DRAFT - Exhibit G - Required Services and Scheduling Times 13 July.pdf

EXHIBIT G – Required Services and Scheduling and Referral Processing Times

Group A = PWS 5.5.1: For orders placed prior to 10 AM local time, the contractor shall complete tests and/or services in Group A of Exhibit G, to include appointment on the same day of the request with results due within 3 business days of appointment. For orders placed after 10 AM local time, the contractor shall complete tests and/or services in Group A of Exhibit G, to include appointment within the next business day of the request with results due within 3 business days of appointment.

Group B = PWS 5.5.2: The contractor shall complete tests and/or services in Group B of Exhibit G to include appointment within five business days of the request with results due within 3 business days of the appointment.

Group C = PWS 5.5.3: The contractor shall complete tests and/or services in Group C of Exhibit G within 15 business days of the request with results due within 3 business days of appointment. The appointment scheduling shall be completed within the first 5 business days of the 15 business days allotted for execution of services. For example, for an order placed on Business Day 0, the date of the appointment must be confirmed by Business Day 0+5, and that appointment date must occur prior to Business Day 0+15. When the Government requests a 3-day appointment notice, the contractor shall provide an appointment within 18 business days of the request due within 3 business days of appointment.

Table 1 – Required Specialty Consultant Types, Ancillary Services and Laboratory Services by MEPS

Separate Document

Table 2 Services Required and Estimated Annual Quantities

CPT Code CPT Code Description Group Projected Annual

Quantity

31575 31575 - Laryngoscopy, flexible; diagnostic C 5 36000 36000 - Introduction of needle or intracatheter, vein C 35 36415 36415 - Venipuncture Fee C 355

69200 69200 - Removal Foreign Body From External Auditory Canal; Without General Anesthesia C 0

69210 69210 - Wax Removal B 450

70160 70160 - Radiologic Examination, Nasal Bones, Complete, Minimum Of 3 Views C 0

70210 70210 - Radiologic Examination, Sinuses, Paranasal, Less Than 3 Views C 30

70220 70220 - Radiologic Examination, Sinuses, Paranasal, Complete, Minimum Of 3 Views C 10

70260 70260 - Radiologic Examination, Skull; Complete, Minimum Of 4 Views C 10

70310 70310 - Radiologic examination, teeth; partial exam, less than full mouth C 0

71045 71045 - chest; single view C 5 71046 71046 - chest; 2 views C 45 71047 71047 - chest 3 views C 5 71100 71100 – X-Ray Exam Of Ribs C 25 71101 71101 – X-Ray Exam Of Ribs/Chest C 215 71110 71110 - Radiologic Examination, Ribs, Bilateral; 3 Views C 25 71111 71111 – X-Ray Exam Of Ribs C 5 71120 71120 – X-Ray Exam Of Breastbone C 0 71130 71130 – X-Ray Exam Of Breastbone C 5 72020 72020 - Radiologic Examination, Spine, Single View, Specify Level C 5 72040 72040 – X-Ray Exam Of Neck Spine C 0 72050 72050 - Radiologic examination, spine, cervical; 4 or 5 views C 10 72052 72052 - Radiologic Examination, Spine, Cervical; 6 Or More Views C 20 72070 72070 - Radiologic Examination, Spine; Thoracic, 2 Views C 25 72072 72072 - Radiologic Examination, Spine; Thoracic, 3 Views C 35 72074 72074 -Radiologic Examination, Spine; Thoracic, Minimum Of 4 Views C 30 72080 72080 – X-Ray Exam Of Trunk Spine C 0

72081 72081 - Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); one view C 80

72082 72082 - Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); 2 or 3 views C 730

72100 72100 – X-Ray Exam Of Lower Spine C 100 72110 72110 - X-ray Lumbosacral spine, minimum 4 views C 35

72114 72114 - Radiologic Examination, Spine, Lumbosacral; Complete, Including Bending Views, Minimum Of 6 Views C 40

72120 72120 - Radiologic Examination, Spine, Lumbosacral; Bending Views Only, 2 Or 3 Views C 0

