DRAFT REVISED - Exhibit G - Required Services and Scheduling Times.docx

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Medical Referral Services
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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.

ANCILLARY SERVICES
CPT
Annual QTY
Group (Time Rqmt)
36000 - Introduction of needle or intracatheter, vein
36000
1
C
36415 - Venipuncture Fee
36415
100
C
69200 - Removal Foreign Body From External Auditory Canal; Without General Anesthesia
69200
10
C
69210 - Wax Removal
69210
1500
B
70160 - Radiologic Examination, Nasal Bones, Complete, Minimum Of 3 Views
70160
1
C
70210 - Radiologic Examination, Sinuses, Paranasal, Less Than 3 Views
70210
1
C
70220 - Radiologic Examination, Sinuses, Paranasal, Complete, Minimum Of 3 Views
70220
1
C
70260 - Radiologic Examination, Skull; Complete, Minimum Of 4 Views
70260
1
C
70310 - Radiologic examination, teeth; partial exam, less than full mouth
70310
60
C
71010 – Chest X-Ray
71010
1
C
71020 - Radiologic Examination, Chest, 2 Views, Frontal And Lateral;
71020
130
C
71022 - Radiologic Examination, Chest, 2 Views, Frontal And Lateral; With Oblique Projections
71022
15
C
71045 chest; single view
71045

C

71046 chest; 2 views
71046

C

71047 - chest 3 views or 71048 - chest 4 or more views
71047

C

71100 – X-Ray Exam Of Ribs
71100
1
C
71101 – X-Ray Exam Of Ribs/Chest
71101
1
C
71110 - Radiologic Examination, Ribs, Bilateral; 3 Views
71110
80
C
71111 – X-Ray Exam Of Ribs
71111
1
C
71120 – X-Ray Exam Of Breastbone
71120
1
C
71130 – X-Ray Exam Of Breastbone
71130
1
C
72020 - Radiologic Examination, Spine, Single View, Specify Level
72020
150
C
72040 – X-Ray Exam Of Neck Spine
72040
50
C
72050 - Radiologic examination, spine, cervical; 4 or 5 views
72050
30
C
72052 - Radiologic Examination, Spine, Cervical; 6 Or More Views
72052
1
C
72070 - Radiologic Examination, Spine; Thoracic, 2 Views
72070
60
C
72072 - Radiologic Examination, Spine; Thoracic, 3 Views
72072
1
C
72074 -Radiologic Examination, Spine; Thoracic, Minimum Of 4 Views
72074
35
C
72080 – X-Ray Exam Of Trunk Spine
72080
100
C
72081 - Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); one view
72081
40
C
72082 - Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); 2 or 3 views
72082
250
C
72100 – X-Ray Exam Of Lower Spine
72100
100
C
72110 - X-ray Lumbosacral spine, minimum 4 views
72110

