 1,360.63 1,333.43 47612 1,287.03 1,222.68 1,406.08 1,377.96 1,377.96 1,350.41 47620 1,394.71 1,324.97 1,523.72 1,493.24 1,493.24 1,463.38

Page 116: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 116Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

47700 1,048.21 995.80 1,145.17 1,122.26 1,122.26 1,099.81 47701 1,717.13 1,631.27 1,875.96 1,838.44 1,838.44 1,801.67 47711 1,574.89 1,496.15 1,720.57 1,686.16 1,686.16 1,652.45 47712 2,016.64 1,915.81 2,203.18 2,159.11 2,159.11 2,115.93 47715 1,347.07 1,279.72 1,471.68 1,442.25 1,442.25 1,413.41 47720 1,162.15 1,104.04 1,269.65 1,244.25 1,244.25 1,219.37 47721 1,372.00 1,303.40 1,498.91 1,468.93 1,468.93 1,439.55 47740 1,316.27 1,250.46 1,438.03 1,409.27 1,409.27 1,381.08 47741 1,486.93 1,412.58 1,624.47 1,591.98 1,591.98 1,560.14 47760 2,291.40 2,176.83 2,503.35 2,453.28 2,453.28 2,404.21 47765 3,080.28 2,926.27 3,365.21 3,297.90 3,297.90 3,231.95 47780 2,508.50 2,383.08 2,740.54 2,685.73 2,685.73 2,632.02 47785 3,298.88 3,133.94 3,604.03 3,531.95 3,531.95 3,461.30 47800 1,594.99 1,515.24 1,742.53 1,707.68 1,707.68 1,673.53 47801 1,008.34 957.92 1,101.61 1,079.57 1,079.57 1,057.98 47802 1,528.03 1,451.63 1,669.37 1,635.99 1,635.99 1,603.27 47900 1,385.70 1,316.42 1,513.88 1,483.60 1,483.60 1,453.93 48000 1,897.41 1,802.54 2,072.92 2,031.46 2,031.46 1,990.83 48001 2,323.97 2,207.77 2,538.94 2,488.15 2,488.15 2,438.39 48020 1,184.70 1,125.47 1,294.29 1,268.40 1,268.40 1,243.04 48100 896.14 851.33 979.03 959.45 959.45 940.25 48102 515.18 489.42 562.83 551.57 551.57 540.55 # 48102 245.99 233.69 268.74 263.37 263.37 258.11 48105 2,895.19 2,750.43 3,162.99 3,099.73 3,099.73 3,037.74 48120 1,121.74 1,065.65 1,225.50 1,200.99 1,200.99 1,176.97 48140 1,584.31 1,505.09 1,730.85 1,696.24 1,696.24 1,662.31 48145 1,648.68 1,566.25 1,801.19 1,765.17 1,765.17 1,729.86 48146 1,899.18 1,804.22 2,074.85 2,033.36 2,033.36 1,992.70 48148 1,260.37 1,197.35 1,376.95 1,349.41 1,349.41 1,322.42 48150 3,158.26 3,000.35 3,450.40 3,381.39 3,381.39 3,313.76 48152 2,912.49 2,766.87 3,181.90 3,118.26 3,118.26 3,055.90 48153 3,141.66 2,984.58 3,432.27 3,363.62 3,363.62 3,296.35 48154 2,946.65 2,799.32 3,219.22 3,154.83 3,154.83 3,091.73 48155 1,839.85 1,747.86 2,010.04 1,969.84 1,969.84 1,930.44 48400 106.97 101.62 116.86 114.53 114.53 112.24 48500 1,136.54 1,079.71 1,241.67 1,216.84 1,216.84 1,192.50 48510 1,098.62 1,043.69 1,200.24 1,176.24 1,176.24 1,152.71 48520 1,107.04 1,051.69 1,209.44 1,185.26 1,185.26 1,161.56 48540 1,317.57 1,251.69 1,439.44 1,410.66 1,410.66 1,382.45 48545 1,350.28 1,282.77 1,475.19 1,445.68 1,445.68 1,416.77 48547 1,815.38 1,724.61 1,983.30 1,943.64 1,943.64 1,904.77 48548 1,686.55 1,602.22 1,842.55 1,805.71 1,805.71 1,769.60 48551 207.07 196.72 226.23 221.71 221.71 217.27 48552 239.09 227.14 261.21 255.99 255.99 250.87 48554 2,568.45 2,440.03 2,806.03 2,749.91 2,749.91 2,694.92 48556 1,278.11 1,214.20 1,396.33 1,368.41 1,368.41 1,341.04 49000 778.75 739.81 850.78 833.76 833.76 817.09 49002 1,059.48 1,006.51 1,157.49 1,134.34 1,134.34 1,111.65 49010 946.30 898.99 1,033.84 1,013.16 1,013.16 992.90

Page 117: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 117Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

49020 1,611.12 1,530.56 1,760.14 1,724.94 1,724.94 1,690.44 49040 1,011.10 960.55 1,104.63 1,082.54 1,082.54 1,060.89 49060 1,113.58 1,057.90 1,216.59 1,192.25 1,192.25 1,168.41 49062 743.12 705.96 811.85 795.62 795.62 779.70 49082 183.53 174.35 200.50 196.49 196.49 192.56 # 49082 74.74 71.00 81.65 80.02 80.02 78.42 49083 281.13 267.07 307.13 300.99 300.99 294.98 # 49083 109.89 104.40 120.06 117.66 117.66 115.30 49084 110.56 105.03 120.78 118.37 118.37 116.00 49180 158.65 150.72 173.33 169.87 169.87 166.47 # 49180 87.00 82.65 95.05 93.15 93.15 91.29 49185 936.73 889.89 1,023.37 1,002.90 1,002.90 982.85 # 49185 124.88 118.64 136.44 133.71 133.71 131.03 49203 1,211.01 1,150.46 1,323.03 1,296.57 1,296.57 1,270.64 49204 1,550.67 1,473.14 1,694.11 1,660.23 1,660.23 1,627.03 49205 1,781.50 1,692.43 1,946.29 1,907.37 1,907.37 1,869.22 49215 2,246.58 2,134.25 2,454.39 2,405.31 2,405.31 2,357.20 49220 896.92 852.07 979.88 960.28 960.28 941.08 49250 590.42 560.90 645.04 632.13 632.13 619.49 49255 796.95 757.10 870.67 853.25 853.25 836.19 49320 327.20 310.84 357.47 350.31 350.31 343.31 49321 347.47 330.10 379.62 372.03 372.03 364.58 49322 370.12 351.61 404.35 396.27 396.27 388.34 49323 640.97 608.92 700.26 686.25 686.25 672.53 49324 394.16 374.45 430.62 422.00 422.00 413.56 49325 420.60 399.57 459.51 450.32 450.32 441.31 49326 193.61 183.93 211.52 207.29 207.29 203.15 49327 133.77 127.08 146.14 143.22 143.22 140.36 49400 133.97 127.27 146.36 143.43 143.43 140.56 # 49400 95.51 90.73 104.34 102.26 102.26 100.21 49402 865.91 822.61 946.00 927.08 927.08 908.55 49405 832.22 790.61 909.20 891.02 891.02 873.20 # 49405 215.28 204.52 235.20 230.49 230.49 225.88 49406 832.55 790.92 909.56 891.37 891.37 873.54 # 49406 215.28 204.52 235.20 230.49 230.49 225.88 49407 698.14 663.23 762.71 747.47 747.47 732.52 # 49407 231.08 219.53 252.46 247.41 247.41 242.47 49411 524.87 498.63 573.42 561.96 561.96 550.72 # 49411 200.46 190.44 219.01 214.62 214.62 210.34 49412 84.61 80.38 92.44 90.59 90.59 88.77 49418 1,357.86 1,289.97 1,483.47 1,453.80 1,453.80 1,424.72 # 49418 221.93 210.83 242.45 237.60 237.60 232.85 49419 447.62 425.24 489.03 479.25 479.25 469.67 49421 235.16 223.40 256.91 251.77 251.77 246.73 49422 384.82 365.58 420.42 412.01 412.01 403.77 49423 518.70 492.77 566.69 555.35 555.35 544.24 # 49423 73.33 69.66 80.11 78.51 78.51 76.94 49424 139.48 132.51 152.39 149.34 149.34 146.35 # 49424 38.90 36.96 42.50 41.65 41.65 40.83

Page 118: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 118Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

49425 739.98 702.98 808.43 792.26 792.26 776.41 49426 619.31 588.34 676.59 663.06 663.06 649.80 49427 46.98 44.63 51.32 50.30 50.30 49.30 49428 435.81 414.02 476.12 466.60 466.60 457.27 49429 463.52 440.34 506.39 496.26 496.26 486.34 49435 123.10 116.95 134.49 131.80 131.80 129.17 49436 187.52 178.14 204.86 200.77 200.77 196.75 49440 986.91 937.56 1,078.19 1,056.63 1,056.63 1,035.49 # 49440 224.69 213.46 245.48 240.57 240.57 235.76 49441 1,113.42 1,057.75 1,216.41 1,192.09 1,192.09 1,168.25 # 49441 260.48 247.46 284.58 278.89 278.89 273.31 49442 918.23 872.32 1,003.17 983.10 983.10 963.44 # 49442 224.05 212.85 244.78 239.88 239.88 235.08 49446 947.27 899.91 1,034.90 1,014.20 1,014.20 993.91 # 49446 165.66 157.38 180.99 177.36 177.36 173.82 49450 629.50 598.03 687.73 673.98 673.98 660.50 # 49450 68.44 65.02 74.77 73.28 73.28 71.82 49451 687.90 653.51 751.54 736.51 736.51 721.77 # 49451 92.66 88.03 101.23 99.21 99.21 97.22 49452 852.14 809.53 930.96 912.34 912.34 894.09 # 49452 142.51 135.38 155.69 152.57 152.57 149.52 49460 690.69 656.16 754.58 739.50 739.50 724.71 # 49460 49.10 46.65 53.65 52.58 52.58 51.53 49465 154.46 146.74 168.75 165.38 165.38 162.07 # 49465 31.54 29.96 34.45 33.76 33.76 33.09 49491 801.28 761.22 875.40 857.90 857.90 840.74 49492 967.50 919.13 1,057.00 1,035.86 1,035.86 1,015.15 49495 383.61 364.43 419.09 410.71 410.71 402.50 49496 618.89 587.95 676.14 662.62 662.62 649.37 49500 360.58 342.55 393.93 386.06 386.06 378.34 49501 586.47 557.15 640.72 627.91 627.91 615.35 49505 523.74 497.55 572.18 560.74 560.74 549.53 49507 589.25 559.79 643.76 630.88 630.88 618.26 49520 637.19 605.33 696.13 682.20 682.20 668.56 49521 722.70 686.57 789.56 773.77 773.77 758.29 49525 576.81 547.97 630.17 617.56 617.56 605.21 49540 676.82 642.98 739.43 724.64 724.64 710.15 49550 579.35 550.38 632.94 620.28 620.28 607.87 49553 635.94 604.14 694.76 680.87 680.87 667.25 49555 602.51 572.38 658.24 645.07 645.07 632.17 49557 730.47 693.95 798.04 782.08 782.08 766.44 49560 744.53 707.30 813.40 797.12 797.12 781.18 49561 940.68 893.65 1,027.70 1,007.15 1,007.15 987.00 49565 775.02 736.27 846.71 829.77 829.77 813.18 49566 949.39 901.92 1,037.21 1,016.46 1,016.46 996.13 49568 272.78 259.14 298.01 292.05 292.05 286.21 49570 417.31 396.44 455.91 446.79 446.79 437.85 49572 518.83 492.89 566.82 555.48 555.48 544.38 49580 331.92 315.32 362.62 355.36 355.36 348.25

Page 119: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 119Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

49582 485.11 460.85 529.98 519.37 519.37 508.99 49585 446.20 423.89 487.47 477.72 477.72 468.17 49587 477.57 453.69 521.74 511.31 511.31 501.09 49590 576.37 547.55 629.68 617.09 617.09 604.75 49600 708.19 672.78 773.70 758.22 758.22 743.05 49605 5,033.94 4,782.24 5,499.58 5,389.59 5,389.59 5,281.80 49606 1,131.39 1,074.82 1,236.04 1,211.32 1,211.32 1,187.09 49610 694.90 660.16 759.18 744.00 744.00 729.12 49611 610.38 579.86 666.84 653.50 653.50 640.42 49650 429.94 408.44 469.71 460.31 460.31 451.10 49651 559.10 531.15 610.82 598.61 598.61 586.64 49652 751.18 713.62 820.66 804.25 804.25 788.16 49653 937.17 890.31 1,023.86 1,003.38 1,003.38 983.31 49654 854.40 811.68 933.43 914.77 914.77 896.47 49655 1,043.55 991.37 1,140.08 1,117.27 1,117.27 1,094.93 49656 928.79 882.35 1,014.70 994.41 994.41 974.52 49657 1,336.42 1,269.60 1,460.04 1,430.84 1,430.84 1,402.23 49900 818.69 777.76 894.42 876.53 876.53 859.00 49904 1,434.41 1,362.69 1,567.09 1,535.76 1,535.76 1,505.04 49905 360.16 342.15 393.47 385.61 385.61 377.89 50010 741.43 704.36 810.01 793.81 793.81 777.93 50020 1,020.12 969.11 1,114.48 1,092.19 1,092.19 1,070.35 50040 928.92 882.47 1,014.84 994.54 994.54 974.65 50045 965.57 917.29 1,054.88 1,033.78 1,033.78 1,013.10 50060 1,148.34 1,090.92 1,254.56 1,229.47 1,229.47 1,204.88 50065 1,214.37 1,153.65 1,326.70 1,300.17 1,300.17 1,274.17 50070 1,190.83 1,131.29 1,300.98 1,274.96 1,274.96 1,249.46 50075 1,464.80 1,391.56 1,600.29 1,568.29 1,568.29 1,536.93 50080 872.65 829.02 953.37 934.31 934.31 915.62 50081 1,282.30 1,218.19 1,400.92 1,372.90 1,372.90 1,345.44 50100 1,061.95 1,008.85 1,160.18 1,136.97 1,136.97 1,114.24 50120 952.66 905.03 1,040.78 1,019.97 1,019.97 999.57 50125 1,034.07 982.37 1,129.73 1,107.13 1,107.13 1,084.99 50130 1,036.40 984.58 1,132.27 1,109.62 1,109.62 1,087.43 50135 1,143.65 1,086.47 1,249.44 1,224.45 1,224.45 1,199.97 50200 583.29 554.13 637.25 624.51 624.51 612.02 # 50200 143.51 136.33 156.78 153.64 153.64 150.57 50205 759.92 721.92 830.21 813.60 813.60 797.33 50220 1,052.10 999.50 1,149.43 1,126.44 1,126.44 1,103.91 50225 1,209.99 1,149.49 1,321.91 1,295.48 1,295.48 1,269.57 50230 1,289.00 1,224.55 1,408.23 1,380.07 1,380.07 1,352.47 50234 1,307.38 1,242.01 1,428.31 1,399.75 1,399.75 1,371.75 50236 1,474.44 1,400.72 1,610.83 1,578.62 1,578.62 1,547.05 50240 1,329.82 1,263.33 1,452.83 1,423.77 1,423.77 1,395.30 50250 1,221.58 1,160.50 1,334.58 1,307.88 1,307.88 1,281.72 50280 957.31 909.44 1,045.86 1,024.94 1,024.94 1,004.44 50290 900.91 855.86 984.24 964.55 964.55 945.27 50320 1,456.77 1,383.93 1,591.52 1,559.69 1,559.69 1,528.50 50323 192.90 183.26 210.75 206.53 206.53 202.40

Page 120: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 120Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

50325 192.90 183.26 210.75 206.53 206.53 202.40 50327 221.23 210.17 241.70 236.87 236.87 232.13 50328 194.16 184.45 212.12 207.87 207.87 203.71 50329 181.53 172.45 198.32 194.35 194.35 190.46 50340 939.97 892.97 1,026.92 1,006.38 1,006.38 986.25 50360 2,445.84 2,323.55 2,672.08 2,618.64 2,618.64 2,566.27 50365 2,856.15 2,713.34 3,120.34 3,057.93 3,057.93 2,996.77 50370 1,207.98 1,147.58 1,319.72 1,293.32 1,293.32 1,267.46 50380 1,998.32 1,898.40 2,183.16 2,139.49 2,139.49 2,096.70 50382 1,128.77 1,072.33 1,233.18 1,208.51 1,208.51 1,184.34 # 50382 275.18 261.42 300.63 294.62 294.62 288.73 50384 902.37 857.25 985.84 966.13 966.13 946.81 # 50384 249.94 237.44 273.06 267.59 267.59 262.25 50385 1,082.79 1,028.65 1,182.95 1,159.29 1,159.29 1,136.11 # 50385 234.79 223.05 256.51 251.38 251.38 246.35 50386 707.14 671.78 772.55 757.09 757.09 741.95 # 50386 178.28 169.37 194.78 190.88 190.88 187.06 50387 516.12 490.31 563.86 552.58 552.58 541.52 # 50387 99.02 94.07 108.18 106.02 106.02 103.90 50389 281.24 267.18 307.26 301.12 301.12 295.09 # 50389 55.10 52.35 60.20 59.00 59.00 57.81 50390 98.24 93.33 107.33 105.18 105.18 103.07 50391 120.67 114.64 131.84 129.20 129.20 126.62 # 50391 98.98 94.03 108.13 105.97 105.97 103.86 50395 180.68 171.65 197.40 193.45 193.45 189.59 50396 118.70 112.77 129.69 127.09 127.09 124.55 50400 1,164.25 1,106.04 1,271.95 1,246.51 1,246.51 1,221.58 50405 1,404.42 1,334.20 1,534.33 1,503.65 1,503.65 1,473.58 50430 497.11 472.25 543.09 532.23 532.23 521.58 # 50430 169.08 160.63 184.72 181.03 181.03 177.41 50431 155.02 147.27 169.36 165.97 165.97 162.64 # 50431 66.61 63.28 72.77 71.31 71.31 69.89 50432 803.30 763.14 877.61 860.06 860.06 842.86 # 50432 223.83 212.64 244.54 239.65 239.65 234.85 50433 1,079.79 1,025.80 1,179.67 1,156.07 1,156.07 1,132.95 # 50433 276.15 262.34 301.69 295.65 295.65 289.74 50434 853.81 811.12 932.79 914.14 914.14 895.85 # 50434 211.56 200.98 231.13 226.50 226.50 221.97 50435 447.19 424.83 488.55 478.78 478.78 469.20 # 50435 102.41 97.29 111.88 109.64 109.64 107.44 50500 1,287.67 1,223.29 1,406.78 1,378.64 1,378.64 1,351.07 50520 1,137.44 1,080.57 1,242.66 1,217.80 1,217.80 1,193.45 50525 1,438.06 1,366.16 1,571.08 1,539.67 1,539.67 1,508.87 50526 1,491.71 1,417.12 1,629.69 1,597.10 1,597.10 1,565.15 50540 1,158.34 1,100.42 1,265.48 1,240.17 1,240.17 1,215.37 50541 923.70 877.52 1,009.15 988.97 988.97 969.19 50542 1,171.92 1,113.32 1,280.32 1,254.71 1,254.71 1,229.61 50543 1,494.14 1,419.43 1,632.34 1,599.70 1,599.70 1,567.70 50544 1,252.26 1,189.65 1,368.10 1,340.74 1,340.74 1,313.92

Page 121: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 121Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

50545 1,347.95 1,280.55 1,472.63 1,443.18 1,443.18 1,414.32 50546 1,208.93 1,148.48 1,320.75 1,294.34 1,294.34 1,268.45 50547 1,622.53 1,541.40 1,772.61 1,737.16 1,737.16 1,702.41 50548 1,356.14 1,288.33 1,481.58 1,451.94 1,451.94 1,422.91 50551 356.62 338.79 389.61 381.81 381.81 374.18 # 50551 297.13 282.27 324.61 318.11 318.11 311.75 50553 378.86 359.92 413.91 405.63 405.63 397.52 # 50553 314.10 298.40 343.16 336.29 336.29 329.57 50555 407.61 387.23 445.31 436.41 436.41 427.69 # 50555 343.19 326.03 374.93 367.44 367.44 360.09 50557 416.14 395.33 454.63 445.53 445.53 436.62 # 50557 349.42 331.95 381.74 374.11 374.11 366.62 50561 472.53 448.90 516.24 505.91 505.91 495.79 # 50561 398.91 378.96 435.80 427.09 427.09 418.54 50562 585.14 555.88 639.26 626.47 626.47 613.94 50570 496.57 471.74 542.50 531.66 531.66 521.02 50572 537.29 510.43 586.99 575.25 575.25 563.75 50574 571.33 542.76 624.17 611.69 611.69 599.45 50575 721.91 685.81 788.68 772.90 772.90 757.45 50576 570.99 542.44 623.81 611.33 611.33 599.10 50580 615.20 584.44 672.11 658.66 658.66 645.50 50590 706.40 671.08 771.74 756.31 756.31 741.19 # 50590 568.02 539.62 620.56 608.15 608.15 595.99 50592 2,398.97 2,279.02 2,620.87 2,568.46 2,568.46 2,517.09 # 50592 365.41 347.14 399.21 391.23 391.23 383.41 50593 4,362.70 4,144.57 4,766.26 4,670.93 4,670.93 4,577.52 # 50593 484.89 460.65 529.75 519.16 519.16 508.77 50600 947.82 900.43 1,035.49 1,014.78 1,014.78 994.49 50605 991.30 941.74 1,083.00 1,061.35 1,061.35 1,040.12 50606 503.90 478.71 550.52 539.51 539.51 528.72 # 50606 160.10 152.10 174.92 171.42 171.42 167.99 50610 980.97 931.92 1,071.71 1,050.27 1,050.27 1,029.26 50620 910.90 865.36 995.16 975.26 975.26 955.75 50630 894.62 849.89 977.37 957.82 957.82 938.66 50650 1,039.90 987.91 1,136.10 1,113.37 1,113.37 1,091.11 50660 1,154.73 1,096.99 1,261.54 1,236.31 1,236.31 1,211.58 50684 101.71 96.62 111.11 108.89 108.89 106.72 # 50684 50.11 47.60 54.74 53.65 53.65 52.58 50686 138.99 132.04 151.85 148.81 148.81 145.83 # 50686 88.38 83.96 96.55 94.62 94.62 92.72 50688 79.42 75.45 86.77 85.03 85.03 83.33 50690 96.06 91.26 104.95 102.84 102.84 100.79 # 50690 70.42 66.90 76.94 75.39 75.39 73.89 50693 1,002.69 952.56 1,095.44 1,073.54 1,073.54 1,052.07 # 50693 221.41 210.34 241.89 237.05 237.05 232.31 50694 1,107.05 1,051.70 1,209.46 1,185.27 1,185.27 1,161.57 # 50694 286.33 272.01 312.81 306.56 306.56 300.43 50695 1,350.90 1,283.36 1,475.86 1,446.34 1,446.34 1,417.42 # 50695 363.54 345.36 397.16 389.22 389.22 381.43

Page 122: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 122Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

50700 934.56 887.83 1,021.00 1,000.58 1,000.58 980.57 50705 1,605.89 1,525.60 1,754.44 1,719.35 1,719.35 1,684.97 # 50705 205.05 194.80 224.02 219.54 219.54 215.14 50706 726.68 690.35 793.90 778.02 778.02 762.46 # 50706 190.60 181.07 208.23 204.07 204.07 199.99 50715 1,226.29 1,164.98 1,339.73 1,312.93 1,312.93 1,286.68 50722 1,023.43 972.26 1,118.10 1,095.73 1,095.73 1,073.81 50725 1,133.93 1,077.23 1,238.81 1,214.04 1,214.04 1,189.77 50727 505.91 480.61 552.70 541.65 541.65 530.82 50728 701.43 666.36 766.31 750.98 750.98 735.97 50740 1,237.90 1,176.01 1,352.41 1,325.36 1,325.36 1,298.86 50750 1,158.55 1,100.62 1,265.71 1,240.40 1,240.40 1,215.60 50760 1,136.46 1,079.64 1,241.59 1,216.76 1,216.76 1,192.42 50770 1,157.23 1,099.37 1,264.28 1,238.99 1,238.99 1,214.20 50780 1,113.81 1,058.12 1,216.84 1,192.50 1,192.50 1,168.65 50782 1,065.71 1,012.42 1,164.28 1,141.00 1,141.00 1,118.18 50783 1,137.93 1,081.03 1,243.18 1,218.32 1,218.32 1,193.95 50785 1,219.46 1,158.49 1,332.26 1,305.62 1,305.62 1,279.50 50800 926.73 880.39 1,012.45 992.20 992.20 972.35 50810 1,266.25 1,202.94 1,383.38 1,355.71 1,355.71 1,328.60 50815 1,229.47 1,168.00 1,343.20 1,316.34 1,316.34 1,290.01 50820 1,321.51 1,255.43 1,443.74 1,414.87 1,414.87 1,386.57 50825 1,666.63 1,583.30 1,820.80 1,784.37 1,784.37 1,748.69 50830 1,822.55 1,731.42 1,991.13 1,951.31 1,951.31 1,912.28 50840 1,236.81 1,174.97 1,351.22 1,324.19 1,324.19 1,297.71 50845 1,254.02 1,191.32 1,370.02 1,342.61 1,342.61 1,315.76 50860 948.28 900.87 1,036.00 1,015.28 1,015.28 994.97 50900 863.62 820.44 943.51 924.63 924.63 906.14 50920 885.10 840.85 966.98 947.63 947.63 928.68 50930 1,186.06 1,126.76 1,295.77 1,269.85 1,269.85 1,244.46 50940 889.18 844.72 971.43 952.00 952.00 932.96 50945 977.05 928.20 1,067.43 1,046.09 1,046.09 1,025.17 50947 1,397.79 1,327.90 1,527.09 1,496.54 1,496.54 1,466.61 50948 1,284.11 1,219.90 1,402.89 1,374.83 1,374.83 1,347.33 50951 372.20 353.59 406.63 398.50 398.50 390.53 # 50951 309.42 293.95 338.04 331.28 331.28 324.66 50953 393.17 373.51 429.54 420.95 420.95 412.53 # 50953 328.09 311.69 358.44 351.28 351.28 344.25 50955 421.81 400.72 460.83 451.62 451.62 442.59 # 50955 355.74 337.95 388.64 380.87 380.87 373.26 50957 425.54 404.26 464.90 455.60 455.60 446.49 # 50957 357.83 339.94 390.93 383.11 383.11 375.45 50961 383.38 364.21 418.84 410.47 410.47 402.26 # 50961 320.28 304.27 349.91 342.91 342.91 336.05 50970 375.73 356.94 410.48 402.27 402.27 394.22 50972 365.65 347.37 399.48 391.48 391.48 383.65 50974 477.96 454.06 522.17 511.73 511.73 501.49 50976 470.24 446.73 513.74 503.47 503.47 493.40 50980 357.68 339.80 390.77 382.95 382.95 375.29

Page 123: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 123Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

51020 467.98 444.58 511.27 501.04 501.04 491.03 51030 474.44 450.72 518.33 507.97 507.97 497.81 51040 287.36 272.99 313.94 307.66 307.66 301.51 51045 490.17 465.66 535.51 524.80 524.80 514.30 51050 471.48 447.91 515.10 504.79 504.79 494.70 51060 583.01 553.86 636.94 624.20 624.20 611.71 51065 578.14 549.23 631.61 618.99 618.99 606.61 51080 408.66 388.23 446.46 437.54 437.54 428.79 51100 59.72 56.73 65.24 63.94 63.94 62.66 # 51100 39.67 37.69 43.34 42.48 42.48 41.63 51101 119.34 113.37 130.38 127.77 127.77 125.21 # 51101 52.62 49.99 57.49 56.34 56.34 55.21 51102 221.04 209.99 241.49 236.66 236.66 231.92 # 51102 145.77 138.48 159.25 156.07 156.07 152.95 51500 638.71 606.77 697.79 683.82 683.82 670.15 51520 598.31 568.39 653.65 640.57 640.57 627.76 51525 861.87 818.78 941.60 922.76 922.76 904.30 51530 798.25 758.34 872.09 854.65 854.65 837.56 51535 781.22 742.16 853.48 836.42 836.42 819.69 51550 968.40 919.98 1,057.98 1,036.82 1,036.82 1,016.08 51555 1,275.13 1,211.37 1,393.08 1,365.21 1,365.21 1,337.91 51565 1,306.59 1,241.26 1,427.45 1,398.89 1,398.89 1,370.92 51570 1,486.80 1,412.46 1,624.33 1,591.84 1,591.84 1,560.01 51575 1,834.36 1,742.64 2,004.04 1,963.96 1,963.96 1,924.67 51580 1,906.08 1,810.78 2,082.40 2,040.74 2,040.74 1,999.93 51585 2,121.82 2,015.73 2,318.09 2,271.73 2,271.73 2,226.30 51590 1,947.07 1,849.72 2,127.18 2,084.64 2,084.64 2,042.95 51595 2,203.19 2,093.03 2,406.98 2,358.85 2,358.85 2,311.67 51596 2,366.84 2,248.50 2,585.78 2,534.06 2,534.06 2,483.38 51597 2,312.54 2,196.91 2,526.45 2,475.92 2,475.92 2,426.40 51600 174.07 165.37 190.18 186.37 186.37 182.64 # 51600 44.90 42.66 49.06 48.08 48.08 47.12 51605 38.22 36.31 41.76 40.92 40.92 40.10 51610 102.94 97.79 112.46 110.20 110.20 108.00 # 51610 64.16 60.95 70.09 68.69 68.69 67.32 51700 80.42 76.40 87.86 86.10 86.10 84.38 # 51700 45.25 42.99 49.44 48.45 48.45 47.48 51701 52.58 49.95 57.44 56.29 56.29 55.17 # 51701 27.92 26.52 30.50 29.89 29.89 29.29 51702 67.04 63.69 73.24 71.78 71.78 70.35 # 51702 30.22 28.71 33.02 32.36 32.36 31.72 51703 125.70 119.42 137.33 134.58 134.58 131.89 # 51703 81.66 77.58 89.22 87.43 87.43 85.69 51705 87.71 83.32 95.82 93.90 93.90 92.02 # 51705 51.88 49.29 56.68 55.55 55.55 54.43 51710 124.34 118.12 135.84 133.12 133.12 130.46 # 51710 79.96 75.96 87.35 85.61 85.61 83.89 51715 283.90 269.71 310.17 303.97 303.97 297.88 # 51715 201.07 191.02 219.67 215.28 215.28 210.98

Page 124: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 124Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

51720 106.73 101.39 116.60 114.26 114.26 111.98 # 51720 80.43 76.41 87.87 86.11 86.11 84.39 51725 179.01 170.06 195.57 191.66 191.66 187.83 51725 TC 102.25 97.14 111.71 109.48 109.48 107.30 51725 26 76.76 72.92 83.86 82.18 82.18 80.53 51726 249.99 237.49 273.11 267.65 267.65 262.30 51726 TC 164.07 155.87 179.25 175.66 175.66 172.16 51726 26 85.92 81.62 93.86 91.99 91.99 90.15 51727 296.30 281.49 323.71 317.24 317.24 310.89 51727 TC 188.72 179.28 206.17 202.04 202.04 198.01 51727 26 107.58 102.20 117.53 115.18 115.18 112.88 51728 298.90 283.96 326.55 320.02 320.02 313.62 51728 TC 193.65 183.97 211.57 207.33 207.33 203.18 51728 26 105.26 100.00 115.00 112.70 112.70 110.45 51729 323.85 307.66 353.81 346.74 346.74 339.80 51729 TC 196.61 186.78 214.80 210.50 210.50 206.29 51729 26 127.25 120.89 139.02 136.24 136.24 133.52 51736 15.01 14.26 16.40 16.07 16.07 15.74 51736 TC 6.60 6.27 7.21 7.06 7.06 6.92 51736 26 8.41 7.99 9.19 9.00 9.00 8.82 51741 15.34 14.57 16.76 16.42 16.42 16.09 51741 TC 6.93 6.58 7.57 7.42 7.42 7.27 51741 26 8.41 7.99 9.19 9.00 9.00 8.82 51784 183.70 174.52 200.70 196.68 196.68 192.75 51784 TC 106.55 101.22 116.40 114.08 114.08 111.80 51784 26 77.15 73.29 84.28 82.59 82.59 80.94 51785 251.39 238.82 274.64 269.15 269.15 263.76 51785 TC 162.75 154.61 177.80 174.25 174.25 170.76 51785 26 88.64 84.21 96.84 94.91 94.91 93.01 51792 200.10 190.10 218.62 214.25 214.25 209.96 51792 TC 144.35 137.13 157.70 154.55 154.55 151.46 51792 26 55.76 52.97 60.92 59.70 59.70 58.50 51797 106.40 101.08 116.24 113.92 113.92 111.64 51797 TC 66.07 62.77 72.19 70.74 70.74 69.32 51797 26 40.34 38.32 44.07 43.18 43.18 42.32 51798 17.80 16.91 19.45 19.06 19.06 18.68 51800 1,044.98 992.73 1,141.64 1,118.81 1,118.81 1,096.43 51820 1,115.61 1,059.83 1,218.80 1,194.42 1,194.42 1,170.54 51840 656.52 623.69 717.24 702.90 702.90 688.85 51841 780.24 741.23 852.41 835.37 835.37 818.66 51845 586.50 557.18 640.76 627.95 627.95 615.39 51860 747.04 709.69 816.14 799.83 799.83 783.83 51865 897.95 853.05 981.01 961.39 961.39 942.16 51880 468.58 445.15 511.92 501.69 501.69 491.66 51900 837.26 795.40 914.71 896.41 896.41 878.49 51920 867.89 824.50 948.18 929.21 929.21 910.63 51925 1,095.33 1,040.56 1,196.64 1,172.71 1,172.71 1,149.26 51940 1,664.49 1,581.27 1,818.46 1,782.09 1,782.09 1,746.45 51960 1,399.06 1,329.11 1,528.48 1,497.91 1,497.91 1,467.95

Page 125: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 125Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

51980 713.78 678.09 779.80 764.21 764.21 748.93 51990 750.96 713.41 820.42 804.01 804.01 787.93 51992 842.18 800.07 920.08 901.68 901.68 883.65 52000 197.85 187.96 216.15 211.83 211.83 207.60 # 52000 126.53 120.20 138.23 135.47 135.47 132.76 52001 365.69 347.41 399.52 391.53 391.53 383.70 # 52001 289.76 275.27 316.56 310.22 310.22 304.01 52005 255.18 242.42 278.78 273.21 273.21 267.74 # 52005 133.57 126.89 145.92 143.00 143.00 140.14 52007 421.95 400.85 460.98 451.75 451.75 442.72 # 52007 166.56 158.23 181.96 178.33 178.33 174.77 52010 356.29 338.48 389.25 381.47 381.47 373.84 # 52010 167.96 159.56 183.49 179.83 179.83 176.23 52204 351.20 333.64 383.69 376.02 376.02 368.49 # 52204 142.49 135.37 155.68 152.56 152.56 149.51 52214 623.99 592.79 681.71 668.07 668.07 654.71 # 52214 178.29 169.38 194.79 190.89 190.89 187.07 52224 654.36 621.64 714.89 700.59 700.59 686.58 # 52224 206.04 195.74 225.10 220.60 220.60 216.19 52234 248.00 235.60 270.94 265.52 265.52 260.21 52235 291.07 276.52 318.00 311.64 311.64 305.41 52240 395.69 375.91 432.30 423.65 423.65 415.17 52250 241.67 229.59 264.03 258.75 258.75 253.58 52260 211.84 201.25 231.44 226.81 226.81 222.28 52265 350.06 332.56 382.44 374.80 374.80 367.30 # 52265 163.70 155.52 178.85 175.27 175.27 171.76 52270 341.84 324.75 373.46 366.00 366.00 358.67 # 52270 182.76 173.62 199.66 195.67 195.67 191.76 52275 461.52 438.44 504.21 494.12 494.12 484.24 # 52275 250.50 237.98 273.68 268.20 268.20 262.84 52276 266.94 253.59 291.63 285.80 285.80 280.08 52277 326.27 309.96 356.45 349.32 349.32 342.33 52281 262.65 249.52 286.95 281.21 281.21 275.59 # 52281 152.87 145.23 167.01 163.68 163.68 160.40 52282 339.54 322.56 370.94 363.53 363.53 356.26 52283 270.75 257.21 295.79 289.88 289.88 284.08 # 52283 202.72 192.58 221.47 217.04 217.04 212.70 52285 272.65 259.02 297.87 291.92 291.92 286.07 # 52285 197.05 187.20 215.28 210.98 210.98 206.76 52287 300.59 285.56 328.39 321.83 321.83 315.39 # 52287 170.43 161.91 186.20 182.47 182.47 178.83 52290 245.88 233.59 268.63 263.26 263.26 257.99 52300 283.05 268.90 309.24 303.05 303.05 296.99 52301 292.57 277.94 319.63 313.24 313.24 306.97 52305 281.43 267.36 307.46 301.31 301.31 295.29 52310 236.23 224.42 258.08 252.92 252.92 247.86 # 52310 152.74 145.10 166.87 163.53 163.53 160.26 52315 402.37 382.25 439.59 430.80 430.80 422.19 # 52315 276.81 262.97 302.42 296.37 296.37 290.44

Page 126: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 126Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

52317 769.14 730.68 840.28 823.48 823.48 807.01 # 52317 351.06 333.51 383.54 375.87 375.87 368.35 52318 478.70 454.77 522.99 512.52 512.52 502.27 52320 248.86 236.42 271.88 266.44 266.44 261.12 52325 324.30 308.09 354.30 347.22 347.22 340.27 52327 264.92 251.67 289.42 283.64 283.64 277.97 52330 476.10 452.30 520.15 509.74 509.74 499.55 # 52330 266.07 252.77 290.69 284.87 284.87 279.17 52332 463.05 439.90 505.89 495.77 495.77 485.85 # 52332 156.39 148.57 170.86 167.44 167.44 164.09 52334 258.50 245.58 282.42 276.77 276.77 271.24 52341 286.51 272.18 313.01 306.75 306.75 300.62 52342 311.78 296.19 340.62 333.81 333.81 327.13 52343 347.24 329.88 379.36 371.77 371.77 364.33 52344 373.22 354.56 407.74 399.59 399.59 391.60 52345 398.49 378.57 435.36 426.65 426.65 418.12 52346 450.43 427.91 492.10 482.25 482.25 472.60 52351 305.54 290.26 333.80 327.12 327.12 320.57 52352 357.42 339.55 390.48 382.67 382.67 375.02 52353 395.69 375.91 432.30 423.65 423.65 415.17 52354 420.96 399.91 459.90 450.70 450.70 441.68 52355 471.85 448.26 515.50 505.18 505.18 495.08 52356 419.97 398.97 458.82 449.64 449.64 440.65 52400 480.06 456.06 524.47 513.98 513.98 503.70 52402 269.81 256.32 294.77 288.87 288.87 283.10 52441 1,169.68 1,111.20 1,277.88 1,252.33 1,252.33 1,227.28 # 52441 230.96 219.41 252.32 247.27 247.27 242.33 52442 887.07 842.72 969.13 949.75 949.75 930.75 # 52442 61.42 58.35 67.10 65.76 65.76 64.45 52450 468.90 445.46 512.28 502.03 502.03 491.99 52500 487.16 462.80 532.22 521.57 521.57 511.14 52601 848.42 806.00 926.90 908.36 908.36 890.19 52630 398.52 378.59 435.38 426.67 426.67 418.14 52640 312.62 296.99 341.54 334.71 334.71 328.01 52647 1,690.82 1,606.28 1,847.22 1,810.27 1,810.27 1,774.07 # 52647 647.91 615.51 707.84 693.68 693.68 679.81 52648 1,742.56 1,655.43 1,903.74 1,865.67 1,865.67 1,828.35 # 52648 691.43 656.86 755.39 740.28 740.28 725.48 52649 824.43 783.21 900.69 882.68 882.68 865.03 52700 440.33 418.31 481.06 471.43 471.43 462.00 53000 147.23 139.87 160.85 157.63 157.63 154.48 53010 293.13 278.47 320.24 313.84 313.84 307.56 53020 97.44 92.57 106.46 104.33 104.33 102.25 53025 71.76 68.17 78.40 76.83 76.83 75.29 53040 391.26 371.70 427.46 418.91 418.91 410.53 53060 180.60 171.57 197.31 193.36 193.36 189.50 # 53060 163.51 155.33 178.63 175.05 175.05 171.56 53080 418.78 397.84 457.52 448.36 448.36 439.39 53085 667.64 634.26 729.40 714.81 714.81 700.51

Page 127: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 127Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

53200 155.36 147.59 169.73 166.34 166.34 163.01 # 53200 142.87 135.73 156.09 152.97 152.97 149.91 53210 771.77 733.18 843.16 826.30 826.30 809.77 53215 932.87 886.23 1,019.16 998.79 998.79 978.81 53220 454.41 431.69 496.44 486.52 486.52 476.79 53230 605.37 575.10 661.37 648.14 648.14 635.18 53235 632.76 601.12 691.29 677.47 677.47 663.92 53240 426.69 405.36 466.16 456.84 456.84 447.71 53250 412.00 391.40 450.11 441.11 441.11 432.29 53260 199.18 189.22 217.60 213.26 213.26 208.99 # 53260 180.12 171.11 196.78 192.84 192.84 188.99 53265 214.71 203.97 234.57 229.87 229.87 225.27 # 53265 185.79 176.50 202.98 198.92 198.92 194.94 53270 205.83 195.54 224.87 220.37 220.37 215.97 # 53270 185.78 176.49 202.96 198.90 198.90 194.93 53275 262.61 249.48 286.90 281.16 281.16 275.54 53400 802.77 762.63 877.02 859.49 859.49 842.29 53405 875.64 831.86 956.64 937.50 937.50 918.76 53410 981.13 932.07 1,071.88 1,050.44 1,050.44 1,029.43 53415 1,134.90 1,078.16 1,239.88 1,215.09 1,215.09 1,190.79 53420 855.77 812.98 934.93 916.23 916.23 897.91 53425 940.03 893.03 1,026.98 1,006.45 1,006.45 986.32 53430 966.67 918.34 1,056.09 1,034.97 1,034.97 1,014.27 53431 1,162.98 1,104.83 1,270.55 1,245.14 1,245.14 1,220.24 53440 753.81 716.12 823.54 807.07 807.07 790.92 53442 782.51 743.38 854.89 837.79 837.79 821.03 53444 794.26 754.55 867.73 850.38 850.38 833.37 53445 752.67 715.04 822.30 805.85 805.85 789.74 53446 642.11 610.00 701.50 687.47 687.47 673.72 53447 809.40 768.93 884.27 866.58 866.58 849.25 53448 1,291.35 1,226.78 1,410.80 1,382.58 1,382.58 1,354.93 53449 611.34 580.77 667.89 654.52 654.52 641.44 53450 408.15 387.74 445.90 436.99 436.99 428.25 53460 456.95 434.10 499.22 489.23 489.23 479.45 53500 748.54 711.11 817.78 801.42 801.42 785.39 53502 485.89 461.60 530.84 520.23 520.23 509.82 53505 487.26 462.90 532.34 521.69 521.69 511.26 53510 631.71 600.12 690.14 676.34 676.34 662.81 53515 797.03 757.18 870.76 853.35 853.35 836.28 53520 555.89 528.10 607.32 595.17 595.17 583.27 53600 81.80 77.71 89.37 87.58 87.58 85.84 # 53600 64.05 60.85 69.98 68.57 68.57 67.21 53601 78.77 74.83 86.05 84.33 84.33 82.64 # 53601 53.79 51.10 58.77 57.59 57.59 56.44 53605 65.30 62.04 71.35 69.92 69.92 68.52 53620 113.71 108.02 124.22 121.74 121.74 119.30 # 53620 87.74 83.35 95.85 93.93 93.93 92.06 53621 106.59 101.26 116.45 114.11 114.11 111.84 # 53621 72.73 69.09 79.45 77.87 77.87 76.31

Page 128: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 128Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

53660 68.04 64.64 74.34 72.85 72.85 71.39 # 53660 41.74 39.65 45.60 44.69 44.69 43.79 53661 66.75 63.41 72.92 71.46 71.46 70.04 # 53661 40.46 38.44 44.21 43.32 43.32 42.46 53665 38.96 37.01 42.56 41.71 41.71 40.87 53850 1,957.07 1,859.22 2,138.10 2,095.35 2,095.35 2,053.44 # 53850 605.52 575.24 661.53 648.30 648.30 635.34 53852 1,808.95 1,718.50 1,976.28 1,936.75 1,936.75 1,898.02 # 53852 622.73 591.59 680.33 666.72 666.72 653.38 53855 724.79 688.55 791.83 776.00 776.00 760.47 # 53855 83.52 79.34 91.24 89.41 89.41 87.63 53860 1,447.24 1,374.88 1,581.11 1,549.49 1,549.49 1,518.49 # 53860 226.84 215.50 247.83 242.87 242.87 238.02 54000 143.53 136.35 156.80 153.66 153.66 150.59 # 54000 107.04 101.69 116.94 114.61 114.61 112.32 54001 179.81 170.82 196.44 192.51 192.51 188.66 # 54001 137.74 130.85 150.48 147.46 147.46 144.52 54015 310.31 294.79 339.01 332.22 332.22 325.58 54050 127.50 121.13 139.30 136.52 136.52 133.79 # 54050 103.18 98.02 112.72 110.47 110.47 108.26 54055 114.87 109.13 125.50 122.99 122.99 120.53 # 54055 91.20 86.64 99.64 97.65 97.65 95.69 54056 137.06 130.21 149.74 146.75 146.75 143.82 # 54056 108.79 103.35 118.85 116.47 116.47 114.14 54057 130.73 124.19 142.82 139.97 139.97 137.17 # 54057 93.59 88.91 102.25 100.20 100.20 98.20 54060 174.06 165.36 190.16 186.36 186.36 182.63 # 54060 129.36 122.89 141.32 138.49 138.49 135.72 54065 212.91 202.26 232.60 227.94 227.94 223.39 # 54065 171.49 162.92 187.36 183.61 183.61 179.94 54100 191.65 182.07 209.38 205.19 205.19 201.09 # 54100 125.26 119.00 136.85 134.11 134.11 131.43 54105 258.97 246.02 282.92 277.27 277.27 271.72 # 54105 212.62 201.99 232.29 227.64 227.64 223.09 54110 632.44 600.82 690.94 677.12 677.12 663.57 54111 802.60 762.47 876.84 859.30 859.30 842.12 54112 942.84 895.70 1,030.06 1,009.46 1,009.46 989.26 54115 448.17 425.76 489.62 479.83 479.83 470.24 # 54115 423.52 402.34 462.69 453.43 453.43 444.36 54120 632.19 600.58 690.67 676.86 676.86 663.32 54125 814.41 773.69 889.74 871.95 871.95 854.52 54130 1,195.54 1,135.76 1,306.12 1,280.00 1,280.00 1,254.40 54135 1,508.17 1,432.76 1,647.67 1,614.72 1,614.72 1,582.42 54150 150.16 142.65 164.05 160.77 160.77 157.55 # 54150 98.56 93.63 107.67 105.52 105.52 103.41 54160 216.62 205.79 236.66 231.92 231.92 227.29 # 54160 145.95 138.65 159.45 156.26 156.26 153.13 54161 196.47 186.65 214.65 210.36 210.36 206.15 54162 251.69 239.11 274.98 269.48 269.48 264.09

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 129Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 54162 198.77 188.83 217.15 212.81 212.81 208.55 54163 217.18 206.32 237.27 232.52 232.52 227.87 54164 191.23 181.67 208.92 204.75 204.75 200.65 54200 103.50 98.33 113.08 110.81 110.81 108.59 # 54200 82.47 78.35 90.10 88.30 88.30 86.53 54205 531.58 505.00 580.75 569.14 569.14 557.75 54220 198.88 188.94 217.28 212.93 212.93 208.68 # 54220 134.78 128.04 147.25 144.30 144.30 141.42 54230 95.05 90.30 103.85 101.76 101.76 99.73 # 54230 79.61 75.63 86.97 85.24 85.24 83.54 54231 138.08 131.18 150.86 147.84 147.84 144.89 # 54231 116.39 110.57 127.16 124.61 124.61 122.12 54235 88.31 83.89 96.47 94.54 94.54 92.66 # 54235 73.20 69.54 79.97 78.37 78.37 76.81 54240 99.98 94.98 109.23 107.04 107.04 104.90 54240 TC 32.57 30.94 35.58 34.87 34.87 34.17 54240 26 67.41 64.04 73.65 72.17 72.17 70.73 54250 120.75 114.71 131.92 129.28 129.28 126.70 54250 TC 10.22 9.71 11.17 10.95 10.95 10.73 54250 26 110.54 105.01 120.76 118.35 118.35 115.98 54300 641.32 609.25 700.64 686.63 686.63 672.90 54304 751.28 713.72 820.78 804.37 804.37 788.28 54308 716.26 680.45 782.52 766.87 766.87 751.53 54312 860.42 817.40 940.01 921.21 921.21 902.78 54316 1,050.28 997.77 1,147.44 1,124.48 1,124.48 1,101.99 54318 747.40 710.03 816.53 800.20 800.20 784.20 54322 770.62 732.09 841.90 825.07 825.07 808.57 54324 999.70 949.72 1,092.18 1,070.34 1,070.34 1,048.94 54326 948.41 900.99 1,036.14 1,015.42 1,015.42 995.11 54328 942.41 895.29 1,029.58 1,008.99 1,008.99 988.80 54332 1,071.27 1,017.71 1,170.37 1,146.96 1,146.96 1,124.02 54336 1,252.38 1,189.76 1,368.22 1,340.85 1,340.85 1,314.04 54340 569.46 540.99 622.14 609.70 609.70 597.51 54344 1,042.95 990.80 1,139.42 1,116.63 1,116.63 1,094.29 54348 1,017.05 966.20 1,111.13 1,088.91 1,088.91 1,067.13 54352 1,423.26 1,352.10 1,554.92 1,523.82 1,523.82 1,493.34 54360 721.71 685.62 788.46 772.70 772.70 757.24 54380 800.86 760.82 874.94 857.44 857.44 840.29 54385 976.34 927.52 1,066.65 1,045.32 1,045.32 1,024.41 54390 1,306.45 1,241.13 1,427.30 1,398.76 1,398.76 1,370.78 54400 529.94 503.44 578.96 567.38 567.38 556.03 54401 653.39 620.72 713.83 699.56 699.56 685.56 54405 810.49 769.97 885.47 867.76 867.76 850.40 54406 731.62 695.04 799.30 783.31 783.31 767.65 54408 791.11 751.55 864.28 847.00 847.00 830.06 54410 860.63 817.60 940.24 921.44 921.44 903.01 54411 1,027.63 976.25 1,122.69 1,100.24 1,100.24 1,078.24 54415 527.37 501.00 576.15 564.63 564.63 553.33 54416 709.25 673.79 774.86 759.36 759.36 744.17

Page 130: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 130Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