72170 72170 – X-Ray Exam Of Pelvis C 40 72190 72190 – X-Ray Exam Of Pelvis C 295 72200 72200 – X-Ray Exam Sacroiliac Joints C 40 72202 72202 - X-Ray Exam Sacroiliac Joints C 0 72220 72220 – X-Ray Exam Of Tailbone C 0 72285 72285 – X-Ray C/T Spine Disk C 0 72295 72295 – X-Ray Of Lower Spine Disk C 0 73000 73000 – X-Ray Exam Of Collar Bone C 30 73010 73010 – X-Ray Exam Of Shoulder Blade C 5 73020 73020 – X-Ray Exam Of Shoulder C 5 73030 73030 – X-Ray Exam Of Shoulder C 265 73040 73040 – X-Ray Exam Of Shoulder C 5

73050 73050 - Radiologic Examination; Acromioclavicular Joints, Bilateral, With Or Without Weighted Distraction C 15

73060 73060 – X-Ray Exam Of Humerus C 10 73070 73070 – X-Ray Exam Of Elbow C 25 73080 73080 – X-Ray Exam Of Elbow C 55 73085 73085 – Contrast X-Ray Of Elbow C 0 73090 73090 – X-Ray Exam Of Forearm C 15 73100 73100 – X-Ray Of Wrist 2 Views C 0 73110 73110 – X-Ray Exam Of Wrist C 0

73120 73120 – X-Ray Exam Of Hand C 0 73130 73130 – X-Ray Exam Of Hand C 0 73140 73140 – X-Ray Exam Of Finder (S) C 25

73501 73501 - Radiologic examination, hip, unilateral, with pelvis when performed; 1 view C 5

73502 73502 - Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views C 20

73503 73503 - Radiologic examination, hip, unilateral, with pelvis when performed;

minimum of 4 views C 5

73521 73521 - Radiologic examination, hip, unilateral, with pelvis when performed;

minimum of 4 views C 0

73522 73522 - Radiologic examination, hip, unilateral, with pelvis when performed; 3-4 views C 0

73523 73523 - Radiologic examination, hip, unilateral, with pelvis when performed;

minimum of 5 views C 5

73551 73551 - Radiologic examination, femur; 1 view C 0 73552 73552 - x-ray , femur this is the 2 + views C 20 73560 73560 – X-Ray Exam Of Knee, 1 Or 2 C 45 73562 73562 – X-Ray Exam Of Knee, 3 C 75 73564 73564 – X-Ray Exam, Knee 4 Or More C 95 73565 73565 – X-Ray Exam Of Knees C 0 73590 73590 – X-Ray Exam Of Lower Leg C 35 73600 73600 – X-Ray Exam Of Ankle C 0 73610 73610 – X-Ray Exam Of Ankle C 125 73620 73620 – X-Ray Exam Of Foot C 0 73630 73630 – X-Ray Foot 2 Views C 0 73650 73650 – X-Ray Exam Of Heel C 0 73660 73660 – X-Ray Exam Of Toe (S) C 0 74018 74000 – X-Ray Exam Of Abdomen C 0 74019 74010 – X-Ray Exam Of Abdomen C 0

74021 74020 – X-Ray Exam Of Abdomen C 0 74022 74022 – X-Ray Exam Series, Abdomen C 0

74176 74176 – Computed tomography, abdomen and pelvis; without contrast material C 5

74440 74440 – X-Ray, Male Genital Tract C 0 74455 74455 – X-Ray, Urethra/Bladder C 0 74740 74740 – X-Ray, Female Genital Tract C 0

76514 76514 – Oph. U/S, diag.; corneal pachymetry, unilateral/bilateral (determ. of corneal thickness) C 25

76700 76700 – U/S, retroperitoneal (eg, renal, aorta, nodes), real time w/image documentation; complete C 10

76856 76856 – Ultrasound, pelvic (nonobstetric), real time with image documentation;

complete C 0

76870 76870 – Ultrasound, scrotum and contents C 170

76881 76881 – U/S, complete jnt (jnt space & peri-articular sft tissue struct) real-time w/image doc. C 20

86003 86003 - Allergen specific IgE; quantitative or semiquantitative, crude allergen extract (LabCorp) A 115

86005 86005 - Allergen specific IgE; qualitative, multiallergen screen (eg, disk, sponge, card) A 15

92015 92015 - Refraction Test C 7545 92025 92025 - Corneal Topography Test C 7455

92060 92060 - Sensorimotor Examination With Multiple Measurements Of Ocular

Deviation (e.g., Restrictive Or Paretic Muscle With Diplopia) With Interpretation And Report (Separate Procedure)