C

72114 - Radiologic Examination, Spine, Lumbosacral; Complete, Including Bending Views, Minimum Of 6 Views
72114
50
C
72120 - Radiologic Examination, Spine, Lumbosacral; Bending Views Only, 2 Or 3 Views
72120
1
C
72170 – X-Ray Exam Of Pelvis
72170
50
C
72190 – X-Ray Exam Of Pelvis
72190
40
C
72200 – X-Ray Exam Sacroiliac Joints
72200
15
C
72202 - X-Ray Exam Sacroiliac Joints
72202
15
C
72220 – X-Ray Exam Of Tailbone
72220
15
C
72285 – X-Ray C/T Spine Disk
72285
15
C
72295 – X-Ray Of Lower Spine Disk
72295
15
C
73000 – X-Ray Exam Of Collar Bone
73000
75
C
73010 – X-Ray Exam Of Shoulder Blade
73010
30
C
73020 – X-Ray Exam Of Shoulder
73020
30
C
73030 – X-Ray Exam Of Shoulder
73030
450
C
73040 – X-Ray Exam Of Shoulder
73040
55
C
73050 - Radiologic Examination; Acromioclavicular Joints, Bilateral, With Or Without Weighted Distraction
73050
1
C
73060 – X-Ray Exam Of Humerus
73060
55
C
73070 – X-Ray Exam Of Elbow
73070
90
C
73080 – X-Ray Exam Of Elbow
73080
100
C
73085 – Contrast X-Ray Of Elbow
73085
15
C
73090 – X-Ray Exam Of Forearm
73090
70
C
73100 – X-Ray Of Wrist 2 Views
73100
70
C
73110 – X-Ray Exam Of Wrist
73110
100
C
73120 – X-Ray Exam Of Hand
73120
30
C
73130 – X-Ray Exam Of Hand
73130
55
C
73140 – X-Ray Exam Of Finder (S)
73140
55
C
73501 - Radiologic examination, hip, unilateral, with pelvis when performed; 1 view
73501
95
C
73502 - Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views
73502
30
C
73503 - Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views
73503
1
C
73521 - Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views
73521
30
C
73522 - Radiologic examination, hip, unilateral, with pelvis when performed; 3-4 views
73522
30
C
73523 - Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 5 views
73523
15
C
73551 - Radiologic examination, femur; 1 view
73551
65
C
73552 - x-ray , femur this is the 2 + views
73552
30
C
73560 – X-Ray Exam Of Knee, 1 Or 2
73560
300
C
73562 – X-Ray Exam Of Knee, 3
73562
350
C
73564 – X-Ray Exam, Knee 4 Or More
73564
225
C
73565 – X-Ray Exam Of Knees
73565
65
C
73590 – X-Ray Exam Of Lower Leg
73590
100
C
73600 – X-Ray Exam Of Ankle
73600
150
C
73610 – X-Ray Exam Of Ankle
73610
300
C
73620 – X-Ray Exam Of Foot
73620
150
C
73630 – X-Ray Foot 2 Views
73630
350
C
73650 – X-Ray Exam Of Heel
73650
40
C
73660 – X-Ray Exam Of Toe (S)
73660
40
C
74000 – X-Ray Exam Of Abdomen
74000
50
C
74010 – X-Ray Exam Of Abdomen
74010
1
C
74020 – X-Ray Exam Of Abdomen
74020
1
C
74022 – X-Ray Exam Series, Abdomen
74022
1
C
74440 – X-Ray, Male Genital Tract
74440
1
C
74445 – X-Ray Exam Of Penis
74445
1
C
74450 – X-Ray, Urethra/Bladder
74450
1
C
74455 – X-Ray, Urethra/Bladder
74455
1
C
74470 – X-Ray Exam Of Kidney Lesion
74470
1
C
74740 – X-Ray, Female Genital Tract
74740
1
C
74742 – X-Ray, Fallopian Tube
74742
1
C
92015 - Refraction Test
92015
8000
C
92025 - Corneal Topography Test
92025
6750
C
92060 - Sensorimotor Examination With Multiple Measurements Of Ocular Deviation (e.g., Restrictive Or Paretic Muscle With Diplopia) With Interpretation And Report (Separate Procedure)
92060
10
C
92081 - Visual Field Testing (Automated Perimeter)
92081
50
C
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)
92082
125
C
92083 - Visual Field Examination, Unilateral Or Bilateral, With Interpretation And Report
92083
460
C
92100 - Contact Tonometry
92100
50
C
92132 - Scanning Computerized Ophthalmic Diagnostic Imaging, Anterior Segment, With Interpretation And Report, Unilateral Or Bilateral
92132
25
C
92133 - Scanning Computerized Ophthalmic Diagnostic Imaging, Posterior Segment, With Interpretation And Report, Unilateral Or Bilateral; Optic Nerve
92133
40
C
92134 - Scanning Computerized Ophthalmic Diagnostic Imaging, Posterior Segment, With Interpretation And Report, Unilateral Or Bilateral; Retina
92134
30
C
92225 - Ophthalmoscopy, Extended, With Retinal Drawing (e.g., For Retinal Detachment, Melanoma), With Interpretation And Report; Initial
92225
550
C
92235 - Fluorescein angiography (includes multiframe imaging) with interpretation and report
92235
10
C
92250 - Fundus Photography With Interpretation And Report
92250
60
C
92275 - Electroretinography With Interpretation And Report
92275
1
C
92283 - Color Vision Examination, Extended, e.g., Anomaloscope Or Equivalent
92283
1
C
92285 - External Ocular Photography With Interpretation And Report For Documentation Of Medical Progress (e.g., Close-Up Photography, Slit Lamp Photography, Goniophotography, Stereo-Photography)
92285
30
C
92285 - Stereoscopic
92285
175
C
92286 - Anterior segment imaging with interpretation and report; with specular microscopy and endothelial cell analysis
92286
10
C
92504 - Binocular Ear Test
92504
20
C
92504 - Binocular Microscopy (Separate Diagnostic Procedure)
92504
15
C
92550 - Tympanometry And Reflex Threshold Measurements
92550
30
C
92552 - Pure Tone Audiometry (Threshold); Air Only
92552
30
C
92553 - Audiogram W/Air & Bone Conduction
92553
150
C
92555 - Speech Audiometry Threshold;
92555
10
C
92556 - Speech Audiometry Threshold; With Speech Recognition
92556
50
C
92557 - Audiogram W/Speech Reception Threshold
92557
120
C
92567 - Tympanometry (Impedance Testing)
92567
100
C
92571 - Filtered Speech Test
92571
30
C
92577 - Stenger Test, Speech
92577
1
C
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
92587
1
C
93000 - ECG – Complete, 12-Lead
93000
900
C
93005 - Electrocardiogram, Routine ECG With At Least 12 Leads; Tracing Only, Without Interpretation And Report
93005
25
C
93010 - Electrocardiogram, Routine Ecg With At Least 12 Leads; Interpretation And Report Only
93010
30
C
93306 - Echocardiogram (2D-M/Mode W/Color), Global
93306
325
C
93307 - EEG, Echocardiogram (2D-M/Mode Doppler W/O Color)
93307
50
C
93320 - Doppler Echocardiography, Pulsed Wave And/or Continuous Wave With Spectral Display (List Separately In Addition To Codes For Echocardiographic Imaging); Complete
93320
1
C
93325 - Doppler Echocardiography Color Flow Velocity Mapping (List Separately In Addition To Codes For Echocardiography)
93325
10
C
94010 - Pft – Pre/Post Bronchodilator, Global
94010
175
C
94060 - Bronchodilation Responsiveness, Spirometry As In 94010, Pre- And Post-Bronchodilator Administration
94060
500
C
95004 - Allergy Test
95004
150
C
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
95017
40
C
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
95018
40
C
95044 - Patch Or Application Test(S) (Specify Number Of Tests)
95044
20
C
96101 - Psychological Testing (Includes Psychodiagnostic Assessment Of Emotionality, Intellectual Abilities
96101
300
C
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
96130