54417 900.35 855.33 983.63 963.95 963.95 944.68 54420 705.67 670.39 770.95 755.53 755.53 740.42 54430 640.22 608.21 699.44 685.46 685.46 671.75 54435 414.46 393.74 452.80 443.75 443.75 434.87 54437 681.17 647.11 744.18 729.30 729.30 714.71 54438 1,378.24 1,309.33 1,505.73 1,475.61 1,475.61 1,446.10 54450 69.37 65.90 75.79 74.27 74.27 72.78 # 54450 58.20 55.29 63.58 62.31 62.31 61.07 54500 74.56 70.83 81.45 79.82 79.82 78.22 54505 209.85 199.36 229.26 224.68 224.68 220.18 54512 540.11 513.10 590.07 578.27 578.27 566.70 54520 325.31 309.04 355.40 348.29 348.29 341.32 54522 620.65 589.62 678.06 664.50 664.50 651.21 54530 504.72 479.48 551.40 540.37 540.37 529.56 54535 745.02 707.77 813.94 797.65 797.65 781.70 54550 493.37 468.70 539.01 528.23 528.23 517.66 54560 687.97 653.57 751.61 736.58 736.58 721.84 54600 454.99 432.24 497.08 487.14 487.14 477.40 54620 301.85 286.76 329.77 323.17 323.17 316.71 54640 478.25 454.34 522.49 512.04 512.04 501.80 54650 710.13 674.62 775.81 760.30 760.30 745.10 54660 355.80 338.01 388.71 380.94 380.94 373.32 54670 403.39 383.22 440.70 431.89 431.89 423.26 54680 793.57 753.89 866.97 849.63 849.63 832.63 54690 742.46 705.34 811.14 794.91 794.91 779.02 54692 859.87 816.88 939.41 920.62 920.62 902.21 54700 213.87 203.18 233.66 228.99 228.99 224.41 54800 128.19 121.78 140.05 137.24 137.24 134.49 54830 371.54 352.96 405.90 397.79 397.79 389.83 54840 320.46 304.44 350.11 343.10 343.10 336.24 54860 417.91 397.01 456.56 447.43 447.43 438.48 54861 566.15 537.84 618.52 606.14 606.14 594.02 54865 357.20 339.34 390.24 382.43 382.43 374.79 54900 841.99 799.89 919.87 901.47 901.47 883.44 54901 1,111.59 1,056.01 1,214.41 1,190.12 1,190.12 1,166.32 55000 114.44 108.72 125.03 122.53 122.53 120.08 # 55000 85.18 80.92 93.06 91.20 91.20 89.37 55040 337.25 320.39 368.45 361.08 361.08 353.86 55041 508.92 483.47 555.99 544.87 544.87 533.97 55060 379.60 360.62 414.71 406.42 406.42 398.29 55100 210.52 199.99 229.99 225.39 225.39 220.88 # 55100 165.16 156.90 180.44 176.82 176.82 173.28 55110 386.78 367.44 422.56 414.10 414.10 405.82 55120 355.52 337.74 388.40 380.64 380.64 373.03 55150 490.99 466.44 536.41 525.68 525.68 515.17 55175 361.17 343.11 394.58 386.69 386.69 378.96 55180 692.43 657.81 756.48 741.35 741.35 726.52 55200 421.97 400.87 461.00 451.78 451.78 442.74 # 55200 277.67 263.79 303.36 297.29 297.29 291.34

Page 131: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 131Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

55250 369.51 351.03 403.68 395.61 395.61 387.70 # 55250 225.22 213.96 246.05 241.13 241.13 236.31 55300 188.48 179.06 205.92 201.80 201.80 197.77 55400 510.32 484.80 557.52 546.37 546.37 535.44 55450 349.91 332.41 382.27 374.62 374.62 367.13 # 55450 257.22 244.36 281.01 275.39 275.39 269.88 55500 395.81 376.02 432.42 423.78 423.78 415.30 55520 453.50 430.83 495.45 485.54 485.54 475.84 55530 350.65 333.12 383.09 375.43 375.43 367.92 55535 429.51 408.03 469.23 459.85 459.85 450.65 55540 543.37 516.20 593.63 581.76 581.76 570.12 55550 428.91 407.46 468.58 459.21 459.21 450.02 55600 420.71 399.67 459.62 450.43 450.43 441.43 55605 547.28 519.92 597.91 585.95 585.95 574.23 55650 719.71 683.72 786.28 770.56 770.56 755.15 55680 354.11 336.40 386.86 379.12 379.12 371.54 55700 211.81 201.22 231.40 226.78 226.78 222.25 # 55700 140.16 133.15 153.12 150.06 150.06 147.06 55705 266.37 253.05 291.01 285.19 285.19 279.48 55706 373.02 354.37 407.53 399.37 399.37 391.38 55720 452.95 430.30 494.85 484.94 484.94 475.25 55725 592.59 562.96 647.40 634.46 634.46 621.77 55801 1,104.50 1,049.28 1,206.67 1,182.53 1,182.53 1,158.88 55810 1,326.48 1,260.16 1,449.18 1,420.20 1,420.20 1,391.80 55812 1,617.84 1,536.95 1,767.49 1,732.14 1,732.14 1,697.50 55815 1,781.36 1,692.29 1,946.13 1,907.21 1,907.21 1,869.06 55821 876.68 832.85 957.78 938.62 938.62 919.85 55831 948.99 901.54 1,036.77 1,016.04 1,016.04 995.72 55840 1,176.85 1,118.01 1,285.71 1,260.00 1,260.00 1,234.80 55842 1,176.14 1,117.33 1,284.93 1,259.23 1,259.23 1,234.04 55845 1,371.28 1,302.72 1,498.13 1,468.17 1,468.17 1,438.81 55860 878.55 834.62 959.81 940.62 940.62 921.81 55862 1,154.79 1,097.05 1,261.61 1,236.38 1,236.38 1,211.65 55865 1,340.30 1,273.29 1,464.28 1,434.99 1,434.99 1,406.29 55866 1,393.67 1,323.99 1,522.59 1,492.14 1,492.14 1,462.29 55870 173.02 164.37 189.03 185.24 185.24 181.54 # 55870 143.11 135.95 156.34 153.21 153.21 150.16 55873 6,635.95 6,304.15 7,249.77 7,104.78 7,104.78 6,962.69 # 55873 769.60 731.12 840.79 823.98 823.98 807.50 55875 763.83 725.64 834.49 817.80 817.80 801.45 55876 132.43 125.81 144.68 141.78 141.78 138.94 # 55876 100.55 95.52 109.85 107.65 107.65 105.50 55920 450.22 427.71 491.87 482.03 482.03 472.40 56405 106.45 101.13 116.30 113.98 113.98 111.70 # 56405 105.79 100.50 115.58 113.26 113.26 111.00 56420 117.78 111.89 128.67 126.10 126.10 123.58 # 56420 89.84 85.35 98.15 96.19 96.19 94.27 56440 179.38 170.41 195.97 192.05 192.05 188.21 56441 140.68 133.65 153.70 150.63 150.63 147.61

Page 132: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 132Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 56441 135.75 128.96 148.30 145.34 145.34 142.43 56442 46.91 44.56 51.24 50.22 50.22 49.22 56501 126.79 120.45 138.52 135.75 135.75 133.03 # 56501 112.33 106.71 122.72 120.27 120.27 117.86 56515 221.24 210.18 241.71 236.88 236.88 232.14 # 56515 198.56 188.63 216.92 212.59 212.59 208.33 56605 80.19 76.18 87.61 85.86 85.86 84.15 # 56605 60.14 57.13 65.70 64.39 64.39 63.10 56606 37.00 35.15 40.42 39.62 39.62 38.82 # 56606 29.77 28.28 32.52 31.87 31.87 31.23 56620 514.57 488.84 562.17 550.92 550.92 539.90 56625 625.13 593.87 682.95 669.29 669.29 655.90 56630 926.62 880.29 1,012.33 992.08 992.08 972.24 56631 1,184.81 1,125.57 1,294.41 1,268.52 1,268.52 1,243.15 56632 1,374.32 1,305.60 1,501.44 1,471.41 1,471.41 1,441.99 56633 1,214.21 1,153.50 1,326.53 1,299.99 1,299.99 1,273.99 56634 1,312.01 1,246.41 1,433.37 1,404.70 1,404.70 1,376.61 56637 1,512.40 1,436.78 1,652.30 1,619.25 1,619.25 1,586.86 56640 1,524.00 1,447.80 1,664.97 1,631.67 1,631.67 1,599.03 56700 182.77 173.63 199.67 195.68 195.68 191.77 56740 297.59 282.71 325.12 318.62 318.62 312.25 56800 237.70 225.82 259.69 254.50 254.50 249.40 56805 1,153.90 1,096.21 1,260.64 1,235.43 1,235.43 1,210.72 56810 256.94 244.09 280.70 275.09 275.09 269.59 56820 109.90 104.41 120.07 117.67 117.67 115.31 # 56820 86.56 82.23 94.56 92.68 92.68 90.83 56821 144.87 137.63 158.27 155.11 155.11 152.01 # 56821 115.29 109.53 125.96 123.44 123.44 120.97 57000 185.32 176.05 202.46 198.41 198.41 194.44 57010 426.26 404.95 465.69 456.38 456.38 447.25 57020 91.33 86.76 99.77 97.77 97.77 95.82 # 57020 80.48 76.46 87.93 86.17 86.17 84.44 57022 167.35 158.98 182.83 179.17 179.17 175.58 57023 305.76 290.47 334.04 327.36 327.36 320.82 57061 110.11 104.60 120.29 117.89 117.89 115.53 # 57061 95.98 91.18 104.86 102.76 102.76 100.71 57065 190.67 181.14 208.31 204.15 204.15 200.07 # 57065 172.27 163.66 188.21 184.45 184.45 180.76 57100 87.16 82.80 95.22 93.31 93.31 91.45 # 57100 66.79 63.45 72.97 71.51 71.51 70.08 57105 133.01 126.36 145.31 142.40 142.40 139.55 # 57105 123.80 117.61 135.25 132.55 132.55 129.89 57106 488.82 464.38 534.04 523.35 523.35 512.89 57107 1,452.96 1,380.31 1,587.36 1,555.61 1,555.61 1,524.50 57109 1,739.56 1,652.58 1,900.47 1,862.46 1,862.46 1,825.21 57110 882.97 838.82 964.64 945.35 945.35 926.44 57111 1,597.92 1,518.02 1,745.72 1,710.81 1,710.81 1,676.60 57112 1,857.36 1,764.49 2,029.16 1,988.58 1,988.58 1,948.81 57120 501.59 476.51 547.99 537.03 537.03 526.29

Page 133: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 133Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

57130 172.34 163.72 188.28 184.52 184.52 180.83 # 57130 155.91 148.11 170.33 166.92 166.92 163.59 57135 187.70 178.32 205.07 200.96 200.96 196.95 # 57135 170.61 162.08 186.39 182.67 182.67 179.01 57150 43.52 41.34 47.54 46.59 46.59 45.66 # 57150 28.73 27.29 31.38 30.75 30.75 30.14 57155 419.78 398.79 458.61 449.43 449.43 440.44 # 57155 290.61 276.08 317.49 311.14 311.14 304.92 57156 193.15 183.49 211.01 206.79 206.79 202.65 # 57156 146.15 138.84 159.67 156.47 156.47 153.34 57160 73.55 69.87 80.35 78.74 78.74 77.17 # 57160 46.60 44.27 50.91 49.89 49.89 48.89 57170 59.50 56.53 65.01 63.71 63.71 62.43 # 57170 48.33 45.91 52.80 51.74 51.74 50.70 57180 135.81 129.02 148.37 145.41 145.41 142.50 # 57180 103.60 98.42 113.18 110.92 110.92 108.70 57200 297.03 282.18 324.51 318.02 318.02 311.66 57210 361.21 343.15 394.62 386.73 386.73 378.99 57220 312.93 297.28 341.87 335.03 335.03 328.33 57230 388.33 368.91 424.25 415.76 415.76 407.45 57240 663.53 630.35 724.90 710.40 710.40 696.20 57250 667.20 633.84 728.92 714.33 714.33 700.05 57260 823.04 781.89 899.17 881.19 881.19 863.57 57265 901.52 856.44 984.91 965.21 965.21 945.90 57267 255.47 242.70 279.11 273.53 273.53 268.05 57268 476.09 452.29 520.13 509.73 509.73 499.54 57270 791.74 752.15 864.97 847.68 847.68 830.73 57280 944.31 897.09 1,031.65 1,011.02 1,011.02 990.81 57282 492.65 468.02 538.22 527.46 527.46 516.91 57283 679.94 645.94 742.83 727.97 727.97 713.41 57284 807.51 767.13 882.20 864.56 864.56 847.26 57285 664.84 631.60 726.34 711.82 711.82 697.58 57287 671.85 638.26 734.00 719.31 719.31 704.93 57288 707.91 672.51 773.39 757.92 757.92 742.76 57289 728.92 692.47 796.34 780.41 780.41 764.81 57291 602.54 572.41 658.27 645.10 645.10 632.20 57292 812.95 772.30 888.15 870.38 870.38 852.97 57295 470.80 447.26 514.35 504.06 504.06 493.97 57296 937.52 890.64 1,024.24 1,003.75 1,003.75 983.68 57300 556.62 528.79 608.11 595.94 595.94 584.03 57305 932.79 886.15 1,019.07 998.69 998.69 978.72 57307 1,080.42 1,026.40 1,180.36 1,156.75 1,156.75 1,133.61 57308 652.14 619.53 712.46 698.21 698.21 684.25 57310 458.93 435.98 501.38 491.35 491.35 481.52 57311 525.24 498.98 573.83 562.35 562.35 551.10 57320 530.54 504.01 579.61 568.02 568.02 556.66 57330 739.46 702.49 807.86 791.71 791.71 775.87 57335 1,126.88 1,070.54 1,231.12 1,206.50 1,206.50 1,182.37 57400 133.79 127.10 146.17 143.24 143.24 140.38

Page 134: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 134Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

57410 106.69 101.36 116.56 114.23 114.23 111.94 57415 157.67 149.79 172.26 168.81 168.81 165.43 57420 115.15 109.39 125.80 123.28 123.28 120.82 # 57420 91.48 86.91 99.95 97.95 97.95 95.99 57421 154.62 146.89 168.92 165.54 165.54 162.23 # 57421 124.38 118.16 135.88 133.17 133.17 130.50 57423 902.72 857.58 986.22 966.49 966.49 947.16 57425 959.69 911.71 1,048.47 1,027.50 1,027.50 1,006.95 57426 833.12 791.46 910.18 891.97 891.97 874.14 57452 106.50 101.18 116.36 114.03 114.03 111.76 # 57452 91.38 86.81 99.83 97.83 97.83 95.88 57454 149.91 142.41 163.77 160.49 160.49 157.29 # 57454 134.46 127.74 146.90 143.97 143.97 141.09 57455 139.30 132.34 152.19 149.14 149.14 146.17 # 57455 110.05 104.55 120.23 117.83 117.83 115.47 57456 131.28 124.72 143.43 140.56 140.56 137.76 # 57456 102.35 97.23 111.81 109.58 109.58 107.39 57460 271.87 258.28 297.02 291.08 291.08 285.26 # 57460 161.43 153.36 176.36 172.83 172.83 169.37 57461 308.03 292.63 336.52 329.80 329.80 323.20 # 57461 186.74 177.40 204.01 199.93 199.93 195.93 57500 122.58 116.45 133.92 131.24 131.24 128.62 # 57500 74.92 71.17 81.85 80.21 80.21 78.61 57505 98.91 93.96 108.05 105.89 105.89 103.78 # 57505 90.04 85.54 98.37 96.40 96.40 94.47 57510 128.14 121.73 139.99 137.20 137.20 134.45 # 57510 114.00 108.30 124.55 122.05 122.05 119.61 57511 141.10 134.05 154.16 151.08 151.08 148.05 # 57511 129.27 122.81 141.23 138.40 138.40 135.63 57513 141.57 134.49 154.66 151.57 151.57 148.53 # 57513 131.71 125.12 143.89 141.01 141.01 138.20 57520 299.93 284.93 327.67 321.11 321.11 314.70 # 57520 271.01 257.46 296.08 290.16 290.16 284.35 57522 256.91 244.06 280.67 275.06 275.06 269.56 # 57522 239.16 227.20 261.28 256.06 256.06 250.94 57530 341.87 324.78 373.50 366.02 366.02 358.70 57531 1,832.00 1,740.40 2,001.46 1,961.43 1,961.43 1,922.20 57540 773.37 734.70 844.91 828.01 828.01 811.45 57545 837.27 795.41 914.72 896.43 896.43 878.50 57550 399.22 379.26 436.15 427.42 427.42 418.88 57555 590.43 560.91 645.05 632.14 632.14 619.51 57556 559.01 531.06 610.72 598.51 598.51 586.53 57558 121.28 115.22 132.50 129.86 129.86 127.26 # 57558 111.09 105.54 121.37 118.94 118.94 116.56 57700 311.02 295.47 339.79 332.99 332.99 326.34 57720 300.61 285.58 328.42 321.85 321.85 315.41 57800 58.73 55.79 64.16 62.87 62.87 61.62 # 57800 47.89 45.50 52.33 51.28 51.28 50.26 58100 106.57 101.24 116.43 114.10 114.10 111.83

Page 135: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 135Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 58100 86.84 82.50 94.88 92.98 92.98 91.11 58110 47.20 44.84 51.57 50.53 50.53 49.52 # 58110 40.63 38.60 44.39 43.50 43.50 42.63 58120 252.43 239.81 275.78 270.26 270.26 264.86 # 58120 216.27 205.46 236.28 231.55 231.55 226.92 58140 913.83 868.14 998.36 978.40 978.40 958.82 58145 541.17 514.11 591.23 579.40 579.40 567.81 58146 1,136.66 1,079.83 1,241.80 1,216.96 1,216.96 1,192.63 58150 1,006.49 956.17 1,099.60 1,077.61 1,077.61 1,056.06 58152 1,236.66 1,174.83 1,351.05 1,324.03 1,324.03 1,297.55 58180 954.44 906.72 1,042.73 1,021.88 1,021.88 1,001.44 58200 1,368.48 1,300.06 1,495.07 1,465.17 1,465.17 1,435.87 58210 1,848.56 1,756.13 2,019.55 1,979.16 1,979.16 1,939.58 58240 2,918.10 2,772.20 3,188.03 3,124.27 3,124.27 3,061.78 58260 814.90 774.16 890.28 872.48 872.48 855.04 58262 910.56 865.03 994.78 974.89 974.89 955.40 58263 976.79 927.95 1,067.14 1,045.80 1,045.80 1,024.88 58267 1,041.42 989.35 1,137.75 1,114.99 1,114.99 1,092.70 58270 870.31 826.79 950.81 931.79 931.79 913.16 58275 972.42 923.80 1,062.37 1,041.12 1,041.12 1,020.29 58280 1,035.45 983.68 1,131.23 1,108.61 1,108.61 1,086.44 58285 1,329.11 1,262.65 1,452.05 1,423.01 1,423.01 1,394.55 58290 1,137.05 1,080.20 1,242.23 1,217.39 1,217.39 1,193.04 58291 1,227.37 1,166.00 1,340.90 1,314.08 1,314.08 1,287.80 58292 1,296.37 1,231.55 1,416.28 1,387.96 1,387.96 1,360.20 58293 1,347.15 1,279.79 1,471.76 1,442.32 1,442.32 1,413.48 58294 1,205.22 1,144.96 1,316.70 1,290.37 1,290.37 1,264.56 58301 92.22 87.61 100.75 98.74 98.74 96.76 # 58301 67.24 63.88 73.46 71.99 71.99 70.55 58321 74.32 70.60 81.19 79.57 79.57 77.98 # 58321 48.68 46.25 53.19 52.13 52.13 51.08 58322 83.12 78.96 90.80 88.99 88.99 87.20 # 58322 58.14 55.23 63.51 62.25 62.25 61.01 58323 14.86 14.12 16.24 15.92 15.92 15.59 # 58323 11.90 11.31 13.01 12.74 12.74 12.49 58340 113.29 107.63 123.77 121.30 121.30 118.88 # 58340 57.41 54.54 62.72 61.47 61.47 60.24 58345 268.64 255.21 293.49 287.63 287.63 281.88 58346 441.73 419.64 482.59 472.94 472.94 463.48 58350 92.51 87.88 101.06 99.04 99.04 97.06 # 58350 76.40 72.58 83.47 81.80 81.80 80.17 58353 943.54 896.36 1,030.81 1,010.19 1,010.19 989.99 # 58353 215.51 204.73 235.44 230.74 230.74 226.12 58356 1,764.25 1,676.04 1,927.45 1,888.90 1,888.90 1,851.12 # 58356 343.02 325.87 374.75 367.25 367.25 359.90 58400 433.82 412.13 473.95 464.47 464.47 455.18 58410 808.81 768.37 883.63 865.95 865.95 848.63 58520 845.12 802.86 923.29 904.82 904.82 886.72 58540 894.47 849.75 977.21 957.67 957.67 938.52

Page 136: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 136Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

58541 707.20 671.84 772.62 757.16 757.16 742.01 58542 809.45 768.98 884.33 866.64 866.64 849.31 58543 818.59 777.66 894.31 876.43 876.43 858.90 58544 893.78 849.09 976.45 956.93 956.93 937.79 58545 894.63 849.90 977.39 957.84 957.84 938.68 58546 1,109.05 1,053.60 1,211.64 1,187.41 1,187.41 1,163.66 58548 1,904.98 1,809.73 2,081.19 2,039.57 2,039.57 1,998.78 58550 870.30 826.79 950.81 931.79 931.79 913.16 58552 978.24 929.33 1,068.73 1,047.35 1,047.35 1,026.41 58553 1,124.79 1,068.55 1,228.83 1,204.26 1,204.26 1,180.18 58554 1,317.85 1,251.96 1,439.75 1,410.96 1,410.96 1,382.74 58555 300.09 285.09 327.85 321.30 321.30 314.87 # 58555 187.35 177.98 204.68 200.58 200.58 196.57 58558 391.51 371.93 427.72 419.16 419.16 410.78 # 58558 263.99 250.79 288.41 282.64 282.64 276.98 58559 338.27 321.36 369.56 362.17 362.17 354.92 58560 381.65 362.57 416.96 408.62 408.62 400.44 58561 541.35 514.28 591.42 579.59 579.59 568.00 58562 405.79 385.50 443.33 434.46 434.46 425.76 # 58562 286.81 272.47 313.34 307.07 307.07 300.93 58563 1,565.19 1,486.93 1,709.97 1,675.77 1,675.77 1,642.26 # 58563 337.88 320.99 369.14 361.76 361.76 354.52 58565 1,751.71 1,664.12 1,913.74 1,875.47 1,875.47 1,837.95 # 58565 425.80 404.51 465.19 455.88 455.88 446.76 58570 769.47 731.00 840.65 823.84 823.84 807.36 58571 891.74 847.15 974.22 954.74 954.74 935.65 58572 1,010.36 959.84 1,103.82 1,081.74 1,081.74 1,060.10 58573 1,208.29 1,147.88 1,320.06 1,293.66 1,293.66 1,267.78 58600 357.39 339.52 390.45 382.64 382.64 374.99 58605 323.45 307.28 353.37 346.30 346.30 339.38 58611 76.70 72.87 83.80 82.12 82.12 80.48 58615 238.94 226.99 261.04 255.82 255.82 250.70 58660 667.07 633.72 728.78 714.21 714.21 699.92 58661 644.78 612.54 704.42 690.33 690.33 676.52 58662 702.10 667.00 767.05 751.71 751.71 736.68 58670 359.14 341.18 392.36 384.51 384.51 376.82 58671 358.46 340.54 391.62 383.79 383.79 376.12 58672 724.30 688.09 791.30 775.48 775.48 759.97 58673 787.54 748.16 860.38 843.18 843.18 826.32 58700 774.65 735.92 846.31 829.38 829.38 812.80 58720 731.06 694.51 798.69 782.71 782.71 767.06 58740 875.44 831.67 956.42 937.30 937.30 918.55 58750 969.23 920.77 1,058.89 1,037.70 1,037.70 1,016.95 58752 917.04 871.19 1,001.87 981.84 981.84 962.19 58760 812.10 771.50 887.23 869.48 869.48 852.09 58770 918.45 872.53 1,003.41 983.34 983.34 963.68 58800 309.84 294.35 338.50 331.73 331.73 325.09 # 58800 292.09 277.49 319.11 312.73 312.73 306.48 58805 396.22 376.41 432.87 424.21 424.21 415.73

Page 137: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 137Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

58820 305.17 289.91 333.40 326.73 326.73 320.19 58822 746.16 708.85 815.18 798.87 798.87 782.90 58825 687.30 652.94 750.88 735.86 735.86 721.14 58900 450.91 428.36 492.61 482.76 482.76 473.10 58920 759.54 721.56 829.79 813.20 813.20 796.94 58925 740.10 703.10 808.57 792.40 792.40 776.55 58940 521.05 495.00 569.25 557.87 557.87 546.71 58943 1,176.26 1,117.45 1,285.07 1,259.37 1,259.37 1,234.18 58950 1,128.74 1,072.30 1,233.15 1,208.48 1,208.48 1,184.30 58951 1,454.50 1,381.78 1,589.05 1,557.26 1,557.26 1,526.12 58952 1,645.12 1,562.86 1,797.29 1,761.34 1,761.34 1,726.12 58953 2,036.37 1,934.55 2,224.73 2,180.24 2,180.24 2,136.63 58954 2,213.70 2,103.02 2,418.47 2,370.10 2,370.10 2,322.70 58956 1,380.47 1,311.45 1,508.17 1,478.00 1,478.00 1,448.45 58957 1,590.41 1,510.89 1,737.52 1,702.77 1,702.77 1,668.72 58958 1,747.81 1,660.42 1,909.48 1,871.29 1,871.29 1,833.87 58960 972.96 924.31 1,062.96 1,041.69 1,041.69 1,020.86 58970 218.53 207.60 238.74 233.97 233.97 229.29 # 58970 198.15 188.24 216.48 212.15 212.15 207.91 58976 248.94 236.49 271.96 266.52 266.52 261.19 # 58976 217.05 206.20 237.13 232.39 232.39 227.75 59000 123.03 116.88 134.41 131.72 131.72 129.09 # 59000 81.61 77.53 89.16 87.38 87.38 85.63 59001 182.15 173.04 199.00 195.02 195.02 191.12 59012 205.76 195.47 224.79 220.29 220.29 215.89 59015 155.21 147.45 169.57 166.18 166.18 162.85 # 59015 133.52 126.84 145.87 142.95 142.95 140.08 59020 69.09 65.64 75.49 73.98 73.98 72.50 59020 TC 31.58 30.00 34.50 33.81 33.81 33.13 59020 26 37.51 35.63 40.97 40.16 40.16 39.35 59025 47.26 44.90 51.64 50.60 50.60 49.59 59025 TC 17.12 16.26 18.70 18.32 18.32 17.95 59025 26 30.15 28.64 32.94 32.28 32.28 31.64 59030 101.56 96.48 110.95 108.73 108.73 106.56 59050 51.55 48.97 56.32 55.19 55.19 54.08 59051 42.78 40.64 46.74 45.80 45.80 44.88 59070 394.63 374.90 431.14 422.51 422.51 414.06 # 59070 305.55 290.27 333.81 327.13 327.13 320.59 59072 472.22 448.61 515.90 505.59 505.59 495.48 59074 378.64 359.71 413.67 405.40 405.40 397.29 # 59074 302.71 287.57 330.71 324.09 324.09 317.61 59076 472.22 448.61 515.90 505.59 505.59 495.48 59100 797.92 758.02 871.72 854.29 854.29 837.20 59120 798.56 758.63 872.42 854.98 854.98 837.88 59121 801.22 761.16 875.33 857.83 857.83 840.67 59130 936.93 890.08 1,023.59 1,003.12 1,003.12 983.05 59135 831.96 790.36 908.91 890.73 890.73 872.92 59136 851.87 809.28 930.67 912.05 912.05 893.81 59140 398.11 378.20 434.93 426.24 426.24 417.71

Page 138: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 138Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

59150 775.61 736.83 847.35 830.40 830.40 813.80 59151 752.74 715.10 822.37 805.92 805.92 789.80 59160 202.62 192.49 221.36 216.94 216.94 212.60 # 59160 174.35 165.63 190.47 186.67 186.67 182.93 59200 70.21 66.70 76.71 75.18 75.18 73.67 # 59200 45.23 42.97 49.42 48.43 48.43 47.46 59300 191.16 181.60 208.84 204.67 204.67 200.57 # 59300 150.07 142.57 163.96 160.68 160.68 157.47 59320 153.92 146.22 168.15 164.80 164.80 161.49 59325 245.80 233.51 268.54 263.17 263.17 257.90 59350 268.99 255.54 293.87 287.99 287.99 282.23 59400 2,093.00 1,988.35 2,286.60 2,240.87 2,240.87 2,196.05 59409 825.48 784.21 901.84 883.81 883.81 866.13 59410 1,051.92 999.32 1,149.22 1,126.23 1,126.23 1,103.70 59412 104.81 99.57 114.51 112.22 112.22 109.97 59414 93.28 88.62 101.91 99.88 99.88 97.88 59425 451.43 428.86 493.19 483.32 483.32 473.65 # 59425 360.39 342.37 393.73 385.85 385.85 378.13 59426 806.43 766.11 881.03 863.41 863.41 846.14 # 59426 635.52 603.74 694.30 680.42 680.42 666.82 59430 182.66 173.53 199.56 195.57 195.57 191.66 # 59430 140.91 133.86 153.94 150.86 150.86 147.84 59510 2,324.43 2,208.21 2,539.44 2,488.66 2,488.66 2,438.89 59514 930.45 883.93 1,016.52 996.19 996.19 976.27 59515 1,277.36 1,213.49 1,395.51 1,367.60 1,367.60 1,340.26 59525 490.54 466.01 535.91 525.19 525.19 514.69 59610 2,203.78 2,093.59 2,407.63 2,359.48 2,359.48 2,312.29 59612 931.72 885.13 1,017.90 997.54 997.54 977.59 59614 1,157.59 1,099.71 1,264.67 1,239.38 1,239.38 1,214.60 59618 2,356.49 2,238.67 2,574.47 2,522.99 2,522.99 2,472.52 59620 954.38 906.66 1,042.66 1,021.81 1,021.81 1,001.37 59622 1,312.76 1,247.12 1,434.19 1,405.51 1,405.51 1,377.40 59812 316.82 300.98 346.13 339.20 339.20 332.42 # 59812 296.11 281.30 323.50 317.02 317.02 310.68 59820 375.48 356.71 410.22 402.02 402.02 393.98 # 59820 354.44 336.72 387.23 379.49 379.49 371.90 59821 379.66 360.68 414.78 406.49 406.49 398.36 # 59821 356.65 338.82 389.64 381.85 381.85 374.21 59830 437.73 415.84 478.22 468.65 468.65 459.28 59840 216.36 205.54 236.37 231.64 231.64 227.01 # 59840 208.14 197.73 227.39 222.85 222.85 218.39 59841 382.72 363.58 418.12 409.76 409.76 401.56 # 59841 363.00 344.85 396.58 388.64 388.64 380.87 59850 347.49 330.12 379.64 372.05 372.05 364.61 59851 367.60 349.22 401.60 393.58 393.58 385.71 59852 501.71 476.62 548.11 537.15 537.15 526.41 59855 417.10 396.25 455.69 446.58 446.58 437.64 59856 491.38 466.81 536.83 526.09 526.09 515.57 59857 518.30 492.39 566.25 554.92 554.92 543.82

Page 139: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 139Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

59866 217.26 206.40 237.36 232.61 232.61 227.95 59870 470.86 447.32 514.42 504.13 504.13 494.04 59871 134.58 127.85 147.03 144.08 144.08 141.20 60000 167.42 159.05 182.91 179.25 179.25 175.66 # 60000 151.32 143.75 165.31 162.01 162.01 158.77 60100 110.82 105.28 121.07 118.65 118.65 116.28 # 60100 79.92 75.92 87.31 85.56 85.56 83.85 60200 661.21 628.15 722.37 707.93 707.93 693.77 60210 711.42 675.85 777.23 761.68 761.68 746.44 60212 1,013.68 963.00 1,107.45 1,085.30 1,085.30 1,063.60 60220 710.95 675.40 776.71 761.17 761.17 745.95 60225 937.31 890.44 1,024.01 1,003.52 1,003.52 983.46 60240 926.76 880.42 1,012.48 992.23 992.23 972.38 60252 1,333.44 1,266.77 1,456.79 1,427.64 1,427.64 1,399.09 60254 1,690.48 1,605.96 1,846.85 1,809.92 1,809.92 1,773.71 60260 1,103.08 1,047.93 1,205.12 1,181.02 1,181.02 1,157.39 60270 1,381.81 1,312.72 1,509.63 1,479.44 1,479.44 1,449.85 60271 1,067.13 1,013.77 1,165.84 1,142.51 1,142.51 1,119.66 60280 441.71 419.62 482.56 472.91 472.91 463.46 60281 587.46 558.09 641.80 628.97 628.97 616.39 60300 114.24 108.53 124.81 122.31 122.31 119.86 # 60300 50.47 47.95 55.14 54.04 54.04 52.96 60500 972.19 923.58 1,062.12 1,040.88 1,040.88 1,020.06 60502 1,298.12 1,233.21 1,418.19 1,389.83 1,389.83 1,362.04 60505 1,397.53 1,327.65 1,526.80 1,496.27 1,496.27 1,466.34 60512 247.89 235.50 270.83 265.41 265.41 260.10 60520 1,053.86 1,001.17 1,151.35 1,128.32 1,128.32 1,105.76 60521 1,138.92 1,081.97 1,244.27 1,219.38 1,219.38 1,194.99 60522 1,378.64 1,309.71 1,506.17 1,476.05 1,476.05 1,446.53 60540 1,069.23 1,015.77 1,168.14 1,144.77 1,144.77 1,121.87 60545 1,227.54 1,166.16 1,341.08 1,314.27 1,314.27 1,287.98 60600 1,418.44 1,347.52 1,549.65 1,518.66 1,518.66 1,488.28 60605 1,756.64 1,668.81 1,919.13 1,880.74 1,880.74 1,843.13 60650 1,206.65 1,146.32 1,318.27 1,291.90 1,291.90 1,266.06 61000 117.18 111.32 128.02 125.45 125.45 122.95 61001 85.44 81.17 93.35 91.48 91.48 89.65 61020 102.22 97.11 111.68 109.45 109.45 107.26 61026 103.61 98.43 113.19 110.93 110.93 108.71 61050 86.05 81.75 94.01 92.14 92.14 90.30 61055 121.82 115.73 133.09 130.43 130.43 127.82 61070 57.93 55.03 63.28 62.02 62.02 60.78 61105 459.91 436.91 502.45 492.40 492.40 482.55 61107 326.35 310.03 356.53 349.40 349.40 342.41 61108 920.52 874.49 1,005.66 985.55 985.55 965.84 61120 756.91 719.06 826.92 810.38 810.38 794.18 61140 1,290.28 1,225.77 1,409.64 1,381.44 1,381.44 1,353.81 61150 1,368.67 1,300.24 1,495.28 1,465.38 1,465.38 1,436.07 61151 1,018.73 967.79 1,112.96 1,090.69 1,090.69 1,068.88 61154 1,294.17 1,229.46 1,413.88 1,385.60 1,385.60 1,357.89

Page 140: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 140Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

61156 1,272.84 1,209.20 1,390.58 1,362.77 1,362.77 1,335.52 61210 382.43 363.31 417.81 409.45 409.45 401.26 61215 511.06 485.51 558.34 547.17 547.17 536.22 61250 821.70 780.62 897.71 879.76 879.76 862.17 61253 823.16 782.00 899.30 881.31 881.31 863.68 61304 1,683.27 1,599.11 1,838.98 1,802.20 1,802.20 1,766.16 61305 2,052.91 1,950.26 2,242.80 2,197.94 2,197.94 2,153.98 61312 2,133.38 2,026.71 2,330.72 2,284.11 2,284.11 2,238.43 61313 2,031.70 1,930.12 2,219.64 2,175.25 2,175.25 2,131.74 61314 1,864.98 1,771.73 2,037.49 1,996.75 1,996.75 1,956.81 61315 2,118.90 2,012.96 2,314.90 2,268.61 2,268.61 2,223.24 61316 91.07 86.52 99.50 97.51 97.51 95.55 61320 1,948.46 1,851.04 2,128.70 2,086.12 2,086.12 2,044.40 61321 2,151.48 2,043.91 2,350.50 2,303.48 2,303.48 2,257.42 61322 2,437.98 2,316.08 2,663.49 2,610.22 2,610.22 2,558.01 61323 2,470.67 2,347.14 2,699.21 2,645.23 2,645.23 2,592.33 61330 1,619.08 1,538.13 1,768.85 1,733.48 1,733.48 1,698.80 61332 1,778.68 1,689.75 1,943.21 1,904.35 1,904.35 1,866.27 61333 1,836.40 1,744.58 2,006.27 1,966.14 1,966.14 1,926.83 61340 1,456.22 1,383.41 1,590.92 1,559.10 1,559.10 1,527.92 61343 2,249.84 2,137.35 2,457.95 2,408.79 2,408.79 2,360.62 61345 2,084.24 1,980.03 2,277.03 2,231.49 2,231.49 2,186.86 61450 1,971.58 1,873.00 2,153.95 2,110.87 2,110.87 2,068.65 61458 2,055.66 1,952.88 2,245.81 2,200.89 2,200.89 2,156.87 61460 2,167.69 2,059.31 2,368.21 2,320.84 2,320.84 2,274.42 61480 1,629.59 1,548.11 1,780.33 1,744.72 1,744.72 1,709.83 61500 1,341.44 1,274.37 1,465.53 1,436.21 1,436.21 1,407.49 61501 1,168.35 1,109.93 1,276.42 1,250.89 1,250.89 1,225.88 61510 2,234.54 2,122.81 2,441.23 2,392.40 2,392.40 2,344.55 61512 2,612.02 2,481.42 2,853.63 2,796.56 2,796.56 2,740.62 61514 1,943.50 1,846.33 2,123.28 2,080.81 2,080.81 2,039.19 61516 1,897.07 1,802.22 2,072.55 2,031.11 2,031.11 1,990.49 61517 91.04 86.49 99.46 97.47 97.47 95.52 61518 2,823.54 2,682.36 3,084.71 3,023.02 3,023.02 2,962.56 61519 3,004.82 2,854.58 3,282.77 3,217.11 3,217.11 3,152.77 61520 3,863.13 3,669.97 4,220.47 4,136.06 4,136.06 4,053.34 61521 3,233.90 3,072.21 3,533.04 3,462.39 3,462.39 3,393.13 61522 2,222.56 2,111.43 2,428.14 2,379.58 2,379.58 2,331.99 61524 2,121.57 2,015.49 2,317.81 2,271.46 2,271.46 2,226.03 61526 3,770.73 3,582.19 4,119.52 4,037.13 4,037.13 3,956.39 61530 3,178.05 3,019.15 3,472.02 3,402.59 3,402.59 3,334.53 61531 1,240.86 1,178.82 1,355.64 1,328.53 1,328.53 1,301.96 61533 1,555.23 1,477.47 1,699.09 1,665.11 1,665.11 1,631.80 61534 1,659.78 1,576.79 1,813.31 1,777.04 1,777.04 1,741.50 61535 1,012.90 962.26 1,106.60 1,084.46 1,084.46 1,062.77 61536 2,661.14 2,528.08 2,907.29 2,849.15 2,849.15 2,792.17 61537 2,526.93 2,400.58 2,760.67 2,705.46 2,705.46 2,651.35 61538 2,750.38 2,612.86 3,004.79 2,944.69 2,944.69 2,885.80 61539 2,406.48 2,286.16 2,629.08 2,576.51 2,576.51 2,524.97

Page 141: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 141Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

61540 2,249.11 2,136.65 2,457.15 2,408.01 2,408.01 2,359.85 61541 2,213.58 2,102.90 2,418.34 2,369.97 2,369.97 2,322.56 61543 2,165.55 2,057.27 2,365.86 2,318.54 2,318.54 2,272.17 61544 1,959.46 1,861.49 2,140.71 2,097.90 2,097.90 2,055.94 61545 3,284.45 3,120.23 3,588.26 3,516.50 3,516.50 3,446.17 61546 2,378.52 2,259.59 2,598.53 2,546.56 2,546.56 2,495.63 61548 1,604.15 1,523.94 1,752.53 1,717.48 1,717.48 1,683.13 61550 969.17 920.71 1,058.82 1,037.65 1,037.65 1,016.89 61552 1,170.45 1,111.93 1,278.72 1,253.14 1,253.14 1,228.09 61556 1,606.61 1,526.28 1,755.22 1,720.11 1,720.11 1,685.72 61557 1,632.12 1,550.51 1,783.09 1,747.43 1,747.43 1,712.48 61558 1,930.98 1,834.43 2,109.59 2,067.40 2,067.40 2,026.06 61559 2,135.35 2,028.58 2,332.87 2,286.21 2,286.21 2,240.49 61563 1,954.18 1,856.47 2,134.94 2,092.24 2,092.24 2,050.39 61564 2,356.98 2,239.13 2,575.00 2,523.50 2,523.50 2,473.03 61566 2,303.56 2,188.38 2,516.64 2,466.30 2,466.30 2,416.98 61567 2,640.80 2,508.76 2,885.07 2,827.37 2,827.37 2,770.82 61570 1,910.13 1,814.62 2,086.81 2,045.08 2,045.08 2,004.17 61571 2,036.70 1,934.87 2,225.10 2,180.60 2,180.60 2,136.99 61575 2,171.44 2,062.87 2,372.30 2,324.85 2,324.85 2,278.36 61576 3,655.79 3,473.00 3,993.95 3,914.07 3,914.07 3,835.79 61580 2,519.21 2,393.25 2,752.24 2,697.20 2,697.20 2,643.25 61581 2,664.05 2,530.85 2,910.48 2,852.26 2,852.26 2,795.22 61582 2,920.40 2,774.38 3,190.54 3,126.72 3,126.72 3,064.19 61583 2,939.40 2,792.43 3,211.29 3,147.07 3,147.07 3,084.13 61584 2,899.98 2,754.98 3,168.23 3,104.86 3,104.86 3,042.76 61585 3,287.55 3,123.17 3,591.65 3,519.82 3,519.82 3,449.43 61586 2,426.28 2,304.97 2,650.72 2,597.70 2,597.70 2,545.74 61590 3,070.89 2,917.35 3,354.95 3,287.85 3,287.85 3,222.09 61591 3,134.38 2,977.66 3,424.31 3,355.83 3,355.83 3,288.71 61592 3,228.21 3,066.80 3,526.82 3,456.28 3,456.28 3,387.15 61595 2,380.70 2,261.67 2,600.92 2,548.91 2,548.91 2,497.93 61596 2,452.27 2,329.66 2,679.11 2,625.53 2,625.53 2,573.02 61597 2,869.58 2,726.10 3,135.02 3,072.32 3,072.32 3,010.87 61598 2,883.28 2,739.12 3,149.99 3,086.99 3,086.99 3,025.25 61600 2,149.32 2,041.85 2,348.13 2,301.16 2,301.16 2,255.14 61601 2,450.54 2,328.01 2,677.21 2,623.67 2,623.67 2,571.19 61605 2,184.14 2,074.93 2,386.17 2,338.44 2,338.44 2,291.67 61606 3,034.55 2,882.82 3,315.24 3,248.93 3,248.93 3,183.96 61607 2,753.16 2,615.50 3,007.83 2,947.67 2,947.67 2,888.72 61608 3,313.19 3,147.53 3,619.66 3,547.27 3,547.27 3,476.32 61610 1,576.61 1,497.78 1,722.45 1,687.99 1,687.99 1,654.23 61611 394.24 374.53 430.71 422.10 422.10 413.66 61612 1,481.64 1,407.56 1,618.69 1,586.32 1,586.32 1,554.59 61613 3,285.04 3,120.79 3,588.91 3,517.13 3,517.13 3,446.78 61615 2,289.78 2,175.29 2,501.58 2,451.55 2,451.55 2,402.51 61616 3,391.32 3,221.75 3,705.01 3,630.92 3,630.92 3,558.30 61618 1,320.21 1,254.20 1,442.33 1,413.49 1,413.49 1,385.22 61619 1,466.69 1,393.36 1,602.36 1,570.31 1,570.31 1,538.91

Page 142: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 142Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

61623 580.23 551.22 633.90 621.23 621.23 608.81 61624 1,166.43 1,108.11 1,274.33 1,248.84 1,248.84 1,223.86 61626 877.21 833.35 958.35 939.18 939.18 920.40 61630 1,352.90 1,285.26 1,478.05 1,448.48 1,448.48 1,419.51 61635 1,452.71 1,380.07 1,587.08 1,555.34 1,555.34 1,524.23 61645 794.70 754.97 868.22 850.85 850.85 833.83 61650 529.55 503.07 578.53 566.96 566.96 555.62 61651 224.90 213.66 245.71 240.80 240.80 235.98 61680 2,296.34 2,181.52 2,508.75 2,458.57 2,458.57 2,409.40 61682 4,280.33 4,066.31 4,676.26 4,582.73 4,582.73 4,491.07 61684 2,935.04 2,788.29 3,206.53 3,142.40 3,142.40 3,079.55 61686 4,615.12 4,384.36 5,042.01 4,941.17 4,941.17 4,842.35 61690 2,220.34 2,109.32 2,425.72 2,377.20 2,377.20 2,329.66 61692 3,748.52 3,561.09 4,095.25 4,013.35 4,013.35 3,933.08 61697 4,346.34 4,129.02 4,748.37 4,653.41 4,653.41 4,560.34 61698 4,769.18 4,530.72 5,210.33 5,106.13 5,106.13 5,004.01 61700 3,492.74 3,318.10 3,815.82 3,739.50 3,739.50 3,664.72 61702 4,128.78 3,922.34 4,510.69 4,420.47 4,420.47 4,332.06 61703 1,394.93 1,325.18 1,523.96 1,493.48 1,493.48 1,463.62 61705 2,630.90 2,499.36 2,874.26 2,816.78 2,816.78 2,760.44 61708 2,140.99 2,033.94 2,339.03 2,292.25 2,292.25 2,246.40 61710 2,218.62 2,107.69 2,423.84 2,375.37 2,375.37 2,327.86 61711 2,661.71 2,528.62 2,907.91 2,849.76 2,849.76 2,792.76 61720 1,304.00 1,238.80 1,424.62 1,396.12 1,396.12 1,368.20 61735 1,613.78 1,533.09 1,763.05 1,727.79 1,727.79 1,693.24 61750 1,440.14 1,368.13 1,573.35 1,541.89 1,541.89 1,511.04 61751 1,412.54 1,341.91 1,543.20 1,512.33 1,512.33 1,482.09 61760 1,625.74 1,544.45 1,776.12 1,740.59 1,740.59 1,705.78 61770 1,660.48 1,577.46 1,814.08 1,777.80 1,777.80 1,742.24 61781 243.72 231.53 266.26 260.94 260.94 255.71 61782 178.61 169.68 195.13 191.23 191.23 187.40 61783 239.73 227.74 261.90 256.67 256.67 251.54 61790 898.21 853.30 981.30 961.66 961.66 942.44 61791 1,091.64 1,037.06 1,192.62 1,168.77 1,168.77 1,145.39 61796 1,037.98 986.08 1,133.99 1,111.31 1,111.31 1,089.08 61797 229.04 217.59 250.23 245.23 245.23 240.33 61798 1,419.12 1,348.16 1,550.38 1,519.38 1,519.38 1,489.00 61799 315.56 299.78 344.75 337.85 337.85 331.09 61800 158.96 151.01 173.66 170.19 170.19 166.78 61850 1,005.61 955.33 1,098.63 1,076.65 1,076.65 1,055.13 61860 1,610.11 1,529.60 1,759.04 1,723.86 1,723.86 1,689.38 61863 1,534.85 1,458.11 1,676.83 1,643.29 1,643.29 1,610.43 61864 295.20 280.44 322.51 316.05 316.05 309.73 61867 2,337.20 2,220.34 2,553.39 2,502.32 2,502.32 2,452.27 61868 517.58 491.70 565.46 554.15 554.15 543.06 61870 1,168.13 1,109.72 1,276.18 1,250.66 1,250.66 1,225.65 61880 577.40 548.53 630.81 618.19 618.19 605.83 61885 518.86 492.92 566.86 555.52 555.52 544.41 61886 851.91 809.31 930.71 912.09 912.09 893.85

Page 143: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 143Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

61888 402.49 382.37 439.73 430.93 430.93 422.31 62000 1,055.01 1,002.26 1,152.60 1,129.54 1,129.54 1,106.96 62005 1,268.82 1,205.38 1,386.19 1,358.46 1,358.46 1,331.29 62010 1,563.91 1,485.71 1,708.57 1,674.40 1,674.40 1,640.91 62100 1,629.12 1,547.66 1,779.81 1,744.22 1,744.22 1,709.34 62115 1,319.08 1,253.13 1,441.10 1,412.28 1,412.28 1,384.04 62117 1,647.67 1,565.29 1,800.08 1,764.08 1,764.08 1,728.80 62120 1,670.77 1,587.23 1,825.31 1,788.81 1,788.81 1,753.04 62121 1,612.36 1,531.74 1,761.50 1,726.28 1,726.28 1,691.75 62140 1,050.95 998.40 1,148.16 1,125.19 1,125.19 1,102.69 62141 1,157.90 1,100.01 1,265.01 1,239.71 1,239.71 1,214.92 62142 901.20 856.14 984.56 964.87 964.87 945.58 62143 1,057.29 1,004.43 1,155.09 1,131.99 1,131.99 1,109.35 62145 1,440.77 1,368.73 1,574.04 1,542.56 1,542.56 1,511.71 62146 1,269.42 1,205.95 1,386.84 1,359.10 1,359.10 1,331.92 62147 1,445.26 1,373.00 1,578.95 1,547.37 1,547.37 1,516.42 62148 132.01 125.41 144.22 141.34 141.34 138.51 62160 197.52 187.64 215.79 211.47 211.47 207.24 62161 1,555.38 1,477.61 1,699.25 1,665.27 1,665.27 1,631.97 62162 1,934.82 1,838.08 2,113.79 2,071.52 2,071.52 2,030.08 62163 1,130.07 1,073.57 1,234.61 1,209.92 1,209.92 1,185.72 62164 2,127.06 2,020.71 2,323.82 2,277.35 2,277.35 2,231.79 62165 1,573.08 1,494.43 1,718.59 1,684.22 1,684.22 1,650.54 62180 1,633.85 1,552.16 1,784.98 1,749.29 1,749.29 1,714.31 62190 897.17 852.31 980.16 960.55 960.55 941.33 62192 993.82 944.13 1,085.75 1,064.04 1,064.04 1,042.76 62194 468.00 444.60 511.29 501.07 501.07 491.05 62200 1,409.10 1,338.65 1,539.45 1,508.66 1,508.66 1,478.49 62201 1,231.12 1,169.56 1,344.99 1,318.10 1,318.10 1,291.74 62220 1,048.87 996.43 1,145.89 1,122.98 1,122.98 1,100.52 62223 1,065.71 1,012.42 1,164.28 1,141.00 1,141.00 1,118.18 62225 529.83 503.34 578.84 567.26 567.26 555.91 62230 857.68 814.80 937.02 918.28 918.28 899.91 62252 84.14 79.93 91.92 90.08 90.08 88.27 62252 TC 36.18 34.37 39.53 38.73 38.73 37.96 62252 26 47.95 45.55 52.38 51.34 51.34 50.31 62256 605.14 574.88 661.11 647.89 647.89 634.93 62258 1,148.19 1,090.78 1,254.40 1,229.30 1,229.30 1,204.72 62263 627.43 596.06 685.47 671.76 671.76 658.33 # 62263 337.21 320.35 368.40 361.03 361.03 353.81 62264 410.39 389.87 448.35 439.38 439.38 430.59 # 62264 240.13 228.12 262.34 257.09 257.09 251.95 62267 243.23 231.07 265.73 260.42 260.42 255.21 # 62267 161.06 153.01 175.96 172.44 172.44 168.99 62268 260.98 247.93 285.12 279.42 279.42 273.83 62269 273.30 259.64 298.59 292.62 292.62 286.76 62270 153.75 146.06 167.97 164.61 164.61 161.32 # 62270 78.49 74.57 85.76 84.04 84.04 82.36 62272 194.09 184.39 212.05 207.81 207.81 203.65

