MEDICINE GROUND RULES

1.

GENERAL: Visits, examinations, consultations and similar services listed in this section reflect the
variation in time and skills required in the diagnosis and treatment of illness or injury. The stipulated Unit
Value applies only when the services are performed by or under the responsibility and direct supervision
of a health care provider, unless otherwise stated.

2.

UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the
procedure should be identified and the amount charged substantiated "by report" (BR). Unlisted service
or procedure codes usually end in "99."

3.

PROCEDURES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE: "BR" in the Unit Value
column indicates that the amount charged for this service is to be determined "by report" because the
service is too unusual or variable to be assigned a Unit Value. Pertinent information should be furnished
concerning the nature, extent, and need for the procedure or service, the time, skill, and equipment
necessary, etc.

4.

MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and materials provided by the
health care provider (e.g., sterile trays, drugs) over and above those usually included with the office visit
or other services rendered may be listed separately. The statement of charges will need to reflect any
drugs, trays, supplies, and materials that were provided. Payment shall not exceed the cost of the item(s)
to the health care provider plus 25%, or the cost of the item(s) plus $15.00 per item, whichever is less.
Use procedure code 99070.

5.

SEPARATE PROCEDURES: Some of the procedures or services listed are commonly carried out as an
integral part of a total service and identified by the inclusion of the term “separate procedure.” The codes
designated as “separate procedure” should not be reported in addition to the code for the total procedure
or service of which it is considered an integral component.
However, when a procedure or service that is designated as a “separate procedure” is carried out
independently or considered to be unrelated or distinct from other procedures/services at that time, it may
be reported by itself, or in addition to other procedures/services by appending modifier -59 to the specific
“separate procedure” code to indicate that the procedure is not considered to be a component of another
procedure, but is a distinct, independent procedure. This may represent a different session or patient
encounter, different procedure or surgery, different site or organ system, separate incision/excision,
separate lesion, or separate injury (or area of injury in extensive injuries).

6.

MULTIPLE PROCEDURES: It is appropriate to designate multiple procedures that are rendered on the
same day by separate entries. Use modifier -51 to reflect multiple procedures except for the Add-On
Codes.

7.

ADD-ON CODES: Certain codes, by the nature of their description and the unit values assigned, have
already been reduced, as they are not to be billed as primary procedures. For a complete list of the
codes which are considered to be add-on codes, refer to the appropriate appendix found within the most
recent publication of the AMA Current Procedural Terminology (CPT).

8.

CODES THAT ARE NOT CLASSIFIED AS ADD-ON CODES BUT ARE EXEMPT FROM THE
MULTIPLE PROCEDURE RULE / MODIFIER -51: For a complete list of the codes which fall within this
category, refer to the appropriate appendix found within the most recent publication of the AMA Current
Procedural Terminology (CPT).

9.

CONCURRENT CARE: When the condition of the patient requires the skills of two or more health care
providers to treat different conditions, payment is due each health care provider who plays an active role
in the treatment program. The services rendered by each health care provider shall be distinct,
identifiable, and adequately documented in the records and reports.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

67

MEDICINE GROUND RULES
10.

ALTERNATING HEALTH CARE PROVIDERS: When health care providers of similar skills alternate in
the care of a patient (e.g., partners, groups of same facility, covering providers on weekends or vacation
periods), each health care provider shall charge individually for the services personally rendered and
such charges shall be in accordance with this Fee Schedule.

11.

PRORATION OF SCHEDULED FEE: Where the schedule specifies a unit value for a definite treatment,
and the patient is transferred from one health care provider to another, the unit value multiplied by the
conversion factor or the usual and customary charge, whichever is less, should be apportioned between
or among the providers. The providers involved shall agree upon the amount of proration, and shall
render separate bills accordingly, with an explanatory note.

12.

MISCELLANEOUS: The Unit Values for other diagnostic therapeutics, anesthesia, surgery, x-rays, and
laboratory procedures are listed in the following sections: Anesthesia, Surgery, Radiology, Pathology and
Laboratory, Medicine, and Evaluation and Management.

13.