C 15

92081 92081 - Visual Field Testing (Automated Perimeter) C 0

92082

92082 - Visual Field Examination, Unilateral Or Bilateral, With Interpretation And Report; Intermediate Examination (e.g., At Least 2 Isopters On Goldmann Perimeter, Or Semiquantitative, Automated Suprathreshold Screening Program, Humphrey Suprathreshold Automatic Diagnostic Test, Octopus Program 33)

C 5

92083 92083 - Visual Field Examination, Unilateral Or Bilateral, With Interpretation And Report C 145

92100 92100 - Contact Tonometry C 85

92132 92132 - Scanning Computerized Ophthalmic Diagnostic Imaging, Anterior Segment, With Interpretation And Report, Unilateral Or Bilateral C 0

92133 92133 - Scanning Computerized Ophthalmic Diagnostic Imaging, Posterior Segment, With Interpretation And Report, Unilateral Or Bilateral; Optic Nerve C 0

92134 92134 - Scanning Computerized Ophthalmic Diagnostic Imaging, Posterior Segment, With Interpretation And Report, Unilateral Or Bilateral; Retina C 25

92201 92201 – Ophthalmoscopy, ext; w/retnl drawng & scleral depression of periph retnl disease w/I & R C 240

92202 92202 – Ophthalmoscopy, extended; w/drawing of optic nerve or macula w/I & R, unilateral/bilateral C 10

92229 92225 - Ophthalmoscopy, Extended, With Retinal Drawing (e.g., For Retinal Detachment, Melanoma), With Interpretation And Report; Initial C 0

92235 92235 - Fluorescein angiography (includes multiframe imaging) with interpretation and report C 0

92250 92250 - Fundus Photography With Interpretation And Report C 1605 92273 92275 - Electroretinography With Interpretation And Report C 0

92283 92283 - Color Vision Examination, Extended, e.g., Anomaloscope Or Equivalent C 30

92285 92285 - Stereoscopic C 0

92286 92286 - Anterior segment imaging with interpretation and report; with specular microscopy and endothelial cell analysis C 0

92504 92504 - Binocular Microscopy (Separate Diagnostic Procedure) C 0 92504 92504 - Binocular Ear Test C 0 92550 92550 - Tympanometry And Reflex Threshold Measurements C 60 92552 92552 - Pure Tone Audiometry (Threshold); Air Only C 5 92553 92553 - Audiogram W/Air & Bone Conduction C 0 92555 92555 - Speech Audiometry Threshold; C 5 92556 92556 - Speech Audiometry Threshold; With Speech Recognition C 0 92557 92557 - Audiogram W/Speech Reception Threshold C 0 92567 92567 - Tympanometry (Impedance Testing) C 25 92571 92571 - Filtered Speech Test C 0 92577 92577 - Stenger Test, Speech C 5

92587 92587 - Distortion Product Evoked Otoacoustic Emissions; Limited Evaluation (To Confirm The Presence Or Absence Of Hearing Disorder, 3-6 Frequencies) Or Transient Evoked Otoacoustic Emissions, With Interpretation And Report

C 0

93000 93000 - ECG – Complete, 12-Lead C 1010

93005 93005 - Electrocardiogram, Routine ECG With At Least 12 Leads; Tracing Only, Without Interpretation And Report C 65

93010 93010 - Electrocardiogram, Routine Ecg With At Least 12 Leads; Interpretation And Report Only C 0

93018 CV strs tst using exercise, continuous ECG monitoring, interpretation and report only C 10

93306 93306 - Echocardiogram (2D-M/Mode W/Color), Global C 1455 93307 93307 - EEG, Echocardiogram (2D-M/Mode Doppler W/O Color) C 15

93320 93320 - Doppler Echocardiography, Pulsed Wave And/or Continuous Wave With

Spectral Display (List Separately In Addition To Codes For Echocardiographic Imaging); Complete

C 0

93325 93325 - Doppler Echocardiography Color Flow Velocity Mapping (List Separately In Addition To Codes For Echocardiography) C 0

93880 Duplex scan of extracranial arteries; complete bilateral study C 5 94010 94010 - Pft – Pre/Post Bronchodilator, Global C 0

94060 94060 - Bronchodilation Responsiveness, Spirometry As In 94010, Pre- And Post-Bronchodilator Administration C 845

