Pain Management Fee Schedule Courtesy, Mowles Medical Practice Management, LLC. October, 2004
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1 INJECTIONS/ BLOCKS Epidural lumbar/sacral/caudal Epidural cervical/thoracic Inject. Incl.cath placement, continuous cervical/thoracic Inject. Incl.cath placement, continuous Lumbar/sacral Scar Infiltration (up to 7) Scar Infiltration (over 7) Injection Tendon Trigger Point 1 or Trigger Points 3 or more Small Joint Injection Medium Joint Injection Large Joint Injection SI Joint Injection G00 Inj for sacroiliac jt anesth Trigeminal Nerve, any Facial Nerve Greater/lesser Occipital nerve Vagus Nerve Phrenic Nerve Spinal Accessory Nerve Cervical Plexus Brachial Plexus Brachial Plexus Continuous infusion Axillary Nerve Block Suprascapular Nerve Intercostal, single Intercostal, multiple Ilionguinal, Iliohypogastric Nerve
2 64430 Pudental Nerve Transforaminal, epidural cerv/thor. 1st level Transforaminal, epidural cerv/thor. Ea. Addt'l Transforaminal epidural lumbar/sacral, 1st level Transforaminal epidural lumbar/sacral ea. addt l Facet, lumbar/sacral single Facet, lumbar/sacral additional Facet, cerv./thoracic single Facet, cervical/thoracic additional Sciatic Nerve Sciatic Nerve, Continuous Infusion Femoral Nerve, sing;le Femoral Nerve, Continuous Infusion Lumbar Plexus N/A Other peripheral Sphenopalatine Stellate Ganglion Hypogastric Plexus N/A Lumbar sympathetic Celiac Plexus DESTRUCTION RF,CYRO,CHEMICAL Subarachnoid Epidural, cervical/thoracic Epidural, lumbar/caudal Trigeminal Nerve, any Botox Injection, facial nerve Botox Injection, Cervical spinal muscle Botox Injection, Extremity/Trunk muscles N/A Spinal puncture lumbar
3 64620 Intercostal: destruct Destruct Paravetebral Facet, lumbar single Destruct Paravetebral Facet, lumbar ea. addt l Facet joint or facet joint nerve cerv/thor. 1st level Facet joint or facet joint nerve cerv/thor, ea. add l Other peripheral Celiac Plexus: destruction by neuro agent S. Hypogastric Plexis: destruction by neuro agent N/A 623 Percutaneous lysis of adhesions Percutaneous lysis of adhesions 1 day T Endoscopic lysis of adhesions New N/A Percutaneous Laser Discectomy 1339* OTHER Conscious Sedation by physician performing procedure Tens application N/A Blood Patch Discography, lumbar Discography, cervical RADIOLOGY Epidurogram (with dictation) w/o use Epidurogram (with dictation) professional N/A Radiological exam, SI arthrography, global Radiological exam, SI arthrography, professional N/A Fluoroscopic guidance Fluoroscopic guidance professional N/A Fluoroscpic guidance Fluoroscpic guidance professional N/A Radiological interpretation, cervical, global Radiological interpretation, cervical, professional only N/A
4 Radiological interpretation, lumbar, global Radiological interpretation, lumbar, professional only N/A IMPLANTS: CATHETERS, PUMPS Implant Catheter Remove implanted catheter Implant non-programmable pump Implant programmable pump Remove implanted pump Analysis pump w/o reprogram * Analysis pump w/o Program * N/A Analysis pump with reprogram * Analysis pump with Reprogram * N/A Refill implantable pump Refill implantable pump N/A IMPLANTS: NEUROSTIMULATOR Percutaneous implant neurolectrode Revision/remove electrode Implant spinal transmitter Revision/remove spinal transmitter Electronic Analysis w/o reprogramming Electronic Analysis w/reprogramming NEW PATIENT VISITS New patient N/A New patient N/A New patient N/A New patient N/A New patient N/A ESTABLISHED PATIENT VISITS Established pt N/A
5 99212 Established pt N/A Established pt N/A Established pt N/A Established pt N/A CONSULTATIONS Consultation N/A Consultation N/A Consultation N/A Consultation N/A Consultation N/A INITIAL INPATIENT CONSULTATIONS In-pt. Consult N/A In-pt. Consult N/A In-pt. Consult N/A In-pt. Consult N/A FOLLOW UP INPATIENT CONSULTATIONS 991 F/U N/A 992 F/U N/A 993 F/U N/A
6 Explanation of Column Titles: - AMA approved code for the description as listed Description - Short description of code National Average Facility Fee - National Average Allowance without Geogrpahical Adjustment factors for facility fee payment to ASC 1- $333 2-$446 3-$510 4-$630 5-$717 6-$8 ($676 + $150 for intraocular lenses (IOLs) 7-$995 8-$973 ($823 + $150 for IOLs) *9-$1339 National Average APC rate - indicates payment by Medicare to the hospital for procedures performed in the outpatient department Total Facility - indicates the total relative value unit for the procedure performed in a facility setting Medicare Pro. Pmt facility - indicates payment from Medicare to the physician performing the procedure in either an ASC or Hospital - Total Office - indicates the total relative value unit for the procedure performed in an office setting Medicare Pro. Pmt office - indicates payment from Medicare to the physician performing the procedure in a private office only when all expenses are incurred by the provider Non-Medicare Pro. Fee range - indicates current year average of physician charges (not reimbursement) Relative Value - indicates the total relative value unit recommended by the ASA for the procedure
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