Page 144: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 144Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 62272 84.31 80.09 92.10 90.26 90.26 88.46 62273 169.52 161.04 185.20 181.49 181.49 177.86 # 62273 114.63 108.90 125.24 122.73 122.73 120.28 62280 295.55 280.77 322.89 316.42 316.42 310.10 # 62280 161.45 153.38 176.39 172.86 172.86 169.40 62281 234.86 223.12 256.59 251.46 251.46 246.43 # 62281 157.62 149.74 172.20 168.76 168.76 165.39 62282 282.40 268.28 308.52 302.35 302.35 296.30 # 62282 145.34 138.07 158.78 155.61 155.61 152.49 62284 175.87 167.08 192.14 188.30 188.30 184.54 # 62284 86.46 82.14 94.46 92.58 92.58 90.72 62287 567.28 538.92 619.76 607.36 607.36 595.22 62290 322.82 306.68 352.68 345.63 345.63 338.72 # 62290 173.27 164.61 189.30 185.52 185.52 181.80 62291 319.49 303.52 349.05 342.07 342.07 335.23 # 62291 171.26 162.70 187.11 183.37 183.37 179.70 62292 580.32 551.30 634.00 621.31 621.31 608.88 62294 784.97 745.72 857.58 840.43 840.43 823.62 62302 233.42 221.75 255.01 249.92 249.92 244.92 # 62302 123.64 117.46 135.08 132.38 132.38 129.73 62303 242.30 230.19 264.72 259.43 259.43 254.24 # 62303 125.61 119.33 137.23 134.48 134.48 131.79 62304 231.00 219.45 252.37 247.32 247.32 242.37 # 62304 121.88 115.79 133.16 130.49 130.49 127.88 62305 251.35 238.78 274.60 269.10 269.10 263.72 # 62305 127.10 120.75 138.86 136.09 136.09 133.37 62310 231.19 219.63 252.57 247.53 247.53 242.58 # 62310 108.92 103.47 118.99 116.61 116.61 114.28 62311 212.63 202.00 232.30 227.65 227.65 223.10 # 62311 89.70 85.22 98.00 96.05 96.05 94.13 62318 222.04 210.94 242.58 237.73 237.73 232.98 # 62318 100.42 95.40 109.71 107.51 107.51 105.36 62319 163.36 155.19 178.47 174.90 174.90 171.41 # 62319 96.64 91.81 105.58 103.47 103.47 101.40 62350 402.75 382.61 440.00 431.20 431.20 422.58 62351 875.50 831.73 956.49 937.37 937.37 918.62 62355 268.81 255.37 293.68 287.80 287.80 282.04 62360 312.42 296.80 341.32 334.49 334.49 327.80 62361 360.50 342.48 393.85 385.97 385.97 378.26 62362 388.53 369.10 424.47 415.98 415.98 407.66 62365 297.03 282.18 324.51 318.02 318.02 311.66 62367 40.33 38.31 44.06 43.17 43.17 42.31 # 62367 25.54 24.26 27.90 27.34 27.34 26.78 62368 55.40 52.63 60.52 59.32 59.32 58.13 # 62368 35.68 33.90 38.99 38.20 38.20 37.44 62369 114.89 109.15 125.52 123.02 123.02 120.55 # 62369 36.01 34.21 39.34 38.56 38.56 37.79 62370 121.54 115.46 132.78 130.12 130.12 127.52 # 62370 47.26 44.90 51.64 50.60 50.60 49.59

Page 145: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 145Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

63001 1,263.30 1,200.14 1,380.16 1,352.56 1,352.56 1,325.51 63003 1,256.30 1,193.49 1,372.51 1,345.06 1,345.06 1,318.16 63005 1,196.88 1,137.04 1,307.60 1,281.45 1,281.45 1,255.81 63011 1,104.54 1,049.31 1,206.71 1,182.57 1,182.57 1,158.91 63012 1,206.11 1,145.80 1,317.67 1,291.31 1,291.31 1,265.48 63015 1,510.40 1,434.88 1,650.11 1,617.11 1,617.11 1,584.77 63016 1,544.17 1,466.96 1,687.00 1,653.26 1,653.26 1,620.20 63017 1,271.50 1,207.93 1,389.12 1,361.34 1,361.34 1,334.10 63020 1,173.87 1,115.18 1,282.46 1,256.81 1,256.81 1,231.67 63030 976.21 927.40 1,066.51 1,045.18 1,045.18 1,024.27 63035 196.16 186.35 214.30 210.01 210.01 205.82 63040 1,411.11 1,340.55 1,541.63 1,510.80 1,510.80 1,480.59 63042 1,309.07 1,243.62 1,430.16 1,401.56 1,401.56 1,373.54 63043 266.73 253.39 291.40 285.57 285.57 279.85 63044 266.73 253.39 291.40 285.57 285.57 279.85 63045 1,307.77 1,242.38 1,428.74 1,400.16 1,400.16 1,372.16 63046 1,235.34 1,173.57 1,349.61 1,322.62 1,322.62 1,296.17 63047 1,113.99 1,058.29 1,217.03 1,192.69 1,192.69 1,168.84 63048 216.82 205.98 236.88 232.14 232.14 227.49 63050 1,510.01 1,434.51 1,649.69 1,616.69 1,616.69 1,584.36 63051 1,734.89 1,648.15 1,895.37 1,857.47 1,857.47 1,820.32 63055 1,658.34 1,575.42 1,811.73 1,775.50 1,775.50 1,739.98 63056 1,503.53 1,428.35 1,642.60 1,609.75 1,609.75 1,577.55 63057 328.02 311.62 358.36 351.20 351.20 344.17 63064 1,799.07 1,709.12 1,965.49 1,926.18 1,926.18 1,887.66 63066 215.03 204.28 234.92 230.22 230.22 225.62 63075 1,374.60 1,305.87 1,501.75 1,471.71 1,471.71 1,442.28 63076 253.29 240.63 276.72 271.19 271.19 265.77 63077 1,521.36 1,445.29 1,662.08 1,628.84 1,628.84 1,596.26 63078 197.84 187.95 216.14 211.82 211.82 207.59 63081 1,785.04 1,695.79 1,950.16 1,911.15 1,911.15 1,872.92 63082 273.15 259.49 298.41 292.45 292.45 286.59 63085 1,941.96 1,844.86 2,121.59 2,079.15 2,079.15 2,037.57 63086 194.97 185.22 213.00 208.75 208.75 204.57 63087 2,446.26 2,323.95 2,672.54 2,619.09 2,619.09 2,566.71 63088 265.46 252.19 290.02 284.22 284.22 278.54 63090 1,977.60 1,878.72 2,160.53 2,117.32 2,117.32 2,074.98 63091 180.38 171.36 197.06 193.12 193.12 189.26 63101 2,354.49 2,236.77 2,572.29 2,520.83 2,520.83 2,470.42 63102 2,304.46 2,189.24 2,517.63 2,467.28 2,467.28 2,417.93 63103 300.38 285.36 328.16 321.60 321.60 315.17 63170 1,636.20 1,554.39 1,787.55 1,751.80 1,751.80 1,716.75 63172 1,413.78 1,343.09 1,544.55 1,513.66 1,513.66 1,483.40 63173 1,752.48 1,664.86 1,914.59 1,876.29 1,876.29 1,838.77 63180 1,525.20 1,448.94 1,666.28 1,632.95 1,632.95 1,600.29 63182 1,414.47 1,343.75 1,545.31 1,514.41 1,514.41 1,484.12 63185 1,145.05 1,087.80 1,250.97 1,225.95 1,225.95 1,201.43 63190 1,271.15 1,207.59 1,388.73 1,360.96 1,360.96 1,333.74 63191 1,380.73 1,311.69 1,508.44 1,478.28 1,478.28 1,448.71

Page 146: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 146Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

63194 1,640.02 1,558.02 1,791.72 1,755.89 1,755.89 1,720.77 63195 1,580.31 1,501.29 1,726.48 1,691.95 1,691.95 1,658.10 63196 1,426.48 1,355.16 1,558.43 1,527.27 1,527.27 1,496.73 63197 1,759.48 1,671.51 1,922.24 1,883.79 1,883.79 1,846.12 63198 1,680.39 1,596.37 1,835.83 1,799.11 1,799.11 1,763.12 63199 1,763.79 1,675.60 1,926.94 1,888.40 1,888.40 1,850.64 63200 1,564.63 1,486.40 1,709.36 1,675.17 1,675.17 1,641.67 63250 2,875.26 2,731.50 3,141.23 3,078.40 3,078.40 3,016.83 63251 3,122.60 2,966.47 3,411.44 3,343.21 3,343.21 3,276.35 63252 3,118.77 2,962.83 3,407.25 3,339.11 3,339.11 3,272.33 63265 1,702.85 1,617.71 1,860.37 1,823.16 1,823.16 1,786.70 63266 1,750.94 1,663.39 1,912.90 1,874.64 1,874.64 1,837.15 63267 1,390.27 1,320.76 1,518.87 1,488.49 1,488.49 1,458.72 63268 1,462.63 1,389.50 1,597.93 1,565.97 1,565.97 1,534.65 63270 2,133.65 2,026.97 2,331.02 2,284.39 2,284.39 2,238.71 63271 2,113.25 2,007.59 2,308.73 2,262.56 2,262.56 2,217.30 63272 1,925.49 1,829.22 2,103.60 2,061.54 2,061.54 2,020.31 63273 1,907.69 1,812.31 2,084.16 2,042.47 2,042.47 2,001.62 63275 1,834.92 1,743.17 2,004.65 1,964.56 1,964.56 1,925.26 63276 1,820.49 1,729.47 1,988.89 1,949.11 1,949.11 1,910.13 63277 1,575.76 1,496.97 1,721.52 1,687.08 1,687.08 1,653.34 63278 1,631.88 1,550.29 1,782.83 1,747.17 1,747.17 1,712.22 63280 2,160.94 2,052.89 2,360.82 2,313.60 2,313.60 2,267.33 63281 2,133.59 2,026.91 2,330.95 2,284.33 2,284.33 2,238.64 63282 2,007.17 1,906.81 2,192.83 2,148.97 2,148.97 2,106.00 63283 1,930.81 1,834.27 2,109.41 2,067.22 2,067.22 2,025.87 63285 2,690.46 2,555.94 2,939.33 2,880.54 2,880.54 2,822.93 63286 2,648.61 2,516.18 2,893.61 2,835.74 2,835.74 2,779.02 63287 2,832.41 2,690.79 3,094.41 3,032.52 3,032.52 2,971.86 63290 2,826.95 2,685.60 3,088.44 3,026.67 3,026.67 2,966.14 63295 344.94 327.69 376.84 369.31 369.31 361.93 63300 1,872.75 1,779.11 2,045.98 2,005.06 2,005.06 1,964.96 63301 2,260.42 2,147.40 2,469.51 2,420.12 2,420.12 2,371.71 63302 2,224.89 2,113.65 2,430.70 2,382.09 2,382.09 2,334.44 63303 2,369.43 2,250.96 2,588.60 2,536.83 2,536.83 2,486.09 63304 2,389.30 2,269.84 2,610.32 2,558.11 2,558.11 2,506.94 63305 2,482.19 2,358.08 2,711.79 2,657.56 2,657.56 2,604.41 63306 2,346.43 2,229.11 2,563.48 2,512.21 2,512.21 2,461.97 63307 2,353.31 2,235.64 2,570.99 2,519.57 2,519.57 2,469.18 63308 333.56 316.88 364.41 357.12 357.12 349.98 63600 909.13 863.67 993.22 973.36 973.36 953.89 63610 433.02 411.37 473.08 463.61 463.61 454.34 63615 984.76 935.52 1,075.85 1,054.33 1,054.33 1,033.24 63620 1,143.46 1,086.29 1,249.23 1,224.24 1,224.24 1,199.76 63621 263.34 250.17 287.70 281.95 281.95 276.31 63650 1,267.84 1,204.45 1,385.12 1,357.41 1,357.41 1,330.26 # 63650 414.91 394.16 453.28 444.22 444.22 435.33 63655 833.33 791.66 910.41 892.20 892.20 874.36 63661 561.86 533.77 613.84 601.55 601.55 589.52

Page 147: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 147Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 63661 322.25 306.14 352.06 345.02 345.02 338.12 63662 840.52 798.49 918.26 899.90 899.90 881.90 63663 769.47 731.00 840.65 823.84 823.84 807.36 # 63663 455.58 432.80 497.72 487.76 487.76 478.01 63664 866.64 823.31 946.81 927.87 927.87 909.31 63685 368.02 349.62 402.06 394.02 394.02 386.15 63688 370.94 352.39 405.25 397.14 397.14 389.19 63700 1,172.10 1,113.50 1,280.53 1,254.91 1,254.91 1,229.82 63702 1,278.94 1,214.99 1,397.24 1,369.29 1,369.29 1,341.91 63704 1,690.33 1,605.81 1,846.68 1,809.74 1,809.74 1,773.55 63706 1,714.75 1,629.01 1,873.36 1,835.89 1,835.89 1,799.18 63707 927.63 881.25 1,013.44 993.17 993.17 973.31 63709 1,113.28 1,057.62 1,216.26 1,191.94 1,191.94 1,168.10 63710 1,095.27 1,040.51 1,196.59 1,172.66 1,172.66 1,149.21 63740 956.49 908.67 1,044.97 1,024.08 1,024.08 1,003.59 63741 683.92 649.72 747.18 732.24 732.24 717.60 63744 680.84 646.80 743.82 728.94 728.94 714.36 63746 609.51 579.03 665.88 652.57 652.57 639.52 64400 123.16 117.00 134.55 131.86 131.86 129.23 # 64400 70.90 67.36 77.46 75.91 75.91 74.39 64402 126.31 119.99 137.99 135.23 135.23 132.53 # 64402 78.65 74.72 85.93 84.21 84.21 82.54 64405 97.93 93.03 106.98 104.85 104.85 102.75 # 64405 63.09 59.94 68.93 67.55 67.55 66.21 64408 100.11 95.10 109.37 107.18 107.18 105.04 # 64408 74.80 71.06 81.72 80.09 80.09 78.49 64410 118.88 112.94 129.88 127.28 127.28 124.74 # 64410 70.23 66.72 76.73 75.20 75.20 73.69 64413 123.28 117.12 134.69 132.00 132.00 129.35 # 64413 81.20 77.14 88.71 86.94 86.94 85.20 64415 115.11 109.35 125.75 123.23 123.23 120.77 # 64415 66.13 62.82 72.24 70.79 70.79 69.38 64416 79.97 75.97 87.37 85.62 85.62 83.90 64417 125.53 119.25 137.14 134.40 134.40 131.71 # 64417 71.63 68.05 78.26 76.69 76.69 75.16 64418 140.33 133.31 153.31 150.24 150.24 147.23 # 64418 76.23 72.42 83.28 81.62 81.62 79.98 64420 108.94 103.49 119.01 116.63 116.63 114.30 # 64420 68.18 64.77 74.49 72.99 72.99 71.53 64421 146.31 138.99 159.84 156.64 156.64 153.51 # 64421 92.08 87.48 100.60 98.59 98.59 96.62 64425 129.21 122.75 141.16 138.35 138.35 135.57 # 64425 93.71 89.02 102.37 100.33 100.33 98.33 64430 134.19 127.48 146.60 143.67 143.67 140.79 # 64430 82.26 78.15 89.87 88.08 88.08 86.32 64435 131.91 125.31 144.11 141.22 141.22 138.39 # 64435 83.27 79.11 90.98 89.16 89.16 87.38 64445 131.98 125.38 144.19 141.30 141.30 138.47 # 64445 73.14 69.48 79.90 78.30 78.30 76.74

Page 148: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 148Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

64446 80.30 76.29 87.73 85.97 85.97 84.25 64447 116.81 110.97 127.62 125.06 125.06 122.57 # 64447 67.18 63.82 73.39 71.92 71.92 70.48 64448 72.19 68.58 78.87 77.29 77.29 75.75 64449 84.98 80.73 92.84 90.99 90.99 89.17 64450 77.00 73.15 84.12 82.44 82.44 80.80 # 64450 45.45 43.18 49.66 48.67 48.67 47.69 64455 47.06 44.71 51.42 50.39 50.39 49.38 # 64455 35.23 33.47 38.49 37.72 37.72 36.96 64461 144.27 137.06 157.62 154.47 154.47 151.37 # 64461 87.41 83.04 95.50 93.59 93.59 91.71 64462 82.05 77.95 89.64 87.85 87.85 86.09 # 64462 55.10 52.35 60.20 59.00 59.00 57.81 64463 156.56 148.73 171.04 167.62 167.62 164.27 # 64463 84.90 80.66 92.76 90.91 90.91 89.09 64479 228.14 216.73 249.24 244.26 244.26 239.37 # 64479 132.49 125.87 144.75 141.85 141.85 139.01 64480 109.65 104.17 119.80 117.40 117.40 115.06 # 64480 63.64 60.46 69.53 68.14 68.14 66.78 64483 211.76 201.17 231.35 226.72 226.72 222.19 # 64483 112.83 107.19 123.27 120.81 120.81 118.39 64484 85.32 81.05 93.21 91.34 91.34 89.52 # 64484 52.45 49.83 57.30 56.15 56.15 55.03 64486 120.40 114.38 131.54 128.90 128.90 126.33 # 64486 63.87 60.68 69.78 68.39 68.39 67.02 64487 148.05 140.65 161.75 158.52 158.52 155.34 # 64487 74.76 71.02 81.67 80.04 80.04 78.44 64488 148.76 141.32 162.52 159.26 159.26 156.08 # 64488 80.72 76.68 88.18 86.42 86.42 84.70 64489 205.61 195.33 224.63 220.13 220.13 215.73 # 64489 90.90 86.36 99.31 97.32 97.32 95.38 64490 184.25 175.04 201.30 197.27 197.27 193.33 # 64490 106.68 101.35 116.55 114.22 114.22 111.93 64491 91.76 87.17 100.25 98.24 98.24 96.28 # 64491 60.87 57.83 66.50 65.17 65.17 63.87 64492 92.09 87.49 100.61 98.60 98.60 96.63 # 64492 61.52 58.44 67.21 65.86 65.86 64.54 64493 166.88 158.54 182.32 178.68 178.68 175.10 # 64493 91.28 86.72 99.73 97.74 97.74 95.78 64494 84.36 80.14 92.16 90.32 90.32 88.52 # 64494 52.48 49.86 57.34 56.19 56.19 55.06 64495 84.69 80.46 92.53 90.68 90.68 88.86 # 64495 53.14 50.48 58.05 56.89 56.89 55.75 64505 102.34 97.22 111.80 109.57 109.57 107.38 # 64505 86.57 82.24 94.58 92.69 92.69 90.84 64508 62.17 59.06 67.92 66.56 66.56 65.23 # 64508 73.02 69.37 79.78 78.18 78.18 76.61 64510 122.83 116.69 134.19 131.51 131.51 128.88 # 64510 73.53 69.85 80.33 78.72 78.72 77.14

Page 149: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 149Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

64517 177.50 168.63 193.92 190.05 190.05 186.24 # 64517 122.61 116.48 133.95 131.27 131.27 128.65 64520 178.49 169.57 195.01 191.11 191.11 187.29 # 64520 80.87 76.83 88.35 86.58 86.58 84.85 64530 183.46 174.29 200.43 196.42 196.42 192.49 # 64530 92.09 87.49 100.61 98.60 98.60 96.63 64550 15.35 14.58 16.77 16.43 16.43 16.10 # 64550 8.77 8.33 9.58 9.38 9.38 9.20 64553 203.06 192.91 221.85 217.41 217.41 213.06 # 64553 154.74 147.00 169.05 165.67 165.67 162.36 64555 204.99 194.74 223.95 219.48 219.48 215.08 # 64555 152.08 144.48 166.15 162.83 162.83 159.57 64561 780.84 741.80 853.07 836.00 836.00 819.28 # 64561 303.26 288.10 331.32 324.69 324.69 318.19 64565 183.09 173.94 200.03 196.03 196.03 192.11 # 64565 130.17 123.66 142.21 139.37 139.37 136.59 64566 120.28 114.27 131.41 128.78 128.78 126.20 # 64566 30.87 29.33 33.73 33.05 33.05 32.40 64568 661.89 628.80 723.12 708.65 708.65 694.49 64569 791.58 752.00 864.80 847.50 847.50 830.55 64570 655.67 622.89 716.32 701.99 701.99 687.95 64575 317.35 301.48 346.70 339.77 339.77 332.97 64580 301.60 286.52 329.50 322.91 322.91 316.45 64581 665.80 632.51 727.39 712.84 712.84 698.58 64585 235.66 223.88 257.46 252.31 252.31 247.26 # 64585 141.98 134.88 155.11 152.01 152.01 148.97 64590 255.52 242.74 279.15 273.57 273.57 268.10 # 64590 159.55 151.57 174.31 170.82 170.82 167.41 64595 235.26 223.50 257.03 251.88 251.88 246.85 # 64595 125.16 118.90 136.74 134.00 134.00 131.32 64600 378.09 359.19 413.07 404.81 404.81 396.72 # 64600 219.67 208.69 239.99 235.20 235.20 230.49 64605 727.11 690.75 794.36 778.48 778.48 762.91 # 64605 414.86 394.12 453.24 444.18 444.18 435.30 64610 729.40 692.93 796.87 780.93 780.93 765.31 # 64610 495.38 470.61 541.20 530.38 530.38 519.78 64611 114.18 108.47 124.74 122.25 122.25 119.80 # 64611 100.70 95.67 110.02 107.82 107.82 105.66 64612 128.89 122.45 140.82 138.00 138.00 135.24 # 64612 115.74 109.95 126.44 123.91 123.91 121.44 64615 143.17 136.01 156.41 153.28 153.28 150.21 # 64615 125.42 119.15 137.02 134.29 134.29 131.59 64616 124.84 118.60 136.39 133.66 133.66 131.00 # 64616 109.40 103.93 119.52 117.13 117.13 114.78 64617 191.55 181.97 209.27 205.08 205.08 200.97 # 64617 125.16 118.90 136.74 134.00 134.00 131.32 64620 200.42 190.40 218.96 214.58 214.58 210.29 # 64620 171.17 162.61 187.00 183.26 183.26 179.60 64630 228.44 217.02 249.57 244.58 244.58 239.69

Page 150: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 150Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 64630 192.61 182.98 210.43 206.22 206.22 202.09 64632 83.70 79.52 91.45 89.62 89.62 87.83 # 64632 68.58 65.15 74.92 73.43 73.43 71.96 64633 408.50 388.08 446.29 437.37 437.37 428.62 # 64633 227.07 215.72 248.08 243.12 243.12 238.26 64634 182.32 173.20 199.18 195.20 195.20 191.30 # 64634 69.25 65.79 75.66 74.14 74.14 72.66 64635 403.69 383.51 441.04 432.22 432.22 423.57 # 64635 223.90 212.71 244.62 239.73 239.73 234.93 64636 165.69 157.41 181.02 177.40 177.40 173.85 # 64636 60.51 57.48 66.10 64.78 64.78 63.48 64640 128.45 122.03 140.33 137.53 137.53 134.78 # 64640 91.64 87.06 100.12 98.12 98.12 96.15 64642 138.98 132.03 151.83 148.80 148.80 145.82 # 64642 108.74 103.30 118.80 116.41 116.41 114.09 64643 91.71 87.12 100.19 98.19 98.19 96.22 # 64643 73.30 69.64 80.09 78.49 78.49 76.92 64644 159.28 151.32 174.02 170.53 170.53 167.12 # 64644 119.18 113.22 130.20 127.60 127.60 125.05 64645 112.42 106.80 122.82 120.36 120.36 117.96 # 64645 84.15 79.94 91.93 90.09 90.09 88.29 64646 147.77 140.38 161.44 158.21 158.21 155.04 # 64646 117.53 111.65 128.40 125.83 125.83 123.31 64647 174.54 165.81 190.68 186.86 186.86 183.13 # 64647 137.39 130.52 150.10 147.10 147.10 144.15 64650 74.71 70.97 81.62 79.98 79.98 78.38 # 64650 42.17 40.06 46.07 45.15 45.15 44.24 64653 93.97 89.27 102.66 100.60 100.60 98.59 # 64653 54.86 52.12 59.94 58.74 58.74 57.57 64680 298.44 283.52 326.05 319.53 319.53 313.13 # 64680 165.65 157.37 180.98 177.35 177.35 173.81 64681 332.70 316.07 363.48 356.21 356.21 349.09 # 64681 191.69 182.11 209.43 205.24 205.24 201.14 64702 491.63 467.05 537.11 526.37 526.37 515.84 64704 314.87 299.13 344.00 337.12 337.12 330.38 64708 490.95 466.40 536.36 525.63 525.63 515.12 64712 570.48 541.96 623.25 610.79 610.79 598.58 64713 725.78 689.49 792.91 777.06 777.06 761.52 64714 640.30 608.29 699.53 685.54 685.54 671.83 64716 531.84 505.25 581.04 569.42 569.42 558.04 64718 583.37 554.20 637.33 624.59 624.59 612.10 64719 394.55 374.82 431.04 422.42 422.42 413.97 64721 421.94 400.84 460.97 451.74 451.74 442.70 # 64721 419.31 398.34 458.09 448.93 448.93 439.94 64722 365.76 347.47 399.59 391.60 391.60 383.77 64726 272.23 258.62 297.41 291.47 291.47 285.64 64727 186.04 176.74 203.25 199.19 199.19 195.21 64732 370.74 352.20 405.03 396.93 396.93 389.00 64734 409.00 388.55 446.83 437.90 437.90 429.13

Page 151: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 151Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

64736 393.35 373.68 429.73 421.14 421.14 412.72 64738 421.43 400.36 460.41 451.20 451.20 442.18 64740 453.55 430.87 495.50 485.59 485.59 475.88 64742 479.91 455.91 524.30 513.81 513.81 503.53 64744 492.38 467.76 537.92 527.16 527.16 516.61 64746 450.46 427.94 492.13 482.29 482.29 472.64 64755 930.97 884.42 1,017.08 996.74 996.74 976.81 64760 505.58 480.30 552.35 541.29 541.29 530.47 64763 506.42 481.10 553.27 542.20 542.20 531.36 64766 600.46 570.44 656.01 642.88 642.88 630.03 64771 593.46 563.79 648.36 635.39 635.39 622.68 64772 557.86 529.97 609.47 597.28 597.28 585.33 64774 413.69 393.01 451.96 442.92 442.92 434.07 64776 388.44 369.02 424.37 415.89 415.89 407.57 64778 145.52 138.24 158.98 155.80 155.80 152.69 64782 449.87 427.38 491.49 481.65 481.65 472.02 64783 222.18 211.07 242.73 237.88 237.88 233.12 64784 727.23 690.87 794.50 778.61 778.61 763.04 64786 1,073.54 1,019.86 1,172.84 1,149.38 1,149.38 1,126.39 64787 245.13 232.87 267.80 262.44 262.44 257.20 64788 396.13 376.32 432.77 424.11 424.11 415.62 64790 840.91 798.86 918.69 900.31 900.31 882.30 64792 1,213.61 1,152.93 1,325.87 1,299.35 1,299.35 1,273.36 64795 194.36 184.64 212.34 208.09 208.09 203.93 64802 664.57 631.34 726.04 711.52 711.52 697.29 64804 1,012.21 961.60 1,105.84 1,083.73 1,083.73 1,062.05 64809 1,027.22 975.86 1,122.24 1,099.79 1,099.79 1,077.79 64818 619.36 588.39 676.65 663.11 663.11 649.85 64820 720.42 684.40 787.06 771.32 771.32 755.90 64821 680.90 646.86 743.89 729.01 729.01 714.43 64822 680.90 646.86 743.89 729.01 729.01 714.43 64823 776.08 737.28 847.87 830.91 830.91 814.29 64831 678.53 644.60 741.29 726.47 726.47 711.94 64832 340.10 323.10 371.57 364.14 364.14 356.86 64834 737.29 700.43 805.49 789.38 789.38 773.59 64835 804.88 764.64 879.34 861.75 861.75 844.51 64836 807.57 767.19 882.27 864.63 864.63 847.33 64837 374.37 355.65 409.00 400.82 400.82 392.81 64840 1,015.82 965.03 1,109.78 1,087.59 1,087.59 1,065.84 64856 1,013.40 962.73 1,107.14 1,085.00 1,085.00 1,063.30 64857 1,053.21 1,000.55 1,150.63 1,127.62 1,127.62 1,105.07 64858 1,134.18 1,077.47 1,239.09 1,214.31 1,214.31 1,190.02 64859 254.57 241.84 278.12 272.55 272.55 267.10 64861 1,330.61 1,264.08 1,453.69 1,424.62 1,424.62 1,396.12 64862 1,561.31 1,483.24 1,705.73 1,671.62 1,671.62 1,638.19 64864 879.46 835.49 960.81 941.60 941.60 922.76 64865 1,125.05 1,068.80 1,229.12 1,204.53 1,204.53 1,180.44 64866 1,149.47 1,092.00 1,255.80 1,230.68 1,230.68 1,206.07 64868 1,013.90 963.21 1,107.69 1,085.54 1,085.54 1,063.83

Page 152: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 152Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

64872 121.79 115.70 133.06 130.40 130.40 127.79 64874 173.55 164.87 189.60 185.81 185.81 182.09 64876 179.42 170.45 196.02 192.10 192.10 188.26 64885 1,150.66 1,093.13 1,257.10 1,231.96 1,231.96 1,207.32 64886 1,307.71 1,242.32 1,428.67 1,400.09 1,400.09 1,372.09 64890 1,087.96 1,033.56 1,188.59 1,164.82 1,164.82 1,141.52 64891 1,163.29 1,105.13 1,270.90 1,245.48 1,245.48 1,220.58 64892 1,041.79 989.70 1,138.16 1,115.40 1,115.40 1,093.09 64893 1,131.98 1,075.38 1,236.69 1,211.95 1,211.95 1,187.71 64895 1,338.77 1,271.83 1,462.60 1,433.35 1,433.35 1,404.68 64896 1,434.98 1,363.23 1,567.71 1,536.37 1,536.37 1,505.64 64897 1,242.50 1,180.38 1,357.44 1,330.29 1,330.29 1,303.67 64898 1,368.92 1,300.47 1,495.54 1,465.63 1,465.63 1,436.32 64901 565.98 537.68 618.33 605.97 605.97 593.85 64902 666.25 632.94 727.88 713.32 713.32 699.05 64905 1,025.50 974.23 1,120.36 1,097.96 1,097.96 1,076.01 64907 1,384.05 1,314.85 1,512.08 1,481.83 1,481.83 1,452.20 64910 818.58 777.65 894.30 876.42 876.42 858.89 64911 1,006.09 955.79 1,099.16 1,077.17 1,077.17 1,055.63 65091 612.73 582.09 669.40 656.02 656.02 642.90 65093 605.51 575.23 661.51 648.29 648.29 635.33 65101 711.31 675.74 777.10 761.56 761.56 746.34 65103 743.22 706.06 811.97 795.73 795.73 779.82 65105 819.95 778.95 895.79 877.88 877.88 860.32 65110 1,186.70 1,127.37 1,296.48 1,270.54 1,270.54 1,245.13 65112 1,380.58 1,311.55 1,508.28 1,478.12 1,478.12 1,448.55 65114 1,450.53 1,378.00 1,584.70 1,553.01 1,553.01 1,521.94 65125 434.66 412.93 474.87 465.37 465.37 456.07 # 65125 282.48 268.36 308.61 302.44 302.44 296.39 65130 706.08 670.78 771.40 755.96 755.96 740.84 65135 716.85 681.01 783.16 767.50 767.50 752.15 65140 779.68 740.70 851.81 834.77 834.77 818.08 65150 551.90 524.31 602.96 590.89 590.89 579.07 65155 817.52 776.64 893.14 875.28 875.28 857.77 65175 633.90 602.21 692.54 678.70 678.70 665.13 65205 54.12 51.41 59.12 57.94 57.94 56.78 # 65205 43.28 41.12 47.29 46.35 46.35 45.41 65210 66.37 63.05 72.51 71.06 71.06 69.63 # 65210 52.23 49.62 57.06 55.92 55.92 54.81 65220 56.20 53.39 61.40 60.17 60.17 58.96 # 65220 41.74 39.65 45.60 44.69 44.69 43.79 65222 64.39 61.17 70.35 68.94 68.94 67.56 # 65222 51.25 48.69 55.99 54.88 54.88 53.79 65235 690.19 655.68 754.03 738.96 738.96 724.18 65260 932.95 886.30 1,019.25 998.86 998.86 978.88 65265 1,052.01 999.41 1,149.32 1,126.33 1,126.33 1,103.80 65270 253.63 240.95 277.09 271.55 271.55 266.12 # 65270 136.94 130.09 149.60 146.61 146.61 143.68 65272 480.88 456.84 525.37 514.86 514.86 504.56

Page 153: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 153Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 65272 341.52 324.44 373.11 365.64 365.64 358.33 65273 371.15 352.59 405.48 397.37 397.37 389.42 65275 556.77 528.93 608.27 596.10 596.10 584.18 # 65275 450.28 427.77 491.94 482.09 482.09 472.45 65280 653.65 620.97 714.12 699.83 699.83 685.84 65285 1,080.50 1,026.48 1,180.45 1,156.84 1,156.84 1,133.70 65286 674.51 640.78 736.90 722.15 722.15 707.71 # 65286 482.55 458.42 527.18 516.64 516.64 506.31 65290 475.71 451.92 519.71 509.31 509.31 499.12 65400 655.23 622.47 715.84 701.52 701.52 687.49 # 65400 585.22 555.96 639.35 626.57 626.57 614.03 65410 137.40 130.53 150.11 147.11 147.11 144.16 # 65410 101.90 96.81 111.33 109.10 109.10 106.92 65420 492.88 468.24 538.48 527.71 527.71 517.16 # 65420 365.35 347.08 399.14 391.16 391.16 383.34 65426 624.38 593.16 682.13 668.50 668.50 655.12 # 65426 464.64 441.41 507.62 497.47 497.47 487.52 65430 110.75 105.21 120.99 118.58 118.58 116.21 # 65430 100.89 95.85 110.23 108.02 108.02 105.86 65435 76.82 72.98 83.93 82.25 82.25 80.60 # 65435 67.61 64.23 73.86 72.39 72.39 70.94 65436 375.66 356.88 410.41 402.20 402.20 394.16 # 65436 361.52 343.44 394.96 387.06 387.06 379.32 65450 312.95 297.30 341.90 335.05 335.05 328.35 # 65450 310.32 294.80 339.02 332.24 332.24 325.59 65600 379.62 360.64 414.74 406.44 406.44 398.31 # 65600 333.60 316.92 364.46 357.17 357.17 350.03 65710 1,075.01 1,021.26 1,174.45 1,150.95 1,150.95 1,127.93 65730 1,193.37 1,133.70 1,303.76 1,277.68 1,277.68 1,252.13 65750 1,201.34 1,141.27 1,312.46 1,286.21 1,286.21 1,260.48 65755 1,194.75 1,135.01 1,305.26 1,279.16 1,279.16 1,253.57 65756 1,156.13 1,098.32 1,263.07 1,237.80 1,237.80 1,213.04 65757 126.89 120.55 138.63 135.86 135.86 133.15 65770 1,369.30 1,300.84 1,495.97 1,466.04 1,466.04 1,436.72 65772 435.34 413.57 475.61 466.10 466.10 456.77 # 65772 394.58 374.85 431.08 422.45 422.45 414.00 65775 535.03 508.28 584.52 572.83 572.83 561.37 65778 1,335.61 1,268.83 1,459.15 1,429.97 1,429.97 1,401.37 # 65778 57.69 54.81 63.03 61.77 61.77 60.54 65779 1,124.69 1,068.46 1,228.73 1,204.15 1,204.15 1,180.07 # 65779 149.81 142.32 163.67 160.39 160.39 157.18 65780 693.66 658.98 757.83 742.67 742.67 727.81 65781 1,298.24 1,233.33 1,418.33 1,389.96 1,389.96 1,362.16 65782 1,119.19 1,063.23 1,222.71 1,198.27 1,198.27 1,174.30 65785 1,985.64 1,886.36 2,169.31 2,125.92 2,125.92 2,083.41 # 65785 380.35 361.33 415.53 407.22 407.22 399.07 65800 115.55 109.77 126.24 123.71 123.71 121.23 # 65800 90.25 85.74 98.60 96.63 96.63 94.70 65810 451.45 428.88 493.21 483.35 483.35 473.67

Page 154: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 154Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

65815 611.08 580.53 667.61 654.26 654.26 641.17 # 65815 463.51 440.33 506.38 496.25 496.25 486.32 65820 724.71 688.47 791.74 775.91 775.91 760.39 65850 817.28 776.42 892.88 875.02 875.02 857.52 65855 262.39 249.27 286.66 280.92 280.92 275.30 # 65855 232.15 220.54 253.62 248.55 248.55 243.58 65860 298.18 283.27 325.76 319.24 319.24 312.86 # 65860 247.23 234.87 270.10 264.70 264.70 259.41 65865 458.18 435.27 500.56 490.54 490.54 480.73 65870 573.03 544.38 626.04 613.51 613.51 601.24 65875 610.83 580.29 667.33 653.98 653.98 640.91 65880 641.50 609.43 700.84 686.83 686.83 673.10 65900 932.51 885.88 1,018.76 998.38 998.38 978.42 65920 765.24 726.98 836.03 819.31 819.31 802.92 65930 619.54 588.56 676.84 663.31 663.31 650.04 66020 178.35 169.43 194.84 190.95 190.95 187.13 # 66020 127.74 121.35 139.55 136.76 136.76 134.02 66030 157.91 150.01 172.51 169.06 169.06 165.68 # 66030 107.29 101.93 117.22 114.87 114.87 112.57 66130 670.74 637.20 732.78 718.13 718.13 703.77 # 66130 554.06 526.36 605.31 593.20 593.20 581.34 66150 848.45 806.03 926.93 908.40 908.40 890.23 66155 847.76 805.37 926.18 907.65 907.65 889.49 66160 957.79 909.90 1,046.39 1,025.46 1,025.46 1,004.95 66170 938.51 891.58 1,025.32 1,004.81 1,004.81 984.72 66172 1,178.59 1,119.66 1,287.61 1,261.86 1,261.86 1,236.62 66174 922.11 876.00 1,007.40 987.25 987.25 967.51 66175 966.52 918.19 1,055.92 1,034.80 1,034.80 1,014.10 66179 1,046.66 994.33 1,143.48 1,120.61 1,120.61 1,098.19 66180 1,105.66 1,050.38 1,207.94 1,183.78 1,183.78 1,160.10 66183 1,000.10 950.10 1,092.62 1,070.77 1,070.77 1,049.35 66184 760.34 722.32 830.67 814.05 814.05 797.77 66185 819.67 778.69 895.49 877.59 877.59 860.04 66220 723.35 687.18 790.26 774.46 774.46 758.97 66225 906.34 861.02 990.17 970.37 970.37 950.96 66250 717.74 681.85 784.13 768.44 768.44 753.08 # 66250 541.23 514.17 591.30 579.47 579.47 567.88 66500 341.01 323.96 372.55 365.10 365.10 357.80 66505 374.12 355.41 408.72 400.55 400.55 392.53 66600 805.45 765.18 879.96 862.36 862.36 845.11 66605 1,027.96 976.56 1,123.04 1,100.58 1,100.58 1,078.57 66625 416.29 395.48 454.80 445.71 445.71 436.79 66630 552.63 525.00 603.75 591.68 591.68 579.84 66635 558.18 530.27 609.81 597.61 597.61 585.66 66680 501.87 476.78 548.30 537.33 537.33 526.59 66682 615.92 585.12 672.89 659.43 659.43 646.24 66700 434.50 412.78 474.70 465.20 465.20 455.89 # 66700 382.24 363.13 417.60 409.25 409.25 401.06 66710 424.97 403.72 464.28 455.00 455.00 445.90

Page 155: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 155Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 66710 381.91 362.81 417.23 408.88 408.88 400.71 66711 622.36 591.24 679.93 666.33 666.33 653.00 66720 456.46 433.64 498.69 488.72 488.72 478.94 # 66720 410.12 389.61 448.05 439.09 439.09 430.31 66740 422.67 401.54 461.77 452.54 452.54 443.49 # 66740 382.24 363.13 417.60 409.25 409.25 401.06 66761 284.84 270.60 311.19 304.97 304.97 298.87 # 66761 229.29 217.83 250.50 245.49 245.49 240.58 66762 458.26 435.35 500.65 490.64 490.64 480.83 # 66762 413.89 393.20 452.18 443.14 443.14 434.27 66770 509.60 484.12 556.74 545.61 545.61 534.69 # 66770 469.50 446.03 512.93 502.68 502.68 492.63 66820 378.05 359.15 413.02 404.77 404.77 396.67 66821 317.37 301.50 346.73 339.79 339.79 332.99 # 66821 300.28 285.27 328.06 321.49 321.49 315.07 66825 735.22 698.46 803.23 787.16 787.16 771.42 66830 692.26 657.65 756.30 741.18 741.18 726.35 66840 677.24 643.38 739.89 725.09 725.09 710.59 66850 770.94 732.39 842.25 825.40 825.40 808.90 66852 821.94 780.84 897.97 880.00 880.00 862.41 66920 733.80 697.11 801.68 785.65 785.65 769.94 66930 834.08 792.38 911.24 893.01 893.01 875.15 66940 760.85 722.81 831.23 814.60 814.60 798.31 66982 774.87 736.13 846.55 829.62 829.62 813.03 66983 720.22 684.21 786.84 771.11 771.11 755.69 66984 621.90 590.81 679.43 665.84 665.84 652.52 66985 748.09 710.69 817.29 800.95 800.95 784.93 66986 884.09 839.89 965.87 946.55 946.55 927.62 66990 89.20 84.74 97.45 95.51 95.51 93.60 67005 458.55 435.62 500.96 490.95 490.95 481.13 67010 527.31 500.94 576.08 564.56 564.56 553.27 67015 562.06 533.96 614.05 601.77 601.77 589.73 67025 700.18 665.17 764.95 749.65 749.65 734.65 # 67025 614.40 583.68 671.23 657.81 657.81 644.66 67027 830.17 788.66 906.96 888.82 888.82 871.04 67028 99.51 94.53 108.71 106.54 106.54 104.41 # 67028 97.87 92.98 106.93 104.79 104.79 102.70 67030 514.14 488.43 561.69 550.46 550.46 539.45 67031 375.23 356.47 409.94 401.74 401.74 393.70 # 67031 346.31 328.99 378.34 370.77 370.77 363.35 67036 877.46 833.59 958.63 939.46 939.46 920.67 67039 940.28 893.27 1,027.26 1,006.71 1,006.71 986.57 67040 1,017.01 966.16 1,111.08 1,088.87 1,088.87 1,067.09 67041 1,124.62 1,068.39 1,228.65 1,204.07 1,204.07 1,179.99 67042 1,124.95 1,068.70 1,229.01 1,204.43 1,204.43 1,180.34 67043 1,188.13 1,128.72 1,298.03 1,272.07 1,272.07 1,246.63 67101 755.92 718.12 825.84 809.32 809.32 793.13 # 67101 655.01 622.26 715.60 701.28 701.28 687.25 67105 695.25 660.49 759.56 744.37 744.37 729.48

Page 156: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 156Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 67105 626.23 594.92 684.16 670.47 670.47 657.06 67107 991.31 941.74 1,083.00 1,061.35 1,061.35 1,040.12 67108 1,255.49 1,192.72 1,371.63 1,344.20 1,344.20 1,317.31 67110 733.03 696.38 800.84 784.82 784.82 769.12 # 67110 674.53 640.80 736.92 722.18 722.18 707.73 67113 1,372.61 1,303.98 1,499.58 1,469.59 1,469.59 1,440.19 67115 484.23 460.02 529.02 518.44 518.44 508.07 67120 632.61 600.98 691.13 677.30 677.30 663.76 # 67120 541.89 514.80 592.02 580.18 580.18 568.57 67121 884.06 839.86 965.84 946.52 946.52 927.59 67141 506.37 481.05 553.21 542.14 542.14 531.30 # 67141 473.51 449.83 517.30 506.95 506.95 496.81 67145 509.86 484.37 557.03 545.88 545.88 534.97 # 67145 483.56 459.38 528.29 517.72 517.72 507.37 67208 581.41 552.34 635.19 622.48 622.48 610.03 # 67208 562.68 534.55 614.73 602.44 602.44 590.39 67210 501.76 476.67 548.17 537.21 537.21 526.47 # 67210 485.65 461.37 530.58 519.96 519.96 509.57 67218 1,352.52 1,284.89 1,477.62 1,448.07 1,448.07 1,419.11 67220 516.55 490.72 564.33 553.05 553.05 541.98 # 67220 485.65 461.37 530.58 519.96 519.96 509.57 67221 277.36 263.49 303.01 296.95 296.95 291.02 # 67221 209.98 199.48 229.40 224.81 224.81 220.32 67225 29.07 27.62 31.76 31.13 31.13 30.51 # 67225 27.43 26.06 29.97 29.37 29.37 28.78 67227 280.14 266.13 306.05 299.93 299.93 293.93 # 67227 250.23 237.72 273.38 267.92 267.92 262.56 67228 330.60 314.07 361.18 353.96 353.96 346.87 # 67228 300.03 285.03 327.78 321.23 321.23 314.80 67229 1,092.71 1,038.07 1,193.78 1,169.91 1,169.91 1,146.50 67250 756.48 718.66 826.46 809.93 809.93 793.73 67255 661.92 628.82 723.14 708.68 708.68 694.51 67311 581.13 552.07 634.88 622.18 622.18 609.74 67312 693.22 658.56 757.34 742.20 742.20 727.35 67314 654.33 621.61 714.85 700.56 700.56 686.55 67316 780.35 741.33 852.53 835.48 835.48 818.77 67318 683.94 649.74 747.20 732.26 732.26 717.62 67320 318.33 302.41 347.77 340.81 340.81 333.99 67331 302.04 286.94 329.98 323.38 323.38 316.92 67332 327.70 311.32 358.02 350.85 350.85 343.84 67334 297.83 282.94 325.38 318.87 318.87 312.49 67335 146.50 139.18 160.06 156.86 156.86 153.72 67340 354.05 336.35 386.80 379.06 379.06 371.48 67343 635.28 603.52 694.05 680.17 680.17 666.56 67345 236.43 224.61 258.30 253.14 253.14 248.08 # 67345 214.08 203.38 233.89 229.21 229.21 224.62 67346 189.85 180.36 207.41 203.26 203.26 199.20 67400 899.93 854.93 983.17 963.50 963.50 944.23 67405 768.31 729.89 839.37 822.58 822.58 806.13

Page 157: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 157Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

67412 823.83 782.64 900.04 882.04 882.04 864.40 67413 828.39 786.97 905.02 886.91 886.91 869.18 67414 1,290.01 1,225.51 1,409.34 1,381.15 1,381.15 1,353.53 67415 103.14 97.98 112.68 110.42 110.42 108.22 67420 1,575.97 1,497.17 1,721.75 1,687.31 1,687.31 1,653.57 67430 1,201.52 1,141.44 1,312.66 1,286.40 1,286.40 1,260.68 67440 1,166.83 1,108.49 1,274.76 1,249.27 1,249.27 1,224.28 67445 1,365.14 1,296.88 1,491.41 1,461.58 1,461.58 1,432.35 67450 1,216.30 1,155.49 1,328.81 1,302.24 1,302.24 1,276.19 67500 77.49 73.62 84.66 82.97 82.97 81.32 # 67500 71.90 68.31 78.56 76.98 76.98 75.44 67505 86.80 82.46 94.83 92.93 92.93 91.07 # 67505 79.90 75.91 87.30 85.55 85.55 83.84 67515 94.44 89.72 103.18 101.12 101.12 99.10 # 67515 87.54 83.16 95.63 93.73 93.73 91.85 67550 933.98 887.28 1,020.37 999.96 999.96 979.96 67560 957.67 909.79 1,046.26 1,025.33 1,025.33 1,004.82 67570 1,129.85 1,073.36 1,234.36 1,209.67 1,209.67 1,185.48 67700 252.89 240.25 276.29 270.77 270.77 265.35 # 67700 112.87 107.23 123.31 120.85 120.85 118.44 67710 210.43 199.91 229.90 225.30 225.30 220.79 # 67710 94.07 89.37 102.78 100.72 100.72 98.70 67715 224.93 213.68 245.73 240.82 240.82 236.00 # 67715 105.29 100.03 115.03 112.73 112.73 110.48 67800 122.41 116.29 133.73 131.05 131.05 128.43 # 67800 100.71 95.67 110.02 107.82 107.82 105.66 67801 156.52 148.69 170.99 167.58 167.58 164.23 # 67801 130.55 124.02 142.62 139.77 139.77 136.98 67805 194.47 184.75 212.46 208.22 208.22 204.06 # 67805 160.62 152.59 175.48 171.97 171.97 168.53 67808 358.28 340.37 391.43 383.59 383.59 375.92 67810 163.61 155.43 178.74 175.17 175.17 171.66 # 67810 71.25 67.69 77.84 76.29 76.29 74.76 67820 48.54 46.11 53.03 51.97 51.97 50.93 # 67820 51.82 49.23 56.61 55.49 55.49 54.38 67825 123.78 117.59 135.23 132.53 132.53 129.88 # 67825 117.53 111.65 128.40 125.83 125.83 123.31 67830 252.36 239.74 275.70 270.19 270.19 264.79 # 67830 134.36 127.64 146.79 143.85 143.85 140.98 67835 425.76 404.47 465.14 455.84 455.84 446.72 67840 261.62 248.54 285.82 280.11 280.11 274.51 # 67840 154.14 146.43 168.39 165.03 165.03 161.72 67850 204.80 194.56 223.74 219.27 219.27 214.89 # 67850 132.82 126.18 145.11 142.21 142.21 139.37 67875 163.34 155.17 178.45 174.88 174.88 171.38 # 67875 94.98 90.23 103.76 101.69 101.69 99.66 67880 440.09 418.09 480.80 471.19 471.19 461.77 # 67880 357.59 339.71 390.67 382.86 382.86 375.20 67882 542.15 515.04 592.30 580.45 580.45 568.85