CONSULTATIONS AND REFERRALS: A consultation is a service rendered by a specialist at the
request of the attending health care provider or other appropriate source seeking further evaluation or an
opinion on how to proceed in the management of a patient's illness. Consultations always require a
narrative report from the consultant to the attending health care provider requesting the opinion. The fee
payable should correspond appropriately to the level of service. When the consulting specialist assumes
responsibility for the continuing care of the patient, any service rendered subsequent to the consultation
will be reimbursed according to the actual level of service rendered, as listed under the appropriate
subsection headings (e.g., office or hospital visits).
A referral is the transfer of a patient to a specialist for diagnosis, and where necessary, treatment of a
specific illness or injury, rather than for advice. A referral will be reimbursed according to the actual level
of services rendered, as listed under the appropriate subsection headings (e.g., office or hospital visits).

14.

LIMITATIONS ON PATIENT VISITS FOR PSYCHOTHERAPY OR PSYCHOLOGICAL COUNSELING:
Psychotherapy or Psychological counseling, for work-related conditions requiring either more than 21
visits or continuing for more than 3 months after initiation of therapy, whichever comes first, requires prior
authorization from the employer, insurance carrier, the Workers Compensation Fund, or the Kansas
Division of Workers Compensation, unless such authorization was previously received for a greater
number of visits.

15.

PROFESSIONAL/TECHNICAL COMPONENTS: When the professional and technical components are
furnished by different providers (inclusive of hospitals and ambulatory surgical centers), the
professional component and the technical component shall be identified by adding either modifier -26 or
modifier -TC to the usual procedure number. If any of the medical procedures in this section become
subject to either the professional or technical component, the unit value for the professional component is
60% of the total unit value, and the unit value for the technical component is 40% of the total unit value for
the procedure code submitted. See Appendix A- Modifiers for a listing of the modifiers.
Additionally, and with the exception of Pathology and Laboratory, hospitals and ambulatory surgical
centers will continue to be reimbursed at their usual and customary charge less the specified discount as
contained within the Hospital/Ambulatory Surgical Center Section of the fee schedule. However,
hospitals and ambulatory surgical centers need to amend their billing process to specify, by use of
modifiers, when only the technical component or the professional component was provided.

16.

FAILURE OF PATIENT TO KEEP A SCHEDULED APPOINTMENT: In the event a patient fails to keep
a scheduled appointment, the health care provider is not to bill for any services that would have been
provided by said appointment nor shall there be any reimbursement for such scheduled services (i.e.,
reimbursement for a "no show" appointment is not allowed). This rule does not apply with regard to a
deposition, testimony, or IME.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

68

MEDICINE GROUND RULES
17.

MODIFIERS: Procedure codes for medicine services may be modified under certain circumstances. The
circumstances are to be identified by the addition of a hyphen and the appropriate two-digit modifier code.
Refer to Appendix A - Modifiers for a list of modifiers that may be used.

18.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care
costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please
refer to K.S.A. 44-510i(e) for further clarification, if necessary.

CONVERSION FACTOR = $52.42
CPT only copyright 2004 American Medical Association. All Rights Reserved.

69

MEDICINE
(CONVERSION FACTOR = $52.42)
CODE
90281
90283
90287
90288
90291
90296
90371
90375
90376
90378
90379
90384
90385
90386
90389
90393
90396
90399
90465
90466
90467
90468
90471
90472
90473
90474
90476
90477
90581
90585
90586
90632
90633
90634
90636
90645
90646
90647
90648
90655
90656
90657
90658
90660
90665
90669
90675
90676
90680
90690
90691
90692

UNIT VALUE
BR
BR
BR
BR
BR
BR
BR
3.35
2.80
BR
BR
2.43
1.47
BR
3.28
BR
BR
BR
0.49
0.29
0.51
0.51
0.49
0.29
0.44
0.44
BR
BR
2.84
4.58
4.79
1.81
0.84
0.84
2.00
0.75
BR
0.67
0.68
0.32
0.32
0.23
0.23
BR
BR
1.57
4.13
BR
BR
0.87
1.21
BR