C

Each additional hour
96131

C

LABORATORY SERVICES
CPT
QTY
Group (Time Rqmt)
86003 - Allergen Specific IgE; Quantitative Or Semiquantitative, Each Allergen
86003
10
A
86005 - Allergen specific IgE; qualitative, multiallergen screen (dipstick, paddle, or disk)
86005
10
A
MEDICAL CONSULTATIONS
CPT
QTY
Group (Time Rqmt)
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.
99242
22000
C
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.
99243
1600
C
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.
99244
4500
C
DENTAL CONSULTATIONS
CPT
QTY
Group (Time Rqmt)
D0150 – Comprehensive Oral Evaluation – New or Established Patient
D0150
20
C
D0220 - Intraoral-periapical first film;
D0220
20
C
D0230 - Intraoral-periapical each additional film.
D0230
20
C
D0272 – Bitewings – Two Radiographic Images
D0272
20
C
D0273 – Bitewings – Three Radiographic Images
D0273
20
C
D0274 – Bitewings – Four Radiographic Images
D0274
30
C
NO SHOW/LATE CANCELLATION FEE
CPT
QTY
Group (Time Rqmt)
Fee for No Show/Late Cancellation
N/A
6000
N/A
SERVICE CONTRACT REPORTING
CPT
QTY
Group (Time Rqmt)
SERVICE CONTRACT Reporting (Not Separately Priced - No Fee)
N/A
1
N/A

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