Page 158: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 158Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 67882 458.66 435.73 501.09 491.07 491.07 481.25 67900 616.22 585.41 673.22 659.76 659.76 646.56 # 67900 496.58 471.75 542.51 531.67 531.67 521.03 67901 725.96 689.66 793.11 777.25 777.25 761.70 # 67901 561.29 533.23 613.21 600.96 600.96 588.94 67902 704.81 669.57 770.01 754.61 754.61 739.52 67903 571.38 542.81 624.23 611.74 611.74 599.51 # 67903 471.13 447.57 514.71 504.41 504.41 494.33 67904 704.81 669.57 770.01 754.61 754.61 739.52 # 67904 581.55 552.47 635.34 622.63 622.63 610.18 67906 494.09 469.39 539.80 529.00 529.00 518.42 67908 474.79 451.05 518.71 508.33 508.33 498.17 # 67908 412.01 391.41 450.12 441.12 441.12 432.30 67909 514.86 489.12 562.49 551.24 551.24 540.21 # 67909 426.12 404.81 465.53 456.22 456.22 447.10 67911 547.50 520.13 598.15 586.19 586.19 574.47 67912 839.11 797.15 916.72 898.39 898.39 880.43 # 67912 478.22 454.31 522.46 512.00 512.00 501.77 67914 446.97 424.62 488.31 478.55 478.55 468.98 # 67914 316.81 300.97 346.12 339.19 339.19 332.41 67915 277.53 263.65 303.20 297.14 297.14 291.19 # 67915 190.75 181.21 208.39 204.23 204.23 200.15 67916 566.50 538.18 618.91 606.53 606.53 594.40 # 67916 418.92 397.97 457.67 448.51 448.51 439.54 67917 577.74 548.85 631.18 618.55 618.55 606.18 # 67917 445.61 423.33 486.83 477.09 477.09 467.54 67921 437.52 415.64 477.99 468.43 468.43 459.06 # 67921 300.13 285.12 327.89 321.33 321.33 314.90 67922 275.23 261.47 300.69 294.68 294.68 288.79 # 67922 190.43 180.91 208.05 203.88 203.88 199.80 67923 565.76 537.47 618.09 605.73 605.73 593.62 # 67923 418.51 397.58 457.22 448.07 448.07 439.12 67924 603.35 573.18 659.16 645.98 645.98 633.06 # 67924 445.58 423.30 486.80 477.05 477.05 467.51 67930 349.03 331.58 381.32 373.69 373.69 366.22 # 67930 235.30 223.54 257.07 251.93 251.93 246.89 67935 571.73 543.14 624.61 612.12 612.12 599.87 # 67935 433.03 411.38 473.09 463.62 463.62 454.35 67938 228.46 217.04 249.60 244.61 244.61 239.72 # 67938 112.10 106.50 122.48 120.03 120.03 117.62 67950 550.41 522.89 601.32 589.29 589.29 577.51 # 67950 450.82 428.28 492.52 482.67 482.67 473.02 67961 551.54 523.96 602.55 590.50 590.50 578.69 # 67961 442.09 419.99 482.99 473.33 473.33 463.86 67966 742.14 705.03 810.78 794.57 794.57 778.68 # 67966 640.91 608.86 700.19 686.18 686.18 672.46 67971 705.59 670.31 770.86 755.44 755.44 740.32 67973 908.30 862.89 992.32 972.47 972.47 953.03 67974 906.57 861.24 990.43 970.62 970.62 951.21

Page 159: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 159Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

67975 667.06 633.71 728.77 714.20 714.20 699.91 68020 115.53 109.75 126.21 123.69 123.69 121.22 # 68020 107.32 101.95 117.24 114.90 114.90 112.60 68040 60.81 57.77 66.44 65.10 65.10 63.80 # 68040 49.96 47.46 54.58 53.49 53.49 52.42 68100 161.67 153.59 176.63 173.10 173.10 169.64 # 68100 94.95 90.20 103.73 101.66 101.66 99.62 68110 214.74 204.00 234.60 229.91 229.91 225.31 # 68110 144.07 136.87 157.40 154.25 154.25 151.17 68115 296.47 281.65 323.90 317.42 317.42 311.08 # 68115 179.13 170.17 195.70 191.79 191.79 187.94 68130 515.57 489.79 563.26 551.99 551.99 540.95 # 68130 399.87 379.88 436.86 428.12 428.12 419.55 68135 151.53 143.95 165.54 162.23 162.23 158.99 # 68135 146.60 139.27 160.16 156.95 156.95 153.81 68200 40.00 38.00 43.70 42.83 42.83 41.98 # 68200 34.09 32.39 37.25 36.50 36.50 35.78 68320 693.00 658.35 757.10 741.96 741.96 727.12 # 68320 523.07 496.92 571.46 560.03 560.03 548.83 68325 640.82 608.78 700.10 686.09 686.09 672.37 68326 627.90 596.51 685.99 672.27 672.27 658.82 68328 689.37 654.90 753.14 738.07 738.07 723.30 68330 578.86 549.92 632.41 619.76 619.76 607.36 # 68330 447.71 425.32 489.12 479.33 479.33 469.74 68335 629.64 598.16 687.88 674.13 674.13 660.65 68340 521.10 495.05 569.31 557.92 557.92 546.77 # 68340 387.65 368.27 423.51 415.04 415.04 406.73 68360 509.96 484.46 557.13 545.99 545.99 535.06 # 68360 400.51 380.48 437.55 428.80 428.80 420.22 68362 638.32 606.40 697.36 683.41 683.41 669.74 68371 400.50 380.48 437.55 428.80 428.80 420.22 68400 268.40 254.98 293.23 287.36 287.36 281.61 # 68400 128.39 121.97 140.27 137.46 137.46 134.71 68420 305.53 290.25 333.79 327.12 327.12 320.57 # 68420 164.52 156.29 179.73 176.13 176.13 172.62 68440 98.08 93.18 107.16 105.02 105.02 102.91 # 68440 95.45 90.68 104.28 102.20 102.20 100.15 68500 947.81 900.42 1,035.48 1,014.77 1,014.77 994.47 68505 942.02 894.92 1,029.16 1,008.57 1,008.57 988.40 68510 427.93 406.53 467.51 458.16 458.16 448.99 # 68510 287.25 272.89 313.82 307.54 307.54 301.39 68520 668.32 634.90 730.14 715.53 715.53 701.22 68525 260.10 247.10 284.17 278.48 278.48 272.92 68530 408.34 387.92 446.11 437.18 437.18 428.44 # 68530 251.88 239.29 275.18 269.68 269.68 264.28 68540 904.67 859.44 988.36 968.59 968.59 949.22 68550 1,080.56 1,026.53 1,180.51 1,156.90 1,156.90 1,133.76 68700 587.07 557.72 641.38 628.56 628.56 615.99 68705 225.86 214.57 246.76 241.82 241.82 236.98

Page 160: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 160Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 68705 161.76 153.67 176.72 173.19 173.19 169.73 68720 735.65 698.87 803.70 787.62 787.62 771.87 68745 738.33 701.41 806.62 790.49 790.49 774.67 68750 764.05 725.85 834.73 818.03 818.03 801.67 68760 192.27 182.66 210.06 205.86 205.86 201.74 # 68760 141.65 134.57 154.76 151.66 151.66 148.63 68761 141.44 134.37 154.53 151.43 151.43 148.41 # 68761 115.15 109.39 125.80 123.28 123.28 120.82 68770 611.34 580.77 667.89 654.52 654.52 641.44 68801 95.89 91.10 104.77 102.67 102.67 100.61 # 68801 83.40 79.23 91.11 89.30 89.30 87.52 68810 185.92 176.62 203.11 199.05 199.05 195.07 # 68810 146.15 138.84 159.67 156.47 156.47 153.34 68811 160.60 152.57 175.46 171.95 171.95 168.51 68815 376.95 358.10 411.82 403.58 403.58 395.51 # 68815 215.23 204.47 235.14 230.44 230.44 225.83 68816 604.47 574.25 660.39 647.19 647.19 634.24 # 68816 194.93 185.18 212.96 208.70 208.70 204.53 68840 122.71 116.57 134.06 131.38 131.38 128.75 # 68840 112.85 107.21 123.29 120.83 120.83 118.42 68850 59.40 56.43 64.89 63.60 63.60 62.32 # 68850 54.80 52.06 59.87 58.67 58.67 57.50 69000 180.76 171.72 197.48 193.53 193.53 189.66 # 69000 117.32 111.45 128.17 125.60 125.60 123.10 69005 209.64 199.16 229.03 224.46 224.46 219.97 # 69005 156.07 148.27 170.51 167.10 167.10 163.75 69020 224.31 213.09 245.05 240.15 240.15 235.35 # 69020 139.84 132.85 152.78 149.72 149.72 146.73 69100 96.35 91.53 105.26 103.16 103.16 101.10 # 69100 49.02 46.57 53.56 52.49 52.49 51.44 69105 134.95 128.20 147.43 144.49 144.49 141.60 # 69105 63.30 60.14 69.16 67.78 67.78 66.42 69110 442.77 420.63 483.72 474.05 474.05 464.58 # 69110 318.53 302.60 347.99 341.03 341.03 334.21 69120 397.59 377.71 434.37 425.68 425.68 417.17 69140 858.61 815.68 938.03 919.28 919.28 900.89 69145 383.67 364.49 419.16 410.78 410.78 402.57 # 69145 245.96 233.66 268.71 263.34 263.34 258.07 69150 1,038.80 986.86 1,134.89 1,112.19 1,112.19 1,089.95 69155 1,661.66 1,578.58 1,815.37 1,779.06 1,779.06 1,743.48 69200 95.55 90.77 104.39 102.29 102.29 100.25 # 69200 47.23 44.87 51.60 50.57 50.57 49.55 69205 100.31 95.29 109.58 107.39 107.39 105.24 69209 11.86 11.27 12.96 12.70 12.70 12.44 69210 47.99 45.59 52.43 51.38 51.38 50.36 # 69210 32.88 31.24 35.93 35.21 35.21 34.51 69220 106.95 101.60 116.84 114.51 114.51 112.22 # 69220 52.06 49.46 56.88 55.74 55.74 54.63 69222 211.89 201.30 231.50 226.86 226.86 222.32

Page 161: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 161Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 69222 134.65 127.92 147.11 144.16 144.16 141.28 69300 715.96 680.16 782.18 766.54 766.54 751.21 # 69300 475.04 451.29 518.98 508.60 508.60 498.42 69310 1,072.65 1,019.02 1,171.87 1,148.44 1,148.44 1,125.47 69320 1,524.85 1,448.61 1,665.90 1,632.59 1,632.59 1,599.94 69420 185.36 176.09 202.50 198.46 198.46 194.49 # 69420 118.97 113.02 129.97 127.37 127.37 124.82 69421 147.26 139.90 160.89 157.67 157.67 154.51 69424 123.12 116.96 134.50 131.81 131.81 129.18 # 69424 61.98 58.88 67.71 66.36 66.36 65.03 69433 196.19 186.38 214.34 210.05 210.05 205.85 # 69433 131.11 124.55 143.23 140.37 140.37 137.56 69436 158.86 150.92 173.56 170.09 170.09 166.68 69440 680.38 646.36 743.31 728.44 728.44 713.87 69450 536.28 509.47 585.89 574.17 574.17 562.68 69501 727.47 691.10 794.77 778.87 778.87 763.29 69502 965.44 917.17 1,054.75 1,033.65 1,033.65 1,012.98 69505 1,185.97 1,126.67 1,295.67 1,269.76 1,269.76 1,244.37 69511 1,212.31 1,151.69 1,324.44 1,297.96 1,297.96 1,272.00 69530 1,640.56 1,558.53 1,792.31 1,756.46 1,756.46 1,721.33 69535 2,676.67 2,542.84 2,924.27 2,865.78 2,865.78 2,808.46 69540 201.36 191.29 219.98 215.58 215.58 211.27 # 69540 124.78 118.54 136.32 133.60 133.60 130.93 69550 1,026.04 974.74 1,120.95 1,098.54 1,098.54 1,076.57 69552 1,551.16 1,473.60 1,694.64 1,660.75 1,660.75 1,627.54 69554 2,432.96 2,311.31 2,658.01 2,604.84 2,604.84 2,552.75 69601 1,038.64 986.71 1,134.72 1,112.03 1,112.03 1,089.79 69602 1,079.45 1,025.48 1,179.30 1,155.72 1,155.72 1,132.60 69603 1,256.80 1,193.96 1,373.05 1,345.59 1,345.59 1,318.68 69604 1,103.91 1,048.71 1,206.02 1,181.90 1,181.90 1,158.27 69605 1,544.81 1,467.57 1,687.71 1,653.95 1,653.95 1,620.88 69610 378.04 359.14 413.01 404.75 404.75 396.66 # 69610 291.27 276.71 318.22 311.86 311.86 305.62 69620 676.78 642.94 739.38 724.59 724.59 710.10 # 69620 484.83 460.59 529.68 519.09 519.09 508.70 69631 873.21 829.55 953.98 934.90 934.90 916.21 69632 1,065.61 1,012.33 1,164.18 1,140.89 1,140.89 1,118.08 69633 1,033.65 981.97 1,129.27 1,106.68 1,106.68 1,084.54 69635 1,219.61 1,158.63 1,332.42 1,305.78 1,305.78 1,279.66 69636 1,364.35 1,296.13 1,490.55 1,460.74 1,460.74 1,431.53 69637 1,356.77 1,288.93 1,482.27 1,452.62 1,452.62 1,423.57 69641 1,032.18 980.57 1,127.66 1,105.10 1,105.10 1,083.00 69642 1,325.77 1,259.48 1,448.40 1,419.43 1,419.43 1,391.04 69643 1,215.10 1,154.35 1,327.50 1,300.95 1,300.95 1,274.92 69644 1,461.38 1,388.31 1,596.56 1,564.62 1,564.62 1,533.33 69645 1,436.77 1,364.93 1,569.67 1,538.27 1,538.27 1,507.51 69646 1,528.32 1,451.90 1,669.69 1,636.29 1,636.29 1,603.56 69650 798.04 758.14 871.86 854.43 854.43 837.34 69660 921.22 875.16 1,006.43 986.31 986.31 966.59

Page 162: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 162Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

69661 1,201.75 1,141.66 1,312.91 1,286.65 1,286.65 1,260.92 69662 1,153.42 1,095.75 1,260.11 1,234.92 1,234.92 1,210.21 69666 801.01 760.96 875.10 857.60 857.60 840.45 69667 801.37 761.30 875.50 857.98 857.98 840.82 69670 939.38 892.41 1,026.27 1,005.74 1,005.74 985.63 69676 821.38 780.31 897.36 879.41 879.41 861.82 69700 678.95 645.00 741.75 726.92 726.92 712.38 69711 856.29 813.48 935.50 916.79 916.79 898.46 69714 1,072.65 1,019.02 1,171.87 1,148.44 1,148.44 1,125.47 69715 1,326.48 1,260.16 1,449.18 1,420.20 1,420.20 1,391.80 69717 1,127.10 1,070.75 1,231.36 1,206.74 1,206.74 1,182.60 69718 1,340.12 1,273.11 1,464.08 1,434.80 1,434.80 1,406.11 69720 1,207.14 1,146.78 1,318.80 1,292.42 1,292.42 1,266.56 69725 1,879.90 1,785.91 2,053.80 2,012.72 2,012.72 1,972.47 69740 1,163.71 1,105.52 1,271.35 1,245.92 1,245.92 1,221.00 69745 1,389.49 1,320.02 1,518.02 1,487.66 1,487.66 1,457.91 69801 191.90 182.31 209.66 205.46 205.46 201.35 # 69801 126.49 120.17 138.20 135.44 135.44 132.72 69805 1,051.04 998.49 1,148.26 1,125.30 1,125.30 1,102.79 69806 940.59 893.56 1,027.59 1,007.04 1,007.04 986.91 69820 849.12 806.66 927.66 909.11 909.11 890.93 69840 891.32 846.75 973.76 954.29 954.29 935.20 69905 909.10 863.65 993.20 973.34 973.34 953.87 69910 1,013.22 962.56 1,106.94 1,084.81 1,084.81 1,063.11 69915 1,538.99 1,462.04 1,681.35 1,647.72 1,647.72 1,614.76 69930 1,223.48 1,162.31 1,336.66 1,309.92 1,309.92 1,283.72 69950 1,787.51 1,698.13 1,952.85 1,913.80 1,913.80 1,875.52 69955 1,995.14 1,895.38 2,179.69 2,136.09 2,136.09 2,093.37 69960 1,922.13 1,826.02 2,099.92 2,057.93 2,057.93 2,016.77 69970 2,147.91 2,040.51 2,346.59 2,299.66 2,299.66 2,253.67 69990 225.84 214.55 246.73 241.80 241.80 236.96 70010 61.28 58.22 66.95 65.62 65.62 64.31 70015 145.86 138.57 159.36 156.17 156.17 153.04 70015 TC 83.84 79.65 91.60 89.77 89.77 87.98 70015 26 62.02 58.92 67.76 66.40 66.40 65.08 70030 26.19 24.88 28.61 28.04 28.04 27.47 70030 TC 17.78 16.89 19.42 19.03 19.03 18.65 70030 26 8.41 7.99 9.19 9.00 9.00 8.82 70100 30.82 29.28 33.67 32.99 32.99 32.34 70100 TC 21.72 20.63 23.72 23.25 23.25 22.79 70100 26 9.10 8.65 9.95 9.75 9.75 9.56 70110 35.63 33.85 38.93 38.15 38.15 37.39 70110 TC 23.03 21.88 25.16 24.66 24.66 24.16 70110 26 12.59 11.96 13.75 13.48 13.48 13.21 70120 31.81 30.22 34.75 34.06 34.06 33.38 70120 TC 22.71 21.57 24.81 24.31 24.31 23.83 70120 26 9.10 8.65 9.95 9.75 9.75 9.56 70130 51.37 48.80 56.12 54.99 54.99 53.89 70130 TC 34.21 32.50 37.38 36.63 36.63 35.89

Page 163: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 163Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

70130 26 17.16 16.30 18.75 18.37 18.37 18.00 70134 48.38 45.96 52.85 51.80 51.80 50.76 70134 TC 30.92 29.37 33.78 33.10 33.10 32.43 70134 26 17.46 16.59 19.08 18.70 18.70 18.32 70140 27.89 26.50 30.48 29.87 29.87 29.27 70140 TC 17.45 16.58 19.07 18.69 18.69 18.32 70140 26 10.45 9.93 11.42 11.19 11.19 10.97 70150 38.94 36.99 42.54 41.69 41.69 40.86 70150 TC 25.66 24.38 28.04 27.47 27.47 26.92 70150 26 13.28 12.62 14.51 14.23 14.23 13.94 70160 30.46 28.94 33.28 32.61 32.61 31.96 70160 TC 21.72 20.63 23.72 23.25 23.25 22.79 70160 26 8.74 8.30 9.55 9.35 9.35 9.17 70170 194.45 184.73 212.44 208.20 208.20 204.03 70170 TC 179.38 170.41 195.97 192.05 192.05 188.21 70170 26 15.07 14.32 16.47 16.13 16.13 15.81 70190 33.54 31.86 36.64 35.90 35.90 35.19 70190 TC 22.38 21.26 24.45 23.95 23.95 23.47 70190 26 11.16 10.60 12.19 11.95 11.95 11.71 70200 39.66 37.68 43.33 42.47 42.47 41.62 70200 TC 25.66 24.38 28.04 27.47 27.47 26.92 70200 26 14.00 13.30 15.30 14.98 14.98 14.69 70210 27.83 26.44 30.41 29.80 29.80 29.20 70210 TC 19.09 18.14 20.86 20.45 20.45 20.03 70210 26 8.74 8.30 9.55 9.35 9.35 9.17 70220 35.30 33.54 38.57 37.80 37.80 37.04 70220 TC 22.71 21.57 24.81 24.31 24.31 23.83 70220 26 12.59 11.96 13.75 13.48 13.48 13.21 70240 28.22 26.81 30.83 30.21 30.21 29.60 70240 TC 18.43 17.51 20.14 19.73 19.73 19.34 70240 26 9.79 9.30 10.70 10.48 10.48 10.27 70250 33.96 32.26 37.10 36.35 36.35 35.63 70250 TC 21.39 20.32 23.37 22.90 22.90 22.44 70250 26 12.56 11.93 13.72 13.44 13.44 13.18 70260 43.15 40.99 47.14 46.20 46.20 45.28 70260 TC 25.66 24.38 28.04 27.47 27.47 26.92 70260 26 17.49 16.62 19.11 18.73 18.73 18.35 70300 14.15 13.44 15.46 15.15 15.15 14.85 70300 TC 8.24 7.83 9.00 8.82 8.82 8.65 70300 26 5.91 5.61 6.45 6.33 6.33 6.20 70310 34.38 32.66 37.56 36.81 36.81 36.08 70310 TC 26.32 25.00 28.75 28.18 28.18 27.61 70310 26 8.06 7.66 8.81 8.64 8.64 8.46 70320 49.02 46.57 53.56 52.49 52.49 51.44 70320 TC 37.17 35.31 40.61 39.79 39.79 39.00 70320 26 11.85 11.26 12.95 12.68 12.68 12.43 70328 28.85 27.41 31.52 30.89 30.89 30.27 70328 TC 19.75 18.76 21.57 21.14 21.14 20.71 70328 26 9.10 8.65 9.95 9.75 9.75 9.56

Page 164: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 164Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

70330 44.14 41.93 48.22 47.25 47.25 46.31 70330 TC 31.58 30.00 34.50 33.81 33.81 33.13 70330 26 12.56 11.93 13.72 13.44 13.44 13.18 70332 76.66 72.83 83.75 82.08 82.08 80.43 70332 TC 45.71 43.42 49.93 48.93 48.93 47.96 70332 26 30.95 29.40 33.81 33.13 33.13 32.46 70336 301.09 286.04 328.95 322.37 322.37 315.92 70336 TC 227.50 216.13 248.55 243.58 243.58 238.71 70336 26 73.58 69.90 80.39 78.78 78.78 77.20 70350 18.99 18.04 20.75 20.33 20.33 19.93 70350 TC 8.90 8.46 9.73 9.53 9.53 9.34 70350 26 10.08 9.58 11.02 10.80 10.80 10.58 70355 19.73 18.74 21.55 21.13 21.13 20.70 70355 TC 8.57 8.14 9.36 9.18 9.18 8.99 70355 26 11.16 10.60 12.19 11.95 11.95 11.71 70360 26.52 25.19 28.97 28.39 28.39 27.83 70360 TC 18.10 17.20 19.78 19.39 19.39 19.00 70360 26 8.41 7.99 9.19 9.00 9.00 8.82 C 70370 71.69 68.11 78.33 76.76 76.76 75.23 C 70370 TC 55.57 52.79 60.71 59.49 59.49 58.31 70370 26 16.11 15.30 17.60 17.24 17.24 16.89 70371 87.10 82.75 95.16 93.27 93.27 91.40 70371 TC 44.40 42.18 48.51 47.54 47.54 46.59 70371 26 42.70 40.57 46.66 45.72 45.72 44.80 70380 33.75 32.06 36.87 36.13 36.13 35.41 70380 TC 24.68 23.45 26.97 26.43 26.43 25.90 70380 26 9.07 8.62 9.91 9.72 9.72 9.52 70390 87.97 83.57 96.11 94.19 94.19 92.30 70390 TC 69.05 65.60 75.44 73.93 73.93 72.45 70390 26 18.92 17.97 20.67 20.25 20.25 19.85 70450 110.14 104.63 120.32 117.92 117.92 115.56 70450 TC 67.41 64.04 73.65 72.17 72.17 70.73 70450 26 42.73 40.59 46.68 45.75 45.75 44.83 70460 153.06 145.41 167.22 163.88 163.88 160.60 70460 TC 96.66 91.83 105.60 103.49 103.49 101.42 70460 26 56.40 53.58 61.62 60.39 60.39 59.18 70470 181.43 172.36 198.21 194.25 194.25 190.36 70470 TC 117.70 111.82 128.59 126.02 126.02 123.50 70470 26 63.74 60.55 69.63 68.24 68.24 66.87 C 70480 167.33 158.96 182.80 179.15 179.15 175.56 C 70480 TC 103.23 98.07 112.78 110.53 110.53 108.32 70480 26 64.10 60.90 70.04 68.63 68.63 67.26 70481 259.68 246.70 283.71 278.04 278.04 272.47 70481 TC 190.66 181.13 208.30 204.14 204.14 200.05 70481 26 69.02 65.57 75.41 73.90 73.90 72.42 70482 283.25 269.09 309.45 303.27 303.27 297.21 70482 TC 211.07 200.52 230.60 225.99 225.99 221.47 70482 26 72.18 68.57 78.86 77.28 77.28 75.74 70486 132.16 125.55 144.38 141.50 141.50 138.67

Page 165: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 165Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

70486 TC 89.43 84.96 97.70 95.75 95.75 93.83 70486 26 42.73 40.59 46.68 45.75 45.75 44.83 70487 159.30 151.34 174.04 170.56 170.56 167.14 70487 TC 102.90 97.76 112.42 110.17 110.17 107.96 70487 26 56.40 53.58 61.62 60.39 60.39 59.18 70488 193.59 183.91 211.50 207.26 207.26 203.12 70488 TC 130.19 123.68 142.23 139.39 139.39 136.61 70488 26 63.41 60.24 69.28 67.90 67.90 66.54 C 70490 167.33 158.96 182.80 179.15 179.15 175.56 C 70490 TC 103.23 98.07 112.78 110.53 110.53 108.32 70490 26 64.10 60.90 70.04 68.63 68.63 67.26 70491 222.21 211.10 242.77 237.91 237.91 233.15 70491 TC 152.86 145.22 167.00 163.67 163.67 160.39 70491 26 69.35 65.88 75.76 74.24 74.24 72.76 70492 261.53 248.45 285.72 280.00 280.00 274.40 70492 TC 189.02 179.57 206.51 202.38 202.38 198.33 70492 26 72.51 68.88 79.21 77.63 77.63 76.07 70496 277.61 263.73 303.29 297.23 297.23 291.28 70496 TC 190.36 180.84 207.97 203.80 203.80 199.73 70496 26 87.25 82.89 95.32 93.41 93.41 91.55 70498 276.62 262.79 302.21 296.16 296.16 290.24 70498 TC 189.38 179.91 206.90 202.76 202.76 198.70 70498 26 87.25 82.89 95.32 93.41 93.41 91.55 C 70540 317.80 301.91 347.20 340.25 340.25 333.44 C 70540 TC 250.51 237.98 273.68 268.20 268.20 262.84 70540 26 67.29 63.93 73.52 72.05 72.05 70.61 70542 376.46 357.64 411.29 403.06 403.06 395.00 70542 TC 295.54 280.76 322.87 316.41 316.41 310.09 70542 26 80.92 76.87 88.40 86.63 86.63 84.89 70543 461.26 438.20 503.93 493.86 493.86 483.98 70543 TC 354.05 336.35 386.80 379.06 379.06 371.48 70543 26 107.21 101.85 117.13 114.78 114.78 112.48 C 70544 310.76 295.22 339.50 332.72 332.72 326.06 C 70544 TC 250.51 237.98 273.68 268.20 268.20 262.84 70544 26 60.24 57.23 65.81 64.50 64.50 63.22 70545 361.37 343.30 394.80 386.89 386.89 379.16 70545 TC 301.46 286.39 329.35 322.76 322.76 316.31 70545 26 59.92 56.92 65.46 64.15 64.15 62.86 C 70546 505.86 480.57 552.66 541.60 541.60 530.77 C 70546 TC 415.84 395.05 454.31 445.22 445.22 436.32 70546 26 90.02 85.52 98.35 96.38 96.38 94.45 C 70547 310.76 295.22 339.50 332.72 332.72 326.06 C 70547 TC 250.51 237.98 273.68 268.20 268.20 262.84 70547 26 60.24 57.23 65.81 64.50 64.50 63.22 70548 385.37 366.10 421.02 412.60 412.60 404.34 70548 TC 325.12 308.86 355.19 348.08 348.08 341.12 70548 26 60.24 57.23 65.81 64.50 64.50 63.22 C 70549 505.86 480.57 552.66 541.60 541.60 530.77 C 70549 TC 415.84 395.05 454.31 445.22 445.22 436.32

Page 166: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 166Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

70549 26 90.02 85.52 98.35 96.38 96.38 94.45 70551 217.57 206.69 237.69 232.94 232.94 228.29 70551 TC 143.66 136.48 156.95 153.81 153.81 150.74 70551 26 73.91 70.21 80.74 79.13 79.13 77.54 70552 301.03 285.98 328.88 322.30 322.30 315.85 70552 TC 212.05 201.45 231.67 227.03 227.03 222.49 70552 26 88.98 84.53 97.21 95.27 95.27 93.36 70553 356.19 338.38 389.14 381.35 381.35 373.73 70553 TC 241.64 229.56 263.99 258.72 258.72 253.54 70553 26 114.55 108.82 125.14 122.64 122.64 120.19 70554 423.40 402.23 462.56 453.32 453.32 444.26 70554 TC 317.26 301.40 346.61 339.68 339.68 332.88 70554 26 106.14 100.83 115.95 113.63 113.63 111.35 70555 638.53 606.60 697.59 683.64 683.64 669.97 70555 TC 512.37 486.75 559.76 548.57 548.57 537.60 70555 26 126.16 119.85 137.83 135.07 135.07 132.37 70557 26 145.70 138.42 159.18 156.00 156.00 152.88 70558 26 160.42 152.40 175.26 171.75 171.75 168.31 70559 26 161.81 153.72 176.78 173.25 173.25 169.79 71010 21.29 20.23 23.26 22.80 22.80 22.34 71010 TC 12.19 11.58 13.32 13.05 13.05 12.79 71010 26 9.10 8.65 9.95 9.75 9.75 9.56 71015 26.31 24.99 28.74 28.16 28.16 27.60 71015 TC 15.47 14.70 16.91 16.57 16.57 16.24 71015 26 10.83 10.29 11.83 11.59 11.59 11.36 71020 26.34 25.02 28.77 28.20 28.20 27.63 71020 TC 15.47 14.70 16.91 16.57 16.57 16.24 71020 26 10.86 10.32 11.87 11.63 11.63 11.40 71021 32.07 30.47 35.04 34.34 34.34 33.65 71021 TC 18.43 17.51 20.14 19.73 19.73 19.34 71021 26 13.64 12.96 14.90 14.61 14.61 14.32 71022 39.42 37.45 43.07 42.21 42.21 41.37 71022 TC 23.03 21.88 25.16 24.66 24.66 24.16 71022 26 16.39 15.57 17.91 17.55 17.55 17.19 71023 59.70 56.72 65.23 63.93 63.93 62.65 71023 TC 40.78 38.74 44.55 43.67 43.67 42.79 71023 26 18.92 17.97 20.67 20.25 20.25 19.85 71030 39.45 37.48 43.10 42.24 42.24 41.40 71030 TC 23.69 22.51 25.89 25.37 25.37 24.86 71030 26 15.75 14.96 17.20 16.86 16.86 16.53 71034 78.40 74.48 85.65 83.94 83.94 82.26 71034 TC 54.92 52.17 60.00 58.80 58.80 57.63 71034 26 23.48 22.31 25.66 25.14 25.14 24.63 71035 30.82 29.28 33.67 32.99 32.99 32.34 71035 TC 21.72 20.63 23.72 23.25 23.25 22.79 71035 26 9.10 8.65 9.95 9.75 9.75 9.56 71100 30.94 29.39 33.80 33.12 33.12 32.45 71100 TC 19.75 18.76 21.57 21.14 21.14 20.71 71100 26 11.19 10.63 12.22 11.98 11.98 11.74

Page 167: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 167Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

71101 34.40 32.68 37.58 36.83 36.83 36.10 71101 TC 20.73 19.69 22.64 22.20 22.20 21.75 71101 26 13.67 12.99 14.94 14.64 14.64 14.35 71110 35.36 33.59 38.63 37.86 37.86 37.10 71110 TC 21.72 20.63 23.72 23.25 23.25 22.79 71110 26 13.64 12.96 14.90 14.61 14.61 14.32 71111 45.06 42.81 49.23 48.24 48.24 47.28 71111 TC 28.62 27.19 31.27 30.65 30.65 30.04 71111 26 16.44 15.62 17.96 17.61 17.61 17.25 71120 27.92 26.52 30.50 29.89 29.89 29.29 71120 TC 17.78 16.89 19.42 19.03 19.03 18.65 71120 26 10.15 9.64 11.09 10.87 10.87 10.65 71130 33.90 32.21 37.04 36.31 36.31 35.58 71130 TC 22.71 21.57 24.81 24.31 24.31 23.83 71130 26 11.19 10.63 12.22 11.98 11.98 11.74 C 71250 154.38 146.66 168.66 165.29 165.29 161.99 C 71250 TC 103.23 98.07 112.78 110.53 110.53 108.32 71250 26 51.14 48.58 55.87 54.75 54.75 53.66 71260 215.86 205.07 235.83 231.12 231.12 226.49 71260 TC 153.52 145.84 167.72 164.36 164.36 161.07 71260 26 62.33 59.21 68.09 66.73 66.73 65.40 71270 258.69 245.76 282.62 276.97 276.97 271.42 71270 TC 189.68 180.20 207.23 203.09 203.09 199.03 71270 26 69.02 65.57 75.41 73.90 73.90 72.42 71275 282.75 268.61 308.90 302.73 302.73 296.68 71275 TC 192.00 182.40 209.76 205.56 205.56 201.46 71275 26 90.74 86.20 99.13 97.15 97.15 95.21 C 71550 323.38 307.21 353.29 346.23 346.23 339.31 C 71550 TC 250.51 237.98 273.68 268.20 268.20 262.84 71550 26 72.87 69.23 79.61 78.03 78.03 76.46 71551 428.75 407.31 468.41 459.03 459.03 449.86 71551 TC 342.54 325.41 374.22 366.74 366.74 359.40 71551 26 86.20 81.89 94.17 92.29 92.29 90.45 C 71552 529.01 502.56 577.94 566.39 566.39 555.06 C 71552 TC 415.87 395.08 454.34 445.26 445.26 436.36 71552 26 113.15 107.49 123.61 121.14 121.14 118.71 71555 372.75 354.11 407.23 399.08 399.08 391.10 71555 TC 283.38 269.21 309.59 303.40 303.40 297.33 71555 26 89.37 84.90 97.64 95.68 95.68 93.77 72020 20.87 19.83 22.80 22.34 22.34 21.90 72020 TC 13.17 12.51 14.39 14.10 14.10 13.81 72020 26 7.70 7.32 8.42 8.25 8.25 8.08 72040 31.27 29.71 34.17 33.49 33.49 32.82 72040 TC 20.08 19.08 21.94 21.51 21.51 21.08 72040 26 11.19 10.63 12.22 11.98 11.98 11.74 72050 42.40 40.28 46.32 45.39 45.39 44.48 72050 TC 26.65 25.32 29.12 28.53 28.53 27.96 72050 26 15.75 14.96 17.20 16.86 16.86 16.53 72052 53.07 50.42 57.98 56.82 56.82 55.68

Page 168: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 168Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

72052 TC 34.87 33.13 38.10 37.34 37.34 36.59 72052 26 18.20 17.29 19.88 19.48 19.48 19.09 72070 31.92 30.32 34.87 34.17 34.17 33.49 72070 TC 20.73 19.69 22.64 22.20 22.20 21.75 72070 26 11.19 10.63 12.22 11.98 11.98 11.74 72072 32.58 30.95 35.59 34.88 34.88 34.18 72072 TC 21.72 20.63 23.72 23.25 23.25 22.79 72072 26 10.86 10.32 11.87 11.63 11.63 11.40 72074 36.85 35.01 40.26 39.46 39.46 38.66 72074 TC 25.99 24.69 28.39 27.83 27.83 27.28 72074 26 10.86 10.32 11.87 11.63 11.63 11.40 72080 28.97 27.52 31.65 31.02 31.02 30.39 72080 TC 18.10 17.20 19.78 19.39 19.39 19.00 72080 26 10.86 10.32 11.87 11.63 11.63 11.40 72081 36.67 34.84 40.07 39.26 39.26 38.48 72081 TC 23.36 22.19 25.52 25.01 25.01 24.52 72081 26 13.31 12.64 14.54 14.25 14.25 13.96 72082 58.51 55.58 63.92 62.64 62.64 61.39 72082 TC 42.43 40.31 46.36 45.43 45.43 44.52 72082 26 16.08 15.28 17.57 17.22 17.22 16.87 72083 63.56 60.38 69.44 68.05 68.05 66.69 72083 TC 46.04 43.74 50.30 49.30 49.30 48.31 72083 26 17.52 16.64 19.14 18.76 18.76 18.38 72084 75.90 72.11 82.93 81.27 81.27 79.65 72084 TC 55.57 52.79 60.71 59.49 59.49 58.31 72084 26 20.32 19.30 22.20 21.75 21.75 21.31 72100 32.91 31.26 35.95 35.22 35.22 34.52 72100 TC 21.72 20.63 23.72 23.25 23.25 22.79 72100 26 11.19 10.63 12.22 11.98 11.98 11.74 72110 46.02 43.72 50.28 49.28 49.28 48.29 72110 TC 30.27 28.76 33.07 32.41 32.41 31.76 72110 26 15.75 14.96 17.20 16.86 16.86 16.53 72114 58.54 55.61 63.95 62.68 62.68 61.42 72114 TC 42.10 40.00 46.00 45.08 45.08 44.18 72114 26 16.44 15.62 17.96 17.61 17.61 17.25 72120 37.84 35.95 41.34 40.51 40.51 39.71 72120 TC 26.65 25.32 29.12 28.53 28.53 27.96 72120 26 11.19 10.63 12.22 11.98 11.98 11.74 C 72125 156.82 148.98 171.33 167.90 167.90 164.54 C 72125 TC 103.23 98.07 112.78 110.53 110.53 108.32 72125 26 53.59 50.91 58.55 57.37 57.37 56.22 72126 215.47 204.70 235.41 230.70 230.70 226.09 72126 TC 154.51 146.78 168.80 165.42 165.42 162.10 72126 26 60.96 57.91 66.60 65.26 65.26 63.96 72127 254.40 241.68 277.93 272.38 272.38 266.93 72127 TC 190.99 181.44 208.66 204.48 204.48 200.39 72127 26 63.41 60.24 69.28 67.90 67.90 66.54 C 72128 153.33 145.66 167.51 164.16 164.16 160.89 C 72128 TC 103.23 98.07 112.78 110.53 110.53 108.32

Page 169: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 169Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

72128 26 50.10 47.60 54.74 53.65 53.65 52.58 72129 215.80 205.01 235.76 231.05 231.05 226.42 72129 TC 154.84 147.10 169.17 165.78 165.78 162.47 72129 26 60.96 57.91 66.60 65.26 65.26 63.96 72130 256.04 243.24 279.73 274.14 274.14 268.65 72130 TC 192.64 183.01 210.46 206.25 206.25 202.12 72130 26 63.41 60.24 69.28 67.90 67.90 66.54 C 72131 153.33 145.66 167.51 164.16 164.16 160.89 C 72131 TC 103.23 98.07 112.78 110.53 110.53 108.32 72131 26 50.10 47.60 54.74 53.65 53.65 52.58 72132 215.14 204.38 235.04 230.33 230.33 225.72 72132 TC 154.18 146.47 168.44 165.07 165.07 161.77 72132 26 60.96 57.91 66.60 65.26 65.26 63.96 72133 254.10 241.40 277.61 272.06 272.06 266.62 72133 TC 190.66 181.13 208.30 204.14 204.14 200.05 72133 26 63.44 60.27 69.31 67.92 67.92 66.56 72141 211.68 201.10 231.27 226.64 226.64 222.11 72141 TC 137.42 130.55 150.13 147.13 147.13 144.19 72141 26 74.27 70.56 81.14 79.52 79.52 77.94 72142 305.99 290.69 334.29 327.61 327.61 321.06 72142 TC 216.33 205.51 236.34 231.61 231.61 226.98 72142 26 89.66 85.18 97.96 96.00 96.00 94.08 72146 211.68 201.10 231.27 226.64 226.64 222.11 72146 TC 137.42 130.55 150.13 147.13 147.13 144.19 72146 26 74.27 70.56 81.14 79.52 79.52 77.94 72147 302.68 287.55 330.68 324.07 324.07 317.58 72147 TC 213.70 203.02 233.47 228.80 228.80 224.23 72147 26 88.98 84.53 97.21 95.27 95.27 93.36 72148 210.70 200.17 230.20 225.60 225.60 221.09 72148 TC 136.43 129.61 149.05 146.07 146.07 143.15 72148 26 74.27 70.56 81.14 79.52 79.52 77.94 72149 302.38 287.26 330.35 323.74 323.74 317.26 72149 TC 212.71 202.07 232.38 227.73 227.73 223.18 72149 26 89.66 85.18 97.96 96.00 96.00 94.08 72156 357.83 339.94 390.93 383.11 383.11 375.45 72156 TC 243.28 231.12 265.79 260.48 260.48 255.27 72156 26 114.55 108.82 125.14 122.64 122.64 120.19 72157 358.49 340.57 391.66 383.82 383.82 376.14 72157 TC 243.94 231.74 266.50 261.18 261.18 255.96 72157 26 114.55 108.82 125.14 122.64 122.64 120.19 72158 357.17 339.31 390.21 382.40 382.40 374.75 72158 TC 242.62 230.49 265.06 259.76 259.76 254.56 72158 26 114.55 108.82 125.14 122.64 122.64 120.19 72159 390.82 371.28 426.97 418.43 418.43 410.06 72159 TC 300.47 285.45 328.27 321.70 321.70 315.27 72159 26 90.35 85.83 98.70 96.73 96.73 94.79 72170 29.81 28.32 32.57 31.91 31.91 31.28 72170 TC 21.06 20.01 23.01 22.55 22.55 22.10 72170 26 8.74 8.30 9.55 9.35 9.35 9.17

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 170Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

72190 35.84 34.05 39.16 38.38 38.38 37.61 72190 TC 25.01 23.76 27.32 26.77 26.77 26.23 72190 26 10.83 10.29 11.83 11.59 11.59 11.36 72191 288.00 273.60 314.64 308.35 308.35 302.19 72191 TC 197.59 187.71 215.87 211.55 211.55 207.32 72191 26 90.41 85.89 98.77 96.80 96.80 94.86 72192 138.48 131.56 151.29 148.27 148.27 145.30 72192 TC 83.84 79.65 91.60 89.77 89.77 87.98 72192 26 54.64 51.91 59.70 58.50 58.50 57.33 72193 212.66 202.03 232.33 227.69 227.69 223.13 72193 TC 154.51 146.78 168.80 165.42 165.42 162.10 72193 26 58.16 55.25 63.54 62.27 62.27 61.03 72194 244.72 232.48 267.35 262.00 262.00 256.76 72194 TC 183.76 174.57 200.76 196.74 196.74 192.81 72194 26 60.96 57.91 66.60 65.26 65.26 63.96 C 72195 323.71 307.52 353.65 346.58 346.58 339.64 C 72195 TC 250.51 237.98 273.68 268.20 268.20 262.84 72195 26 73.20 69.54 79.97 78.37 78.37 76.81 72196 385.69 366.41 421.37 412.94 412.94 404.69 72196 TC 298.83 283.89 326.47 319.94 319.94 313.55 72196 26 86.86 82.52 94.90 93.00 93.00 91.14 72197 474.43 450.71 518.32 507.96 507.96 497.80 72197 TC 361.28 343.22 394.70 386.81 386.81 379.07 72197 26 113.15 107.49 123.61 121.14 121.14 118.71 72198 376.03 357.23 410.81 402.60 402.60 394.55 72198 TC 286.67 272.34 313.19 306.92 306.92 300.78 72198 26 89.37 84.90 97.64 95.68 95.68 93.77 72200 26.85 25.51 29.34 28.75 28.75 28.18 72200 TC 18.10 17.20 19.78 19.39 19.39 19.00 72200 26 8.74 8.30 9.55 9.35 9.35 9.17 72202 30.85 29.31 33.71 33.03 33.03 32.37 72202 TC 21.39 20.32 23.37 22.90 22.90 22.44 72202 26 9.46 8.99 10.34 10.13 10.13 9.92 72220 26.52 25.19 28.97 28.39 28.39 27.83 72220 TC 17.78 16.89 19.42 19.03 19.03 18.65 72220 26 8.74 8.30 9.55 9.35 9.35 9.17 72240 93.22 88.56 101.84 99.81 99.81 97.81 72240 TC 47.69 45.31 52.11 51.06 51.06 50.04 72240 26 45.53 43.25 49.74 48.75 48.75 47.77 72255 92.92 88.27 101.51 99.48 99.48 97.49 72255 TC 46.70 44.37 51.03 50.00 50.00 49.00 72255 26 46.22 43.91 50.50 49.48 49.48 48.50 72265 87.73 83.34 95.84 93.92 93.92 92.05 72265 TC 46.04 43.74 50.30 49.30 49.30 48.31 72265 26 41.68 39.60 45.54 44.63 44.63 43.73 72270 121.82 115.73 133.09 130.43 130.43 127.82 72270 TC 54.92 52.17 60.00 58.80 58.80 57.63 72270 26 66.90 63.56 73.09 71.63 71.63 70.20 72275 109.19 103.73 119.29 116.91 116.91 114.57

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 171Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

72275 TC 70.04 66.54 76.52 74.99 74.99 73.50 72275 26 39.15 37.19 42.77 41.92 41.92 41.08 72285 109.13 103.67 119.22 116.84 116.84 114.51 72285 TC 48.67 46.24 53.18 52.12 52.12 51.07 72285 26 60.46 57.44 66.06 64.73 64.73 63.43 72295 94.00 89.30 102.70 100.64 100.64 98.62 72295 TC 50.64 48.11 55.33 54.22 54.22 53.14 72295 26 43.35 41.18 47.36 46.41 46.41 45.48 73000 25.83 24.54 28.22 27.66 27.66 27.11 73000 TC 17.45 16.58 19.07 18.69 18.69 18.32 73000 26 8.39 7.97 9.17 8.98 8.98 8.80 73010 28.16 26.75 30.76 30.15 30.15 29.56 73010 TC 19.09 18.14 20.86 20.45 20.45 20.03 73010 26 9.07 8.62 9.91 9.72 9.72 9.52 73020 21.53 20.45 23.52 23.05 23.05 22.59 73020 TC 13.83 13.14 15.11 14.81 14.81 14.51 73020 26 7.70 7.32 8.42 8.25 8.25 8.08 73030 27.21 25.85 29.73 29.13 29.13 28.54 73030 TC 17.78 16.89 19.42 19.03 19.03 18.65 73030 26 9.43 8.96 10.30 10.10 10.10 9.89 73040 94.05 89.35 102.75 100.69 100.69 98.68 73040 TC 66.75 63.41 72.92 71.46 71.46 70.04 73040 26 27.30 25.94 29.83 29.23 29.23 28.65 73050 33.18 31.52 36.25 35.52 35.52 34.81 73050 TC 22.71 21.57 24.81 24.31 24.31 23.83 73050 26 10.47 9.95 11.44 11.21 11.21 10.99 73060 27.15 25.79 29.66 29.06 29.06 28.47 73060 TC 18.76 17.82 20.49 20.08 20.08 19.68 73060 26 8.39 7.97 9.17 8.98 8.98 8.80 73070 25.47 24.20 27.83 27.28 27.28 26.74 73070 TC 17.45 16.58 19.07 18.69 18.69 18.32 73070 26 8.03 7.63 8.77 8.60 8.60 8.43 73080 29.15 27.69 31.84 31.21 31.21 30.59 73080 TC 20.41 19.39 22.30 21.85 21.85 21.41 73080 26 8.74 8.30 9.55 9.35 9.35 9.17 73085 91.45 86.88 99.91 97.91 97.91 95.96 73085 TC 62.81 59.67 68.62 67.25 67.25 65.91 73085 26 28.64 27.21 31.29 30.67 30.67 30.06 73090 24.19 22.98 26.43 25.90 25.90 25.38 73090 TC 15.80 15.01 17.26 16.92 16.92 16.58 73090 26 8.39 7.97 9.17 8.98 8.98 8.80 73092 25.50 24.23 27.86 27.31 27.31 26.77 73092 TC 17.45 16.58 19.07 18.69 18.69 18.32 73092 26 8.06 7.66 8.81 8.64 8.64 8.46 73100 27.15 25.79 29.66 29.06 29.06 28.47 73100 TC 18.76 17.82 20.49 20.08 20.08 19.68 73100 26 8.39 7.97 9.17 8.98 8.98 8.80 73110 33.09 31.44 36.16 35.43 35.43 34.72 73110 TC 24.35 23.13 26.60 26.07 26.07 25.55

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 172Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

73110 26 8.74 8.30 9.55 9.35 9.35 9.17 73115 100.32 95.30 109.60 107.40 107.40 105.25 73115 TC 72.01 68.41 78.67 77.10 77.10 75.56 73115 26 28.32 26.90 30.94 30.31 30.31 29.70 73120 24.52 23.29 26.78 26.24 26.24 25.71 73120 TC 16.13 15.32 17.62 17.26 17.26 16.92 73120 26 8.39 7.97 9.17 8.98 8.98 8.80 73130 28.82 27.38 31.49 30.85 30.85 30.23 73130 TC 20.08 19.08 21.94 21.51 21.51 21.08 73130 26 8.74 8.30 9.55 9.35 9.35 9.17 73140 29.36 27.89 32.07 31.43 31.43 30.80 73140 TC 22.38 21.26 24.45 23.95 23.95 23.47 73140 26 6.98 6.63 7.62 7.48 7.48 7.33 C 73200 153.33 145.66 167.51 164.16 164.16 160.89 C 73200 TC 103.23 98.07 112.78 110.53 110.53 108.32 73200 26 50.10 47.60 54.74 53.65 53.65 52.58 73201 209.71 199.22 229.10 224.53 224.53 220.04 73201 TC 151.55 143.97 165.57 162.25 162.25 159.01 73201 26 58.16 55.25 63.54 62.27 62.27 61.03 73202 260.50 247.48 284.60 278.91 278.91 273.33 73202 TC 199.54 189.56 217.99 213.64 213.64 209.36 73202 26 60.96 57.91 66.60 65.26 65.26 63.96 C 73206 306.71 291.37 335.08 328.37 328.37 321.80 C 73206 TC 216.98 206.13 237.05 232.31 232.31 227.67 73206 26 89.73 85.24 98.03 96.07 96.07 94.15 C 73218 318.12 302.21 347.54 340.60 340.60 333.79 C 73218 TC 250.51 237.98 273.68 268.20 268.20 262.84 73218 26 67.61 64.23 73.86 72.39 72.39 70.94 73219 378.76 359.82 413.79 405.51 405.51 397.41 73219 TC 297.51 282.63 325.02 318.53 318.53 312.16 73219 26 81.25 77.19 88.77 87.00 87.00 85.26 73220 468.49 445.07 511.83 501.60 501.60 491.57 73220 TC 360.95 342.90 394.34 386.45 386.45 378.72 73220 26 107.54 102.16 117.48 115.14 115.14 112.84 73221 222.48 211.36 243.06 238.20 238.20 233.44 73221 TC 154.53 146.80 168.82 165.44 165.44 162.13 73221 26 67.94 64.54 74.22 72.74 72.74 71.29 73222 354.44 336.72 387.23 379.49 379.49 371.90 73222 TC 273.19 259.53 298.46 292.49 292.49 286.64 73222 26 81.25 77.19 88.77 87.00 87.00 85.26 73223 439.89 417.90 480.59 470.97 470.97 461.55 73223 TC 332.35 315.73 363.09 355.83 355.83 348.71 73223 26 107.54 102.16 117.48 115.14 115.14 112.84 73225 379.77 360.78 414.90 406.59 406.59 398.46 73225 TC 294.23 279.52 321.45 315.02 315.02 308.72 73225 26 85.55 81.27 93.46 91.59 91.59 89.76 73501 27.86 26.47 30.44 29.83 29.83 29.23 73501 TC 18.43 17.51 20.14 19.73 19.73 19.34 73501 26 9.43 8.96 10.30 10.10 10.10 9.89

Page 173: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 173Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