CODE
90693
90698
90700
90701
90702
90703
90704
90705
90706
90707
90708
90710
90712
90713
90715
90716
90717
90718
90719
90720
90721
90723
90725
90727
90732
90733
90734
90735
90740
90743
90744
90746
90747
90748
90749
90780
90781
90782
90783
90784
90788
90799
90801
90802
90804
90805
90806
90807
90808
90809
90810
90811

UNIT VALUE
BR
BR
0.60
BR
0.28
0.31
0.50
0.41
0.44
0.98
BR
BR
BR
0.78
BR
1.82
1.85
0.28
BR
1.06
1.39
1.78
BR
BR
0.38
2.04
BR
2.02
5.67
0.80
0.80
1.81
5.67
1.46
BR
2.39
0.67
0.50
0.50
1.01
0.44
BR
4.04
4.29
1.73
1.90
2.61
2.77
3.89
4.03
1.87
2.09

CPT only copyright 2004 American Medical Association. All Rights Reserved.

70

CODE
90812
90813
90814
90815
90816
90817
90818
90819
90821
90822
90823
90824
90826
90827
90828
90829
90845
90846
90847
90849
90853
90857
90862
90865
90870
90871
90875
90876
90880
90882
90885
90887
90889
90899
90901
90911
90918
90919
90920
90921
90922
90923
90924
90925
90935
90937
90939
90940
90945
90947
90989
90993

UNIT VALUE
2.81
2.95
4.07
4.19
1.74
1.91
2.63
2.75
3.91
4.02
1.87
2.05
2.78
2.89
4.07
4.16
2.41
2.53
3.08
0.88
0.86
0.94
1.37
4.31
3.86
3.86
2.14
3.11
3.29
2.35
1.36
2.34
2.03
BR
1.08
2.50
17.63
12.82
11.24
7.04
0.59
0.42
0.37
0.24
1.93
3.15
2.14
2.14
2.01
3.22
13.94
2.35

MEDICINE
(CONVERSION FACTOR = $52.42)
CODE
90997
90999
91000
91010
91011
91012
91020
91030
91034
91035
91037
91038
91040
91052
91055
91060
91065
91100
91105
91110
91120
91122
91123
91132
91133
91299
92002
92004
92012
92014
92015
92018
92019
92020
92060
92065
92070
92081
92082
92083
92100
92120
92130
92135
92136
92140
92225
92226
92230
92235
92240
92250

UNIT VALUE
2.56
BR
1.10
5.78
6.86
7.35
6.09
3.40
6.33
12.51
4.02
3.44
12.22
3.30
3.95
2.46
1.69
3.94
2.50
25.98
12.06
7.07
BR
1.12
1.41
BR
1.87
3.41
1.72
2.54
1.88
3.64
1.90
0.72
1.45
0.92
1.79
1.32
1.69
1.95
2.29
1.90
2.11
1.16
2.27
1.50
0.61
0.55
2.15
3.50
7.29
1.99

CODE
92260
92265
92270
92275
92283
92284
92285
92286
92287
92310
92311
92312
92313
92314
92315
92316
92317
92325
92326
92330
92335
92340
92341
92342
92352
92353
92354
92355
92358
92370
92371
92390
92391
92392
92393
92395
92396
92499
92502
92504
92506
92507
92508
92510
92511
92512
92516
92520
92526
92531
92532
92533

UNIT VALUE
0.47
2.36
2.39
3.00
1.03
2.14
1.21
3.75
3.21
2.33
2.20
2.37
2.00
1.64
1.31
1.61
1.40
0.41
1.69
2.10
1.36
1.08
1.22
1.30
1.06
1.25
8.96
4.34
1.02
0.89
0.64
BR
BR
3.81
12.33
1.38
2.23
BR
2.67
0.69
3.48
1.65
0.78
3.65
4.18
1.71
1.64
1.30
2.21
0.62
0.72
1.14

CPT only copyright 2004 American Medical Association. All Rights Reserved.

