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2 0 0 4 M E D I C A R E F E E S C H E D U L E Attached is a 2004 Medicare Fee Schedule (Disclosure Report) for your locality. The fee schedule amounts and the codes that have been added for 2004 are effective for services performed on or after January 1, 2004. The Medicare Fee Schedule report is formatted in three columns and reads from left to right. The 2004 Medicare Fee Schedule includes the following information: PROC/MOD CPT or HCPCS code along with -TC (Technical component) -26 (Professional component) or -53 (Discontinued procedure) modifiers when applicable. NOTE "D" - Deleted/Discontinued Code. This code is "Deleted/Discontinued" effective with the beginning of the year and it is subject to a 90 day grace period. "G" - Not Valid for Medicare Purposes Code. Medicare uses another code for reporting of, and payment for, these services. This code is "Not Valid for Medicare Purposes" effective with the beginning of the year and it is subject to a 90 day grace period. "H" - Deleted/Discontinued Component Code. Either the "TC" or "26" component shown for this code has been "Deleted/Discontinued". This component code is "Deleted/Discontinued" effective with the beginning of the year and it is subject to a 90 day grace period. "F" - Facility Fee. These amounts apply when the service is performed in a facility setting: Inpatient Hospital (Place of Service (POS) 21), Outpatient Hospital (POS 22), Emergency Room of Hospital (POS 23), Ambulatory Surgical Center (POS 24 - Note: ASC is only treated as a facility setting when an ASC list procedure is performed in an ASC), Military Treatment Facility (POS 26), Skilled Nursing Facility (POS 31), Hospice (POS 34), Ambulance via Land (POS 41), Ambulance via Air or Water (POS 42), Inpatient Psychiatric Facility (POS 51), Psychiatric Facility Partial Hospitalization (POS 52), Community Mental Health Center (POS 53), Psychiatric Residential Treatment Facility (POS 56), and Comprehensive Inpatient Rehabilitation Facility (POS 61). "N" - Non-Facility Fee. These amounts apply when the service is performed in a place of service setting other than listed in the "F" - Facility Fee description above. PAR FEE Allowed amount for participating physicians NPAR FEE Allowed amount for non-participating physicians LC FEE The maximum limiting charge amount that can be charged for that service on a non-assigned claim Note: A fee schedule amount has been given for each procedure code listed in the Medicare Fee Schedule Data Base. However, based on Medicare policy, the specific procedure may not be payable by the Medicare program. Special Notice: All pricing as listed in the Fee Schedule is effective for the entire year of 2004, with the exception of the codes J2353, J3240, J7320, J9045, J9201, J9206 and Q3025. These codes are listed in the Fee Schedule with pricing for 01/01/2004 - 03/31/2004. The pricing for these services for 04/01/2004 - 12/31/2004 is as follows: Code Drug Description Par$ Non-par$ J2353 Octreotide, Depot form for intramuscular injection, 1 mg $77.14 $73.28 J3240 Thyrotropin alpha injection, 0.9 mg, provided in 1.1mg vial $585.65 $556.37 J7320 Hylan G-F 20, 16 mg, for intra-articular injection $204.03 $193.83 J9045 Carboplatin, Paraplatin, 50 mg $137.54 $130.66 J9201 Gemcitabine HCl, 200 mg $111.33 $105.76 J9206 Irinotecan, 20 mg $130.24 $123.73 Q3025 Interferon beta-1a injection, 11 mcg for im use $80.22 $76.21 Visit us on the Web at www.TrailBlazerHealth.com.