73502 38.83 36.89 42.42 41.57 41.57 40.74 73502 TC 27.64 26.26 30.20 29.59 29.59 29.00 73502 26 11.19 10.63 12.22 11.98 11.98 11.74 73503 48.53 46.10 53.02 51.96 51.96 50.92 73503 TC 34.21 32.50 37.38 36.63 36.63 35.89 73503 26 14.32 13.60 15.64 15.33 15.33 15.02 73521 37.18 35.32 40.62 39.80 39.80 39.01 73521 TC 25.66 24.38 28.04 27.47 27.47 26.92 73521 26 11.52 10.94 12.58 12.33 12.33 12.09 73522 45.96 43.66 50.21 49.21 49.21 48.22 73522 TC 30.92 29.37 33.78 33.10 33.10 32.43 73522 26 15.04 14.29 16.43 16.10 16.10 15.78 73523 53.25 50.59 58.18 57.02 57.02 55.88 73523 TC 37.17 35.31 40.61 39.79 39.79 39.00 73523 26 16.08 15.28 17.57 17.22 17.22 16.87 73525 95.39 90.62 104.21 102.13 102.13 100.08 73525 TC 66.75 63.41 72.92 71.46 71.46 70.04 73525 26 28.64 27.21 31.29 30.67 30.67 30.06 73551 26.16 24.85 28.58 28.00 28.00 27.44 73551 TC 17.78 16.89 19.42 19.03 19.03 18.65 73551 26 8.39 7.97 9.17 8.98 8.98 8.80 73552 30.49 28.97 33.32 32.65 32.65 31.99 73552 TC 21.06 20.01 23.01 22.55 22.55 22.10 73552 26 9.43 8.96 10.30 10.10 10.10 9.89 73560 29.12 27.66 31.81 31.18 31.18 30.56 73560 TC 20.73 19.69 22.64 22.20 22.20 21.75 73560 26 8.39 7.97 9.17 8.98 8.98 8.80 73562 33.45 31.78 36.55 35.81 35.81 35.10 73562 TC 24.02 22.82 26.24 25.71 25.71 25.20 73562 26 9.43 8.96 10.30 10.10 10.10 9.89 73564 36.85 35.01 40.26 39.46 39.46 38.66 73564 TC 25.66 24.38 28.04 27.47 27.47 26.92 73564 26 11.19 10.63 12.22 11.98 11.98 11.74 73565 33.39 31.72 36.48 35.75 35.75 35.04 73565 TC 24.68 23.45 26.97 26.43 26.43 25.90 73565 26 8.71 8.27 9.51 9.32 9.32 9.13 73580 108.21 102.80 118.22 115.85 115.85 113.54 73580 TC 79.90 75.91 87.30 85.55 85.55 83.84 73580 26 28.32 26.90 30.94 30.31 30.31 29.70 73590 26.82 25.48 29.30 28.72 28.72 28.14 73590 TC 18.43 17.51 20.14 19.73 19.73 19.34 73590 26 8.39 7.97 9.17 8.98 8.98 8.80 73592 26.16 24.85 28.58 28.00 28.00 27.44 73592 TC 18.10 17.20 19.78 19.39 19.39 19.00 73592 26 8.06 7.66 8.81 8.64 8.64 8.46 73600 28.13 26.72 30.73 30.12 30.12 29.52 73600 TC 19.75 18.76 21.57 21.14 21.14 20.71 73600 26 8.39 7.97 9.17 8.98 8.98 8.80 73610 29.15 27.69 31.84 31.21 31.21 30.59

Page 174: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 174Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

73610 TC 20.41 19.39 22.30 21.85 21.85 21.41 73610 26 8.74 8.30 9.55 9.35 9.35 9.17 73615 98.33 93.41 107.42 105.27 105.27 103.17 73615 TC 69.71 66.22 76.15 74.64 74.64 73.14 73615 26 28.62 27.19 31.27 30.65 30.65 30.04 73620 24.52 23.29 26.78 26.24 26.24 25.71 73620 TC 16.79 15.95 18.34 17.97 17.97 17.62 73620 26 7.73 7.34 8.44 8.27 8.27 8.11 73630 27.18 25.82 29.69 29.10 29.10 28.51 73630 TC 18.76 17.82 20.49 20.08 20.08 19.68 73630 26 8.41 7.99 9.19 9.00 9.00 8.82 73650 25.50 24.23 27.86 27.31 27.31 26.77 73650 TC 17.45 16.58 19.07 18.69 18.69 18.32 73650 26 8.06 7.66 8.81 8.64 8.64 8.46 73660 26.40 25.08 28.84 28.27 28.27 27.70 73660 TC 19.75 18.76 21.57 21.14 21.14 20.71 73660 26 6.65 6.32 7.27 7.12 7.12 6.98 C 73700 153.33 145.66 167.51 164.16 164.16 160.89 C 73700 TC 103.23 98.07 112.78 110.53 110.53 108.32 73700 26 50.10 47.60 54.74 53.65 53.65 52.58 73701 212.66 202.03 232.33 227.69 227.69 223.13 73701 TC 154.51 146.78 168.80 165.42 165.42 162.10 73701 26 58.16 55.25 63.54 62.27 62.27 61.03 73702 257.54 244.66 281.36 275.74 275.74 270.22 73702 TC 196.91 187.06 215.12 210.82 210.82 206.60 73702 26 60.63 57.60 66.24 64.92 64.92 63.62 C 73706 311.63 296.05 340.46 333.65 333.65 326.98 C 73706 TC 217.01 206.16 237.08 232.35 232.35 227.70 73706 26 94.62 89.89 103.37 101.30 101.30 99.28 C 73718 318.12 302.21 347.54 340.60 340.60 333.79 C 73718 TC 250.51 237.98 273.68 268.20 268.20 262.84 73718 26 67.61 64.23 73.86 72.39 72.39 70.94 73719 378.44 359.52 413.45 405.18 405.18 397.07 73719 TC 297.51 282.63 325.02 318.53 318.53 312.16 73719 26 80.92 76.87 88.40 86.63 86.63 84.89 73720 471.12 447.56 514.69 504.40 504.40 494.32 73720 TC 363.58 345.40 397.21 389.26 389.26 381.48 73720 26 107.54 102.16 117.48 115.14 115.14 112.84 73721 222.81 211.67 243.42 238.56 238.56 233.78 73721 TC 154.86 147.12 169.19 165.81 165.81 162.50 73721 26 67.94 64.54 74.22 72.74 72.74 71.29 73722 357.73 339.84 390.82 383.00 383.00 375.34 73722 TC 276.48 262.66 302.06 296.02 296.02 290.10 73722 26 81.25 77.19 88.77 87.00 87.00 85.26 73723 441.54 419.46 482.38 472.73 472.73 463.28 73723 TC 334.00 317.30 364.90 357.59 357.59 350.44 73723 26 107.54 102.16 117.48 115.14 115.14 112.84 73725 376.75 357.91 411.60 403.36 403.36 395.30 73725 TC 286.67 272.34 313.19 306.92 306.92 300.78

Page 175: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 175Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

73725 26 90.08 85.58 98.42 96.45 96.45 94.52 74000 22.28 21.17 24.35 23.86 23.86 23.39 74000 TC 13.17 12.51 14.39 14.10 14.10 13.81 74000 26 9.10 8.65 9.95 9.75 9.75 9.56 74010 33.27 31.61 36.35 35.63 35.63 34.91 74010 TC 21.72 20.63 23.72 23.25 23.25 22.79 74010 26 11.55 10.97 12.62 12.36 12.36 12.12 74020 35.39 33.62 38.66 37.89 37.89 37.13 74020 TC 21.72 20.63 23.72 23.25 23.25 22.79 74020 26 13.67 12.99 14.94 14.64 14.64 14.35 74022 42.11 40.00 46.00 45.08 45.08 44.18 74022 TC 25.99 24.69 28.39 27.83 27.83 27.28 74022 26 16.11 15.30 17.60 17.24 17.24 16.89 74150 142.08 134.98 155.23 152.12 152.12 149.07 74150 TC 82.53 78.40 90.16 88.35 88.35 86.58 74150 26 59.56 56.58 65.07 63.77 63.77 62.49 74160 217.26 206.40 237.36 232.61 232.61 227.95 74160 TC 153.52 145.84 167.72 164.36 164.36 161.07 74160 26 63.74 60.55 69.63 68.24 68.24 66.87 74170 246.92 234.57 269.76 264.36 264.36 259.07 74170 TC 176.86 168.02 193.22 189.36 189.36 185.58 74170 26 70.06 66.56 76.54 75.01 75.01 73.52 74174 366.11 347.80 399.97 391.97 391.97 384.12 74174 TC 256.76 243.92 280.51 274.90 274.90 269.40 74174 26 109.36 103.89 119.47 117.08 117.08 114.74 74175 289.32 274.85 316.08 309.75 309.75 303.55 74175 TC 198.91 188.96 217.30 212.96 212.96 208.70 74175 26 90.41 85.89 98.77 96.80 96.80 94.86 74176 190.78 181.24 208.43 204.26 204.26 200.18 74176 TC 103.56 98.38 113.14 110.87 110.87 108.65 74176 26 87.22 82.86 95.29 93.38 93.38 91.52 74177 293.24 278.58 320.37 313.96 313.96 307.68 74177 TC 202.17 192.06 220.87 216.45 216.45 212.13 74177 26 91.07 86.52 99.50 97.51 97.51 95.55 74178 332.63 316.00 363.40 356.13 356.13 349.01 74178 TC 232.10 220.50 253.58 248.50 248.50 243.54 74178 26 100.53 95.50 109.83 107.63 107.63 105.48 74181 312.53 296.90 341.44 334.60 334.60 327.91 74181 TC 239.66 227.68 261.83 256.60 256.60 251.47 74181 26 72.87 69.23 79.61 78.03 78.03 76.46 74182 424.80 403.56 464.09 454.81 454.81 445.72 74182 TC 338.27 321.36 369.56 362.17 362.17 354.92 74182 26 86.53 82.20 94.53 92.64 92.64 90.79 74183 475.08 451.33 519.03 508.65 508.65 498.47 74183 TC 361.93 343.83 395.40 387.49 387.49 379.74 74183 26 113.15 107.49 123.61 121.14 121.14 118.71 74185 378.01 359.11 412.98 404.72 404.72 396.62 74185 TC 288.64 274.21 315.34 309.04 309.04 302.86 74185 26 89.37 84.90 97.64 95.68 95.68 93.77

Page 176: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 176Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

74190 202.79 192.65 221.55 217.12 217.12 212.77 74190 TC 179.28 170.32 195.87 191.95 191.95 188.11 74190 26 23.51 22.33 25.68 25.16 25.16 24.66 74210 72.79 69.15 79.52 77.94 77.94 76.37 74210 TC 54.92 52.17 60.00 58.80 58.80 57.63 74210 26 17.87 16.98 19.53 19.14 19.14 18.76 74220 83.30 79.14 91.01 89.19 89.19 87.41 74220 TC 60.18 57.17 65.75 64.43 64.43 63.15 74220 26 23.12 21.96 25.25 24.75 24.75 24.25 C 74230 118.67 112.74 129.65 127.06 127.06 124.52 C 74230 TC 92.06 87.46 100.58 98.57 98.57 96.60 74230 26 26.62 25.29 29.08 28.50 28.50 27.92 74235 128.81 122.37 140.73 137.91 137.91 135.15 74235 TC 66.49 63.17 72.65 71.20 71.20 69.77 74235 26 62.32 59.20 68.08 66.72 66.72 65.39 74240 106.68 101.35 116.55 114.22 114.22 111.93 74240 TC 72.01 68.41 78.67 77.10 77.10 75.56 74240 26 34.67 32.94 37.88 37.12 37.12 36.37 74241 110.95 105.40 121.21 118.78 118.78 116.40 74241 TC 76.28 72.47 83.34 81.67 81.67 80.04 74241 26 34.67 32.94 37.88 37.12 37.12 36.37 74245 161.26 153.20 176.18 172.66 172.66 169.21 74245 TC 115.72 109.93 126.42 123.89 123.89 121.42 74245 26 45.53 43.25 49.74 48.75 48.75 47.77 74246 119.83 113.84 130.92 128.29 128.29 125.73 74246 TC 85.16 80.90 93.04 91.17 91.17 89.34 74246 26 34.67 32.94 37.88 37.12 37.12 36.37 C 74247 127.06 120.71 138.82 136.05 136.05 133.32 C 74247 TC 92.39 87.77 100.94 98.91 98.91 96.93 74247 26 34.67 32.94 37.88 37.12 37.12 36.37 74249 172.76 164.12 188.74 184.97 184.97 181.26 74249 TC 127.23 120.87 139.00 136.22 136.22 133.49 74249 26 45.53 43.25 49.74 48.75 48.75 47.77 74250 97.46 92.59 106.48 104.35 104.35 102.27 74250 TC 73.98 70.28 80.82 79.20 79.20 77.61 74250 26 23.48 22.31 25.66 25.14 25.14 24.63 C 74251 210.55 200.02 230.02 225.42 225.42 220.92 C 74251 TC 175.87 167.08 192.14 188.30 188.30 184.54 74251 26 34.67 32.94 37.88 37.12 37.12 36.37 C 74260 201.09 191.04 219.70 215.30 215.30 211.00 C 74260 TC 175.87 167.08 192.14 188.30 188.30 184.54 74260 26 25.21 23.95 27.54 26.99 26.99 26.45 C 74261 223.72 212.53 244.41 239.52 239.52 234.73 C 74261 TC 103.23 98.07 112.78 110.53 110.53 108.32 74261 26 120.49 114.47 131.64 129.01 129.01 126.43 C 74262 341.69 324.61 373.30 365.84 365.84 358.52 C 74262 TC 216.63 205.80 236.67 231.93 231.93 227.30 74262 26 125.06 118.81 136.63 133.89 133.89 131.22 C 74270 127.06 120.71 138.82 136.05 136.05 133.32

Page 177: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 177Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

C 74270 TC 92.39 87.77 100.94 98.91 98.91 96.93 74270 26 34.67 32.94 37.88 37.12 37.12 36.37 74280 199.65 189.67 218.12 213.76 213.76 209.48 74280 TC 149.91 142.41 163.77 160.49 160.49 157.29 74280 26 49.74 47.25 54.34 53.26 53.26 52.19 74283 196.26 186.45 214.42 210.13 210.13 205.93 74283 TC 94.36 89.64 103.09 101.03 101.03 99.00 74283 26 101.90 96.81 111.33 109.10 109.10 106.92 74290 65.77 62.48 71.85 70.41 70.41 69.01 74290 TC 49.66 47.18 54.26 53.18 53.18 52.12 74290 26 16.11 15.30 17.60 17.24 17.24 16.89 74300 120.89 114.85 132.08 129.43 129.43 126.85 74300 TC 102.66 97.53 112.16 109.92 109.92 107.72 74300 26 18.23 17.32 19.92 19.52 19.52 19.12 74301 113.19 107.53 123.66 121.19 121.19 118.76 74301 TC 102.66 97.53 112.16 109.92 109.92 107.72 74301 26 10.53 10.00 11.50 11.27 11.27 11.04 74328 26 35.36 33.59 38.63 37.86 37.86 37.10 74329 26 35.69 33.91 39.00 38.21 38.21 37.46 74330 26 45.51 43.23 49.71 48.73 48.73 47.75 74340 105.14 99.88 114.86 112.56 112.56 110.31 74340 TC 78.17 74.26 85.40 83.69 83.69 82.01 74340 26 26.97 25.62 29.46 28.88 28.88 28.30 74355 141.42 134.35 154.50 151.41 151.41 148.38 74355 TC 102.85 97.71 112.37 110.12 110.12 107.92 74355 26 38.57 36.64 42.14 41.30 41.30 40.47 74360 94.58 89.85 103.33 101.26 101.26 99.23 74360 TC 66.57 63.24 72.73 71.28 71.28 69.85 74360 26 28.01 26.61 30.60 29.99 29.99 29.39 74363 263.47 250.30 287.85 282.08 282.08 276.44 74363 TC 220.65 209.62 241.06 236.24 236.24 231.52 74363 26 42.82 40.68 46.78 45.85 45.85 44.93 74400 103.11 97.95 112.64 110.39 110.39 108.18 74400 TC 78.58 74.65 85.85 84.13 84.13 82.46 74400 26 24.53 23.30 26.80 26.25 26.25 25.73 74410 101.47 96.40 110.86 108.64 108.64 106.47 74410 TC 77.27 73.41 84.42 82.73 82.73 81.08 74410 26 24.20 22.99 26.44 25.91 25.91 25.39 74415 127.76 121.37 139.58 136.78 136.78 134.04 74415 TC 103.23 98.07 112.78 110.53 110.53 108.32 74415 26 24.53 23.30 26.80 26.25 26.25 25.73 74420 163.94 155.74 179.10 175.52 175.52 172.02 74420 TC 146.42 139.10 159.97 156.77 156.77 153.63 74420 26 17.52 16.64 19.14 18.76 18.76 18.38 74425 163.96 155.76 179.12 175.54 175.54 172.03 74425 TC 146.42 139.10 159.97 156.77 156.77 153.63 74425 26 17.54 16.66 19.16 18.78 18.78 18.40 74430 35.86 34.07 39.18 38.40 38.40 37.63 74430 TC 19.75 18.76 21.57 21.14 21.14 20.71

Page 178: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 178Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

74430 26 16.11 15.30 17.60 17.24 17.24 16.89 74440 76.11 72.30 83.15 81.48 81.48 79.84 74440 TC 57.88 54.99 63.24 61.97 61.97 60.73 74440 26 18.23 17.32 19.92 19.52 19.52 19.12 74445 200.41 190.39 218.95 214.57 214.57 210.28 74445 TC 146.37 139.05 159.91 156.71 156.71 153.57 74445 26 54.04 51.34 59.04 57.86 57.86 56.70 74450 162.94 154.79 178.01 174.44 174.44 170.96 74450 TC 146.47 139.15 160.02 156.83 156.83 153.69 74450 26 16.47 15.65 18.00 17.64 17.64 17.28 74455 76.32 72.50 83.38 81.71 81.71 80.07 74455 TC 59.85 56.86 65.39 64.08 64.08 62.80 74455 26 16.47 15.65 18.00 17.64 17.64 17.28 74470 129.08 122.63 141.02 138.21 138.21 135.45 74470 TC 102.76 97.62 112.26 110.02 110.02 107.82 74470 26 26.32 25.00 28.75 28.18 28.18 27.61 74485 86.79 82.45 94.82 92.92 92.92 91.06 74485 TC 60.83 57.79 66.46 65.12 65.12 63.83 74485 26 25.96 24.66 28.36 27.80 27.80 27.24 74710 34.93 33.18 38.16 37.40 37.40 36.65 74710 TC 17.78 16.89 19.42 19.03 19.03 18.65 74710 26 17.16 16.30 18.75 18.37 18.37 18.00 C 74712 400.78 380.74 437.85 429.10 429.10 420.52 C 74712 TC 250.51 237.98 273.68 268.20 268.20 262.84 74712 26 150.27 142.76 164.17 160.89 160.89 157.67 74713 219.82 208.83 240.15 235.35 235.35 230.64 74713 TC 130.51 123.98 142.58 139.73 139.73 136.93 74713 26 89.31 84.84 97.57 95.61 95.61 93.70 74740 70.22 66.71 76.72 75.19 75.19 73.68 74740 TC 51.30 48.74 56.05 54.94 54.94 53.83 74740 26 18.92 17.97 20.67 20.25 20.25 19.85 74742 208.79 198.35 228.10 223.54 223.54 219.06 74742 TC 179.28 170.32 195.87 191.95 191.95 188.11 74742 26 29.51 28.03 32.23 31.59 31.59 30.96 74775 177.60 168.72 194.03 190.15 190.15 186.35 74775 TC 146.42 139.10 159.97 156.77 156.77 153.63 74775 26 31.18 29.62 34.06 33.38 33.38 32.72 75557 301.39 286.32 329.27 322.68 322.68 316.23 75557 TC 186.06 176.76 203.27 199.20 199.20 195.22 75557 26 115.33 109.56 125.99 123.48 123.48 121.00 75559 411.95 391.35 450.05 441.05 441.05 432.23 75559 TC 269.22 255.76 294.12 288.24 288.24 282.47 75559 26 142.73 135.59 155.93 152.81 152.81 149.75 75561 399.14 379.18 436.06 427.34 427.34 418.80 75561 TC 271.55 257.97 296.67 290.73 290.73 284.91 75561 26 127.60 121.22 139.40 136.62 136.62 133.88 75563 472.96 449.31 516.71 506.37 506.37 496.24 75563 TC 326.77 310.43 356.99 349.85 349.85 342.86 75563 26 146.19 138.88 159.71 156.52 156.52 153.39

Page 179: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 179Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

75565 51.38 48.81 56.13 55.00 55.00 53.90 75565 TC 39.11 37.15 42.72 41.87 41.87 41.03 75565 26 12.26 11.65 13.40 13.13 13.13 12.87 C 75571 40.59 38.56 44.34 43.46 43.46 42.58 C 75571 TC 11.86 11.27 12.96 12.70 12.70 12.44 75571 26 28.74 27.30 31.40 30.76 30.76 30.15 75572 268.05 254.65 292.85 286.99 286.99 281.26 75572 TC 181.49 172.42 198.28 194.32 194.32 190.43 75572 26 86.56 82.23 94.56 92.68 92.68 90.83 C 75573 342.82 325.68 374.53 367.05 367.05 359.71 C 75573 TC 216.98 206.13 237.05 232.31 232.31 227.67 75573 26 125.83 119.54 137.47 134.72 134.72 132.03 C 75574 334.79 318.05 365.76 358.44 358.44 351.28 C 75574 TC 216.66 205.83 236.70 231.97 231.97 227.33 75574 26 118.13 112.22 129.05 126.48 126.48 123.95 75600 184.68 175.45 201.77 197.73 197.73 193.78 75600 TC 160.42 152.40 175.26 171.75 171.75 168.31 75600 26 24.25 23.04 26.50 25.97 25.97 25.45 75605 132.49 125.87 144.75 141.85 141.85 139.01 75605 TC 76.61 72.78 83.70 82.02 82.02 80.37 75605 26 55.88 53.09 61.05 59.83 59.83 58.64 75625 132.24 125.63 144.47 141.59 141.59 138.76 75625 TC 76.28 72.47 83.34 81.67 81.67 80.04 75625 26 55.96 53.16 61.13 59.92 59.92 58.72 75630 164.52 156.29 179.73 176.13 176.13 172.62 75630 TC 76.28 72.47 83.34 81.67 81.67 80.04 75630 26 88.24 83.83 96.40 94.47 94.47 92.59 C 75635 336.19 319.38 367.29 359.94 359.94 352.74 C 75635 TC 217.01 206.16 237.08 232.35 232.35 227.70 75635 26 119.17 113.21 130.19 127.59 127.59 125.04 75658 159.77 151.78 174.55 171.05 171.05 167.64 75658 TC 95.70 90.92 104.56 102.47 102.47 100.42 75658 26 64.07 60.87 70.00 68.60 68.60 67.23 75705 234.02 222.32 255.67 250.55 250.55 245.54 75705 TC 119.69 113.71 130.77 128.16 128.16 125.59 75705 26 114.33 108.61 124.90 122.41 122.41 119.96 75710 155.93 148.13 170.35 166.95 166.95 163.61 75710 TC 99.32 94.35 108.50 106.33 106.33 104.20 75710 26 56.61 53.78 61.85 60.61 60.61 59.40 75716 178.83 169.89 195.37 191.46 191.46 187.63 75716 TC 114.13 108.42 124.68 122.19 122.19 119.75 75716 26 64.70 61.47 70.69 69.28 69.28 67.90 75726 142.62 135.49 155.81 152.70 152.70 149.64 75726 TC 87.13 82.77 95.19 93.28 93.28 91.41 75726 26 55.49 52.72 60.63 59.42 59.42 58.24 75731 163.63 155.45 178.77 175.19 175.19 171.68 75731 TC 106.55 101.22 116.40 114.08 114.08 111.80 75731 26 57.08 54.23 62.36 61.12 61.12 59.90 75733 174.98 166.23 191.16 187.35 187.35 183.60

Page 180: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 180Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

75733 TC 111.50 105.93 121.82 119.38 119.38 116.99 75733 26 63.47 60.30 69.35 67.95 67.95 66.60 75736 153.22 145.56 167.39 164.05 164.05 160.77 75736 TC 97.67 92.79 106.71 104.57 104.57 102.48 75736 26 55.55 52.77 60.69 59.47 59.47 58.28 75741 144.76 137.52 158.15 154.99 154.99 151.88 75741 TC 81.21 77.15 88.72 86.95 86.95 85.22 75741 26 63.55 60.37 69.43 68.03 68.03 66.68 75743 162.96 154.81 178.03 174.47 174.47 170.98 75743 TC 82.20 78.09 89.80 88.01 88.01 86.25 75743 26 80.77 76.73 88.24 86.48 86.48 84.76 75746 144.92 137.67 158.32 155.16 155.16 152.05 75746 TC 88.80 84.36 97.01 95.07 95.07 93.17 75746 26 56.12 53.31 61.31 60.08 60.08 58.88 75756 159.24 151.28 173.97 170.49 170.49 167.08 75756 TC 102.93 97.78 112.45 110.19 110.19 107.99 75756 26 56.31 53.49 61.51 60.28 60.28 59.08 75774 82.68 78.55 90.33 88.53 88.53 86.76 75774 TC 65.11 61.85 71.13 69.70 69.70 68.31 75774 26 17.57 16.69 19.19 18.81 18.81 18.43 75791 307.42 292.05 335.86 329.14 329.14 322.56 75791 TC 220.90 209.86 241.34 236.51 236.51 231.78 75791 26 86.52 82.19 94.52 92.63 92.63 90.78 C 75801 220.12 209.11 240.48 235.67 235.67 230.95 C 75801 TC 175.54 166.76 191.77 187.93 187.93 184.17 75801 26 44.58 42.35 48.70 47.73 47.73 46.77 75803 237.71 225.82 259.69 254.50 254.50 249.40 75803 TC 179.22 170.26 195.80 191.88 191.88 188.04 75803 26 58.49 55.57 63.91 62.63 62.63 61.38 75805 219.86 208.87 240.20 235.39 235.39 230.69 75805 TC 179.22 170.26 195.80 191.88 191.88 188.04 75805 26 40.64 38.61 44.40 43.52 43.52 42.64 75807 238.06 226.16 260.08 254.89 254.89 249.79 75807 TC 179.22 170.26 195.80 191.88 191.88 188.04 75807 26 58.84 55.90 64.29 63.00 63.00 61.73 75809 93.52 88.84 102.17 100.12 100.12 98.12 75809 TC 69.71 66.22 76.15 74.64 74.64 73.14 75809 26 23.81 22.62 26.01 25.50 25.50 24.99 75810 633.17 601.51 691.74 677.90 677.90 664.34 75810 TC 575.73 546.94 628.98 616.40 616.40 604.07 75810 26 57.44 54.57 62.76 61.50 61.50 60.27 75820 109.39 103.92 119.51 117.12 117.12 114.77 75820 TC 74.64 70.91 81.55 79.91 79.91 78.32 75820 26 34.76 33.02 37.97 37.21 37.21 36.47 75822 131.24 124.68 143.38 140.52 140.52 137.71 75822 TC 78.91 74.96 86.20 84.48 84.48 82.79 75822 26 52.33 49.71 57.17 56.03 56.03 54.91 75825 130.59 124.06 142.67 139.82 139.82 137.02 75825 TC 73.98 70.28 80.82 79.20 79.20 77.61

Page 181: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 181Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

75825 26 56.61 53.78 61.85 60.61 60.61 59.40 75827 132.92 126.27 145.21 142.30 142.30 139.46 75827 TC 76.28 72.47 83.34 81.67 81.67 80.04 75827 26 56.64 53.81 61.88 60.64 60.64 59.43 75831 134.79 128.05 147.26 144.31 144.31 141.43 75831 TC 79.24 75.28 86.57 84.84 84.84 83.13 75831 26 55.55 52.77 60.69 59.47 59.47 58.28 75833 158.08 150.18 172.71 169.26 169.26 165.88 75833 TC 85.51 81.23 93.41 91.55 91.55 89.72 75833 26 72.57 68.94 79.28 77.69 77.69 76.14 75840 141.58 134.50 154.68 151.58 151.58 148.55 75840 TC 84.50 80.28 92.32 90.47 90.47 88.67 75840 26 57.08 54.23 62.36 61.12 61.12 59.90 75842 172.27 163.66 188.21 184.45 184.45 180.76 75842 TC 98.00 93.10 107.07 104.93 104.93 102.83 75842 26 74.27 70.56 81.14 79.52 79.52 77.94 75860 136.73 129.89 149.37 146.38 146.38 143.45 75860 TC 80.88 76.84 88.37 86.60 86.60 84.86 75860 26 55.85 53.06 61.02 59.80 59.80 58.60 75870 140.92 133.87 153.95 150.87 150.87 147.86 75870 TC 83.84 79.65 91.60 89.77 89.77 87.98 75870 26 57.08 54.23 62.36 61.12 61.12 59.90 75872 134.08 127.38 146.49 143.55 143.55 140.68 75872 TC 80.55 76.52 88.00 86.24 86.24 84.51 75872 26 53.52 50.84 58.47 57.29 57.29 56.14 75880 134.65 127.92 147.11 144.16 144.16 141.28 75880 TC 98.63 93.70 107.76 105.60 105.60 103.49 75880 26 36.02 34.22 39.35 38.57 38.57 37.80 75885 151.75 144.16 165.78 162.47 162.47 159.22 75885 TC 82.20 78.09 89.80 88.01 88.01 86.25 75885 26 69.55 66.07 75.98 74.46 74.46 72.98 75887 152.71 145.07 166.83 163.50 163.50 160.23 75887 TC 82.86 78.72 90.53 88.72 88.72 86.95 75887 26 69.85 66.36 76.31 74.78 74.78 73.29 75889 137.66 130.78 150.40 147.38 147.38 144.44 75889 TC 82.53 78.40 90.16 88.35 88.35 86.58 75889 26 55.14 52.38 60.24 59.03 59.03 57.85 75891 138.65 131.72 151.48 148.45 148.45 145.49 75891 TC 82.86 78.72 90.53 88.72 88.72 86.95 75891 26 55.80 53.01 60.96 59.74 59.74 58.55 75893 111.80 106.21 122.14 119.70 119.70 117.31 75893 TC 84.83 80.59 92.68 90.83 90.83 89.01 75893 26 26.97 25.62 29.46 28.88 28.88 28.30 75894 577.10 548.25 630.49 617.88 617.88 605.52 75894 TC 510.76 485.22 558.00 546.85 546.85 535.91 75894 26 66.34 63.02 72.47 71.02 71.02 69.60 75898 187.41 178.04 204.75 200.65 200.65 196.64 75898 TC 103.20 98.04 112.75 110.49 110.49 108.28 75898 26 84.21 80.00 92.00 90.16 90.16 88.35

Page 182: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 182Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

75901 165.89 157.60 181.24 177.62 177.62 174.06 75901 TC 142.02 134.92 155.16 152.05 152.05 149.02 75901 26 23.87 22.68 26.08 25.56 25.56 25.06 75902 67.98 64.58 74.27 72.78 72.78 71.32 75902 TC 49.00 46.55 53.53 52.46 52.46 51.42 75902 26 18.97 18.02 20.72 20.31 20.31 19.91 75952 274.12 260.41 299.47 293.48 293.48 287.62 75952 26 225.61 214.33 246.48 241.55 241.55 236.72 75953 274.12 260.41 299.47 293.48 293.48 287.62 75953 26 68.40 64.98 74.73 73.23 73.23 71.77 75954 26 114.23 108.52 124.80 122.30 122.30 119.85 75956 26 352.26 334.65 384.85 377.15 377.15 369.61 75957 26 302.55 287.42 330.53 323.92 323.92 317.45 75958 26 201.03 190.98 219.63 215.23 215.23 210.93 75959 26 175.68 166.90 191.94 188.09 188.09 184.33 75962 132.29 125.68 144.53 141.65 141.65 138.82 75962 TC 105.56 100.28 115.32 113.01 113.01 110.75 75962 26 26.73 25.39 29.20 28.61 28.61 28.04 75964 83.39 79.22 91.10 89.29 89.29 87.50 75964 TC 65.43 62.16 71.48 70.06 70.06 68.66 75964 26 17.95 17.05 19.61 19.22 19.22 18.84 75966 163.33 155.16 178.43 174.87 174.87 171.37 75966 TC 98.99 94.04 108.15 105.98 105.98 103.87 75966 26 64.34 61.12 70.29 68.89 68.89 67.51 75968 82.35 78.23 89.96 88.17 88.17 86.41 75968 TC 64.45 61.23 70.41 69.01 69.01 67.63 75968 26 17.90 17.01 19.56 19.17 19.17 18.79 75970 420.62 399.59 459.53 450.34 450.34 441.34 75970 TC 380.25 361.24 415.43 407.12 407.12 398.98 75970 26 40.37 38.35 44.10 43.22 43.22 42.35 75978 130.64 124.11 142.73 139.87 139.87 137.08 75978 TC 103.92 98.72 113.53 111.26 111.26 109.04 75978 26 26.73 25.39 29.20 28.61 28.61 28.04 75984 100.85 95.81 110.18 107.97 107.97 105.81 75984 TC 65.76 62.47 71.84 70.40 70.40 69.00 75984 26 35.09 33.34 38.34 37.57 37.57 36.82 75989 115.79 110.00 126.50 123.97 123.97 121.49 75989 TC 57.22 54.36 62.51 61.26 61.26 60.03 75989 26 58.57 55.64 63.99 62.71 62.71 61.46 76000 44.29 42.08 48.39 47.43 47.43 46.48 76000 TC 35.52 33.74 38.80 38.03 38.03 37.27 76000 26 8.77 8.33 9.58 9.38 9.38 9.20 76001 TC 42.03 39.93 45.92 45.00 45.00 44.10 76001 26 35.71 33.92 39.01 38.23 38.23 37.47 76010 24.58 23.35 26.85 26.31 26.31 25.78 76010 TC 15.47 14.70 16.91 16.57 16.57 16.24 76010 26 9.10 8.65 9.95 9.75 9.75 9.56 76080 52.97 50.32 57.87 56.71 56.71 55.57 76080 TC 26.65 25.32 29.12 28.53 28.53 27.96

Page 183: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 183Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76080 26 26.32 25.00 28.75 28.18 28.18 27.61 76098 15.97 15.17 17.45 17.10 17.10 16.76 76098 TC 7.92 7.52 8.65 8.48 8.48 8.30 76098 26 8.06 7.66 8.81 8.64 8.64 8.46 76100 87.32 82.95 95.39 93.48 93.48 91.61 76100 TC 55.90 53.11 61.08 59.86 59.86 58.66 76100 26 31.42 29.85 34.33 33.64 33.64 32.97 76101 123.42 117.25 134.84 132.15 132.15 129.50 76101 TC 90.09 85.59 98.43 96.46 96.46 94.53 76101 26 33.34 31.67 36.42 35.70 35.70 34.98 76102 162.92 154.77 177.99 174.42 174.42 170.94 76102 TC 129.23 122.77 141.19 138.36 138.36 135.59 76102 26 33.69 32.01 36.81 36.08 36.08 35.35 76120 78.44 74.52 85.70 83.98 83.98 82.31 76120 TC 59.19 56.23 64.66 63.38 63.38 62.11 76120 26 19.25 18.29 21.03 20.61 20.61 20.19 76125 57.28 54.42 62.58 61.33 61.33 60.10 76125 TC 42.93 40.78 46.90 45.95 45.95 45.03 76125 26 14.35 13.63 15.67 15.36 15.36 15.05 76376 22.01 20.91 24.05 23.56 23.56 23.09 76376 TC 12.19 11.58 13.32 13.05 13.05 12.79 76376 26 9.82 9.33 10.73 10.51 10.51 10.30 76377 68.55 65.12 74.89 73.39 73.39 71.92 76377 TC 28.95 27.50 31.63 30.99 30.99 30.37 76377 26 39.59 37.61 43.25 42.39 42.39 41.54 C 76380 104.96 99.71 114.67 112.38 112.38 110.14 C 76380 TC 55.90 53.11 61.08 59.86 59.86 58.66 76380 26 49.05 46.60 53.59 52.52 52.52 51.47 76506 112.45 106.83 122.85 120.39 120.39 117.99 76506 TC 80.23 76.22 87.65 85.91 85.91 84.19 76506 26 32.22 30.61 35.20 34.50 34.50 33.81 76510 162.73 154.59 177.78 174.23 174.23 170.74 76510 TC 75.30 71.54 82.27 80.63 80.63 79.02 76510 26 87.43 83.06 95.52 93.61 93.61 91.74 76511 96.82 91.98 105.78 103.66 103.66 101.59 76511 TC 44.73 42.49 48.86 47.89 47.89 46.93 76511 26 52.09 49.49 56.91 55.78 55.78 54.66 76512 88.93 84.48 97.15 95.21 95.21 93.30 76512 TC 36.84 35.00 40.25 39.45 39.45 38.65 76512 26 52.09 49.49 56.91 55.78 55.78 54.66 76513 90.41 85.89 98.77 96.80 96.80 94.86 76513 TC 55.25 52.49 60.36 59.16 59.16 57.97 76513 26 35.16 33.40 38.41 37.64 37.64 36.89 76514 14.69 13.96 16.05 15.73 15.73 15.42 76514 TC 4.96 4.71 5.42 5.31 5.31 5.21 76514 26 9.73 9.24 10.63 10.42 10.42 10.21 76516 74.61 70.88 81.51 79.88 79.88 78.28 76516 TC 44.07 41.87 48.15 47.18 47.18 46.24 76516 26 30.54 29.01 33.36 32.69 32.69 32.04

Page 184: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 184Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76519 79.54 75.56 86.89 85.16 85.16 83.46 76519 TC 49.00 46.55 53.53 52.46 52.46 51.42 76519 26 30.54 29.01 33.36 32.69 32.69 32.04 76529 75.35 71.58 82.32 80.67 80.67 79.06 76529 TC 43.41 41.24 47.43 46.48 46.48 45.55 76529 26 31.94 30.34 34.89 34.19 34.19 33.51 76536 109.89 104.40 120.06 117.66 117.66 115.30 76536 TC 81.87 77.78 89.45 87.65 87.65 85.91 76536 26 28.02 26.62 30.61 30.00 30.00 29.41 76604 83.56 79.38 91.29 89.46 89.46 87.66 76604 TC 56.56 53.73 61.79 60.56 60.56 59.35 76604 26 27.00 25.65 29.50 28.91 28.91 28.34 76641 102.20 97.09 111.65 109.42 109.42 107.24 76641 TC 65.76 62.47 71.84 70.40 70.40 69.00 76641 26 36.43 34.61 39.80 39.01 39.01 38.23 76642 84.30 80.09 92.10 90.26 90.26 88.46 76642 TC 50.32 47.80 54.97 53.87 53.87 52.79 76642 26 33.99 32.29 37.13 36.39 36.39 35.66 76700 116.57 110.74 127.35 124.81 124.81 122.31 76700 TC 76.28 72.47 83.34 81.67 81.67 80.04 76700 26 40.28 38.27 44.01 43.13 43.13 42.26 76705 86.97 82.62 95.01 93.12 93.12 91.25 76705 TC 57.55 54.67 62.87 61.62 61.62 60.39 76705 26 29.42 27.95 32.14 31.50 31.50 30.87 76770 107.81 102.42 117.78 115.43 115.43 113.11 76770 TC 71.02 67.47 77.59 76.04 76.04 74.52 76770 26 36.79 34.95 40.19 39.39 39.39 38.61 76775 55.71 52.92 60.86 59.64 59.64 58.44 76775 TC 26.98 25.63 29.47 28.89 28.89 28.31 76775 26 28.74 27.30 31.40 30.76 30.76 30.15 76776 148.30 140.89 162.02 158.78 158.78 155.61 76776 TC 110.46 104.94 120.68 118.27 118.27 115.90 76776 26 37.84 35.95 41.34 40.51 40.51 39.71 76800 135.25 128.49 147.76 144.81 144.81 141.91 76800 TC 74.97 71.22 81.90 80.27 80.27 78.66 76800 26 60.28 57.27 65.86 64.54 64.54 63.25 76801 117.81 111.92 128.71 126.13 126.13 123.61 76801 TC 67.74 64.35 74.00 72.52 72.52 71.07 76801 26 50.07 47.57 54.71 53.61 53.61 52.54 76802 63.08 59.93 68.92 67.54 67.54 66.19 76802 TC 20.71 19.67 22.62 22.17 22.17 21.72 76802 26 42.37 40.25 46.29 45.37 45.37 44.46 76805 135.58 128.80 148.12 145.15 145.15 142.26 76805 TC 85.16 80.90 93.04 91.17 91.17 89.34 76805 26 50.42 47.90 55.09 53.98 53.98 52.90 76810 90.17 85.66 98.51 96.54 96.54 94.61 76810 TC 40.10 38.10 43.82 42.94 42.94 42.08 76810 26 50.07 47.57 54.71 53.61 53.61 52.54 76811 175.99 167.19 192.27 188.43 188.43 184.66

Page 185: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 185Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76811 TC 77.95 74.05 85.16 83.46 83.46 81.79 76811 26 98.04 93.14 107.11 104.97 104.97 102.87 76812 198.59 188.66 216.96 212.62 212.62 208.37 76812 TC 106.52 101.19 116.37 114.05 114.05 111.77 76812 26 92.07 87.47 100.59 98.58 98.58 96.61 76813 116.83 110.99 127.64 125.09 125.09 122.58 76813 TC 55.90 53.11 61.08 59.86 59.86 58.66 76813 26 60.92 57.87 66.55 65.22 65.22 63.92 76814 79.10 75.15 86.42 84.70 84.70 83.01 76814 TC 27.64 26.26 30.20 29.59 29.59 29.00 76814 26 51.46 48.89 56.22 55.10 55.10 53.99 76815 80.60 76.57 88.06 86.30 86.30 84.57 76815 TC 48.01 45.61 52.45 51.41 51.41 50.38 76815 26 32.58 30.95 35.59 34.88 34.88 34.18 76816 110.19 104.68 120.38 117.98 117.98 115.62 76816 TC 66.42 63.10 72.57 71.12 71.12 69.69 76816 26 43.77 41.58 47.82 46.86 46.86 45.93 76817 93.08 88.43 101.69 99.66 99.66 97.67 76817 TC 54.92 52.17 60.00 58.80 58.80 57.63 76817 26 38.16 36.25 41.69 40.86 40.86 40.04 76818 117.10 111.25 127.94 125.38 125.38 122.88 76818 TC 62.83 59.69 68.64 67.28 67.28 65.93 76818 26 54.27 51.56 59.29 58.11 58.11 56.95 76819 85.28 81.02 93.17 91.31 91.31 89.48 76819 TC 45.71 43.42 49.93 48.93 48.93 47.96 76819 26 39.56 37.58 43.22 42.35 42.35 41.50 76820 45.65 43.37 49.88 48.88 48.88 47.90 76820 TC 20.08 19.08 21.94 21.51 21.51 21.08 76820 26 25.57 24.29 27.93 27.37 27.37 26.82 76821 89.02 84.57 97.26 95.31 95.31 93.40 76821 TC 52.94 50.29 57.83 56.67 56.67 55.53 76821 26 36.07 34.27 39.41 38.62 38.62 37.85 76825 262.91 249.76 287.22 281.47 281.47 275.84 76825 TC 179.19 170.23 195.76 191.85 191.85 188.01 76825 26 83.73 79.54 91.47 89.64 89.64 87.85 76826 154.75 147.01 169.06 165.68 165.68 162.37 76826 TC 113.42 107.75 123.91 121.44 121.44 119.01 76826 26 41.33 39.26 45.15 44.24 44.24 43.36 76827 72.48 68.86 79.19 77.60 77.60 76.05 76827 TC 43.74 41.55 47.78 46.83 46.83 45.90 76827 26 28.74 27.30 31.40 30.76 30.76 30.15 76828 51.74 49.15 56.52 55.40 55.40 54.29 76828 TC 23.36 22.19 25.52 25.01 25.01 24.52 76828 26 28.37 26.95 30.99 30.37 30.37 29.76 76830 115.88 110.09 126.60 124.07 124.07 121.59 76830 TC 81.21 77.15 88.72 86.95 86.95 85.22 76830 26 34.67 32.94 37.88 37.12 37.12 36.37 76831 112.71 107.07 123.13 120.67 120.67 118.25 76831 TC 75.95 72.15 82.97 81.32 81.32 79.70

Page 186: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 186Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76831 26 36.76 34.92 40.16 39.35 39.35 38.57 76856 104.38 99.16 114.03 111.76 111.76 109.53 76856 TC 70.04 66.54 76.52 74.99 74.99 73.50 76856 26 34.34 32.62 37.51 36.77 36.77 36.03 76857 45.95 43.65 50.20 49.20 49.20 48.21 76857 TC 21.06 20.01 23.01 22.55 22.55 22.10 76857 26 24.89 23.65 27.20 26.66 26.66 26.13 76870 64.79 61.55 70.78 69.37 69.37 67.98 76870 TC 32.90 31.26 35.95 35.22 35.22 34.52 76870 26 31.90 30.31 34.86 34.16 34.16 33.48 76872 89.54 85.06 97.82 95.86 95.86 93.94 76872 TC 56.23 53.42 61.43 60.20 60.20 59.00 76872 26 33.30 31.64 36.39 35.66 35.66 34.95 76873 160.86 152.82 175.74 172.22 172.22 168.77 76873 TC 83.51 79.33 91.23 89.40 89.40 87.62 76873 26 77.35 73.48 84.50 82.81 82.81 81.16 76881 108.45 103.03 118.48 116.12 116.12 113.79 76881 TC 77.27 73.41 84.42 82.73 82.73 81.08 76881 26 31.18 29.62 34.06 33.38 33.38 32.72 76882 35.07 33.32 38.32 37.55 37.55 36.80 76882 TC 10.54 10.01 11.51 11.28 11.28 11.05 76882 26 24.53 23.30 26.80 26.25 26.25 25.73 C 76885 121.62 115.54 132.87 130.21 130.21 127.62 C 76885 TC 84.50 80.28 92.32 90.47 90.47 88.67 76885 26 37.12 35.26 40.55 39.73 39.73 38.94 76886 100.53 95.50 109.83 107.63 107.63 105.48 76886 TC 70.04 66.54 76.52 74.99 74.99 73.50 76886 26 30.50 28.98 33.33 32.66 32.66 32.00 76930 26 32.62 30.99 35.64 34.93 34.93 34.22 76932 160.06 152.06 174.87 171.37 171.37 167.95 76932 TC 127.44 121.07 139.23 136.45 136.45 133.72 76932 26 32.62 30.99 35.64 34.93 34.93 34.22 76936 260.01 247.01 284.06 278.38 278.38 272.81 76936 TC 161.11 153.05 176.01 172.49 172.49 169.04 76936 26 98.90 93.96 108.05 105.89 105.89 103.78 76937 30.19 28.68 32.98 32.33 32.33 31.68 76937 TC 15.78 14.99 17.24 16.89 16.89 16.56 76937 26 14.41 13.69 15.74 15.43 15.43 15.12 76940 175.32 166.55 191.53 187.70 187.70 183.95 76940 TC 72.14 68.53 78.81 77.23 77.23 75.69 76940 26 103.18 98.02 112.72 110.47 110.47 108.26 76941 140.52 133.49 153.51 150.44 150.44 147.43 76941 TC 72.14 68.53 78.81 77.23 77.23 75.69 76941 26 68.38 64.96 74.70 73.21 73.21 71.75 76942 58.63 55.70 64.06 62.78 62.78 61.53 76942 TC 25.34 24.07 27.68 27.13 27.13 26.59 76942 26 33.30 31.64 36.39 35.66 35.66 34.95 76945 107.17 101.81 117.08 114.74 114.74 112.44 76945 TC 72.50 68.88 79.21 77.63 77.63 76.07

Page 187: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 187Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

76945 26 34.67 32.94 37.88 37.12 37.12 36.37 76946 31.79 30.20 34.73 34.04 34.04 33.36 76946 TC 12.19 11.58 13.32 13.05 13.05 12.79 76946 26 19.60 18.62 21.41 20.99 20.99 20.57 76948 66.88 63.54 73.07 71.61 71.61 70.17 76948 TC 36.51 34.68 39.88 39.09 39.09 38.31 76948 26 30.37 28.85 33.18 32.51 32.51 31.86 76965 87.88 83.49 96.01 94.09 94.09 92.21 76965 TC 22.05 20.95 24.09 23.61 23.61 23.14 76965 26 65.83 62.54 71.92 70.48 70.48 69.07 76970 87.70 83.32 95.82 93.90 93.90 92.02 76970 TC 68.39 64.97 74.72 73.22 73.22 71.76 76970 26 19.31 18.34 21.09 20.67 20.67 20.25 76975 136.81 129.97 149.47 146.48 146.48 143.54 76975 TC 94.47 89.75 103.21 101.15 101.15 99.13 76975 26 42.34 40.22 46.25 45.33 45.33 44.42 76977 6.77 6.43 7.39 7.25 7.25 7.10 76977 TC 3.97 3.77 4.34 4.24 4.24 4.16 76977 26 2.80 2.66 3.06 3.00 3.00 2.94 76998 158.58 150.65 173.25 169.79 169.79 166.39 76998 TC 94.97 90.22 103.75 101.68 101.68 99.65 76998 26 63.61 60.43 69.49 68.10 68.10 66.75 77001 66.28 62.97 72.42 70.97 70.97 69.55 77001 TC 47.33 44.96 51.70 50.67 50.67 49.66 77001 26 18.95 18.00 20.70 20.29 20.29 19.88 77002 87.83 83.44 95.96 94.04 94.04 92.15 77002 TC 59.85 56.86 65.39 64.08 64.08 62.80 77002 26 27.99 26.59 30.58 29.97 29.97 29.37 77003 81.08 77.03 88.58 86.81 86.81 85.08 77003 TC 50.97 48.42 55.68 54.57 54.57 53.48 77003 26 30.11 28.60 32.89 32.23 32.23 31.59 77011 210.18 199.67 229.62 225.03 225.03 220.54 77011 TC 147.93 140.53 161.61 158.38 158.38 155.22 77011 26 62.25 59.14 68.01 66.65 66.65 65.32 77012 119.32 113.35 130.35 127.74 127.74 125.19 77012 TC 61.82 58.73 67.54 66.19 66.19 64.87 77012 26 57.50 54.63 62.82 61.57 61.57 60.34 77013 488.36 463.94 533.53 522.86 522.86 512.41 77013 TC 293.28 278.62 320.41 314.01 314.01 307.73 77013 26 195.08 185.33 213.13 208.86 208.86 204.69 77014 111.75 106.16 122.08 119.65 119.65 117.25 77014 TC 68.39 64.97 74.72 73.22 73.22 71.76 77014 26 43.36 41.19 47.37 46.43 46.43 45.49 77021 377.73 358.84 412.67 404.41 404.41 396.32 77021 TC 302.74 287.60 330.74 324.13 324.13 317.64 77021 26 74.98 71.23 81.91 80.28 80.28 78.67 77022 487.24 462.88 532.31 521.66 521.66 511.23 77022 TC 275.57 261.79 301.06 295.03 295.03 289.13 77022 26 211.67 201.09 231.25 226.63 226.63 222.10

Page 188: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 188Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