71

CODE
92534
92541
92542
92543
92544
92545
92546
92547
92548
92551
92552
92553
92555
92556
92557
92559
92560
92561
92562
92563
92564
92565
92567
92568
92569
92571
92572
92573
92575
92576
92577
92579
92582
92583
92584
92585
92586
92587
92588
92590
92591
92592
92593
92594
92595
92596
92597
92601
92602
92603
92604
92605

UNIT VALUE
0.50
1.47
1.50
0.69
1.19
1.06
2.30
0.14
2.90
0.29
0.48
0.72
0.42
0.63
1.31
0.94
0.55
0.78
0.45
0.42
0.52
0.44
0.58
0.42
0.45
0.43
0.10
0.39
0.32
0.49
0.79
0.79
0.79
0.97
2.68
2.73
1.99
1.62
2.13
1.12
1.68
0.49
0.74
0.54
0.81
0.65
2.58
3.57
2.45
2.21
1.42
BR

MEDICINE
(CONVERSION FACTOR = $52.42)
CODE
92606
92607
92608
92609
92610
92611
92612
92613
92614
92615
92616
92617
92620
92621
92625
92700
92950
92953
92960
92961
92970
92971
92973
92974
92975
92977
92978
92979
92980
92981
92982
92984
92986
92987
92990
92992
92993
92995
92996
92997
92998
93000
93005
93010
93012
93014
93015
93016
93017
93018
93024
93025

UNIT VALUE
BR
3.13
0.60
1.63
3.51
3.51
4.05
1.16
3.81
1.03
5.33
1.28
1.20
0.31
1.18
BR
8.25
0.32
8.64
6.96
4.76
2.68
4.80
4.39
10.28
8.51
7.37
4.48
21.35
5.92
15.84
4.22
34.30
35.60
27.89
31.02
21.74
17.42
4.63
17.26
8.47
0.71
0.47
0.24
6.19
0.73
2.85
0.64
1.79
0.42
2.87
8.48

CODE
93040
93041
93042
93224
93225
93226
93227
93230
93231
93232
93233
93235
93236
93237
93268
93270
93271
93272
93278
93303
93304
93307
93308
93312
93313
93314
93315
93316
93317
93318
93320
93321
93325
93350
93501
93503
93505
93508
93510
93511
93514
93524
93526
93527
93528
93529
93530
93531
93532
93533
93539
93540

UNIT VALUE
0.38
0.16
0.22
4.37
1.32
2.32
0.73
4.67
1.63
2.31
0.73
3.39
2.76
0.63
8.24
1.32
6.19
0.73
1.62
5.91
3.13
5.39
2.82
7.14
1.22
5.84
8.67
1.24
6.45
6.27
2.37
1.41
3.22
3.99
22.33
3.79
8.51
19.70
46.04
46.01
48.85
60.52
60.51
61.01
63.57
57.32
24.39
63.81
64.86
59.87
0.57
0.61

CPT only copyright 2004 American Medical Association. All Rights Reserved.

72

CODE
93541
93542
93543
93544
93545
93555
93556
93561
93562
93571
93572
93580
93581
93600
93602
93603
93609
93610
93612
93613
93615
93616
93618
93619
93620
93621
93622
93623
93624
93631
93640
93641
93642
93650
93651
93652
93660
93662
93668
93701
93720
93721
93722
93724
93727
93731
93732
93733
93734
93735
93736
93740

UNIT VALUE
0.41
0.41
0.41
0.36
0.57
7.77
11.58
1.27
0.58
7.34
4.41
26.60
35.47
5.19
4.29
4.90
10.18
5.88
6.15
10.23
1.63
2.35
10.26
18.90
30.53
5.44
8.02
7.37
9.25
18.00
12.58
16.02
14.84
15.65
23.67
25.75
4.39
7.27
1.40
1.17
1.00
0.77
0.23
11.15
0.74
1.17
1.85
1.04
0.91
1.53
0.91
0.37

MEDICINE
(CONVERSION FACTOR = $52.42)
CODE
93741
93742
93743
93744
93745
93760
93762
93770
93784
93786
93788
93790
93797
93798
93799
93875
93880
93882
93886
93888
93890
93892
93893
93922
93923
93924
93925
93926
93930
93931
93965
93970
93971
93975
93976
93978
93979
93980
93981
93990
94010
94014
94015
94016
94060
94070
94150
94200
94240
94250
94260
94350