94618 94618 – Pulmonary strs tst (eg, 6minute walk test), incl meas of heart rate, oximetry, & titration C 15

94664 94664 – Demo & eval of patient utilization of an aerosol generator, nebulizer,inhaler/IPPB C 5

94726 94726 – Plethysmography for determination of lung volumes and, when performed, airway resistance C 0

94727 94727 – Gas dilution/washout determ of lung volumes, when performed, distro of ventilation vol C 40

94729 94729 – Diff. capacity (eg, CO, membrane)(List separate in addition to code for primary procedure) C 65

95004 95004 - Allergy Test C 60

95017

95017 - Allergy Testing, Any Combination Of Percutaneous (Scratch, Puncture, Prick) And Intracutaneous (Intradermal), Sequential And Incremental, With

Venoms, Immediate Type Reaction, Including Test Interpretation And Report, Specify Number Of Tests

C 10

95018

95018 - Allergy Testing, Any Combination Of Percutaneous (Scratch, Puncture, Prick) And Intracutaneous (Intradermal), Sequential And Incremental, With

Drugs Or Biologicals, Immediate Type Reaction, Including Test Interpretation And Report, Specify Number Of Tests

C 10

95024 95024 – Intracutaneous test w/allergen extracts, immediate type reaction, incl test intrprt & rprt C 10

95044 95044 - Patch Or Application Test(S) (Specify Number Of Tests) C 0 95076 95076 – Ingestion challenge test; initial 120 minutes of testing C 0

96130

96130 – Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour

C 1810

96131 96131 – Each additional hour C 1510

96136 96136 – Psych or neuropsych test admin/scoring by physician/qual prof, 2+ tests, 1st 30 min C 700

96137 96137 – Psych/neuropsych test admin/scoring, physician/qual prof, 2+ tests, ea add'l 30 min C 765

96156 96101 - Psychological Testing (Includes Psychodiagnostic Assessment Of Emotionality, Intellectual Abilities C 0

99202

99242 - Office Consultation For A New Or Established Patient, Which Requires These 3 Key Components: An Expanded Problem Focused History; An Expanded Problem Focused Examination; And Straightforward Medical Decision Making. Counseling And/or Coordination Of Care With Other Physicians, Other Qualified Health Care Professionals, Or Agencies Are

Provided Consistent With The Nature Of The Problem(S) And The Patient's And/or Family's Needs. Usually, The Presenting Problem(S) Are Of Low Severity. Typically, 30 Minutes Are Spent Face-To-Face With The Patient

And/or Family.

C 6760

99203

99243 - Office Consultation For A New Or Established Patient, Which Requires These 3 Key Components: A Detailed History; A Detailed Examination; And

Medical Decision Making Of Low Complexity. Counseling And/or Coordination Of Care With Other Physicians, Other Qualified Health Care Professionals, Or

Agencies Are Provided Consistent With The Nature Of The Problem(S) And The Patient's And/or Family's Needs. Usually, The Presenting Problem(S) Are Of Moderate Severity. Typically, 40 Minutes Are Spent Face-To-Face With The

Patient And/or Family.

C 4715

99204

99244 - Office Consultation For A New Or Established Patient, Which Requires These 3 Key Components: A Comprehensive History; A Comprehensive Examination; And Medical Decision Making Of Moderate Complexity.

Counseling And/or Coordination Of Care With Other Physicians, Other Qualified Health Care Professionals, Or Agencies Are Provided Consistent With The

Nature Of The Problem(S) And The Patient's And/or Family's Needs. Usually, The Presenting Problem(S) Are Of Moderate To High Severity. Typically, 60

Minutes Are Spent Face-To-Face With The Patient And/or Family.

C 9055

74445-26 74445 – X-Ray Exam Of Penis C 0 74450-26 74450 – X-Ray, Urethra/Bladder C 0 74470-26 74470 – X-Ray Exam Of Kidney Lesion C 0 74470-26 74742 – X-Ray, Fallopian Tube C 0

D0150 D0150 – Comprehensive Oral Evaluation – New or Established Patient C 10 D0220 D0220 - Intraoral-periapical first film; C 5 D0230 D0230 - Intraoral-periapical each additional film. C 0 D0272 D0272 – Bitewings – Two Radiographic Images C 0 D0273 D0273 – Bitewings – Three Radiographic Images C 0 D0274 D0274 – Bitewings – Four Radiographic Images C 10

50175