77051 7.74 7.35 8.45 8.28 8.28 8.12 77051 TC 4.93 4.68 5.38 5.28 5.28 5.18 77051 26 2.81 2.67 3.07 3.01 3.01 2.96 77052 7.74 7.35 8.45 8.28 8.28 8.12 77052 TC 4.93 4.68 5.38 5.28 5.28 5.18 77052 26 2.81 2.67 3.07 3.01 3.01 2.96 77053 55.04 52.29 60.13 58.93 58.93 57.75 77053 TC 37.17 35.31 40.61 39.79 39.79 39.00 77053 26 17.87 16.98 19.53 19.14 19.14 18.76 77054 72.42 68.80 79.12 77.53 77.53 75.98 77054 TC 49.66 47.18 54.26 53.18 53.18 52.12 77054 26 22.77 21.63 24.87 24.38 24.38 23.90 77055 85.02 80.77 92.89 91.02 91.02 89.21 77055 TC 49.99 47.49 54.61 53.52 53.52 52.45 77055 26 35.03 33.28 38.27 37.50 37.50 36.75 77056 109.21 103.75 119.31 116.93 116.93 114.60 77056 TC 65.76 62.47 71.84 70.40 70.40 69.00 77056 26 43.45 41.28 47.47 46.52 46.52 45.59 77057 78.12 74.21 85.34 83.64 83.64 81.97 77057 TC 43.08 40.93 47.07 46.13 46.13 45.21 77057 26 35.03 33.28 38.27 37.50 37.50 36.75 C 77058 497.15 472.29 543.13 532.27 532.27 521.62 C 77058 TC 415.87 395.08 454.34 445.26 445.26 436.36 77058 26 81.28 77.22 88.80 87.03 87.03 85.30 C 77059 497.15 472.29 543.13 532.27 532.27 521.62 C 77059 TC 415.87 395.08 454.34 445.26 445.26 436.36 77059 26 81.28 77.22 88.80 87.03 87.03 85.30 77063 53.12 50.46 58.03 56.87 56.87 55.73 77063 TC 23.34 22.17 25.50 24.99 24.99 24.50 77063 26 29.78 28.29 32.53 31.88 31.88 31.25 77071 46.09 43.79 50.36 49.35 49.35 48.36 77072 21.98 20.88 24.01 23.53 23.53 23.06 77072 TC 12.52 11.89 13.67 13.40 13.40 13.13 77072 26 9.46 8.99 10.34 10.13 10.13 9.92 77073 34.07 32.37 37.23 36.48 36.48 35.75 77073 TC 19.75 18.76 21.57 21.14 21.14 20.71 77073 26 14.32 13.60 15.64 15.33 15.33 15.02 77074 60.92 57.87 66.55 65.22 65.22 63.92 77074 TC 38.15 36.24 41.68 40.85 40.85 40.03 77074 26 22.77 21.63 24.87 24.38 24.38 23.90 77075 82.55 78.42 90.18 88.38 88.38 86.61 77075 TC 55.57 52.79 60.71 59.49 59.49 58.31 77075 26 26.97 25.62 29.46 28.88 28.88 28.30 77076 90.93 86.38 99.34 97.35 97.35 95.40 77076 TC 55.90 53.11 61.08 59.86 59.86 58.66 77076 26 35.03 33.28 38.27 37.50 37.50 36.75 77077 35.50 33.73 38.79 38.02 38.02 37.26 77077 TC 19.42 18.45 21.22 20.79 20.79 20.38 77077 26 16.08 15.28 17.57 17.22 17.22 16.87

Page 189: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 189Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

C 77078 68.17 64.76 74.47 72.98 72.98 71.52 C 77078 TC 55.90 53.11 61.08 59.86 59.86 58.66 77078 26 12.26 11.65 13.40 13.13 13.13 12.87 77080 38.77 36.83 42.35 41.50 41.50 40.68 77080 TC 28.62 27.19 31.27 30.65 30.65 30.04 77080 26 10.15 9.64 11.09 10.87 10.87 10.65 77081 26.67 25.34 29.14 28.55 28.55 27.98 77081 TC 15.80 15.01 17.26 16.92 16.92 16.58 77081 26 10.86 10.32 11.87 11.63 11.63 11.40 C 77084 330.72 314.18 361.31 354.09 354.09 347.00 C 77084 TC 250.51 237.98 273.68 268.20 268.20 262.84 77084 26 80.21 76.20 87.63 85.88 85.88 84.17 77085 53.22 50.56 58.14 56.98 56.98 55.84 77085 TC 37.83 35.94 41.33 40.50 40.50 39.70 77085 26 15.40 14.63 16.82 16.49 16.49 16.16 77086 33.42 31.75 36.51 35.79 35.79 35.08 77086 TC 24.68 23.45 26.97 26.43 26.43 25.90 77086 26 8.74 8.30 9.55 9.35 9.35 9.17 77261 74.66 70.93 81.57 79.94 79.94 78.34 77262 111.78 106.19 122.12 119.68 119.68 117.29 77263 163.66 155.48 178.80 175.23 175.23 171.72 77280 255.58 242.80 279.22 273.63 273.63 268.16 77280 TC 219.92 208.92 240.26 235.45 235.45 230.75 77280 26 35.66 33.88 38.96 38.18 38.18 37.42 77285 402.92 382.77 440.19 431.38 431.38 422.75 77285 TC 349.09 331.64 381.39 373.76 373.76 366.29 77285 26 53.83 51.14 58.81 57.64 57.64 56.49 77290 482.70 458.57 527.36 516.81 516.81 506.47 77290 TC 402.66 382.53 439.91 431.11 431.11 422.49 77290 26 80.04 76.04 87.45 85.70 85.70 83.98 77293 438.71 416.77 479.29 469.69 469.69 460.30 77293 TC 336.30 319.49 367.41 360.07 360.07 352.87 77293 26 102.42 97.30 111.90 109.65 109.65 107.46 77295 468.44 445.02 511.77 501.54 501.54 491.51 77295 TC 249.61 237.13 272.70 267.25 267.25 261.90 77295 26 218.83 207.89 239.07 234.29 234.29 229.61 77300 63.72 60.53 69.61 68.22 68.22 66.85 77300 TC 31.91 30.31 34.86 34.16 34.16 33.48 77300 26 31.81 30.22 34.75 34.06 34.06 33.38 77301 1,838.06 1,746.16 2,008.08 1,967.93 1,967.93 1,928.57 77301 TC 1,430.12 1,358.61 1,562.40 1,531.16 1,531.16 1,500.53 77301 26 407.94 387.54 445.67 436.76 436.76 428.02 77306 143.03 135.88 156.26 153.13 153.13 150.08 77306 TC 71.38 67.81 77.98 76.42 76.42 74.89 77306 26 71.65 68.07 78.28 76.72 76.72 75.19 77307 276.79 262.95 302.39 296.34 296.34 290.42 77307 TC 128.92 122.47 140.84 138.02 138.02 135.26 77307 26 147.87 140.48 161.55 158.32 158.32 155.16 77316 179.54 170.56 196.14 192.22 192.22 188.38

Page 190: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 190Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

77316 TC 107.89 102.50 117.88 115.52 115.52 113.21 77316 26 71.65 68.07 78.28 76.72 76.72 75.19 77317 233.80 222.11 255.43 250.32 250.32 245.32 77317 TC 140.13 133.12 153.09 150.03 150.03 147.03 77317 26 93.67 88.99 102.34 100.29 100.29 98.29 77318 338.01 321.11 369.28 361.89 361.89 354.66 77318 TC 190.14 180.63 207.72 203.57 203.57 199.50 77318 26 147.87 140.48 161.55 158.32 158.32 155.16 77321 89.04 84.59 97.28 95.34 95.34 93.43 77321 TC 40.45 38.43 44.19 43.31 43.31 42.45 77321 26 48.58 46.15 53.07 52.01 52.01 50.98 77331 61.85 58.76 67.57 66.22 66.22 64.89 77331 TC 17.45 16.58 19.07 18.69 18.69 18.32 77331 26 44.40 42.18 48.51 47.54 47.54 46.59 77332 78.58 74.65 85.85 84.13 84.13 82.46 77332 TC 50.64 48.11 55.33 54.22 54.22 53.14 77332 26 27.93 26.53 30.51 29.90 29.90 29.30 77333 51.90 49.31 56.71 55.57 55.57 54.45 77333 TC 8.90 8.46 9.73 9.53 9.53 9.34 77333 26 43.00 40.85 46.98 46.03 46.03 45.11 77334 145.46 138.19 158.92 155.74 155.74 152.63 77334 TC 82.20 78.09 89.80 88.01 88.01 86.25 77334 26 63.27 60.11 69.13 67.75 67.75 66.39 77336 73.81 70.12 80.64 79.03 79.03 77.45 77338 484.57 460.34 529.39 518.80 518.80 508.43 77338 TC 265.74 252.45 290.32 284.51 284.51 278.82 77338 26 218.83 207.89 239.07 234.29 234.29 229.61 77370 113.39 107.72 123.88 121.41 121.41 118.98 77371 6,916.64 6,570.81 7,556.43 7,405.30 7,405.30 7,257.19 77372 995.35 945.58 1,087.42 1,065.67 1,065.67 1,044.36 77373 1,265.31 1,202.04 1,382.35 1,354.70 1,354.70 1,327.61 77401 22.38 21.26 24.45 23.95 23.95 23.47 77417 10.22 9.71 11.17 10.95 10.95 10.73 77427 182.77 173.63 199.67 195.68 195.68 191.77 77431 100.32 95.30 109.60 107.40 107.40 105.25 77432 412.99 392.34 451.19 442.16 442.16 433.32 77435 622.54 591.41 680.12 666.52 666.52 653.19 77469 317.00 301.15 346.32 339.40 339.40 332.61 77470 151.38 143.81 165.38 162.07 162.07 158.83 77470 TC 44.75 42.51 48.89 47.91 47.91 46.95 77470 26 106.63 101.30 116.50 114.16 114.16 111.87 77520 956.76 908.92 1,045.26 1,024.35 1,024.35 1,003.87 77600 395.38 375.61 431.95 423.32 423.32 414.85 77600 TC 314.33 298.61 343.40 336.54 336.54 329.81 77600 26 81.05 77.00 88.55 86.78 86.78 85.04 77605 748.42 711.00 817.65 801.30 801.30 785.27 77605 TC 633.15 601.49 691.71 677.88 677.88 664.32 77605 26 115.27 109.51 125.94 123.42 123.42 120.95 77610 926.82 880.48 1,012.55 992.30 992.30 972.45

Page 191: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 191Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

77610 TC 841.21 799.15 919.02 900.65 900.65 882.64 77610 26 85.61 81.33 93.53 91.66 91.66 89.83 77615 992.67 943.04 1,084.50 1,062.81 1,062.81 1,041.56 77615 TC 886.37 842.05 968.36 948.99 948.99 930.02 77615 26 106.30 100.99 116.14 113.82 113.82 111.54 77620 361.17 343.11 394.58 386.69 386.69 378.96 77620 TC 281.46 267.39 307.50 301.35 301.35 295.32 77620 26 79.71 75.72 87.08 85.34 85.34 83.64 77750 360.14 342.13 393.45 385.58 385.58 377.87 77750 TC 105.29 100.03 115.03 112.73 112.73 110.48 77750 26 254.85 242.11 278.43 272.86 272.86 267.40 77761 373.50 354.83 408.05 399.89 399.89 391.90 77761 TC 178.94 169.99 195.49 191.58 191.58 187.75 77761 26 194.56 184.83 212.55 208.30 208.30 204.14 77762 498.94 473.99 545.09 534.19 534.19 523.50 77762 TC 205.26 195.00 224.25 219.77 219.77 215.37 77762 26 293.68 279.00 320.85 314.43 314.43 308.14 77763 708.02 672.62 773.51 758.05 758.05 742.89 77763 TC 265.82 252.53 290.41 284.60 284.60 278.91 77763 26 442.20 420.09 483.10 473.44 473.44 463.98 77767 212.01 201.41 231.62 226.99 226.99 222.44 77767 TC 158.18 150.27 172.81 169.35 169.35 165.96 77767 26 53.83 51.14 58.81 57.64 57.64 56.49 77768 331.45 314.88 362.11 354.87 354.87 347.77 77768 TC 260.12 247.11 284.18 278.50 278.50 272.93 77768 26 71.32 67.75 77.91 76.36 76.36 74.83 77770 303.83 288.64 331.94 325.30 325.30 318.79 77770 TC 204.22 194.01 223.11 218.65 218.65 214.28 77770 26 99.61 94.63 108.82 106.65 106.65 104.52 77771 565.93 537.63 618.27 605.91 605.91 593.79 77771 TC 371.93 353.33 406.33 398.20 398.20 390.23 77771 26 194.01 184.31 211.96 207.71 207.71 203.56 77772 863.48 820.31 943.36 924.49 924.49 905.99 77772 TC 588.01 558.61 642.40 629.56 629.56 616.96 77772 26 275.47 261.70 300.96 294.94 294.94 289.04 77778 749.14 711.68 818.43 802.07 802.07 786.03 77778 TC 341.82 324.73 373.44 365.98 365.98 358.66 77778 26 407.32 386.95 444.99 436.09 436.09 427.37 77789 114.60 108.87 125.20 122.69 122.69 120.24 77789 TC 55.90 53.11 61.08 59.86 59.86 58.66 77789 26 58.70 55.77 64.14 62.85 62.85 61.59 77790 13.83 13.14 15.11 14.81 14.81 14.51 78012 76.24 72.43 83.29 81.63 81.63 79.99 78012 TC 66.78 63.44 72.96 71.50 71.50 70.07 78012 26 9.46 8.99 10.34 10.13 10.13 9.92 78013 183.97 174.77 200.99 196.96 196.96 193.02 78013 TC 165.74 157.45 181.07 177.45 177.45 173.89 78013 26 18.23 17.32 19.92 19.52 19.52 19.12 78014 233.02 221.37 254.58 249.48 249.48 244.49

Page 192: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 192Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78014 TC 208.47 198.05 227.76 223.20 223.20 218.74 78014 26 24.56 23.33 26.83 26.29 26.29 25.76 78015 212.81 202.17 232.50 227.85 227.85 223.30 78015 TC 180.20 171.19 196.87 192.94 192.94 189.07 78015 26 32.62 30.99 35.64 34.93 34.93 34.22 78016 269.76 256.27 294.71 288.81 288.81 283.04 78016 TC 235.44 223.67 257.22 252.08 252.08 247.04 78016 26 34.32 32.60 37.49 36.74 36.74 36.01 78018 302.17 287.06 330.12 323.52 323.52 317.04 78018 TC 260.75 247.71 284.87 279.17 279.17 273.59 78018 26 41.42 39.35 45.25 44.34 44.34 43.46 78020 81.74 77.65 89.30 87.52 87.52 85.77 78020 TC 53.96 51.26 58.95 57.76 57.76 56.61 78020 26 27.78 26.39 30.35 29.74 29.74 29.14 78070 289.48 275.01 316.26 309.94 309.94 303.74 78070 TC 250.54 238.01 273.71 268.24 268.24 262.88 78070 26 38.94 36.99 42.54 41.69 41.69 40.86 78071 346.61 329.28 378.67 371.09 371.09 363.68 78071 TC 288.03 273.63 314.67 308.38 308.38 302.22 78071 26 58.57 55.64 63.99 62.71 62.71 61.46 78072 400.73 380.69 437.79 429.04 429.04 420.46 78072 TC 324.19 307.98 354.18 347.09 347.09 340.15 78072 26 76.54 72.71 83.62 81.95 81.95 80.30 78075 411.93 391.33 450.03 441.03 441.03 432.20 78075 TC 376.81 357.97 411.67 403.43 403.43 395.36 78075 26 35.12 33.36 38.36 37.59 37.59 36.85 78102 164.15 155.94 179.33 175.74 175.74 172.22 78102 TC 137.47 130.60 150.19 147.19 147.19 144.24 78102 26 26.68 25.35 29.15 28.57 28.57 27.99 78103 215.38 204.61 235.30 230.60 230.60 225.99 78103 TC 179.21 170.25 195.79 191.88 191.88 188.04 78103 26 36.16 34.35 39.50 38.71 38.71 37.94 78104 237.22 225.36 259.16 253.98 253.98 248.89 78104 TC 198.93 188.98 217.33 212.98 212.98 208.73 78104 26 38.28 36.37 41.83 40.99 40.99 40.17 78110 90.40 85.88 98.76 96.78 96.78 94.85 78110 TC 80.94 76.89 88.42 86.65 86.65 84.92 78110 26 9.46 8.99 10.34 10.13 10.13 9.92 78111 92.78 88.14 101.36 99.34 99.34 97.35 78111 TC 81.92 77.82 89.49 87.70 87.70 85.94 78111 26 10.86 10.32 11.87 11.63 11.63 11.40 78120 90.51 85.98 98.88 96.90 96.90 94.96 78120 TC 78.96 75.01 86.26 84.54 84.54 82.85 78120 26 11.55 10.97 12.62 12.36 12.36 12.12 78121 98.69 93.76 107.82 105.66 105.66 103.55 78121 TC 82.58 78.45 90.22 88.41 88.41 86.64 78121 26 16.11 15.30 17.60 17.24 17.24 16.89 78122 94.80 90.06 103.57 101.50 101.50 99.46 78122 TC 73.38 69.71 80.17 78.57 78.57 76.99

Page 193: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 193Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78122 26 21.42 20.35 23.40 22.93 22.93 22.47 78130 162.68 154.55 177.73 174.18 174.18 170.69 78130 TC 132.57 125.94 144.83 141.93 141.93 139.09 78130 26 30.11 28.60 32.89 32.23 32.23 31.59 C 78135 336.34 319.52 367.45 360.10 360.10 352.90 C 78135 TC 304.47 289.25 332.64 325.99 325.99 319.47 78135 26 31.87 30.28 34.82 34.12 34.12 33.44 78140 132.44 125.82 144.69 141.80 141.80 138.95 78140 TC 101.97 96.87 111.40 109.17 109.17 106.98 78140 26 30.47 28.95 33.29 32.63 32.63 31.97 78185 204.11 193.90 222.99 218.52 218.52 214.15 78185 TC 184.14 174.93 201.17 197.14 197.14 193.20 78185 26 19.96 18.96 21.80 21.37 21.37 20.94 78190 379.07 360.12 414.14 405.86 405.86 397.74 78190 TC 325.18 308.92 355.26 348.15 348.15 341.19 78190 26 53.90 51.21 58.89 57.72 57.72 56.57 78191 162.68 154.55 177.73 174.18 174.18 170.69 78191 TC 132.57 125.94 144.83 141.93 141.93 139.09 78191 26 30.11 28.60 32.89 32.23 32.23 31.59 78195 344.66 327.43 376.54 369.01 369.01 361.63 78195 TC 285.73 271.44 312.16 305.91 305.91 299.79 78195 26 58.93 55.98 64.38 63.09 63.09 61.82 78201 181.22 172.16 197.98 194.03 194.03 190.15 78201 TC 160.15 152.14 174.96 171.47 171.47 168.04 78201 26 21.07 20.02 23.02 22.56 22.56 22.11 78202 194.90 185.16 212.93 208.68 208.68 204.50 78202 TC 171.00 162.45 186.82 183.08 183.08 179.42 78202 26 23.90 22.71 26.12 25.60 25.60 25.08 78205 204.71 194.47 223.64 219.17 219.17 214.79 78205 TC 171.00 162.45 186.82 183.08 183.08 179.42 78205 26 33.72 32.03 36.83 36.10 36.10 35.37 78206 331.09 314.54 361.72 354.49 354.49 347.40 78206 TC 284.42 270.20 310.73 304.52 304.52 298.43 78206 26 46.67 44.34 50.99 49.97 49.97 48.97 78215 187.96 178.56 205.34 201.24 201.24 197.21 78215 TC 163.76 155.57 178.91 175.33 175.33 171.82 78215 26 24.20 22.99 26.44 25.91 25.91 25.39 78216 122.13 116.02 133.42 130.76 130.76 128.14 78216 TC 94.74 90.00 103.50 101.43 101.43 99.41 78216 26 27.39 26.02 29.92 29.33 29.33 28.74 78226 320.22 304.21 349.84 342.85 342.85 336.00 78226 TC 283.76 269.57 310.01 303.81 303.81 297.74 78226 26 36.46 34.64 39.84 39.04 39.04 38.26 C 78227 348.99 331.54 381.27 373.65 373.65 366.17 C 78227 TC 304.47 289.25 332.64 325.99 325.99 319.47 78227 26 44.52 42.29 48.63 47.66 47.66 46.70 78230 136.52 129.69 149.14 146.17 146.17 143.24 78230 TC 117.42 111.55 128.28 125.72 125.72 123.20 78230 26 19.10 18.15 20.87 20.46 20.46 20.04

Page 194: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 194Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78231 126.26 119.95 137.94 135.18 135.18 132.48 78231 TC 100.00 95.00 109.25 107.07 107.07 104.93 78231 26 26.26 24.95 28.69 28.12 28.12 27.55 78232 95.82 91.03 104.68 102.59 102.59 100.54 78232 TC 76.01 72.21 83.04 81.39 81.39 79.75 78232 26 19.81 18.82 21.64 21.21 21.21 20.78 78258 214.69 203.96 234.55 229.86 229.86 225.26 78258 TC 178.23 169.32 194.72 190.82 190.82 187.00 78258 26 36.46 34.64 39.84 39.04 39.04 38.26 78261 240.18 228.17 262.40 257.15 257.15 252.01 78261 TC 206.17 195.86 225.24 220.73 220.73 216.32 78261 26 34.02 32.32 37.17 36.42 36.42 35.70 78262 236.18 224.37 258.03 252.86 252.86 247.80 78262 TC 203.21 193.05 222.01 217.57 217.57 213.22 78262 26 32.97 31.32 36.02 35.29 35.29 34.59 78264 322.85 306.71 352.72 345.67 345.67 338.76 78264 TC 286.39 272.07 312.88 306.62 306.62 300.50 78264 26 36.46 34.64 39.84 39.04 39.04 38.26 C 78265 352.86 335.22 385.50 377.80 377.80 370.24 C 78265 TC 304.82 289.58 333.02 326.36 326.36 319.83 78265 26 48.04 45.64 52.49 51.44 51.44 50.42 78266 457.05 434.20 499.33 489.35 489.35 479.56 78266 TC 403.76 383.57 441.11 432.29 432.29 423.64 78266 26 53.29 50.63 58.22 57.06 57.06 55.92 78270 97.33 92.46 106.33 104.20 104.20 102.12 78270 TC 86.85 82.51 94.89 92.99 92.99 91.13 78270 26 10.47 9.95 11.44 11.21 11.21 10.99 78271 86.81 82.47 94.84 92.94 92.94 91.08 78271 TC 76.66 72.83 83.75 82.08 82.08 80.43 78271 26 10.15 9.64 11.09 10.87 10.87 10.65 78272 93.26 88.60 101.89 99.85 99.85 97.85 78272 TC 79.95 75.95 87.34 85.59 85.59 83.88 78272 26 13.31 12.64 14.54 14.25 14.25 13.96 78278 337.42 320.55 368.63 361.26 361.26 354.04 78278 TC 288.69 274.26 315.40 309.09 309.09 302.90 78278 26 48.73 46.29 53.23 52.16 52.16 51.12 78282 239.97 227.97 262.17 256.92 256.92 251.78 78282 TC 221.05 210.00 241.50 236.67 236.67 231.93 78282 26 18.92 17.97 20.67 20.25 20.25 19.85 78290 322.02 305.92 351.81 344.77 344.77 337.87 78290 TC 288.36 273.94 315.03 308.73 308.73 302.55 78290 26 33.66 31.98 36.78 36.04 36.04 35.32 78291 244.03 231.83 266.60 261.27 261.27 256.05 78291 TC 201.89 191.80 220.57 216.15 216.15 211.83 78291 26 42.13 40.02 46.02 45.10 45.10 44.21 78300 175.22 166.46 191.43 187.60 187.60 183.85 78300 TC 144.04 136.84 157.37 154.22 154.22 151.13 78300 26 31.18 29.62 34.06 33.38 33.38 32.72 78305 223.86 212.67 244.57 239.68 239.68 234.89

Page 195: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 195Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78305 TC 182.83 173.69 199.74 195.75 195.75 191.84 78305 26 41.03 38.98 44.83 43.93 43.93 43.06 78306 244.32 232.10 266.92 261.58 261.58 256.35 78306 TC 201.89 191.80 220.57 216.15 216.15 211.83 78306 26 42.43 40.31 46.36 45.43 45.43 44.52 78315 335.54 318.76 366.57 359.24 359.24 352.05 78315 TC 285.40 271.13 311.80 305.57 305.57 299.46 78315 26 50.13 47.62 54.76 53.67 53.67 52.60 78320 221.51 210.43 241.99 237.15 237.15 232.42 78320 TC 171.32 162.75 187.16 183.43 183.43 179.76 78320 26 50.19 47.68 54.83 53.74 53.74 52.67 78414 87.67 83.29 95.78 93.86 93.86 91.99 78414 TC 65.59 62.31 71.66 70.22 70.22 68.82 78414 26 22.08 20.98 24.13 23.64 23.64 23.17 78428 175.01 166.26 191.20 187.37 187.37 183.62 78428 TC 137.47 130.60 150.19 147.19 147.19 144.24 78428 26 37.54 35.66 41.01 40.19 40.19 39.39 78445 169.20 160.74 184.85 181.16 181.16 177.54 78445 TC 146.02 138.72 159.53 156.34 156.34 153.21 78445 26 23.19 22.03 25.33 24.83 24.83 24.33 78451 331.03 314.48 361.65 354.42 354.42 347.33 78451 TC 264.04 250.84 288.47 282.69 282.69 277.04 78451 26 66.99 63.64 73.19 71.73 71.73 70.29 78452 457.70 434.82 500.04 490.04 490.04 480.24 78452 TC 379.13 360.17 414.20 405.92 405.92 397.80 78452 26 78.57 74.64 85.84 84.12 84.12 82.44 78453 294.39 279.67 321.62 315.19 315.19 308.89 78453 TC 245.31 233.04 268.00 262.64 262.64 257.38 78453 26 49.09 46.64 53.64 52.57 52.57 51.52 78454 423.00 401.85 462.13 452.88 452.88 443.82 78454 TC 356.43 338.61 389.40 381.62 381.62 373.98 78454 26 66.57 63.24 72.73 71.28 71.28 69.85 78456 305.54 290.26 333.80 327.12 327.12 320.57 78456 TC 257.14 244.28 280.92 275.30 275.30 269.79 78456 26 48.40 45.98 52.88 51.82 51.82 50.78 78457 182.65 173.52 199.55 195.56 195.56 191.65 78457 TC 144.37 137.15 157.72 154.57 154.57 151.48 78457 26 38.28 36.37 41.83 40.99 40.99 40.17 78458 162.85 154.71 177.92 174.36 174.36 170.88 78458 TC 124.65 118.42 136.18 133.46 133.46 130.79 78458 26 38.19 36.28 41.72 40.88 40.88 40.07 78459 792.12 752.51 865.39 848.08 848.08 831.12 78459 TC 721.49 685.42 788.23 772.47 772.47 757.02 78459 26 70.63 67.10 77.17 75.62 75.62 74.11 78466 184.61 175.38 201.69 197.65 197.65 193.69 78466 TC 149.96 142.46 163.83 160.55 160.55 157.34 78466 26 34.65 32.92 37.86 37.10 37.10 36.35 78468 191.83 182.24 209.58 205.39 205.39 201.28 78468 TC 152.92 145.27 167.06 163.71 163.71 160.44

Page 196: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 196Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78468 26 38.91 36.96 42.50 41.65 41.65 40.83 78469 219.49 208.52 239.80 235.00 235.00 230.30 78469 TC 174.28 165.57 190.41 186.60 186.60 182.86 78469 26 45.21 42.95 49.39 48.40 48.40 47.44 78472 222.65 211.52 243.25 238.38 238.38 233.61 78472 TC 174.94 166.19 191.12 187.30 187.30 183.55 78472 26 47.71 45.32 52.12 51.07 51.07 50.05 78473 281.01 266.96 307.00 300.86 300.86 294.85 78473 TC 210.14 199.63 229.57 224.99 224.99 220.49 78473 26 70.87 67.33 77.43 75.88 75.88 74.36 78481 169.68 161.20 185.38 181.68 181.68 178.04 78481 TC 122.32 116.20 133.63 130.96 130.96 128.34 78481 26 47.36 44.99 51.74 50.70 50.70 49.69 78483 235.29 223.53 257.06 251.92 251.92 246.88 78483 TC 164.42 156.20 179.63 176.04 176.04 172.52 78483 26 70.87 67.33 77.43 75.88 75.88 74.36 78491 792.78 753.14 866.11 848.79 848.79 831.82 78491 TC 721.49 685.42 788.23 772.47 772.47 757.02 78491 26 71.29 67.73 77.89 76.34 76.34 74.81 78492 810.65 770.12 885.64 867.93 867.93 850.57 78492 TC 721.49 685.42 788.23 772.47 772.47 757.02 78492 26 89.16 84.70 97.41 95.46 95.46 93.55 78494 218.67 207.74 238.90 234.13 234.13 229.45 78494 TC 160.81 152.77 175.69 172.17 172.17 168.73 78494 26 57.86 54.97 63.22 61.95 61.95 60.71 78496 43.62 41.44 47.66 46.70 46.70 45.77 78496 TC 19.42 18.45 21.22 20.79 20.79 20.38 78496 26 24.20 22.99 26.44 25.91 25.91 25.39 78579 180.38 171.36 197.06 193.12 193.12 189.26 78579 TC 156.86 149.02 171.37 167.95 167.95 164.59 78579 26 23.51 22.33 25.68 25.16 25.16 24.66 78580 231.78 220.19 253.22 248.16 248.16 243.19 78580 TC 195.32 185.55 213.38 209.12 209.12 204.93 78580 26 36.46 34.64 39.84 39.04 39.04 38.26 78582 324.53 308.30 354.55 347.45 347.45 340.50 78582 TC 271.93 258.33 297.08 291.13 291.13 285.32 78582 26 52.61 49.98 57.48 56.33 56.33 55.20 78597 195.96 186.16 214.08 209.81 209.81 205.61 78597 TC 160.48 152.46 175.33 171.82 171.82 168.38 78597 26 35.48 33.71 38.77 38.00 38.00 37.24 78598 296.88 282.04 324.35 317.86 317.86 311.50 78598 TC 255.49 242.72 279.13 273.55 273.55 268.08 78598 26 41.39 39.32 45.22 44.31 44.31 43.42 78600 178.94 169.99 195.49 191.58 191.58 187.75 78600 TC 156.53 148.70 171.01 167.59 167.59 164.24 78600 26 22.41 21.29 24.48 23.99 23.99 23.51 78601 206.43 196.11 225.53 221.02 221.02 216.60 78601 TC 181.51 172.43 198.29 194.33 194.33 190.44 78601 26 24.91 23.66 27.21 26.67 26.67 26.14

Page 197: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 197Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78605 192.35 182.73 210.14 205.94 205.94 201.83 78605 TC 165.74 157.45 181.07 177.45 177.45 173.89 78605 26 26.62 25.29 29.08 28.50 28.50 27.92 78606 319.25 303.29 348.78 341.80 341.80 334.97 78606 TC 288.03 273.63 314.67 308.38 308.38 302.22 78606 26 31.21 29.65 34.10 33.42 33.42 32.75 78607 339.79 322.80 371.22 363.79 363.79 356.51 78607 TC 280.80 266.76 306.77 300.63 300.63 294.62 78607 26 58.99 56.04 64.45 63.16 63.16 61.89 78608 915.37 869.60 1,000.04 980.04 980.04 960.45 78608 TC 843.73 801.54 921.77 903.34 903.34 885.27 78608 26 71.64 68.06 78.27 76.71 76.71 75.18 78610 168.64 160.21 184.24 180.56 180.56 176.95 78610 TC 153.58 145.90 167.79 164.43 164.43 161.14 78610 26 15.07 14.32 16.47 16.13 16.13 15.81 78630 326.62 310.29 356.83 349.69 349.69 342.70 78630 TC 292.96 278.31 320.06 313.65 313.65 307.38 78630 26 33.66 31.98 36.78 36.04 36.04 35.32 78635 326.72 310.38 356.94 349.80 349.80 342.80 78635 TC 296.25 281.44 323.66 317.18 317.18 310.83 78635 26 30.47 28.95 33.29 32.63 32.63 31.97 78645 311.15 295.59 339.93 333.13 333.13 326.47 78645 TC 283.43 269.26 309.65 303.45 303.45 297.38 78645 26 27.72 26.33 30.28 29.67 29.67 29.07 78647 338.14 321.23 369.41 362.03 362.03 354.79 78647 TC 293.29 278.63 320.42 314.02 314.02 307.74 78647 26 44.85 42.61 49.00 48.02 48.02 47.06 78650 317.52 301.64 346.89 339.95 339.95 333.16 78650 TC 287.71 273.32 314.32 308.03 308.03 301.86 78650 26 29.81 28.32 32.57 31.91 31.91 31.28 78660 174.28 165.57 190.41 186.60 186.60 182.86 78660 TC 147.66 140.28 161.32 158.09 158.09 154.93 78660 26 26.62 25.29 29.08 28.50 28.50 27.92 78700 166.13 157.82 181.49 177.86 177.86 174.31 78700 TC 144.04 136.84 157.37 154.22 154.22 151.13 78700 26 22.08 20.98 24.13 23.64 23.64 23.17 78701 203.38 193.21 222.19 217.75 217.75 213.39 78701 TC 179.87 170.88 196.51 192.58 192.58 188.73 78701 26 23.51 22.33 25.68 25.16 25.16 24.66 78707 225.55 214.27 246.41 241.48 241.48 236.65 78707 TC 178.88 169.94 195.43 191.52 191.52 187.69 78707 26 46.67 44.34 50.99 49.97 49.97 48.97 78708 170.13 161.62 185.86 182.15 182.15 178.50 78708 TC 111.20 105.64 121.49 119.06 119.06 116.68 78708 26 58.93 55.98 64.38 63.09 63.09 61.82 78709 352.51 334.88 385.11 377.41 377.41 369.86 78709 TC 284.09 269.89 310.37 304.16 304.16 298.08 78709 26 68.42 65.00 74.75 73.26 73.26 71.79 78710 193.72 184.03 211.63 207.40 207.40 203.25

Page 198: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 198Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78710 TC 163.11 154.95 178.19 174.63 174.63 171.13 78710 26 30.61 29.08 33.44 32.78 32.78 32.12 78725 105.11 99.85 114.83 112.53 112.53 110.27 78725 TC 86.85 82.51 94.89 92.99 92.99 91.13 78725 26 18.26 17.35 19.95 19.55 19.55 19.16 78730 73.46 69.79 80.26 78.65 78.65 77.07 78730 TC 65.76 62.47 71.84 70.40 70.40 69.00 78730 26 7.70 7.32 8.42 8.25 8.25 8.08 78740 210.52 199.99 229.99 225.39 225.39 220.88 78740 TC 183.16 174.00 200.10 196.10 196.10 192.18 78740 26 27.36 25.99 29.89 29.29 29.29 28.70 78761 202.11 192.00 220.80 216.38 216.38 212.06 78761 TC 166.39 158.07 181.78 178.15 178.15 174.58 78761 26 35.72 33.93 39.02 38.24 38.24 37.48 78800 185.26 176.00 202.40 198.35 198.35 194.38 78800 TC 151.60 144.02 165.62 162.31 162.31 159.07 78800 26 33.65 31.97 36.77 36.03 36.03 35.31 78801 252.39 239.77 275.74 270.22 270.22 264.81 78801 TC 212.41 201.79 232.06 227.41 227.41 222.87 78801 26 39.98 37.98 43.68 42.80 42.80 41.95 78802 314.00 298.30 343.05 336.18 336.18 329.45 78802 TC 272.26 258.65 297.45 291.50 291.50 285.67 78802 26 41.75 39.66 45.61 44.70 44.70 43.80 78803 329.17 312.71 359.62 352.43 352.43 345.38 78803 TC 277.19 263.33 302.83 296.77 296.77 290.84 78803 26 51.98 49.38 56.79 55.65 55.65 54.53 78804 546.78 519.44 597.36 585.41 585.41 573.70 78804 TC 494.86 470.12 540.64 529.83 529.83 519.24 78804 26 51.92 49.32 56.72 55.58 55.58 54.46 78805 176.86 168.02 193.22 189.36 189.36 185.58 78805 TC 141.09 134.04 154.15 151.06 151.06 148.04 78805 26 35.78 33.99 39.09 38.31 38.31 37.54 78806 321.89 305.80 351.67 344.63 344.63 337.74 78806 TC 280.15 266.14 306.06 299.94 299.94 293.94 78806 26 41.75 39.66 45.61 44.70 44.70 43.80 78807 329.17 312.71 359.62 352.43 352.43 345.38 78807 TC 277.52 263.64 303.19 297.13 297.13 291.18 78807 26 51.65 49.07 56.43 55.30 55.30 54.20 78808 43.67 41.49 47.71 46.76 46.76 45.83 78811 920.80 874.76 1,005.97 985.85 985.85 966.13 78811 TC 843.73 801.54 921.77 903.34 903.34 885.27 78811 26 77.07 73.22 84.20 82.52 82.52 80.87 78812 937.40 890.53 1,024.11 1,003.63 1,003.63 983.56 78812 TC 843.73 801.54 921.77 903.34 903.34 885.27 78812 26 93.67 88.99 102.34 100.29 100.29 98.29 78813 941.57 894.49 1,028.66 1,008.09 1,008.09 987.93 78813 TC 843.73 801.54 921.77 903.34 903.34 885.27 78813 26 97.84 92.95 106.89 104.75 104.75 102.66 78814 1,045.18 992.92 1,141.86 1,119.02 1,119.02 1,096.64

Page 199: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 199Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

78814 TC 937.19 890.33 1,023.88 1,003.40 1,003.40 983.33 78814 26 107.99 102.59 117.98 115.62 115.62 113.31 78815 1,056.43 1,003.61 1,154.15 1,131.07 1,131.07 1,108.45 78815 TC 937.19 890.33 1,023.88 1,003.40 1,003.40 983.33 78815 26 119.24 113.28 130.27 127.66 127.66 125.11 78816 1,057.59 1,004.71 1,155.42 1,132.31 1,132.31 1,109.67 78816 TC 937.19 890.33 1,023.88 1,003.40 1,003.40 983.33 78816 26 120.40 114.38 131.54 128.90 128.90 126.33 79005 133.41 126.74 145.75 142.84 142.84 139.99 79005 TC 45.74 43.45 49.97 48.97 48.97 47.99 79005 26 87.67 83.29 95.78 93.86 93.86 91.99 79101 139.44 132.47 152.34 149.29 149.29 146.30 79101 TC 44.40 42.18 48.51 47.54 47.54 46.59 79101 26 95.04 90.29 103.83 101.75 101.75 99.72 79200 155.33 147.56 169.69 166.30 166.30 162.98 79200 TC 54.29 51.58 59.32 58.13 58.13 56.97 79200 26 101.05 96.00 110.40 108.19 108.19 106.03 79300 26 79.11 75.15 86.42 84.70 84.70 83.01 79403 187.07 177.72 204.38 200.30 200.30 196.29 79403 TC 76.66 72.83 83.75 82.08 82.08 80.43 79403 26 110.41 104.89 120.62 118.21 118.21 115.84 79440 141.47 134.40 154.56 151.47 151.47 148.44 79440 TC 46.70 44.37 51.03 50.00 50.00 49.00 79440 26 94.78 90.04 103.55 101.48 101.48 99.45 79445 26 115.18 109.42 125.83 123.31 123.31 120.85 80500 21.52 20.44 23.51 23.03 23.03 22.57 # 80500 19.22 18.26 21.00 20.57 20.57 20.16 80502 70.46 66.94 76.98 75.44 75.44 73.93 # 80502 68.16 64.75 74.46 72.98 72.98 71.52 83020 26 18.20 17.29 19.88 19.48 19.48 19.09 84165 26 18.20 17.29 19.88 19.48 19.48 19.09 84166 26 18.20 17.29 19.88 19.48 19.48 19.09 84181 26 18.20 17.29 19.88 19.48 19.48 19.09 84182 26 18.20 17.29 19.88 19.48 19.48 19.09 85060 24.71 23.47 26.99 26.45 26.45 25.92 85097 86.38 82.06 94.37 92.48 92.48 90.63 # 85097 49.57 47.09 54.15 53.07 53.07 52.01 85390 26 18.20 17.29 19.88 19.48 19.48 19.09 85396 20.53 19.50 22.43 21.98 21.98 21.54 85576 26 18.20 17.29 19.88 19.48 19.48 19.09 86077 55.48 52.71 60.62 59.41 59.41 58.22 # 86077 51.54 48.96 56.30 55.18 55.18 54.07 86078 55.15 52.39 60.25 59.04 59.04 57.86 # 86078 51.54 48.96 56.30 55.18 55.18 54.07 86079 54.50 51.78 59.55 58.35 58.35 57.19 # 86079 50.88 48.34 55.59 54.48 54.48 53.38 86153 26 33.96 32.26 37.10 36.35 36.35 35.63 86255 26 18.20 17.29 19.88 19.48 19.48 19.09 86256 26 18.20 17.29 19.88 19.48 19.48 19.09

Page 200: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 200Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

86320 26 18.20 17.29 19.88 19.48 19.48 19.09 86325 26 18.20 17.29 19.88 19.48 19.48 19.09 86327 26 20.65 19.62 22.56 22.11 22.11 21.68 86334 26 18.20 17.29 19.88 19.48 19.48 19.09 86335 26 18.20 17.29 19.88 19.48 19.48 19.09 86486 4.63 4.40 5.06 4.96 4.96 4.85 86490 64.78 61.54 70.77 69.36 69.36 67.97 86510 5.61 5.33 6.13 6.00 6.00 5.89 86580 7.26 6.90 7.94 7.77 7.77 7.61 87164 26 18.20 17.29 19.88 19.48 19.48 19.09 87207 26 18.20 17.29 19.88 19.48 19.48 19.09 88104 72.04 68.44 78.71 77.13 77.13 75.59 88104 TC 42.76 40.62 46.71 45.78 45.78 44.86 88104 26 29.28 27.82 31.99 31.35 31.35 30.72 88106 70.49 66.97 77.02 75.47 75.47 73.97 88106 TC 50.64 48.11 55.33 54.22 54.22 53.14 88106 26 19.85 18.86 21.69 21.25 21.25 20.83 88108 68.40 64.98 74.73 73.23 73.23 71.77 88108 TC 45.39 43.12 49.59 48.60 48.60 47.62 88108 26 23.01 21.86 25.14 24.63 24.63 24.14 88112 68.09 64.69 74.39 72.91 72.91 71.45 88112 TC 39.80 37.81 43.48 42.61 42.61 41.76 88112 26 28.29 26.88 30.91 30.29 30.29 29.68 88120 591.01 561.46 645.68 632.76 632.76 620.11 88120 TC 532.19 505.58 581.42 569.79 569.79 558.39 88120 26 58.82 55.88 64.26 62.97 62.97 61.71 88121 515.76 489.97 563.47 552.20 552.20 541.16 88121 TC 465.11 441.85 508.13 497.96 497.96 488.00 88121 26 50.65 48.12 55.34 54.23 54.23 53.15 88125 22.54 21.41 24.62 24.13 24.13 23.64 88125 TC 8.90 8.46 9.73 9.53 9.53 9.34 88125 26 13.64 12.96 14.90 14.61 14.61 14.32 88141 31.53 29.95 34.44 33.75 33.75 33.07 88160 68.57 65.14 74.91 73.42 73.42 71.94 88160 TC 42.10 40.00 46.00 45.08 45.08 44.18 88160 26 26.47 25.15 28.92 28.35 28.35 27.78 88161 61.67 58.59 67.38 66.03 66.03 64.71 88161 TC 36.18 34.37 39.53 38.73 38.73 37.96 88161 26 25.49 24.22 27.85 27.30 27.30 26.76 88162 99.30 94.34 108.49 106.32 106.32 104.19 88162 TC 59.22 56.26 64.70 63.40 63.40 62.13 88162 26 40.08 38.08 43.79 42.92 42.92 42.06 88172 55.35 52.58 60.47 59.26 59.26 58.08 88172 TC 18.43 17.51 20.14 19.73 19.73 19.34 88172 26 36.92 35.07 40.33 39.53 39.53 38.73 88173 146.86 139.52 160.45 157.24 157.24 154.10 88173 TC 74.66 70.93 81.57 79.94 79.94 78.34 88173 26 72.20 68.59 78.88 77.30 77.30 75.76 88177 29.53 28.05 32.26 31.61 31.61 30.98

Page 201: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 201Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

88177 TC 6.90 6.56 7.54 7.39 7.39 7.25 88177 26 22.62 21.49 24.71 24.22 24.22 23.74 88182 106.23 100.92 116.06 113.74 113.74 111.46 88182 TC 69.43 65.96 75.85 74.34 74.34 72.85 88182 26 36.80 34.96 40.20 39.40 39.40 38.61 88184 70.04 66.54 76.52 74.99 74.99 73.50 88185 42.73 40.59 46.68 45.75 45.75 44.83 88187 71.23 67.67 77.82 76.27 76.27 74.74 88188 90.66 86.13 99.05 97.07 97.07 95.13 88189 111.67 106.09 122.00 119.57 119.57 117.17 88291 31.16 29.60 34.04 33.36 33.36 32.69 88300 14.42 13.70 15.76 15.44 15.44 15.13 88300 TC 9.89 9.40 10.81 10.59 10.59 10.38 88300 26 4.53 4.30 4.95 4.84 4.84 4.75 88302 30.67 29.14 33.51 32.84 32.84 32.19 88302 TC 23.36 22.19 25.52 25.01 25.01 24.52 88302 26 7.31 6.94 7.98 7.82 7.82 7.66 88304 43.10 40.95 47.09 46.15 46.15 45.23 88304 TC 31.58 30.00 34.50 33.81 33.81 33.13 88304 26 11.52 10.94 12.58 12.33 12.33 12.09 88305 70.32 66.80 76.82 75.28 75.28 73.77 88305 TC 31.58 30.00 34.50 33.81 33.81 33.13 88305 26 38.74 36.80 42.32 41.47 41.47 40.64 88307 291.44 276.87 318.40 312.03 312.03 305.79 88307 TC 206.47 196.15 225.57 221.06 221.06 216.65 88307 26 84.97 80.72 92.83 90.98 90.98 89.16 88309 443.67 421.49 484.71 475.02 475.02 465.52 88309 TC 293.27 278.61 320.40 314.00 314.00 307.72 88309 26 150.40 142.88 164.31 161.02 161.02 157.80 88311 20.81 19.77 22.74 22.28 22.28 21.83 88311 TC 7.92 7.52 8.65 8.48 8.48 8.30 88311 26 12.89 12.25 14.09 13.81 13.81 13.54 88312 92.36 87.74 100.90 98.89 98.89 96.91 88312 TC 64.78 61.54 70.77 69.36 69.36 67.97 88312 26 27.58 26.20 30.13 29.53 29.53 28.95 88313 64.19 60.98 70.13 68.72 68.72 67.34 88313 TC 51.96 49.36 56.76 55.63 55.63 54.51 88313 26 12.24 11.63 13.37 13.11 13.11 12.85 88314 72.70 69.07 79.43 77.84 77.84 76.29 88314 TC 49.99 47.49 54.61 53.52 53.52 52.45 88314 26 22.71 21.57 24.81 24.31 24.31 23.83 88319 84.11 79.90 91.89 90.05 90.05 88.24 88319 TC 56.56 53.73 61.79 60.56 60.56 59.35 88319 26 27.55 26.17 30.10 29.50 29.50 28.91 88321 99.99 94.99 109.24 107.05 107.05 104.91 # 88321 85.53 81.25 93.44 91.57 91.57 89.75 88323 134.65 127.92 147.11 144.16 144.16 141.28 88323 TC 46.70 44.37 51.03 50.00 50.00 49.00 88323 26 87.95 83.55 96.08 94.16 94.16 92.28

Page 202: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 202Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

88325 168.06 159.66 183.61 179.94 179.94 176.34 # 88325 134.53 127.80 146.97 144.03 144.03 141.15 88329 49.08 46.63 53.62 52.56 52.56 51.51 # 88329 36.91 35.06 40.32 39.51 39.51 38.72 88331 92.67 88.04 101.25 99.22 99.22 97.23 88331 TC 28.95 27.50 31.63 30.99 30.99 30.37 88331 26 63.72 60.53 69.61 68.22 68.22 66.85 88332 48.79 46.35 53.30 52.23 52.23 51.19 88332 TC 17.45 16.58 19.07 18.69 18.69 18.32 88332 26 31.34 29.77 34.24 33.55 33.55 32.88 88333 96.98 92.13 105.95 103.83 103.83 101.75 88333 TC 32.90 31.26 35.95 35.22 35.22 34.52 88333 26 64.08 60.88 70.01 68.61 68.61 67.24 88334 59.74 56.75 65.26 63.96 63.96 62.69 88334 TC 20.41 19.39 22.30 21.85 21.85 21.41 88334 26 39.34 37.37 42.98 42.11 42.11 41.27 88341 84.41 80.19 92.22 90.38 90.38 88.57 88341 TC 57.19 54.33 62.48 61.23 61.23 60.01 88341 26 27.22 25.86 29.74 29.14 29.14 28.55 88342 100.74 95.70 110.06 107.86 107.86 105.70 88342 TC 64.45 61.23 70.41 69.01 69.01 67.63 88342 26 36.29 34.48 39.65 38.86 38.86 38.08 88344 162.08 153.98 177.08 173.54 173.54 170.06 88344 TC 122.30 116.19 133.62 130.95 130.95 128.33 88344 26 39.78 37.79 43.46 42.58 42.58 41.73 88346 88.37 83.95 96.54 94.61 94.61 92.71 88346 TC 50.97 48.42 55.68 54.57 54.57 53.48 88346 26 37.40 35.53 40.86 40.04 40.04 39.24 88348 324.79 308.55 354.83 347.74 347.74 340.78 88348 TC 247.63 235.25 270.54 265.13 265.13 259.83 88348 26 77.15 73.29 84.28 82.59 82.59 80.94 88350 68.07 64.67 74.37 72.89 72.89 71.43 88350 TC 40.10 38.10 43.82 42.94 42.94 42.08 88350 26 27.97 26.57 30.56 29.95 29.95 29.35 88355 150.76 143.22 164.70 161.41 161.41 158.18 88355 TC 68.06 64.66 74.36 72.88 72.88 71.42 88355 26 82.70 78.57 90.36 88.55 88.55 86.78 88356 198.39 188.47 216.74 212.41 212.41 208.16 88356 TC 76.66 72.83 83.75 82.08 82.08 80.43 88356 26 121.72 115.63 132.97 130.32 130.32 127.71 88358 81.75 77.66 89.31 87.53 87.53 85.78 88358 TC 36.51 34.68 39.88 39.09 39.09 38.31 88358 26 45.24 42.98 49.43 48.44 48.44 47.47 88360 115.06 109.31 125.71 123.19 123.19 120.73 88360 TC 59.85 56.86 65.39 64.08 64.08 62.80 88360 26 55.22 52.46 60.33 59.12 59.12 57.94 88361 140.96 133.91 154.00 150.91 150.91 147.90 88361 TC 81.54 77.46 89.08 87.30 87.30 85.55 88361 26 59.42 56.45 64.92 63.62 63.62 62.34

Page 203: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 203Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