UNIT VALUE
1.85
2.01
2.24
2.39
BR
1.66
2.44
0.26
1.96
0.92
0.52
0.52
0.49
0.75
BR
2.67
6.54
4.16
8.13
5.18
6.35
6.76
6.63
3.08
4.74
5.59
7.75
4.71
6.22
4.06
3.28
6.38
4.34
9.99
5.90
5.59
3.92
4.52
3.64
4.50
0.87
1.31
0.60
0.71
1.45
1.55
0.56
0.58
0.98
0.77
0.76
1.07

CODE
94360
94370
94375
94400
94450
94452
94453
94620
94621
94640
94642
94656
94657
94660
94662
94664
94667
94668
94680
94681
94690
94720
94725
94750
94760
94761
94762
94770
94772
94799
95004
95010
95015
95024
95027
95028
95044
95052
95056
95060
95065
95070
95071
95075
95078
95115
95117
95120
95125
95130
95131
95132

UNIT VALUE
1.03
1.01
0.94
1.33
1.29
1.37
1.95
3.26
3.78
0.32
1.58
2.45
1.85
1.45
1.02
0.35
0.57
0.47
2.19
2.85
2.11
1.33
3.30
1.62
0.06
0.13
0.57
0.98
BR
BR
0.11
0.48
0.30
0.16
0.16
0.24
0.21
0.26
0.18
0.37
0.21
2.30
2.94
1.80
0.27
0.41
0.52
0.51
0.63
0.88
1.12
1.35

CPT only copyright 2004 American Medical Association. All Rights Reserved.

73

CODE
95133
95134
95144
95145
95146
95147
95148
95149
95165
95170
95180
95199
95250
95805
95806
95807
95808
95810
95811
95812
95813
95816
95819
95822
95824
95827
95829
95830
95831
95832
95833
95834
95851
95852
95857
95858
95860
95861
95863
95864
95867
95868
95869
95870
95872
95875
95900
95903
95904
95920
95921
95922

UNIT VALUE
1.63
1.95
0.26
0.39
0.51
0.49
0.65
0.87
0.26
0.20
4.09
BR
4.11
19.57
5.37
14.01
16.39
21.60
23.59
5.28
6.96
4.95
4.22
5.87
2.72
3.97
37.70
5.10
0.75
0.64
1.07
1.26
0.53
0.38
1.15
2.75
2.45
3.09
3.76
4.86
1.79
2.50
0.78
0.78
2.86
2.66
1.72
1.84
1.47
4.58
1.67
1.81

MEDICINE
(CONVERSION FACTOR = $52.42)
CODE
95923
95925
95926
95927
95928
95929
95930
95933
95934
95936
95937
95950
95951
95953
95954
95955
95956
95957
95958
95961
95962
95965
95966
95967
95970
95971
95972
95973
95974
95975
95978
95979
95990
95991
95999
96000
96001
96002
96003
96004
96100
96105
96110
96111
96115
96117
96150
96151
96152
96153
96154
96155

UNIT VALUE
2.91
1.77
1.77
1.79
4.61
4.80
2.62
1.71
0.98
1.05
1.35
5.95
22.18
11.30
6.86
3.56
19.08
4.76
8.09
6.14
6.30
59.30
29.45
24.10
1.33
1.53
2.85
1.61
4.87
2.71
5.61
2.59
1.56
2.29
BR
2.44
2.91
0.58
0.51
3.19
1.94
1.94
0.36
3.83
1.94
1.94
0.69
0.67
0.64
0.15
0.63
0.64

CODE
96400
96405
96406
96408
96410
96412
96414
96420
96422
96423
96425
96440
96445
96450
96520
96530
96542
96545
96549
96567
96570
96571
96900
96902
96910
96912
96913
96920
96921
96922
96999

UNIT VALUE
1.30
2.85
3.84
3.14
4.41
0.98
5.47
2.90
5.08
2.07
4.72
10.46
10.37
8.92
4.03
2.91
5.72
BR
BR
1.00
1.58
0.77
0.46
0.60
1.03
1.31
1.78
3.71
3.80
5.63
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

74

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