88362 246.52 234.19 269.32 263.94 263.94 258.66 88362 TC 136.46 129.64 149.09 146.11 146.11 143.19 88362 26 110.07 104.57 120.26 117.85 117.85 115.49 88363 22.50 21.38 24.59 24.09 24.09 23.61 # 88363 19.55 18.57 21.36 20.93 20.93 20.52 88364 126.29 119.98 137.98 135.22 135.22 132.51 88364 TC 92.06 87.46 100.58 98.57 98.57 96.60 88364 26 34.23 32.52 37.40 36.65 36.65 35.91 88365 166.35 158.03 181.73 178.10 178.10 174.54 88365 TC 121.64 115.56 132.89 130.24 130.24 127.64 88365 26 44.71 42.47 48.84 47.86 47.86 46.91 88366 245.33 233.06 268.02 262.66 262.66 257.40 88366 TC 182.12 173.01 198.96 194.98 194.98 191.08 88366 26 63.21 60.05 69.06 67.68 67.68 66.32 88367 100.47 95.45 109.77 107.57 107.57 105.42 88367 TC 65.43 62.16 71.48 70.06 70.06 68.66 88367 26 35.04 33.29 38.28 37.51 37.51 36.77 88368 107.82 102.43 117.79 115.44 115.44 113.13 88368 TC 67.41 64.04 73.65 72.17 72.17 70.73 88368 26 40.41 38.39 44.15 43.26 43.26 42.40 88369 101.61 96.53 111.01 108.79 108.79 106.62 88369 TC 70.37 66.85 76.88 75.34 75.34 73.83 88369 26 31.25 29.69 34.14 33.47 33.47 32.80 88371 26 18.20 17.29 19.88 19.48 19.48 19.09 88372 26 18.20 17.29 19.88 19.48 19.48 19.09 88373 70.31 66.79 76.81 75.27 75.27 73.76 88373 TC 49.30 46.84 53.87 52.79 52.79 51.73 88373 26 21.01 19.96 22.95 22.49 22.49 22.05 88374 320.32 304.30 349.95 342.94 342.94 336.09 88374 TC 275.13 261.37 300.58 294.56 294.56 288.67 88374 26 45.18 42.92 49.36 48.37 48.37 47.40 88375 48.82 46.38 53.34 52.27 52.27 51.22 88377 382.53 363.40 417.91 409.55 409.55 401.36 88377 TC 317.23 301.37 346.58 339.64 339.64 332.84 88377 26 65.30 62.04 71.35 69.92 69.92 68.52 88380 137.26 130.40 149.96 146.96 146.96 144.01 88380 TC 79.92 75.92 87.31 85.56 85.56 83.85 88380 26 57.33 54.46 62.63 61.38 61.38 60.15 88381 110.10 104.60 120.29 117.89 117.89 115.53 88381 TC 84.85 80.61 92.70 90.85 90.85 89.03 88381 26 25.25 23.99 27.59 27.04 27.04 26.50 88387 41.01 38.96 44.80 43.91 43.91 43.03 88387 TC 8.57 8.14 9.36 9.18 9.18 8.99 88387 26 32.44 30.82 35.44 34.73 34.73 34.04 88388 33.59 31.91 36.70 35.96 35.96 35.24 88388 TC 9.23 8.77 10.09 9.88 9.88 9.68 88388 26 24.36 23.14 26.61 26.08 26.08 25.56 89049 246.65 234.32 269.47 264.07 264.07 258.80 # 89049 65.54 62.26 71.60 70.16 70.16 68.76

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 204Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

89060 26 18.20 17.29 19.88 19.48 19.48 19.09 89220 15.15 14.39 16.55 16.22 16.22 15.89 89230 4.96 4.71 5.42 5.31 5.31 5.21 90460 23.86 22.67 26.07 25.55 25.55 25.05 90461 11.97 11.37 13.08 12.81 12.81 12.56 90471 23.86 22.67 26.07 25.55 25.55 25.05 90472 11.97 11.37 13.08 12.81 12.81 12.56 90473 23.86 22.67 26.07 25.55 25.55 25.05 90474 11.97 11.37 13.08 12.81 12.81 12.56 90785 13.81 13.12 15.09 14.79 14.79 14.49 90791 130.72 124.18 142.81 139.96 139.96 137.16 # 90791 126.77 120.43 138.49 135.72 135.72 133.01 90792 144.35 137.13 157.70 154.55 154.55 151.46 # 90792 140.41 133.39 153.40 150.33 150.33 147.33 90832 63.37 60.20 69.23 67.85 67.85 66.49 # 90832 63.04 59.89 68.87 67.49 67.49 66.15 90833 65.37 62.10 71.42 69.99 69.99 68.59 # 90833 64.71 61.47 70.69 69.28 69.28 67.90 90834 84.29 80.08 92.09 90.25 90.25 88.45 # 90834 83.96 79.76 91.72 89.88 89.88 88.09 90836 83.03 78.88 90.71 88.90 88.90 87.11 # 90836 82.38 78.26 90.00 88.19 88.19 86.43 90837 126.77 120.43 138.49 135.72 135.72 133.01 # 90837 125.79 119.50 137.43 134.68 134.68 131.99 90838 109.53 104.05 119.66 117.27 117.27 114.92 # 90838 108.87 103.43 118.94 116.56 116.56 114.23 90839 132.08 125.48 144.30 141.42 141.42 138.59 # 90839 131.43 124.86 143.59 140.71 140.71 137.90 90840 63.04 59.89 68.87 67.49 67.49 66.15 # 90840 62.72 59.58 68.52 67.15 67.15 65.80 90845 90.85 86.31 99.26 97.27 97.27 95.32 # 90845 90.52 85.99 98.89 96.91 96.91 94.97 90846 102.28 97.17 111.75 109.51 109.51 107.33 # 90846 101.62 96.54 111.02 108.80 108.80 106.63 90847 105.86 100.57 115.66 113.34 113.34 111.08 # 90847 105.20 99.94 114.93 112.63 112.63 110.38 90849 33.37 31.70 36.46 35.73 35.73 35.02 # 90849 30.08 28.58 32.87 32.21 32.21 31.57 90853 25.45 24.18 27.81 27.26 27.26 26.71 # 90853 25.12 23.86 27.44 26.89 26.89 26.35 90865 162.79 154.65 177.85 174.29 174.29 170.81 # 90865 127.95 121.55 139.78 136.99 136.99 134.25 90870 171.95 163.35 187.85 184.09 184.09 180.41 # 90870 110.16 104.65 120.35 117.94 117.94 115.59 90880 100.32 95.30 109.60 107.40 107.40 105.25 # 90880 93.42 88.75 102.06 100.03 100.03 98.03 90901 36.43 34.61 39.80 39.01 39.01 38.23 # 90901 19.66 18.68 21.48 21.06 21.06 20.63 90911 80.67 76.64 88.14 86.38 86.38 84.65

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 205Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 90911 44.19 41.98 48.28 47.31 47.31 46.37 90935 71.94 68.34 78.59 77.02 77.02 75.47 90937 103.15 97.99 112.69 110.43 110.43 108.23 90945 84.69 80.46 92.53 90.68 90.68 88.86 90947 123.17 117.01 134.56 131.87 131.87 129.24 90951 933.03 886.38 1,019.34 998.95 998.95 978.97 90952 458.18 435.27 500.56 490.54 490.54 480.73 90953 394.25 374.54 430.72 422.11 422.11 413.67 90954 806.56 766.23 881.16 863.55 863.55 846.27 90955 451.53 428.95 493.29 483.43 483.43 473.75 90956 314.22 298.51 343.29 336.42 336.42 329.69 90957 637.66 605.78 696.65 682.71 682.71 669.06 90958 430.74 409.20 470.58 461.17 461.17 451.95 90959 292.12 277.51 319.14 312.75 312.75 306.50 90960 279.62 265.64 305.49 299.38 299.38 293.39 90961 234.71 222.97 256.42 251.29 251.29 246.26 90962 180.65 171.62 197.36 193.42 193.42 189.55 90963 537.88 510.99 587.64 575.89 575.89 564.36 90964 470.09 446.59 513.58 503.31 503.31 493.25 90965 447.30 424.94 488.68 478.91 478.91 469.33 90966 234.03 222.33 255.68 250.56 250.56 245.55 90967 17.84 16.95 19.49 19.10 19.10 18.72 90968 15.40 14.63 16.82 16.49 16.49 16.16 90969 15.04 14.29 16.43 16.10 16.10 15.78 90970 7.67 7.29 8.38 8.21 8.21 8.05 90997 92.47 87.85 101.03 99.00 99.00 97.03 91010 167.36 158.99 182.84 179.18 179.18 175.59 91010 TC 100.60 95.57 109.91 107.71 107.71 105.56 91010 26 66.75 63.41 72.92 71.46 71.46 70.04 91013 21.92 20.82 23.94 23.46 23.46 22.99 91013 TC 12.49 11.87 13.65 13.37 13.37 13.11 91013 26 9.43 8.96 10.30 10.10 10.10 9.89 91020 221.40 210.33 241.88 237.04 237.04 232.30 91020 TC 146.65 139.32 160.22 157.01 157.01 153.87 91020 26 74.75 71.01 81.66 80.03 80.03 78.43 91022 159.55 151.57 174.31 170.82 170.82 167.41 91022 TC 85.16 80.90 93.04 91.17 91.17 89.34 91022 26 74.40 70.68 81.28 79.66 79.66 78.06 91030 129.02 122.57 140.96 138.14 138.14 135.38 91030 TC 82.20 78.09 89.80 88.01 88.01 86.25 91030 26 46.82 44.48 51.15 50.13 50.13 49.13 91034 178.91 169.96 195.45 191.54 191.54 187.71 91034 TC 127.88 121.49 139.71 136.92 136.92 134.18 91034 26 51.02 48.47 55.74 54.63 54.63 53.53 91035 450.05 427.55 491.68 481.85 481.85 472.21 91035 TC 366.51 348.18 400.41 392.40 392.40 384.56 91035 26 83.55 79.37 91.28 89.45 89.45 87.65 91037 151.57 143.99 165.59 162.28 162.28 159.03 91037 TC 101.26 96.20 110.63 108.42 108.42 106.25

Page 206: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 206Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

91037 26 50.31 47.79 54.96 53.85 53.85 52.77 91038 419.53 398.55 458.33 449.17 449.17 440.19 91038 TC 362.56 344.43 396.09 388.17 388.17 380.41 91038 26 56.97 54.12 62.24 61.00 61.00 59.78 91040 405.59 385.31 443.11 434.24 434.24 425.56 91040 TC 355.99 338.19 388.92 381.14 381.14 373.52 91040 26 49.60 47.12 54.19 53.11 53.11 52.05 91065 72.95 69.30 79.70 78.10 78.10 76.53 91065 TC 62.81 59.67 68.62 67.25 67.25 65.91 91065 26 10.15 9.64 11.09 10.87 10.87 10.65 91110 828.58 787.15 905.22 887.12 887.12 869.38 91110 TC 639.97 607.97 699.17 685.18 685.18 671.47 91110 26 188.61 179.18 206.06 201.94 201.94 197.90 91111 673.94 640.24 736.28 721.56 721.56 707.12 91111 TC 621.90 590.81 679.43 665.84 665.84 652.52 91111 26 52.04 49.44 56.86 55.72 55.72 54.60 91112 1,007.33 956.96 1,100.50 1,078.49 1,078.49 1,056.92 91112 TC 898.32 853.40 981.41 961.78 961.78 942.54 91112 26 109.01 103.56 119.09 116.71 116.71 114.38 91117 136.80 129.96 149.45 146.46 146.46 143.53 91120 396.83 376.99 433.54 424.87 424.87 416.37 91120 TC 346.79 329.45 378.87 371.29 371.29 363.86 91120 26 50.04 47.54 54.67 53.58 53.58 52.51 91122 216.29 205.48 236.30 231.58 231.58 226.94 91122 TC 126.27 119.96 137.95 135.19 135.19 132.49 91122 26 90.02 85.52 98.35 96.38 96.38 94.45 91132 145.05 137.80 158.47 155.30 155.30 152.19 91132 TC 117.04 111.19 127.87 125.32 125.32 122.81 91132 26 28.01 26.61 30.60 29.99 29.99 29.39 91133 161.46 153.39 176.40 172.87 172.87 169.41 91133 TC 127.23 120.87 139.00 136.22 136.22 133.49 91133 26 34.23 32.52 37.40 36.65 36.65 35.91 91200 30.10 28.60 32.89 32.23 32.23 31.59 91200 TC 17.12 16.26 18.70 18.32 18.32 17.95 91200 26 12.98 12.33 14.18 13.89 13.89 13.62 92002 77.60 73.72 84.78 83.09 83.09 81.43 # 92002 47.04 44.69 51.39 50.37 50.37 49.36 92004 142.92 135.77 156.14 153.01 153.01 149.95 # 92004 98.22 93.31 107.31 105.16 105.16 103.05 92012 81.69 77.61 89.25 87.47 87.47 85.72 # 92012 51.78 49.19 56.57 55.44 55.44 54.34 92014 118.71 112.77 129.69 127.09 127.09 124.55 # 92014 78.61 74.68 85.88 84.17 84.17 82.49 92018 142.70 135.57 155.91 152.79 152.79 149.73 92019 70.70 67.17 77.25 75.70 75.70 74.19 92020 25.76 24.47 28.14 27.58 27.58 27.03 # 92020 20.51 19.48 22.40 21.95 21.95 21.52 92025 36.25 34.44 39.61 38.81 38.81 38.04 92025 TC 16.46 15.64 17.99 17.63 17.63 17.27

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 207Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92025 26 19.79 18.80 21.62 21.18 21.18 20.76 92060 62.23 59.12 67.99 66.63 66.63 65.30 92060 TC 24.68 23.45 26.97 26.43 26.43 25.90 92060 26 37.55 35.67 41.02 40.20 40.20 39.40 92065 50.44 47.92 55.11 54.00 54.00 52.92 92065 TC 32.57 30.94 35.58 34.87 34.87 34.17 92065 26 17.88 16.99 19.54 19.15 19.15 18.77 92071 37.01 35.16 40.43 39.63 39.63 38.84 # 92071 33.07 31.42 36.13 35.41 35.41 34.70 92072 131.20 124.64 143.34 140.47 140.47 137.67 # 92072 101.95 96.85 111.38 109.15 109.15 106.96 92081 32.16 30.55 35.13 34.43 34.43 33.74 92081 TC 16.13 15.32 17.62 17.26 17.26 16.92 92081 26 16.03 15.23 17.51 17.17 17.17 16.82 92082 45.60 43.32 49.82 48.82 48.82 47.84 92082 TC 24.35 23.13 26.60 26.07 26.07 25.55 92082 26 21.25 20.19 23.22 22.76 22.76 22.30 92083 61.01 57.96 66.65 65.32 65.32 64.01 92083 TC 33.55 31.87 36.65 35.91 35.91 35.20 92083 26 27.46 26.09 30.00 29.41 29.41 28.82 92100 75.80 72.01 82.81 81.16 81.16 79.53 # 92100 33.40 31.73 36.49 35.77 35.77 35.05 92132 33.29 31.63 36.37 35.65 35.65 34.94 92132 TC 14.49 13.77 15.84 15.51 15.51 15.20 92132 26 18.80 17.86 20.54 20.13 20.13 19.72 92133 42.28 40.17 46.20 45.28 45.28 44.37 92133 TC 14.82 14.08 16.19 15.87 15.87 15.55 92133 26 27.46 26.09 30.00 29.41 29.41 28.82 92134 43.26 41.10 47.27 46.32 46.32 45.39 92134 TC 15.15 14.39 16.55 16.22 16.22 15.89 92134 26 28.12 26.71 30.72 30.11 30.11 29.51 92136 85.12 80.86 92.99 91.13 91.13 89.31 92136 TC 54.59 51.86 59.64 58.44 58.44 57.27 92136 26 30.54 29.01 33.36 32.69 32.69 32.04 92140 60.05 57.05 65.61 64.30 64.30 63.01 # 92140 26.53 25.20 28.98 28.41 28.41 27.84 92145 14.69 13.96 16.05 15.73 15.73 15.42 92145 TC 6.27 5.96 6.85 6.72 6.72 6.58 92145 26 8.41 7.99 9.19 9.00 9.00 8.82 92225 26.12 24.81 28.53 27.96 27.96 27.39 # 92225 20.86 19.82 22.79 22.33 22.33 21.88 92226 24.00 22.80 26.22 25.69 25.69 25.17 # 92226 18.74 17.80 20.47 20.06 20.06 19.65 92227 13.50 12.83 14.75 14.46 14.46 14.17 92228 33.02 31.37 36.08 35.35 35.35 34.65 92228 TC 12.52 11.89 13.67 13.40 13.40 13.13 92228 26 20.51 19.48 22.40 21.95 21.95 21.52 92230 55.75 52.96 60.90 59.69 59.69 58.49 # 92230 33.07 31.42 36.13 35.41 35.41 34.70

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 208Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92235 104.00 98.80 113.62 111.34 111.34 109.11 92235 TC 57.88 54.99 63.24 61.97 61.97 60.73 92235 26 46.12 43.81 50.38 49.37 49.37 48.38 92240 239.63 227.65 261.80 256.57 256.57 251.44 92240 TC 176.86 168.02 193.22 189.36 189.36 185.58 92240 26 62.77 59.63 68.57 67.21 67.21 65.86 92250 74.31 70.59 81.18 79.56 79.56 77.97 92250 TC 50.64 48.11 55.33 54.22 54.22 53.14 92250 26 23.67 22.49 25.86 25.35 25.35 24.84 92260 17.71 16.82 19.34 18.95 18.95 18.57 # 92260 10.80 10.26 11.80 11.56 11.56 11.33 92265 75.78 71.99 82.79 81.13 81.13 79.51 92265 TC 33.22 31.56 36.29 35.57 35.57 34.86 92265 26 42.56 40.43 46.49 45.56 45.56 44.65 92270 87.29 82.93 95.37 93.46 93.46 91.59 92270 TC 46.37 44.05 50.66 49.65 49.65 48.66 92270 26 40.91 38.86 44.69 43.79 43.79 42.92 92275 140.44 133.42 153.43 150.36 150.36 147.36 92275 TC 87.15 82.79 95.21 93.30 93.30 91.44 92275 26 53.28 50.62 58.21 57.05 57.05 55.91 92283 51.83 49.24 56.63 55.50 55.50 54.38 92283 TC 42.76 40.62 46.71 45.78 45.78 44.86 92283 26 9.07 8.62 9.91 9.72 9.72 9.52 92284 57.62 54.74 62.95 61.70 61.70 60.47 92284 TC 45.39 43.12 49.59 48.60 48.60 47.62 92284 26 12.24 11.63 13.37 13.11 13.11 12.85 92285 19.26 18.30 21.05 20.62 20.62 20.21 92285 TC 16.13 15.32 17.62 17.26 17.26 16.92 92285 26 3.13 2.97 3.42 3.35 3.35 3.28 92286 36.73 34.89 40.12 39.32 39.32 38.54 92286 TC 14.82 14.08 16.19 15.87 15.87 15.55 92286 26 21.91 20.81 23.93 23.45 23.45 22.98 C 92287 129.33 122.86 141.29 138.46 138.46 135.69 C 92287 TC 83.54 79.36 91.26 89.44 89.44 87.64 92287 26 45.79 43.50 50.03 49.02 49.02 48.05 92311 96.95 92.10 105.92 103.80 103.80 101.72 # 92311 55.21 52.45 60.32 59.11 59.11 57.93 92312 111.61 106.03 121.93 119.50 119.50 117.10 # 92312 62.97 59.82 68.79 67.41 67.41 66.07 92313 92.51 87.88 101.06 99.04 99.04 97.06 # 92313 46.83 44.49 51.16 50.14 50.14 49.14 92315 68.75 65.31 75.11 73.60 73.60 72.13 # 92315 21.75 20.66 23.76 23.29 23.29 22.83 92316 86.85 82.51 94.89 92.99 92.99 91.13 # 92316 32.62 30.99 35.64 34.93 34.93 34.22 92317 71.71 68.12 78.34 76.77 76.77 75.23 # 92317 22.08 20.98 24.13 23.64 23.64 23.17 92325 38.81 36.87 42.40 41.55 41.55 40.72 92326 32.57 30.94 35.58 34.87 34.87 34.17

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 209Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92502 95.77 90.98 104.63 102.53 102.53 100.49 92504 28.49 27.07 31.13 30.51 30.51 29.90 # 92504 9.43 8.96 10.30 10.10 10.10 9.89 92507 77.25 73.39 84.40 82.71 82.71 81.05 92508 22.69 21.56 24.79 24.30 24.30 23.82 92511 106.42 101.10 116.27 113.94 113.94 111.67 # 92511 38.71 36.77 42.29 41.43 41.43 40.61 92512 58.26 55.35 63.65 62.38 62.38 61.13 # 92512 28.67 27.24 31.33 30.71 30.71 30.10 92516 66.75 63.41 72.92 71.46 71.46 70.04 # 92516 23.04 21.89 25.17 24.67 24.67 24.17 92520 72.70 69.07 79.43 77.84 77.84 76.29 # 92520 41.15 39.09 44.95 44.06 44.06 43.17 92521 108.23 102.82 118.24 115.87 115.87 113.55 92522 90.38 85.86 98.74 96.76 96.76 94.83 92523 188.95 179.50 206.43 202.30 202.30 198.25 92524 87.75 83.36 95.86 93.94 93.94 92.07 92526 83.94 79.74 91.70 89.87 89.87 88.08 92537 39.31 37.34 42.94 42.08 42.08 41.24 92537 TC 7.92 7.52 8.65 8.48 8.48 8.30 92537 26 31.40 29.83 34.30 33.61 33.61 32.95 92538 20.00 19.00 21.85 21.41 21.41 20.99 92538 TC 4.30 4.09 4.70 4.61 4.61 4.52 92538 26 15.70 14.92 17.16 16.81 16.81 16.48 92540 98.90 93.96 108.05 105.89 105.89 103.78 92540 TC 20.41 19.39 22.30 21.85 21.85 21.41 92540 26 78.49 74.57 85.76 84.04 84.04 82.36 92541 23.58 22.40 25.76 25.24 25.24 24.74 92541 TC 2.99 2.84 3.27 3.20 3.20 3.13 92541 26 20.59 19.56 22.49 22.05 22.05 21.61 92542 27.46 26.09 30.00 29.41 29.41 28.82 92542 TC 2.66 2.53 2.91 2.85 2.85 2.79 92542 26 24.80 23.56 27.09 26.55 26.55 26.02 92544 16.29 15.48 17.80 17.45 17.45 17.10 92544 TC 2.33 2.21 2.54 2.50 2.50 2.45 92544 26 13.97 13.27 15.26 14.95 14.95 14.65 92545 14.92 14.17 16.30 15.97 15.97 15.65 92545 TC 2.00 1.90 2.19 2.14 2.14 2.09 92545 26 12.92 12.27 14.11 13.82 13.82 13.55 92546 96.58 91.75 105.51 103.41 103.41 101.34 92546 TC 81.90 77.81 89.48 87.69 87.69 85.94 92546 26 14.68 13.95 16.04 15.72 15.72 15.41 92547 5.59 5.31 6.11 5.98 5.98 5.87 92548 96.54 91.71 105.47 103.36 103.36 101.29 92548 TC 70.69 67.16 77.23 75.69 75.69 74.18 92548 26 25.84 24.55 28.23 27.67 27.67 27.12 92550 20.80 19.76 22.72 22.26 22.26 21.82 92552 28.95 27.50 31.63 30.99 30.99 30.37 92553 34.54 32.81 37.73 36.97 36.97 36.24

Page 210: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 210Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92555 21.72 20.63 23.72 23.25 23.25 22.79 92556 34.54 32.81 37.73 36.97 36.97 36.24 92557 36.68 34.85 40.08 39.27 39.27 38.49 # 92557 32.41 30.79 35.41 34.70 34.70 34.01 92561 35.22 33.46 38.48 37.71 37.71 36.95 92562 43.08 40.93 47.07 46.13 46.13 45.21 92563 28.62 27.19 31.27 30.65 30.65 30.04 92564 25.99 24.69 28.39 27.83 27.83 27.28 92565 14.82 14.08 16.19 15.87 15.87 15.55 92567 14.09 13.39 15.40 15.09 15.09 14.79 # 92567 10.80 10.26 11.80 11.56 11.56 11.33 92568 15.70 14.92 17.16 16.81 16.81 16.48 # 92568 15.37 14.60 16.79 16.46 16.46 16.12 92570 31.61 30.03 34.53 33.84 33.84 33.17 # 92570 29.63 28.15 32.37 31.73 31.73 31.10 92571 25.34 24.07 27.68 27.13 27.13 26.59 92572 33.22 31.56 36.29 35.57 35.57 34.86 92575 67.11 63.75 73.31 71.85 71.85 70.41 92576 33.22 31.56 36.29 35.57 35.57 34.86 92577 15.47 14.70 16.91 16.57 16.57 16.24 92579 41.30 39.24 45.13 44.23 44.23 43.34 # 92579 37.03 35.18 40.46 39.65 39.65 38.86 92582 62.83 59.69 68.64 67.28 67.28 65.93 92583 48.67 46.24 53.18 52.12 52.12 51.07 92584 68.09 64.69 74.39 72.91 72.91 71.45 92585 127.46 121.09 139.25 136.47 136.47 133.75 92585 TC 100.96 95.91 110.30 108.09 108.09 105.93 92585 26 26.50 25.18 28.96 28.38 28.38 27.82 92586 79.27 75.31 86.61 84.87 84.87 83.17 92587 21.13 20.07 23.08 22.62 22.62 22.17 92587 TC 2.99 2.84 3.27 3.20 3.20 3.13 92587 26 18.15 17.24 19.83 19.44 19.44 19.04 92588 32.24 30.63 35.22 34.52 34.52 33.83 92588 TC 3.64 3.46 3.98 3.90 3.90 3.82 92588 26 28.59 27.16 31.23 30.61 30.61 30.00 92596 39.17 37.21 42.79 41.94 41.94 41.10 92597 70.94 67.39 77.50 75.95 75.95 74.43 92601 138.60 131.67 151.42 148.40 148.40 145.43 # 92601 118.88 112.94 129.88 127.28 127.28 124.74 92602 87.16 82.80 95.22 93.31 93.31 91.45 # 92602 68.43 65.01 74.76 73.27 73.27 71.81 92603 147.55 140.17 161.20 157.98 157.98 154.81 # 92603 120.93 114.88 132.11 129.47 129.47 126.88 92604 86.96 82.61 95.00 93.10 93.10 91.24 # 92604 66.91 63.56 73.09 71.63 71.63 70.20 92607 122.99 116.84 134.37 131.68 131.68 129.04 92608 51.11 48.55 55.83 54.72 54.72 53.62 92609 107.09 101.74 117.00 114.67 114.67 112.38 92610 83.19 79.03 90.88 89.07 89.07 87.29

Page 211: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 211Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 92610 71.69 68.11 78.33 76.76 76.76 75.23 92611 85.03 80.78 92.90 91.03 91.03 89.22 92612 177.16 168.30 193.55 189.67 189.67 185.87 # 92612 67.71 64.32 73.97 72.48 72.48 71.04 92613 38.07 36.17 41.60 40.77 40.77 39.95 92614 139.69 132.71 152.62 149.57 149.57 146.58 # 92614 67.38 64.01 73.61 72.14 72.14 70.70 92615 33.51 31.83 36.60 35.87 35.87 35.16 # 92615 33.18 31.52 36.25 35.52 35.52 34.81 92616 199.77 189.78 218.25 213.88 213.88 209.60 # 92616 100.50 95.48 109.80 107.61 107.61 105.46 92617 41.57 39.49 45.41 44.51 44.51 43.62 92620 91.99 87.39 100.50 98.49 98.49 96.52 # 92620 81.48 77.41 89.02 87.24 87.24 85.49 92621 21.76 20.67 23.77 23.30 23.30 22.83 # 92621 18.80 17.86 20.54 20.13 20.13 19.72 92625 68.59 65.16 74.93 73.44 73.44 71.97 # 92625 61.69 58.61 67.40 66.06 66.06 64.73 92626 87.40 83.03 95.48 93.58 93.58 91.70 # 92626 75.24 71.48 82.20 80.56 80.56 78.95 92627 21.70 20.62 23.71 23.24 23.24 22.78 # 92627 17.76 16.87 19.40 19.01 19.01 18.63 92640 110.53 105.00 120.75 118.34 118.34 115.97 # 92640 94.76 90.02 103.52 101.45 101.45 99.43 92920 557.50 529.63 609.07 596.90 596.90 584.96 92924 662.18 629.07 723.43 708.96 708.96 694.78 92928 619.01 588.06 676.27 662.75 662.75 649.49 92933 692.44 657.82 756.49 741.36 741.36 726.54 92937 618.65 587.72 675.88 662.37 662.37 649.12 92941 693.84 659.15 758.02 742.87 742.87 728.01 92943 693.48 658.81 757.63 742.47 742.47 727.63 92950 295.71 280.92 323.06 316.60 316.60 310.26 # 92950 187.90 178.51 205.29 201.18 201.18 197.16 92953 11.25 10.69 12.29 12.05 12.05 11.81 92960 198.63 188.70 217.01 212.67 212.67 208.41 # 92960 121.39 115.32 132.62 129.96 129.96 127.36 92961 263.93 250.73 288.34 282.58 282.58 276.93 92970 189.68 180.20 207.23 203.09 203.09 199.03 92971 102.60 97.47 112.09 109.85 109.85 107.65 92973 180.92 171.87 197.65 193.69 193.69 189.82 92974 165.12 156.86 180.39 176.78 176.78 173.25 92975 398.74 378.80 435.62 426.90 426.90 418.37 92977 57.87 54.98 63.23 61.96 61.96 60.72 92978 277.30 263.44 302.96 296.90 296.90 290.96 92978 TC 179.67 170.69 196.29 192.37 192.37 188.52 92978 26 97.63 92.75 106.66 104.54 104.54 102.44 92979 168.76 160.32 184.37 180.68 180.68 177.07 92979 TC 90.79 86.25 99.19 97.21 97.21 95.27 92979 26 77.97 74.07 85.18 83.48 83.48 81.81

Page 212: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 212Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

92986 1,353.55 1,285.87 1,478.75 1,449.17 1,449.17 1,420.19 92987 1,395.82 1,326.03 1,524.93 1,494.44 1,494.44 1,464.55 92990 1,100.38 1,045.36 1,202.16 1,178.12 1,178.12 1,154.55 92997 669.22 635.76 731.12 716.50 716.50 702.17 92998 329.85 313.36 360.36 353.15 353.15 346.09 93000 16.33 15.51 17.84 17.48 17.48 17.14 93005 7.92 7.52 8.65 8.48 8.48 8.30 93010 8.41 7.99 9.19 9.00 9.00 8.82 93015 72.98 69.33 79.73 78.13 78.13 76.57 93016 22.08 20.98 24.13 23.64 23.64 23.17 93017 36.51 34.68 39.88 39.09 39.09 38.31 93018 14.38 13.66 15.71 15.40 15.40 15.09 93024 107.46 102.09 117.40 115.06 115.06 112.76 93024 TC 50.67 48.14 55.36 54.26 54.26 53.18 93024 26 56.79 53.95 62.04 60.80 60.80 59.58 93025 150.22 142.71 164.12 160.84 160.84 157.62 93025 TC 113.75 108.06 124.27 121.79 121.79 119.35 93025 26 36.47 34.65 39.85 39.05 39.05 38.27 93040 12.33 11.71 13.47 13.20 13.20 12.94 93041 5.29 5.03 5.78 5.67 5.67 5.55 93042 7.04 6.69 7.69 7.54 7.54 7.39 93050 16.66 15.83 18.20 17.84 17.84 17.48 93050 TC 8.24 7.83 9.00 8.82 8.82 8.65 93050 26 8.41 7.99 9.19 9.00 9.00 8.82 93224 86.11 81.80 94.07 92.18 92.18 90.34 93225 24.68 23.45 26.97 26.43 26.43 25.90 93226 35.20 33.44 38.46 37.69 37.69 36.93 93227 26.23 24.92 28.66 28.08 28.08 27.52 93228 25.93 24.63 28.32 27.76 27.76 27.21 93229 673.96 640.26 736.30 721.57 721.57 707.14 93260 64.72 61.48 70.70 69.29 69.29 67.91 93260 TC 20.41 19.39 22.30 21.85 21.85 21.41 93260 26 44.32 42.10 48.42 47.45 47.45 46.49 93261 58.46 55.54 63.87 62.59 62.59 61.34 93261 TC 20.41 19.39 22.30 21.85 21.85 21.41 93261 26 38.05 36.15 41.57 40.74 40.74 39.93 93268 191.94 182.34 209.69 205.49 205.49 201.39 93270 8.57 8.14 9.36 9.18 9.18 8.99 93271 158.12 150.21 172.74 169.29 169.29 165.91 93272 25.25 23.99 27.59 27.04 27.04 26.50 93278 28.73 27.29 31.38 30.75 30.75 30.14 93278 TC 16.46 15.64 17.99 17.63 17.63 17.27 93278 26 12.26 11.65 13.40 13.13 13.13 12.87 93279 48.00 45.60 52.44 51.39 51.39 50.37 93279 TC 16.13 15.32 17.62 17.26 17.26 16.92 93279 26 31.87 30.28 34.82 34.12 34.12 33.44 93280 56.27 53.46 61.48 60.25 60.25 59.04 93280 TC 18.10 17.20 19.78 19.39 19.39 19.00 93280 26 38.17 36.26 41.70 40.86 40.86 40.04

Page 213: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 213Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93281 65.86 62.57 71.96 70.52 70.52 69.10 93281 TC 21.39 20.32 23.37 22.90 22.90 22.44 93281 26 44.47 42.25 48.59 47.62 47.62 46.67 93282 60.78 57.74 66.40 65.08 65.08 63.78 93282 TC 18.76 17.82 20.49 20.08 20.08 19.68 93282 26 42.02 39.92 45.91 44.99 44.99 44.09 93283 79.11 75.15 86.42 84.70 84.70 83.01 93283 TC 22.05 20.95 24.09 23.61 23.61 23.14 93283 26 57.06 54.21 62.34 61.10 61.10 59.88 93284 87.32 82.95 95.39 93.48 93.48 91.61 93284 TC 25.01 23.76 27.32 26.77 26.77 26.23 93284 26 62.31 59.19 68.07 66.71 66.71 65.38 93285 40.72 38.68 44.48 43.60 43.60 42.72 93285 TC 14.82 14.08 16.19 15.87 15.87 15.55 93285 26 25.90 24.61 28.30 27.74 27.74 27.19 93286 26.24 24.93 28.67 28.09 28.09 27.53 93286 TC 11.20 10.64 12.24 11.99 11.99 11.75 93286 26 15.04 14.29 16.43 16.10 16.10 15.78 93287 34.93 33.18 38.16 37.40 37.40 36.65 93287 TC 12.19 11.58 13.32 13.05 13.05 12.79 93287 26 22.74 21.60 24.84 24.35 24.35 23.86 93288 35.53 33.75 38.81 38.04 38.04 37.28 93288 TC 14.49 13.77 15.84 15.51 15.51 15.20 93288 26 21.04 19.99 22.99 22.53 22.53 22.08 93289 63.29 60.13 69.15 67.77 67.77 66.41 93289 TC 18.10 17.20 19.78 19.39 19.39 19.00 93289 26 45.18 42.92 49.36 48.37 48.37 47.40 93290 30.27 28.76 33.07 32.41 32.41 31.76 93290 TC 8.90 8.46 9.73 9.53 9.53 9.34 93290 26 21.37 20.30 23.35 22.87 22.87 22.41 93291 34.87 33.13 38.10 37.34 37.34 36.59 93291 TC 13.50 12.83 14.75 14.46 14.46 14.17 93291 26 21.37 20.30 23.35 22.87 22.87 22.41 93292 31.58 30.00 34.50 33.81 33.81 33.13 93292 TC 10.22 9.71 11.17 10.95 10.95 10.73 93292 26 21.37 20.30 23.35 22.87 22.87 22.41 93293 50.30 47.79 54.96 53.85 53.85 52.77 93293 TC 34.87 33.13 38.10 37.34 37.34 36.59 93293 26 15.43 14.66 16.86 16.53 16.53 16.19 93294 33.57 31.89 36.67 35.94 35.94 35.22 93295 66.81 63.47 72.99 71.53 71.53 70.10 93296 24.02 22.82 26.24 25.71 25.71 25.20 93297 26.26 24.95 28.69 28.12 28.12 27.55 93298 26.26 24.95 28.69 28.12 28.12 27.55 93299 28.27 26.86 30.89 30.27 30.27 29.66 93303 225.21 213.95 246.04 241.12 241.12 236.30 93303 TC 161.77 153.68 176.73 173.20 173.20 169.74 93303 26 63.44 60.27 69.31 67.92 67.92 66.56 93304 146.93 139.58 160.52 157.31 157.31 154.16

Page 214: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 214Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93304 TC 110.46 104.94 120.68 118.27 118.27 115.90 93304 26 36.47 34.65 39.85 39.05 39.05 38.27 93306 215.35 204.58 235.27 230.56 230.56 225.95 93306 TC 152.23 144.62 166.31 162.99 162.99 159.74 93306 26 63.11 59.95 68.94 67.56 67.56 66.22 93307 123.76 117.57 135.21 132.50 132.50 129.86 93307 TC 78.91 74.96 86.20 84.48 84.48 82.79 93307 26 44.85 42.61 49.00 48.02 48.02 47.06 93308 117.33 111.46 128.18 125.61 125.61 123.11 93308 TC 91.73 87.14 100.21 98.21 98.21 96.24 93308 26 25.60 24.32 27.97 27.40 27.40 26.85 93312 291.82 277.23 318.81 312.44 312.44 306.20 93312 TC 171.00 162.45 186.82 183.08 183.08 179.42 93312 26 120.82 114.78 132.00 129.35 129.35 126.76 93313 22.64 21.51 24.74 24.24 24.24 23.76 93314 285.12 270.86 311.49 305.26 305.26 299.15 93314 TC 181.51 172.43 198.29 194.33 194.33 190.44 93314 26 103.61 98.43 113.19 110.93 110.93 108.71 93315 519.96 493.96 568.05 556.69 556.69 545.56 93315 TC 378.85 359.91 413.90 405.62 405.62 397.51 93315 26 141.11 134.05 154.16 151.08 151.08 148.05 93316 38.51 36.58 42.07 41.23 41.23 40.40 93317 26 105.28 100.02 115.02 112.72 112.72 110.47 93318 495.15 470.39 540.95 530.13 530.13 519.52 93318 TC 378.85 359.91 413.90 405.62 405.62 397.51 93318 26 116.30 110.49 127.06 124.52 124.52 122.03 93320 51.43 48.86 56.19 55.06 55.06 53.96 93320 TC 33.20 31.54 36.27 35.55 35.55 34.83 93320 26 18.23 17.32 19.92 19.52 19.52 19.12 93321 25.78 24.49 28.16 27.60 27.60 27.05 93321 TC 18.41 17.49 20.11 19.71 19.71 19.32 93321 26 7.37 7.00 8.05 7.89 7.89 7.73 93325 23.87 22.68 26.08 25.56 25.56 25.06 93325 TC 20.71 19.67 22.62 22.17 22.17 21.72 93325 26 3.16 3.00 3.45 3.38 3.38 3.31 93350 227.98 216.58 249.07 244.09 244.09 239.21 93350 TC 157.16 149.30 171.70 168.26 168.26 164.89 93350 26 70.81 67.27 77.36 75.81 75.81 74.29 93351 256.82 243.98 280.58 274.97 274.97 269.47 93351 TC 172.31 163.69 188.24 184.48 184.48 180.79 93351 26 84.51 80.28 92.32 90.47 90.47 88.67 93352 32.17 30.56 35.14 34.44 34.44 33.75 93355 225.88 214.59 246.78 241.85 241.85 237.00 93451 739.47 702.50 807.88 791.72 791.72 775.88 93451 TC 593.03 563.38 647.89 634.93 634.93 622.23 93451 26 146.44 139.12 159.99 156.79 156.79 153.65 93452 839.16 797.20 916.78 898.45 898.45 880.47 93452 TC 583.19 554.03 637.13 624.39 624.39 611.90 93452 26 255.97 243.17 279.65 274.06 274.06 268.57

Page 215: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 215Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93453 1,083.46 1,029.29 1,183.68 1,160.01 1,160.01 1,136.81 93453 TC 744.93 707.68 813.83 797.56 797.56 781.61 93453 26 338.53 321.60 369.84 362.45 362.45 355.20 93454 851.93 809.33 930.73 912.11 912.11 893.87 93454 TC 592.40 562.78 647.20 634.25 634.25 621.56 93454 26 259.54 246.56 283.54 277.87 277.87 272.32 93455 991.63 942.05 1,083.36 1,061.69 1,061.69 1,040.46 93455 TC 691.68 657.10 755.67 740.55 740.55 725.74 93455 26 299.94 284.94 327.68 321.13 321.13 314.71 93456 1,068.02 1,014.62 1,166.81 1,143.48 1,143.48 1,120.61 93456 TC 735.07 698.32 803.07 787.00 787.00 771.26 93456 26 332.95 316.30 363.75 356.47 356.47 349.34 93457 1,207.03 1,146.68 1,318.68 1,292.31 1,292.31 1,266.47 93457 TC 833.68 792.00 910.80 892.58 892.58 874.74 93457 26 373.35 354.68 407.88 399.73 399.73 391.74 93458 1,022.63 971.50 1,117.23 1,094.88 1,094.88 1,072.98 93458 TC 705.49 670.22 770.75 755.34 755.34 740.23 93458 26 317.15 301.29 346.48 339.55 339.55 332.75 93459 1,130.42 1,073.90 1,234.99 1,210.28 1,210.28 1,186.08 93459 TC 772.87 734.23 844.36 827.48 827.48 810.93 93459 26 357.55 339.67 390.62 382.81 382.81 375.15 93460 1,213.55 1,152.87 1,325.80 1,299.28 1,299.28 1,273.29 93460 TC 815.27 774.51 890.69 872.87 872.87 855.42 93460 26 398.28 378.37 435.13 426.42 426.42 417.89 93461 1,386.80 1,317.46 1,515.08 1,484.78 1,484.78 1,455.08 93461 TC 947.43 900.06 1,035.07 1,014.37 1,014.37 994.08 93461 26 439.37 417.40 480.01 470.41 470.41 461.00 93462 212.77 202.13 232.45 227.80 227.80 223.25 93463 98.58 93.65 107.70 105.55 105.55 103.43 93464 260.58 247.55 284.68 278.99 278.99 273.41 93464 TC 173.60 164.92 189.66 185.86 185.86 182.15 93464 26 86.99 82.64 95.04 93.14 93.14 91.28 93503 130.83 124.29 142.93 140.07 140.07 137.26 93505 726.85 690.51 794.09 778.21 778.21 762.65 93505 TC 490.48 465.96 535.85 525.14 525.14 514.64 93505 26 236.37 224.55 258.23 253.07 253.07 248.01 93530 896.29 851.48 979.20 959.62 959.62 940.42 93530 TC 672.65 639.02 734.87 720.18 720.18 705.78 93530 26 223.64 212.46 244.33 239.44 239.44 234.66 93531 2,360.60 2,242.57 2,578.96 2,527.38 2,527.38 2,476.84 93531 TC 1,923.49 1,827.32 2,101.42 2,059.39 2,059.39 2,018.19 93531 26 437.11 415.25 477.54 467.99 467.99 458.63 93532 26 542.38 515.26 592.55 580.69 580.69 569.08 93533 26 361.84 343.75 395.31 387.41 387.41 379.66 93561 47.33 44.96 51.70 50.67 50.67 49.66 93561 TC 21.73 20.64 23.74 23.26 23.26 22.80 93561 26 25.60 24.32 27.97 27.40 27.40 26.85 93562 21.55 20.47 23.54 23.07 23.07 22.61 93562 TC 13.49 12.82 14.74 14.44 14.44 14.16

Page 216: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 216Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93562 26 8.06 7.66 8.81 8.64 8.64 8.46 93563 59.70 56.72 65.23 63.93 63.93 62.65 93564 62.52 59.39 68.30 66.93 66.93 65.60 93565 46.70 44.37 51.03 50.00 50.00 49.00 93566 162.78 154.64 177.84 174.28 174.28 170.80 # 93566 47.08 44.73 51.44 50.42 50.42 49.40 93567 135.24 128.48 147.75 144.80 144.80 141.90 # 93567 53.40 50.73 58.34 57.18 57.18 56.04 93568 146.40 139.08 159.94 156.75 156.75 153.61 # 93568 48.12 45.71 52.57 51.52 51.52 50.49 93571 276.97 263.12 302.59 296.54 296.54 290.61 93571 TC 179.67 170.69 196.29 192.37 192.37 188.52 93571 26 97.30 92.44 106.31 104.18 104.18 102.10 93572 168.84 160.40 184.46 180.77 180.77 177.16 93572 TC 90.87 86.33 99.28 97.29 97.29 95.35 93572 26 77.97 74.07 85.18 83.48 83.48 81.81 93580 996.83 946.99 1,089.04 1,067.26 1,067.26 1,045.91 93581 1,360.78 1,292.74 1,486.65 1,456.92 1,456.92 1,427.78 93582 682.54 648.41 745.67 730.76 730.76 716.14 93583 770.15 731.64 841.39 824.56 824.56 808.07 93600 197.91 188.01 216.21 211.89 211.89 207.66 93600 TC 78.12 74.21 85.34 83.64 83.64 81.97 93600 26 119.79 113.80 130.87 128.25 128.25 125.68 93602 161.57 153.49 176.51 172.98 172.98 169.52 93602 TC 44.11 41.90 48.19 47.22 47.22 46.28 93602 26 117.46 111.59 128.33 125.76 125.76 123.25 93603 184.36 175.14 201.41 197.39 197.39 193.44 93603 TC 66.90 63.56 73.09 71.63 71.63 70.20 93603 26 117.46 111.59 128.33 125.76 125.76 123.25 93609 389.02 369.57 425.01 416.51 416.51 408.18 93609 TC 108.38 102.96 118.40 116.04 116.04 113.71 93609 26 280.64 266.61 306.60 300.47 300.47 294.46 93610 221.15 210.09 241.60 236.77 236.77 232.04 93610 TC 54.22 51.51 59.24 58.05 58.05 56.89 93610 26 166.93 158.58 182.37 178.72 178.72 175.15 93612 229.89 218.40 251.16 246.13 246.13 241.21 93612 TC 64.30 61.09 70.25 68.85 68.85 67.47 93612 26 165.59 157.31 180.91 177.28 177.28 173.74 93613 403.84 383.65 441.20 432.38 432.38 423.73 93615 64.68 61.45 70.67 69.25 69.25 67.87 93615 TC 12.69 12.06 13.87 13.59 13.59 13.32 93615 26 51.99 49.39 56.80 55.66 55.66 54.54 93616 26 64.71 61.47 70.69 69.28 69.28 67.90 93618 396.93 377.08 433.64 424.97 424.97 416.47 93618 TC 157.32 149.45 171.87 168.43 168.43 165.06 93618 26 239.61 227.63 261.77 256.54 256.54 251.41 93619 715.39 679.62 781.56 765.93 765.93 750.62 93619 TC 306.05 290.75 334.36 327.68 327.68 321.13 93619 26 409.34 388.87 447.20 438.25 438.25 429.49

Page 217: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 217Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93620 983.92 934.72 1,074.93 1,053.43 1,053.43 1,032.37 93620 26 649.30 616.84 709.37 695.18 695.18 681.27 93621 26 118.42 112.50 129.38 126.79 126.79 124.26 93622 26 173.16 164.50 189.18 185.39 185.39 181.69 93623 240.02 228.02 262.22 256.98 256.98 251.84 93623 TC 79.23 75.27 86.56 84.82 84.82 83.12 93623 26 160.79 152.75 175.66 172.16 172.16 168.72 93624 345.42 328.15 377.37 369.83 369.83 362.43 93624 TC 79.23 75.27 86.56 84.82 84.82 83.12 93624 26 266.19 252.88 290.81 284.99 284.99 279.29 93631 26 405.50 385.23 443.01 434.16 434.16 425.48 93640 383.11 363.95 418.54 410.17 410.17 401.97 93640 TC 188.12 178.71 205.52 201.41 201.41 197.39 93640 26 194.99 185.24 213.03 208.77 208.77 204.60 93641 591.14 561.58 645.82 632.90 632.90 620.24 93641 TC 259.93 246.93 283.97 278.29 278.29 272.72 93641 26 331.21 314.65 361.85 354.61 354.61 347.52 93642 416.14 395.33 454.63 445.53 445.53 436.62 93642 TC 141.44 134.37 154.53 151.43 151.43 148.41 93642 26 274.70 260.97 300.12 294.11 294.11 288.24 93644 268.98 255.53 293.86 287.98 287.98 282.22 93644 TC 97.67 92.79 106.71 104.57 104.57 102.48 93644 26 171.31 162.74 187.15 183.41 183.41 179.75 93650 612.52 581.89 669.17 655.79 655.79 642.68 93653 862.60 819.47 942.39 923.54 923.54 905.07 93654 1,149.29 1,091.83 1,255.60 1,230.49 1,230.49 1,205.88 93655 431.30 409.74 471.20 461.78 461.78 452.55 93656 1,150.00 1,092.50 1,256.38 1,231.25 1,231.25 1,206.63 93657 431.33 409.76 471.22 461.79 461.79 452.56 93660 152.38 144.76 166.47 163.14 163.14 159.87 93660 TC 58.89 55.95 64.34 63.05 63.05 61.79 93660 26 93.50 88.83 102.15 100.11 100.11 98.11 93662 296.03 281.23 323.41 316.95 316.95 310.62 93662 TC 154.42 146.70 168.71 165.34 165.34 162.02 93662 26 141.61 134.53 154.71 151.62 151.62 148.58 93701 22.38 21.26 24.45 23.95 23.95 23.47 93702 100.28 95.27 109.56 107.36 107.36 105.21 93724 266.61 253.28 291.27 285.44 285.44 279.74 93724 TC 25.99 24.69 28.39 27.83 27.83 27.28 93724 26 240.62 228.59 262.88 257.62 257.62 252.47 93745 75.22 71.46 82.18 80.53 80.53 78.92 93745 TC 28.36 26.94 30.98 30.36 30.36 29.75 93745 26 46.84 44.50 51.18 50.15 50.15 49.15 93750 54.90 52.16 59.98 58.79 58.79 57.62 # 93750 46.36 44.04 50.65 49.63 49.63 48.65 93784 51.16 48.60 55.89 54.77 54.77 53.68 93786 27.64 26.26 30.20 29.59 29.59 29.00 93788 4.96 4.71 5.42 5.31 5.31 5.21 93790 18.56 17.63 20.27 19.87 19.87 19.47

Page 218: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 218Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

93797 15.67 14.89 17.12 16.78 16.78 16.45 # 93797 8.77 8.33 9.58 9.38 9.38 9.20 93798 24.21 23.00 26.45 25.92 25.92 25.40 # 93798 14.02 13.32 15.32 15.01 15.01 14.71 C 93880 180.74 171.70 197.46 193.51 193.51 189.64 C 93880 TC 140.73 133.69 153.74 150.67 150.67 147.66 93880 26 40.01 38.01 43.71 42.84 42.84 41.99 93882 122.64 116.51 133.99 131.31 131.31 128.69 93882 TC 97.32 92.45 106.32 104.19 104.19 102.11 93882 26 25.32 24.05 27.66 27.11 27.11 26.57 C 93886 187.61 178.23 204.96 200.87 200.87 196.86 C 93886 TC 140.37 133.35 153.35 150.28 150.28 147.28 93886 26 47.23 44.87 51.60 50.57 50.57 49.55 93888 139.65 132.67 152.57 149.52 149.52 146.53 93888 TC 114.08 108.38 124.64 122.14 122.14 119.70 93888 26 25.57 24.29 27.93 27.37 27.37 26.82 C 93890 192.12 182.51 209.89 205.69 205.69 201.57 C 93890 TC 140.70 133.67 153.72 150.65 150.65 147.64 93890 26 51.41 48.84 56.17 55.04 55.04 53.94 C 93892 145.36 138.09 158.80 155.63 155.63 152.51 C 93892 TC 84.50 80.28 92.32 90.47 90.47 88.67 93892 26 60.86 57.82 66.49 65.16 65.16 63.86 C 93893 143.97 136.77 157.29 154.13 154.13 151.05 C 93893 TC 84.50 80.28 92.32 90.47 90.47 88.67 93893 26 59.47 56.50 64.98 63.68 63.68 62.40 93922 84.00 79.80 91.77 89.93 89.93 88.14 93922 TC 71.35 67.78 77.95 76.38 76.38 74.85 93922 26 12.65 12.02 13.82 13.55 13.55 13.27 93923 131.01 124.46 143.13 140.27 140.27 137.46 93923 TC 108.52 103.09 118.55 116.18 116.18 113.86 93923 26 22.49 21.37 24.58 24.08 24.08 23.60 93924 164.03 155.83 179.20 175.62 175.62 172.11 93924 TC 139.09 132.14 151.96 148.93 148.93 145.95 93924 26 24.94 23.69 27.24 26.70 26.70 26.17 C 93925 179.70 170.72 196.33 192.41 192.41 188.55 C 93925 TC 140.37 133.35 153.35 150.28 150.28 147.28 93925 26 39.32 37.35 42.95 42.09 42.09 41.25 93926 144.96 137.71 158.37 155.20 155.20 152.10 93926 TC 120.68 114.65 131.85 129.21 129.21 126.63 93926 26 24.28 23.07 26.53 26.00 26.00 25.48 C 93930 180.76 171.72 197.48 193.53 193.53 189.66 C 93930 TC 140.73 133.69 153.74 150.67 150.67 147.66 93930 26 40.03 38.03 43.73 42.86 42.86 42.00 93931 122.58 116.45 133.92 131.24 131.24 128.62 93931 TC 97.65 92.77 106.69 104.55 104.55 102.45 93931 26 24.94 23.69 27.24 26.70 26.70 26.17 93965 113.22 107.56 123.69 121.22 121.22 118.80 93965 TC 95.67 90.89 104.52 102.43 102.43 100.38 93965 26 17.54 16.66 19.16 18.78 18.78 18.40

Page 219: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 219Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

C 93970 175.49 166.72 191.73 187.90 187.90 184.14 C 93970 TC 140.73 133.69 153.74 150.67 150.67 147.66 93970 26 34.76 33.02 37.97 37.21 37.21 36.47 93971 114.19 108.48 124.75 122.26 122.26 119.81 93971 TC 91.73 87.14 100.21 98.21 98.21 96.24 93971 26 22.46 21.34 24.54 24.05 24.05 23.56 C 93975 198.28 188.37 216.63 212.29 212.29 208.05 C 93975 TC 140.37 133.35 153.35 150.28 150.28 147.28 93975 26 57.91 55.01 63.26 62.00 62.00 60.75 93976 155.02 147.27 169.36 165.97 165.97 162.64 93976 TC 115.07 109.32 125.72 123.20 123.20 120.74 93976 26 39.95 37.95 43.64 42.77 42.77 41.92 C 93978 180.79 171.75 197.51 193.57 193.57 189.69 C 93978 TC 140.73 133.69 153.74 150.67 150.67 147.66 93978 26 40.06 38.06 43.77 42.90 42.90 42.03 93979 114.07 108.37 124.63 122.13 122.13 119.69 93979 TC 89.10 84.65 97.35 95.40 95.40 93.50 93979 26 24.97 23.72 27.28 26.74 26.74 26.21 93980 116.24 110.43 126.99 124.45 124.45 121.97 93980 TC 55.25 52.49 60.36 59.16 59.16 57.97 93980 26 61.00 57.95 66.64 65.31 65.31 64.00 93981 69.82 66.33 76.28 74.75 74.75 73.26 93981 TC 47.69 45.31 52.11 51.06 51.06 50.04 93981 26 22.13 21.02 24.17 23.69 23.69 23.22 93982 41.09 39.04 44.90 44.00 44.00 43.11 C 93990 109.19 103.73 119.29 116.91 116.91 114.57 C 93990 TC 84.17 79.96 91.95 90.11 90.11 88.31 93990 26 25.02 23.77 27.34 26.78 26.78 26.24 94002 93.04 88.39 101.65 99.61 99.61 97.62 94003 66.77 63.43 72.94 71.48 71.48 70.06 94004 48.81 46.37 53.33 52.26 52.26 51.21 94010 34.08 32.38 37.24 36.49 36.49 35.77 94010 TC 25.66 24.38 28.04 27.47 27.47 26.92 94010 26 8.41 7.99 9.19 9.00 9.00 8.82 94011 101.87 96.78 111.30 109.07 109.07 106.88 94012 155.80 148.01 170.21 166.81 166.81 163.47 94013 34.44 32.72 37.63 36.88 36.88 36.14 94014 53.87 51.18 58.86 57.68 57.68 56.53 94015 28.62 27.19 31.27 30.65 30.65 30.04 94016 25.25 23.99 27.59 27.04 27.04 26.50 94060 57.38 54.51 62.69 61.43 61.43 60.20 94060 TC 44.40 42.18 48.51 47.54 47.54 46.59 94060 26 12.98 12.33 14.18 13.89 13.89 13.62 94070 57.42 54.55 62.73 61.48 61.48 60.25 94070 TC 28.62 27.19 31.27 30.65 30.65 30.04 94070 26 28.79 27.35 31.45 30.82 30.82 30.20 94200 23.71 22.52 25.90 25.38 25.38 24.87 94200 TC 18.10 17.20 19.78 19.39 19.39 19.00 94200 26 5.61 5.33 6.13 6.00 6.00 5.89

Page 220: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 220Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

94250 24.70 23.47 26.99 26.45 26.45 25.92 94250 TC 19.42 18.45 21.22 20.79 20.79 20.38 94250 26 5.28 5.02 5.77 5.66 5.66 5.54 94375 37.45 35.58 40.92 40.10 40.10 39.30 94375 TC 22.71 21.57 24.81 24.31 24.31 23.83 94375 26 14.74 14.00 16.10 15.78 15.78 15.47 94400 53.19 50.53 58.11 56.95 56.95 55.81 94400 TC 33.55 31.87 36.65 35.91 35.91 35.20 94400 26 19.63 18.65 21.45 21.02 21.02 20.60 94450 64.69 61.46 70.68 69.26 69.26 67.88 94450 TC 44.73 42.49 48.86 47.89 47.89 46.93 94450 26 19.96 18.96 21.80 21.37 21.37 20.94 94452 54.54 51.81 59.58 58.39 58.39 57.21 94452 TC 40.13 38.12 43.84 42.96 42.96 42.10 94452 26 14.41 13.69 15.74 15.43 15.43 15.12 94453 75.54 71.76 82.52 80.87 80.87 79.25 94453 TC 56.56 53.73 61.79 60.56 60.56 59.35 94453 26 18.98 18.03 20.73 20.32 20.32 19.92 94610 59.14 56.18 64.61 63.32 63.32 62.05 94620 54.25 51.54 59.27 58.09 58.09 56.93 94620 TC 23.69 22.51 25.89 25.37 25.37 24.86 94620 26 30.56 29.03 33.38 32.72 32.72 32.06 94621 156.24 148.43 170.69 167.28 167.28 163.93 94621 TC 87.48 83.11 95.58 93.67 93.67 91.79 94621 26 68.75 65.31 75.11 73.60 73.60 72.13 94640 17.12 16.26 18.70 18.32 18.32 17.95 94642 12.69 12.06 13.87 13.59 13.59 13.32 94644 40.78 38.74 44.55 43.67 43.67 42.79 94645 13.17 12.51 14.39 14.10 14.10 13.81 94660 61.23 58.17 66.90 65.56 65.56 64.25 # 94660 37.89 36.00 41.40 40.57 40.57 39.76 94662 37.26 35.40 40.71 39.89 39.89 39.10 94664 16.13 15.32 17.62 17.26 17.26 16.92 94667 24.38 23.16 26.63 26.11 26.11 25.59 94668 27.01 25.66 29.51 28.92 28.92 28.35 94669 30.62 29.09 33.45 32.79 32.79 32.13 94680 54.06 51.36 59.06 57.88 57.88 56.72 94680 TC 41.44 39.37 45.28 44.37 44.37 43.48 94680 26 12.62 11.99 13.79 13.51 13.51 13.25 94681 49.61 47.13 54.20 53.12 53.12 52.06 94681 TC 39.80 37.81 43.48 42.61 42.61 41.76 94681 26 9.82 9.33 10.73 10.51 10.51 10.30 94690 46.60 44.27 50.91 49.89 49.89 48.89 94690 TC 42.76 40.62 46.71 45.78 45.78 44.86 94690 26 3.85 3.66 4.21 4.13 4.13 4.05 94726 49.79 47.30 54.40 53.30 53.30 52.23 94726 TC 37.50 35.63 40.97 40.16 40.16 39.35 94726 26 12.29 11.68 13.43 13.17 13.17 12.90 94727 39.93 37.93 43.62 42.75 42.75 41.89

Page 221: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 221Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

94727 TC 27.64 26.26 30.20 29.59 29.59 29.00 94727 26 12.29 11.68 13.43 13.17 13.17 12.90 94728 38.29 36.38 41.84 41.00 41.00 40.18 94728 TC 25.66 24.38 28.04 27.47 27.47 26.92 94728 26 12.62 11.99 13.79 13.51 13.51 13.25 94729 51.23 48.67 55.97 54.86 54.86 53.76 94729 TC 42.10 40.00 46.00 45.08 45.08 44.18 94729 26 9.13 8.67 9.97 9.78 9.78 9.58 94750 75.67 71.89 82.67 81.02 81.02 79.40 94750 TC 64.45 61.23 70.41 69.01 69.01 67.63 94750 26 11.22 10.66 12.26 12.02 12.02 11.78 94760 2.99 2.84 3.27 3.20 3.20 3.13 94761 4.63 4.40 5.06 4.96 4.96 4.85 94762 22.71 21.57 24.81 24.31 24.31 23.83 94770 7.37 7.00 8.05 7.89 7.89 7.73 94780 53.78 51.09 58.75 57.58 57.58 56.43 # 94780 22.88 21.74 25.00 24.51 24.51 24.01 94781 21.89 20.80 23.92 23.44 23.44 22.97 # 94781 8.41 7.99 9.19 9.00 9.00 8.82 95004 6.30 5.99 6.89 6.75 6.75 6.61 95012 17.78 16.89 19.42 19.03 19.03 18.65 95017 7.46 7.09 8.15 7.99 7.99 7.83 # 95017 3.52 3.34 3.84 3.76 3.76 3.68 95018 19.50 18.53 21.31 20.88 20.88 20.47 # 95018 7.01 6.66 7.66 7.51 7.51 7.36 95024 7.29 6.93 7.97 7.81 7.81 7.65 # 95024 1.04 0.99 1.14 1.12 1.12 1.09 95027 4.33 4.11 4.73 4.63 4.63 4.54 95028 12.52 11.89 13.67 13.40 13.40 13.13 95044 5.29 5.03 5.78 5.67 5.67 5.55 95052 6.27 5.96 6.85 6.72 6.72 6.58 95056 41.14 39.08 44.94 44.05 44.05 43.16 95060 32.57 30.94 35.58 34.87 34.87 34.17 95065 23.69 22.51 25.89 25.37 25.37 24.86 95070 28.32 26.90 30.94 30.31 30.31 29.70 95071 32.59 30.96 35.60 34.89 34.89 34.19 95076 112.70 107.07 123.13 120.67 120.67 118.25 # 95076 72.93 69.28 79.67 78.07 78.07 76.51 95079 81.10 77.05 88.61 86.84 86.84 85.10 # 95079 66.64 63.31 72.81 71.35 71.35 69.92 95115 8.24 7.83 9.00 8.82 8.82 8.65 95117 9.56 9.08 10.44 10.24 10.24 10.03 95144 11.71 11.12 12.79 12.54 12.54 12.28 # 95144 3.16 3.00 3.45 3.38 3.38 3.31 95145 20.25 19.24 22.13 21.69 21.69 21.25 # 95145 3.16 3.00 3.45 3.38 3.38 3.31 95146 36.36 34.54 39.72 38.93 38.93 38.15 # 95146 3.16 3.00 3.45 3.38 3.38 3.31 95147 32.74 31.10 35.77 35.05 35.05 34.35

Page 222: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 222Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 95147 3.16 3.00 3.45 3.38 3.38 3.31 95148 48.52 46.09 53.00 51.95 51.95 50.91 # 95148 3.16 3.00 3.45 3.38 3.38 3.31 95149 65.28 62.02 71.32 69.90 69.90 68.49 # 95149 3.16 3.00 3.45 3.38 3.38 3.31 95165 12.04 11.44 13.16 12.89 12.89 12.64 # 95165 3.16 3.00 3.45 3.38 3.38 3.31 95170 9.08 8.63 9.92 9.73 9.73 9.53 # 95170 3.16 3.00 3.45 3.38 3.38 3.31 95180 130.36 123.84 142.42 139.56 139.56 136.77 # 95180 100.45 95.43 109.74 107.55 107.55 105.40 95250 146.70 139.37 160.28 157.07 157.07 153.93 95251 43.06 40.91 47.05 46.10 46.10 45.18 95782 962.91 914.76 1,051.97 1,030.93 1,030.93 1,010.31 95782 TC 836.63 794.80 914.02 895.74 895.74 877.82 95782 26 126.28 119.97 137.97 135.21 135.21 132.50 95783 1,009.55 959.07 1,102.93 1,080.87 1,080.87 1,059.25 95783 TC 870.51 826.98 951.03 932.01 932.01 913.36 95783 26 139.04 132.09 151.90 148.87 148.87 145.89 95800 168.87 160.43 184.49 180.80 180.80 177.19 95800 TC 117.37 111.50 128.23 125.66 125.66 123.14 95800 26 51.51 48.93 56.27 55.14 55.14 54.04 95801 87.24 82.88 95.31 93.40 93.40 91.54 95801 TC 38.15 36.24 41.68 40.85 40.85 40.03 95801 26 49.09 46.64 53.64 52.57 52.57 51.52 95803 134.25 127.54 146.67 143.74 143.74 140.86 95803 TC 90.74 86.20 99.13 97.15 97.15 95.21 95803 26 43.51 41.33 47.53 46.58 46.58 45.64 95805 401.22 381.16 438.33 429.57 429.57 420.98 95805 TC 342.35 325.23 374.01 366.54 366.54 359.21 95805 26 58.88 55.94 64.33 63.04 63.04 61.78 95806 160.28 152.27 175.11 171.60 171.60 168.18 95806 TC 99.62 94.64 108.84 106.66 106.66 104.54 95806 26 60.67 57.64 66.29 64.96 64.96 63.66 95807 448.82 426.38 490.34 480.53 480.53 470.91 95807 TC 386.72 367.38 422.49 414.03 414.03 405.75 95807 26 62.10 59.00 67.85 66.49 66.49 65.16 95808 591.91 562.31 646.66 633.72 633.72 621.05 95808 TC 504.42 479.20 551.08 540.06 540.06 529.26 95808 26 87.49 83.12 95.59 93.68 93.68 91.80 95810 587.35 557.98 641.68 628.84 628.84 616.26 95810 TC 465.99 442.69 509.09 498.92 498.92 488.93 95810 26 121.36 115.29 132.58 129.93 129.93 127.33 95811 617.27 586.41 674.37 660.88 660.88 647.67 95811 TC 490.99 466.44 536.41 525.68 525.68 515.17 95811 26 126.28 119.97 137.97 135.21 135.21 132.50 95812 327.49 311.12 357.79 350.64 350.64 343.62 95812 TC 270.26 256.75 295.26 289.36 289.36 283.58 95812 26 57.24 54.38 62.54 61.28 61.28 60.05

Page 223: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 223Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95813 398.18 378.27 435.01 426.31 426.31 417.78 95813 TC 306.74 291.40 335.11 328.41 328.41 321.84 95813 26 91.44 86.87 99.90 97.90 97.90 95.94 95816 339.98 322.98 371.43 364.00 364.00 356.72 95816 TC 282.75 268.61 308.90 302.73 302.73 296.68 95816 26 57.24 54.38 62.54 61.28 61.28 60.05 95819 388.33 368.91 424.25 415.76 415.76 407.45 95819 TC 331.09 314.54 361.72 354.49 354.49 347.40 95819 26 57.24 54.38 62.54 61.28 61.28 60.05 95822 350.17 332.66 382.56 374.91 374.91 367.41 95822 TC 292.94 278.29 320.03 313.63 313.63 307.36 95822 26 57.24 54.38 62.54 61.28 61.28 60.05 95824 26 39.09 37.14 42.71 41.86 41.86 41.02 95827 652.12 619.51 712.44 698.19 698.19 684.23 95827 TC 595.21 565.45 650.27 637.26 637.26 624.52 95827 26 56.91 54.06 62.17 60.93 60.93 59.71 95829 1,770.00 1,681.50 1,933.73 1,895.05 1,895.05 1,857.15 95829 TC 1,435.19 1,363.43 1,567.94 1,536.58 1,536.58 1,505.86 95829 26 334.81 318.07 365.78 358.47 358.47 351.30 95830 233.80 222.11 255.43 250.32 250.32 245.32 # 95830 91.48 86.91 99.95 97.95 97.95 95.99 95831 29.17 27.71 31.87 31.23 31.23 30.61 # 95831 15.04 14.29 16.43 16.10 16.10 15.78 95832 28.24 26.83 30.85 30.23 30.23 29.62 # 95832 15.75 14.96 17.20 16.86 16.86 16.53 95833 35.95 34.15 39.27 38.49 38.49 37.72 # 95833 21.48 20.41 23.47 23.00 23.00 22.54 95834 49.53 47.05 54.11 53.03 53.03 51.97 # 95834 31.12 29.56 33.99 33.32 33.32 32.65 95851 17.59 16.71 19.22 18.84 18.84 18.46 # 95851 7.73 7.34 8.44 8.27 8.27 8.11 95852 15.47 14.70 16.91 16.57 16.57 16.24 # 95852 5.94 5.64 6.49 6.36 6.36 6.23 95857 51.95 49.35 56.75 55.61 55.61 54.50 # 95857 29.27 27.81 31.98 31.34 31.34 30.72 95860 116.35 110.53 127.11 124.57 124.57 122.07 95860 TC 65.11 61.85 71.13 69.70 69.70 68.31 95860 26 51.24 48.68 55.98 54.87 54.87 53.77 95861 164.20 155.99 179.39 175.80 175.80 172.28 95861 TC 81.87 77.78 89.45 87.65 87.65 85.91 95861 26 82.33 78.21 89.94 88.15 88.15 86.39 95863 203.63 193.45 222.47 218.02 218.02 213.66 95863 TC 104.55 99.32 114.22 111.93 111.93 109.69 95863 26 99.08 94.13 108.25 106.09 106.09 103.97 95864 229.75 218.26 251.00 245.97 245.97 241.05 95864 TC 122.30 116.19 133.62 130.95 130.95 128.33 95864 26 107.45 102.08 117.39 115.05 115.05 112.75 95865 139.03 132.08 151.89 148.86 148.86 145.88 95865 TC 54.92 52.17 60.00 58.80 58.80 57.63

Page 224: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 224Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95865 26 84.12 79.91 91.90 90.06 90.06 88.25 95866 128.07 121.67 139.92 137.13 137.13 134.39 95866 TC 61.49 58.42 67.18 65.84 65.84 64.53 95866 26 66.58 63.25 72.74 71.29 71.29 69.86 95867 90.21 85.70 98.56 96.59 96.59 94.66 95867 TC 48.67 46.24 53.18 52.12 52.12 51.07 95867 26 41.54 39.46 45.38 44.47 44.47 43.59 95868 126.94 120.59 138.68 135.91 135.91 133.19 95868 TC 64.12 60.91 70.05 68.64 68.64 67.28 95868 26 62.82 59.68 68.63 67.26 67.26 65.92 95869 87.61 83.23 95.71 93.81 93.81 91.93 95869 TC 67.74 64.35 74.00 72.52 72.52 71.07 95869 26 19.87 18.88 21.71 21.28 21.28 20.85 95870 87.61 83.23 95.71 93.81 93.81 91.93 95870 TC 68.06 64.66 74.36 72.88 72.88 71.42 95870 26 19.55 18.57 21.36 20.93 20.93 20.52 95872 191.33 181.76 209.02 204.84 204.84 200.74 95872 TC 38.81 36.87 42.40 41.55 41.55 40.72 95872 26 152.52 144.89 166.62 163.29 163.29 160.02 95873 69.48 66.01 75.91 74.39 74.39 72.91 95873 TC 49.63 47.15 54.22 53.14 53.14 52.08 95873 26 19.85 18.86 21.69 21.25 21.25 20.83 95874 69.18 65.72 75.58 74.07 74.07 72.59 95874 TC 49.30 46.84 53.87 52.79 52.79 51.73 95874 26 19.87 18.88 21.71 21.28 21.28 20.85 95875 119.47 113.50 130.53 127.91 127.91 125.36 95875 TC 60.83 57.79 66.46 65.12 65.12 63.83 95875 26 58.64 55.71 64.07 62.79 62.79 61.54 95885 55.64 52.86 60.79 59.57 59.57 58.37 95885 TC 36.81 34.97 40.22 39.41 39.41 38.62 95885 26 18.83 17.89 20.57 20.16 20.16 19.76 95886 87.43 83.06 95.52 93.61 93.61 91.74 95886 TC 41.41 39.34 45.24 44.33 44.33 43.45 95886 26 46.02 43.72 50.28 49.28 49.28 48.29 95887 77.46 73.59 84.63 82.94 82.94 81.28 95887 TC 39.77 37.78 43.45 42.57 42.57 41.72 95887 26 37.69 35.81 41.18 40.35 40.35 39.55 95905 65.28 62.02 71.32 69.90 69.90 68.49 95905 TC 62.48 59.36 68.26 66.90 66.90 65.56 95905 26 2.80 2.66 3.06 3.00 3.00 2.94 95907 91.84 87.25 100.34 98.34 98.34 96.37 95907 TC 38.81 36.87 42.40 41.55 41.55 40.72 95907 26 53.03 50.38 57.94 56.78 56.78 55.64 95908 113.97 108.27 124.51 122.02 122.02 119.58 95908 TC 47.69 45.31 52.11 51.06 51.06 50.04 95908 26 66.28 62.97 72.42 70.97 70.97 69.55 95909 138.72 131.78 151.55 148.51 148.51 145.54 95909 TC 59.19 56.23 64.66 63.38 63.38 62.11 95909 26 79.53 75.55 86.88 85.15 85.15 83.44

Page 225: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 225Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95910 184.97 175.72 202.08 198.04 198.04 194.09 95910 TC 78.58 74.65 85.85 84.13 84.13 82.46 95910 26 106.39 101.07 116.23 113.91 113.91 111.63 95911 223.63 212.45 244.32 239.43 239.43 234.65 95911 TC 90.74 86.20 99.13 97.15 97.15 95.21 95911 26 132.89 126.25 145.19 142.29 142.29 139.45 95912 250.82 238.28 274.02 268.54 268.54 263.17 95912 TC 93.04 88.39 101.65 99.61 99.61 97.62 95912 26 157.78 149.89 172.37 168.92 168.92 165.54 95913 287.39 273.02 313.97 307.69 307.69 301.54 95913 TC 100.60 95.57 109.91 107.71 107.71 105.56 95913 26 186.78 177.44 204.06 199.97 199.97 195.97 95921 82.98 78.83 90.65 88.84 88.84 87.07 95921 TC 37.83 35.94 41.33 40.50 40.50 39.70 95921 26 45.15 42.89 49.32 48.33 48.33 47.37 95922 96.63 91.80 105.57 103.45 103.45 101.38 95922 TC 48.34 45.92 52.81 51.75 51.75 50.72 95922 26 48.28 45.87 52.75 51.69 51.69 50.66 95923 155.34 147.57 169.71 166.31 166.31 162.99 95923 TC 109.15 103.69 119.24 116.86 116.86 114.53 95923 26 46.19 43.88 50.46 49.45 49.45 48.46 95924 143.78 136.59 157.08 153.94 153.94 150.86 95924 TC 54.92 52.17 60.00 58.80 58.80 57.63 95924 26 88.86 84.42 97.08 95.14 95.14 93.24 95925 146.34 139.02 159.87 156.68 156.68 153.55 95925 TC 118.38 112.46 129.33 126.74 126.74 124.21 95925 26 27.96 26.56 30.54 29.93 29.93 29.34 95926 129.58 123.10 141.57 138.74 138.74 135.96 95926 TC 102.27 97.16 111.73 109.50 109.50 107.32 95926 26 27.30 25.94 29.83 29.23 29.23 28.65 95927 133.88 127.19 146.27 143.35 143.35 140.48 95927 TC 106.57 101.24 116.43 114.10 114.10 111.83 95927 26 27.30 25.94 29.83 29.23 29.23 28.65 95928 213.36 202.69 233.09 228.44 228.44 223.87 95928 TC 133.80 127.11 146.18 143.26 143.26 140.39 95928 26 79.56 75.58 86.92 85.18 85.18 83.48 95929 215.06 204.31 234.96 230.25 230.25 225.65 95929 TC 134.79 128.05 147.26 144.31 144.31 141.43 95929 26 80.27 76.26 87.70 85.94 85.94 84.23 95930 121.41 115.34 132.64 129.98 129.98 127.39 95930 TC 102.93 97.78 112.45 110.19 110.19 107.99 95930 26 18.47 17.55 20.18 19.78 19.78 19.39 95933 71.52 67.94 78.13 76.57 76.57 75.04 95933 TC 40.45 38.43 44.19 43.31 43.31 42.45 95933 26 31.07 29.52 33.95 33.27 33.27 32.60 95937 77.61 73.73 84.79 83.10 83.10 81.43 95937 TC 43.41 41.24 47.43 46.48 46.48 45.55 95937 26 34.20 32.49 37.36 36.62 36.62 35.88 95938 320.25 304.24 349.88 342.88 342.88 336.03

Page 226: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 226Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

95938 TC 274.53 260.80 299.92 293.92 293.92 288.04 95938 26 45.72 43.43 49.94 48.94 48.94 47.97 95939 472.45 448.83 516.15 505.83 505.83 495.71 95939 TC 353.44 335.77 386.14 378.41 378.41 370.84 95939 26 119.01 113.06 130.02 127.42 127.42 124.87 95940 32.46 30.84 35.47 34.75 34.75 34.06 95943 142.04 134.94 155.18 152.08 152.08 149.04 95943 TC 53.16 50.50 58.08 56.91 56.91 55.78 95943 26 88.87 84.43 97.09 95.15 95.15 93.25 95950 312.38 296.76 341.27 334.44 334.44 327.75 95950 TC 232.79 221.15 254.32 249.24 249.24 244.26 95950 26 79.59 75.61 86.95 85.22 85.22 83.51 95951 1,557.50 1,479.63 1,701.57 1,667.55 1,667.55 1,634.20 95951 TC 1,239.93 1,177.93 1,354.62 1,327.53 1,327.53 1,300.97 95951 26 317.57 301.69 346.94 340.01 340.01 333.21 95953 402.05 381.95 439.24 430.46 430.46 421.84 95953 TC 239.03 227.08 261.14 255.92 255.92 250.80 95953 26 163.02 154.87 178.10 174.54 174.54 171.04 95954 426.75 405.41 466.22 456.90 456.90 447.75 95954 TC 302.52 287.39 330.50 323.89 323.89 317.41 95954 26 124.22 118.01 135.71 133.00 133.00 130.34 95955 204.31 194.09 223.20 218.74 218.74 214.37 95955 TC 150.56 143.03 164.48 161.20 161.20 157.98 95955 26 53.74 51.05 58.71 57.53 57.53 56.38 95956 1,538.38 1,461.46 1,680.68 1,647.06 1,647.06 1,614.13 95956 TC 1,348.11 1,280.70 1,472.81 1,443.35 1,443.35 1,414.49 95956 26 190.27 180.76 207.87 203.71 203.71 199.64 95957 299.02 284.07 326.68 320.15 320.15 313.74 95957 TC 194.63 184.90 212.64 208.38 208.38 204.22 95957 26 104.38 99.16 114.03 111.76 111.76 109.53 95958 545.88 518.59 596.38 584.45 584.45 572.77 95958 TC 320.96 304.91 350.65 343.63 343.63 336.75 95958 26 224.93 213.68 245.73 240.82 240.82 236.00 95961 283.32 269.15 309.52 303.34 303.34 297.26 95961 TC 121.97 115.87 133.25 130.58 130.58 127.97 95961 26 161.35 153.28 176.27 172.74 172.74 169.29 95962 253.95 241.25 277.44 271.89 271.89 266.46 95962 TC 81.54 77.46 89.08 87.30 87.30 85.55 95962 26 172.41 163.79 188.36 184.59 184.59 180.90 95965 26 417.69 396.81 456.33 447.20 447.20 438.25 95966 26 211.49 200.92 231.06 226.44 226.44 221.90 95967 26 184.30 175.09 201.35 197.33 197.33 193.38 95970 64.54 61.31 70.51 69.09 69.09 67.71 # 95970 23.78 22.59 25.98 25.46 25.46 24.96 95971 49.15 46.69 53.69 52.62 52.62 51.57 # 95971 40.61 38.58 44.37 43.48 43.48 42.61 95972 56.80 53.96 62.05 60.81 60.81 59.59 # 95972 41.68 39.60 45.54 44.63 44.63 43.73 95974 203.18 193.02 221.97 217.53 217.53 213.19

Page 227: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 227Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 95974 162.75 154.61 177.80 174.25 174.25 170.76 95975 109.59 104.11 119.73 117.33 117.33 114.99 # 95975 92.17 87.56 100.69 98.68 98.68 96.70 95978 243.62 231.44 266.16 260.83 260.83 255.61 # 95978 191.69 182.11 209.43 205.24 205.24 201.14 95979 106.12 100.81 115.93 113.61 113.61 111.33 # 95979 89.03 84.58 97.27 95.32 95.32 93.41 95980 46.19 43.88 50.46 49.45 49.45 48.46 95981 30.57 29.04 33.40 32.73 32.73 32.07 # 95981 17.75 16.86 19.39 19.00 19.00 18.62 95982 51.12 48.56 55.84 54.73 54.73 53.64 # 95982 36.33 34.51 39.69 38.89 38.89 38.11 95990 85.21 80.95 93.09 91.23 91.23 89.40 95991 115.16 109.40 125.81 123.29 123.29 120.83 # 95991 39.56 37.58 43.22 42.35 42.35 41.50 95992 42.41 40.29 46.33 45.40 45.40 44.49 # 95992 37.15 35.29 40.58 39.77 39.77 38.97 96000 94.35 89.63 103.07 101.02 101.02 98.99 96001 106.82 101.48 116.70 114.37 114.37 112.08 96002 21.66 20.58 23.67 23.20 23.20 22.74 96003 17.22 16.36 18.81 18.43 18.43 18.07 96004 115.84 110.05 126.56 124.03 124.03 121.54 96020 26 163.34 155.17 178.45 174.88 174.88 171.38 96101 79.60 75.62 86.96 85.23 85.23 83.52 # 96101 79.27 75.31 86.61 84.87 84.87 83.17 96102 60.38 57.36 65.96 64.64 64.64 63.35 # 96102 23.24 22.08 25.39 24.89 24.89 24.39 96103 27.24 25.88 29.76 29.16 29.16 28.58 # 96103 26.58 25.25 29.04 28.46 28.46 27.90 96105 104.94 99.69 114.64 112.36 112.36 110.11 96111 127.95 121.55 139.78 136.99 136.99 134.25 # 96111 122.04 115.94 133.33 130.66 130.66 128.05 96116 91.84 87.25 100.34 98.34 98.34 96.37 # 96116 86.59 82.26 94.60 92.70 92.70 90.85 96118 96.37 91.55 105.28 103.18 103.18 101.12 # 96118 78.62 74.69 85.89 84.18 84.18 82.50 96119 75.95 72.15 82.97 81.32 81.32 79.70 # 96119 23.69 22.51 25.89 25.37 25.37 24.86 96120 46.31 43.99 50.59 49.58 49.58 48.59 # 96120 25.93 24.63 28.32 27.76 27.76 27.21 96125 113.97 108.27 124.51 122.02 122.02 119.58 96127 4.96 4.71 5.42 5.31 5.31 5.21 96150 21.57 20.49 23.56 23.09 23.09 22.63 # 96150 21.24 20.18 23.21 22.75 22.75 22.29 96151 20.53 19.50 22.43 21.98 21.98 21.54 # 96151 20.20 19.19 22.07 21.63 21.63 21.19 96152 19.81 18.82 21.64 21.21 21.21 20.78 # 96152 19.48 18.51 21.29 20.86 20.86 20.45 96153 4.59 4.36 5.01 4.91 4.91 4.81

Page 228: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 228Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

96154 19.45 18.48 21.25 20.83 20.83 20.41 # 96154 19.12 18.16 20.88 20.47 20.47 20.06 96360 53.50 50.83 58.45 57.28 57.28 56.13 96361 14.42 13.70 15.76 15.44 15.44 15.13 96365 64.82 61.58 70.82 69.40 69.40 68.01 96366 17.98 17.08 19.64 19.25 19.25 18.87 96367 28.88 27.44 31.56 30.92 30.92 30.30 96368 19.59 18.61 21.40 20.98 20.98 20.56 96369 178.84 169.90 195.39 191.48 191.48 187.65 96370 14.36 13.64 15.69 15.38 15.38 15.07 96371 67.38 64.01 73.61 72.14 72.14 70.70 96372 23.86 22.67 26.07 25.55 25.55 25.05 96373 18.60 17.67 20.32 19.92 19.92 19.52 96374 53.23 50.57 58.16 56.99 56.99 55.86 96375 21.03 19.98 22.98 22.52 22.52 22.07 96401 69.77 66.28 76.22 74.69 74.69 73.20 96402 30.52 28.99 33.34 32.67 32.67 32.02 96405 77.53 73.65 84.70 83.01 83.01 81.35 # 96405 29.55 28.07 32.28 31.64 31.64 31.00 96406 110.62 105.09 120.85 118.44 118.44 116.07 # 96406 45.87 43.58 50.12 49.12 49.12 48.14 96409 103.44 98.27 113.01 110.75 110.75 108.53 96411 58.21 55.30 63.60 62.32 62.32 61.08 96413 126.27 119.96 137.95 135.19 135.19 132.49 96415 26.91 25.56 29.39 28.81 28.81 28.23 96416 130.99 124.44 143.11 140.24 140.24 137.44 96417 58.57 55.64 63.99 62.71 62.71 61.46 96420 98.31 93.39 107.40 105.25 105.25 103.14 96422 157.88 149.99 172.49 169.04 169.04 165.66 96423 73.27 69.61 80.05 78.45 78.45 76.89 96425 168.78 160.34 184.39 180.70 180.70 177.09 96440 793.36 753.69 866.74 849.41 849.41 832.43 # 96440 140.26 133.25 153.24 150.18 150.18 147.18 96446 187.85 178.46 205.23 201.12 201.12 197.10 # 96446 28.76 27.32 31.42 30.79 30.79 30.16 96450 173.76 165.07 189.83 186.04 186.04 182.31 # 96450 80.41 76.39 87.85 86.09 86.09 84.36 96521 128.66 122.23 140.56 137.76 137.76 135.00 96522 105.68 100.40 115.46 113.15 113.15 110.88 96523 23.15 21.99 25.29 24.78 24.78 24.29 96542 114.77 109.03 125.38 122.88 122.88 120.42 # 96542 41.81 39.72 45.68 44.77 44.77 43.87 96567 125.28 119.02 136.87 134.14 134.14 131.46 96570 58.00 55.10 63.37 62.10 62.10 60.86 96571 27.06 25.71 29.57 28.98 28.98 28.41 96900 19.09 18.14 20.86 20.45 20.45 20.03 96904 58.23 55.32 63.62 62.34 62.34 61.10 96910 66.09 62.79 72.21 70.76 70.76 69.35 96912 84.50 80.28 92.32 90.47 90.47 88.67

Page 229: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 229Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

96913 121.36 115.29 132.58 129.93 129.93 127.33 96920 147.83 140.44 161.51 158.27 158.27 155.11 # 96920 65.99 62.69 72.09 70.66 70.66 69.24 96921 162.73 154.59 177.78 174.23 174.23 170.74 # 96921 74.64 70.91 81.55 79.91 79.91 78.32 96922 226.68 215.35 247.65 242.70 242.70 237.84 # 96922 120.51 114.48 131.65 129.02 129.02 126.44 97001 73.34 69.67 80.12 78.52 78.52 76.95 97002 40.60 38.57 44.36 43.47 43.47 42.60 97003 82.21 78.10 89.82 88.02 88.02 86.26 97004 50.46 47.94 55.13 54.03 54.03 52.95 97012 15.55 14.77 16.99 16.64 16.64 16.31 97016 18.30 17.39 20.00 19.60 19.60 19.21 97018 10.39 9.87 11.35 11.12 11.12 10.90 97022 22.22 21.11 24.28 23.79 23.79 23.32 97024 6.12 5.81 6.68 6.54 6.54 6.42 97026 5.79 5.50 6.33 6.20 6.20 6.07 97028 7.16 6.80 7.82 7.66 7.66 7.51 97032 18.51 17.58 20.22 19.81 19.81 19.42 97033 25.11 23.85 27.43 26.88 26.88 26.34 97034 17.41 16.54 19.02 18.64 18.64 18.27 97035 12.48 11.86 13.64 13.36 13.36 13.10 97036 31.42 29.85 34.33 33.64 33.64 32.97 97110 31.29 29.73 34.19 33.51 33.51 32.84 97112 32.60 30.97 35.62 34.90 34.90 34.20 97113 41.09 39.04 44.90 44.00 44.00 43.11 97116 27.50 26.13 30.05 29.45 29.45 28.87 97124 25.38 24.11 27.73 27.17 27.17 26.63 97140 28.90 27.46 31.58 30.95 30.95 30.33 97150 16.98 16.13 18.55 18.18 18.18 17.81 97530 33.53 31.85 36.63 35.89 35.89 35.18 97532 25.97 24.67 28.37 27.81 27.81 27.26 97533 28.27 26.86 30.89 30.27 30.27 29.66 97535 33.91 32.21 37.04 36.31 36.31 35.58 97537 29.31 27.84 32.02 31.37 31.37 30.74 97542 29.97 28.47 32.74 32.09 32.09 31.44 97597 71.23 67.67 77.82 76.27 76.27 74.74 # 97597 23.24 22.08 25.39 24.89 24.89 24.39 97598 23.41 22.24 25.58 25.07 25.07 24.56 # 97598 10.92 10.37 11.93 11.68 11.68 11.45 97605 39.80 37.81 43.48 42.61 42.61 41.76 # 97605 25.01 23.76 27.32 26.77 26.77 26.23 97606 46.84 44.50 51.18 50.15 50.15 49.15 # 97606 27.12 25.76 29.62 29.03 29.03 28.45 97607 42.65 40.52 46.60 45.67 45.67 44.76 # 97607 27.74 26.35 30.30 29.69 29.69 29.10 97608 50.48 47.96 55.15 54.05 54.05 52.97 # 97608 30.58 29.05 33.41 32.74 32.74 32.09 97610 111.82 106.23 122.16 119.73 119.73 117.33

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 230Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 97610 15.85 15.06 17.32 16.97 16.97 16.63 97750 31.94 30.34 34.89 34.19 34.19 33.51 97755 35.07 33.32 38.32 37.55 37.55 36.80 97760 36.54 34.71 39.92 39.12 39.12 38.34 97761 31.94 30.34 34.89 34.19 34.19 33.51 97762 44.80 42.56 48.94 47.97 47.97 47.01 97802 33.82 32.13 36.95 36.21 36.21 35.49 # 97802 31.85 30.26 34.80 34.10 34.10 33.42 97803 29.31 27.84 32.02 31.37 31.37 30.74 # 97803 27.01 25.66 29.51 28.92 28.92 28.35 97804 15.55 14.77 16.99 16.64 16.64 16.31 # 97804 14.89 14.15 16.27 15.95 15.95 15.63 98925 30.68 29.15 33.52 32.86 32.86 32.20 # 98925 23.45 22.28 25.62 25.10 25.10 24.60 98926 44.59 42.36 48.71 47.74 47.74 46.78 # 98926 35.72 33.93 39.02 38.24 38.24 37.48 98927 57.84 54.95 63.19 61.93 61.93 60.69 # 98927 47.00 44.65 51.35 50.32 50.32 49.31 98928 71.09 67.54 77.67 76.12 76.12 74.60 # 98928 59.26 56.30 64.75 63.45 63.45 62.18 98929 85.00 80.75 92.86 91.01 91.01 89.19 # 98929 71.20 67.64 77.79 76.23 76.23 74.70 98940 27.70 26.32 30.27 29.66 29.66 29.06 # 98940 22.44 21.32 24.52 24.02 24.02 23.54 98941 39.94 37.94 43.63 42.76 42.76 41.91 # 98941 34.35 32.63 37.52 36.78 36.78 36.04 98942 52.20 49.59 57.03 55.89 55.89 54.77 # 98942 46.29 43.98 50.58 49.57 49.57 48.58 99143 41.68 39.60 45.54 44.63 44.63 43.73 99144 40.07 38.07 43.78 42.91 42.91 42.04 99145 14.03 13.33 15.33 15.02 15.02 14.72 99148 97.19 92.33 106.18 104.05 104.05 101.97 99149 93.59 88.91 102.25 100.20 100.20 98.20 99150 26.52 25.19 28.97 28.39 28.39 27.83 99170 166.49 158.17 181.90 178.26 178.26 174.70 # 99170 88.59 84.16 96.78 94.85 94.85 92.95 99175 15.80 15.01 17.26 16.92 16.92 16.58 99183 109.74 104.25 119.89 117.50 117.50 115.15 99184 227.25 215.89 248.27 243.31 243.31 238.44 99195 92.85 88.21 101.44 99.42 99.42 97.43 99201 41.97 39.87 45.85 44.93 44.93 44.03 # 99201 26.19 24.88 28.61 28.04 28.04 27.47 99202 71.97 68.37 78.63 77.05 77.05 75.51 # 99202 49.62 47.14 54.21 53.13 53.13 52.07 99203 104.49 99.27 114.16 111.87 111.87 109.63 # 99203 75.90 72.11 82.93 81.27 81.27 79.65 99204 160.23 152.22 175.05 171.56 171.56 168.13 # 99204 128.35 121.93 140.22 137.41 137.41 134.67 99205 201.38 191.31 220.01 215.60 215.60 211.29

Page 231: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 231Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 99205 166.87 158.53 182.31 178.66 178.66 175.09 99211 18.96 18.01 20.71 20.30 20.30 19.90 # 99211 9.10 8.65 9.95 9.75 9.75 9.56 99212 41.62 39.54 45.47 44.56 44.56 43.68 # 99212 24.85 23.61 27.15 26.61 26.61 26.08 99213 70.42 66.90 76.94 75.39 75.39 73.89 # 99213 50.37 47.85 55.03 53.92 53.92 52.84 99214 103.93 98.73 113.54 111.27 111.27 109.04 # 99214 77.31 73.44 84.46 82.77 82.77 81.11 99215 140.37 133.35 153.35 150.28 150.28 147.28 # 99215 109.48 104.01 119.61 117.22 117.22 114.87 99217 71.38 67.81 77.98 76.42 76.42 74.89 99218 98.40 93.48 107.50 105.35 105.35 103.25 99219 133.67 126.99 146.04 143.12 143.12 140.25 99220 182.67 173.54 199.57 195.58 195.58 191.67 99221 100.15 95.14 109.41 107.23 107.23 105.09 99222 135.10 128.35 147.60 144.65 144.65 141.75 99223 199.79 189.80 218.27 213.90 213.90 209.62 99224 39.20 37.24 42.83 41.98 41.98 41.14 99225 71.70 68.12 78.34 76.77 76.77 75.23 99226 103.51 98.33 113.08 110.81 110.81 108.59 99231 38.88 36.94 42.48 41.63 41.63 40.80 99232 71.05 67.50 77.63 76.07 76.07 74.55 99233 102.55 97.42 112.03 109.79 109.79 107.59 99234 131.97 125.37 144.18 141.29 141.29 138.46 99235 166.58 158.25 181.99 178.35 178.35 174.79 99236 214.59 203.86 234.44 229.75 229.75 225.15 99238 71.02 67.47 77.59 76.04 76.04 74.52 99239 105.16 99.90 114.89 112.59 112.59 110.33 99281 21.15 20.09 23.10 22.64 22.64 22.20 99282 41.25 39.19 45.07 44.17 44.17 43.29 99283 61.78 58.69 67.49 66.15 66.15 64.83 99284 117.26 111.40 128.11 125.55 125.55 123.04 99285 173.15 164.49 189.16 185.38 185.38 181.68 99291 268.99 255.54 293.87 287.99 287.99 282.23 # 99291 221.66 210.58 242.17 237.33 237.33 232.58 99292 120.84 114.80 132.02 129.38 129.38 126.79 # 99292 110.98 105.43 121.24 118.82 118.82 116.44 99304 89.91 85.41 98.22 96.26 96.26 94.33 99305 127.93 121.53 139.76 136.97 136.97 134.23 99306 163.32 155.15 178.42 174.86 174.86 171.36 99307 43.78 41.59 47.83 46.87 46.87 45.93 99308 67.71 64.32 73.97 72.48 72.48 71.04 99309 89.29 84.83 97.55 95.60 95.60 93.69 99310 132.89 126.25 145.19 142.29 142.29 139.45 99315 71.68 68.10 78.32 76.75 76.75 75.22 99316 103.88 98.69 113.49 111.23 111.23 109.01 99318 94.06 89.36 102.76 100.71 100.71 98.69 99324 54.43 51.71 59.47 58.28 58.28 57.12

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 232Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

99325 79.34 75.37 86.68 84.94 84.94 83.24 99326 137.02 130.17 149.70 146.71 146.71 143.77 99327 182.65 173.52 199.55 195.56 195.56 191.65 99328 213.53 202.85 233.28 228.61 228.61 224.03 99334 59.21 56.25 64.69 63.40 63.40 62.13 99335 93.43 88.76 102.07 100.03 100.03 98.03 99336 132.22 125.61 144.45 141.57 141.57 138.74 99337 189.63 180.15 207.17 203.03 203.03 198.97 99341 54.10 51.40 59.11 57.93 57.93 56.76 99342 78.03 74.13 85.25 83.55 83.55 81.88 99343 128.18 121.77 140.04 137.23 137.23 134.48 99344 179.16 170.20 195.73 191.82 191.82 187.98 99345 217.23 206.37 237.33 232.58 232.58 227.93 99347 54.40 51.68 59.43 58.25 58.25 57.09 99348 82.77 78.63 90.42 88.62 88.62 86.85 99349 125.93 119.63 137.57 134.83 134.83 132.14 99350 174.92 166.17 191.10 187.28 187.28 183.53 99354 98.23 93.32 107.32 105.17 105.17 103.06 # 99354 91.66 87.08 100.14 98.14 98.14 96.17 99355 95.58 90.80 104.42 102.33 102.33 100.28 # 99355 89.00 84.55 97.23 95.29 95.29 93.38 99356 90.44 85.92 98.81 96.83 96.83 94.90 99357 89.79 85.30 98.10 96.13 96.13 94.21 99406 13.91 13.21 15.19 14.89 14.89 14.59 # 99406 12.26 11.65 13.40 13.13 13.13 12.87 99407 27.21 25.85 29.73 29.13 29.13 28.54 # 99407 25.57 24.29 27.93 27.37 27.37 26.82 99415 8.24 7.83 9.00 8.82 8.82 8.65 99416 4.63 4.40 5.06 4.96 4.96 4.85 99460 95.36 90.59 104.18 102.10 102.10 100.05 99461 88.71 84.27 96.91 94.97 94.97 93.07 # 99461 62.42 59.30 68.20 66.83 66.83 65.49 99462 41.39 39.32 45.22 44.31 44.31 43.42 99463 117.07 111.22 127.90 125.35 125.35 122.84 99464 71.09 67.54 77.67 76.12 76.12 74.60 99465 150.78 143.24 164.73 161.44 161.44 158.21 99466 228.62 217.19 249.77 244.78 244.78 239.88 99467 115.53 109.75 126.21 123.69 123.69 121.22 99468 931.75 885.16 1,017.93 997.58 997.58 977.63 99469 394.27 374.56 430.74 422.13 422.13 413.69 99471 864.89 821.65 944.90 926.00 926.00 907.49 99472 405.05 384.80 442.52 433.67 433.67 424.99 99475 570.11 541.60 622.84 610.39 610.39 598.17 99476 343.02 325.87 374.75 367.25 367.25 359.90 99477 353.29 335.63 385.97 378.26 378.26 370.69 99478 135.43 128.66 147.96 145.00 145.00 142.11 99479 123.47 117.30 134.90 132.19 132.19 129.55 99480 118.22 112.31 129.16 126.57 126.57 124.04 99490 39.37 37.40 43.01 42.15 42.15 41.31

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CGS PART B Ohio - 2016 FEE SCHEDULE

# THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING. C THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT. ** LIMITING CHARGE REDUCED BASED ON THE EHR NEGATIVE ADJUSTMENT PROGRAM. *** LIMITING CHARGE REDUCED BASED ON THE PQRS NEGATIVE ADJUSTMENT PROGRAM. **** LIMITING CHARGE REDUCED FOR EPS THAT ARE SUBJECT TO BOTH EHR AND PQRS NEGATIVE ADJUSTMENT PROGRAMS. LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS. ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2015 BY THE AMERICAN MEDICAL ASSOCIATION.

PAGE 233Originated November 18, 2015 | Revised January 29, 2016

© 2016 Copyright, CGS Administrators, LLC.

NOTE PROCEDURE MOD PAR AMOUNTNON-PAR AMOUNT

LIMITING CHARGE

EHR LIMITING CHARGE**

PQRS LIMITING CHARGE***

EHR/2014 ERX LIMITING CHARGE**

EHR + PQRS LIMITING CHARGE****

EHR/2014 ERX + PQRS LIMITING CHARGE****

# 99490 30.82 29.28 33.67 32.99 32.99 32.34 99495 158.40 150.48 173.05 169.59 169.59 166.20 # 99495 108.76 103.32 118.82 116.44 116.44 114.11 99496 223.44 212.27 244.11 239.22 239.22 234.44 # 99496 157.37 149.50 171.93 168.49 168.49 165.12 99497 83.56 79.38 91.29 89.46 89.46 87.66 # 99497 77.64 73.76 84.82 83.12 83.12 81.45 99498 73.07 69.42 79.83 78.23 78.23 76.67 # 99498 72.75 69.11 79.48 77.89 77.89 76.34

Page 234: OHIO PART B - CGS Medicare...payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment by the end of 2016, and

2016 MEDICARE PARTICIPATION ENROLLMENT

2016 Enrollment Package(Includes Fee Schedule)

Dated Material

Enrollment Period Ends December 31, 2015

Open Immediately.Package contains 2016 Medicare Payment Information

from the Centers for Medicare & Medicaid Services.