Ambulatory Surgery Center Fee Schedule - Washington Department ...

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DOC ASC Fee Schedule Effective Dates of Service 7/1/2012 thru 8/31/2012 Refer to the 2012 CPT® and HCPCS coding books for complete code descriptions Procedure Code Allowed Amount Multiple Procedure Discounting 65815 $1,533.18 Y 65820 $283.20 Y 65850 $1,533.18 Y 65855 $333.09 Y 65860 $333.09 Y 65865 $1,020.89 Y 65870 $1,533.18 Y 65875 $1,533.18 Y 65880 $1,020.89 Y 65900 $1,020.89 Y 65920 $1,533.18 Y 65930 $1,533.18 Y 66020 $1,020.89 Y 66030 $283.20 Y 66130 $1,533.18 Y 66150 $1,533.18 Y 66155 $1,533.18 Y 66160 $1,533.18 Y 66165 $1,533.18 Y 66170 $1,533.18 Y 66172 $1,533.18 Y 66180 $2,631.56 Y 66185 $1,533.18 Y 66220 $2,510.95 Y 66225 $2,631.56 Y 66250 $1,020.89 Y 66500 $283.20 Y 66505 $283.20 Y 66600 $1,533.18 Y 66605 $1,533.18 Y 66625 $1,020.89 Y 66630 $1,533.18 Y 66635 $1,533.18 Y 66680 $1,533.18 Y 66682 $1,533.18 Y 66700 $1,020.89 Y 66710 $1,020.89 Y 66711 $1,020.89 Y Procedure Code Allowed Amount Multiple Procedure Discounting 66720 $1,020.89 Y 66740 $1,533.18 Y 66761 $333.09 Y 66762 $333.09 Y 66770 $333.09 Y 66820 $283.20 Y 66821 $333.09 Y 66825 $1,533.18 Y 66830 $283.20 Y 66840 $993.24 Y 66850 $1,905.58 Y 66852 $1,905.58 Y 66920 $1,905.58 Y 66930 $1,905.58 Y 66940 $993.24 Y 66982 $1,526.00 Y 66983 $1,526.00 Y 66984 $1,526.00 Y 66985 $1,526.00 Y 66986 $1,526.00 Y 66990 Packaged N 66999 $283.20 Y 67005 $1,301.49 Y 67010 $2,510.95 Y 67015 $2,510.95 Y 67025 $1,301.49 Y 67027 $2,510.95 Y 67028 $202.73 N 67030 $1,301.49 Y 67031 $333.09 Y 67036 $2,510.95 Y 67039 $2,510.95 Y 67040 $2,510.95 Y 67041 $2,510.95 Y 67042 $2,510.95 Y 67043 $2,510.95 Y 67101 $1,301.49 Y 67105 $333.09 Y CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 54
DOC ASC Fee Schedule Effective Dates of Service 7/1/2012 thru 8/31/2012 Refer to the 2012 CPT® and HCPCS coding books for complete code descriptions Procedure Code Allowed Amount Multiple Procedure Discounting 67107 $2,510.95 Y 67108 $2,510.95 Y 67110 $1,301.49 Y 67112 $2,510.95 Y 67113 $2,510.95 Y 67115 $1,301.49 Y 67120 $1,301.49 Y 67121 $1,301.49 Y 67141 $367.54 Y 67145 $333.09 Y 67208 $367.54 Y 67210 $333.09 Y 67218 $1,301.49 Y 67220 $367.54 Y 67221 $367.54 Y 67225 $367.54 Y 67227 $1,301.49 Y 67228 $333.09 Y 67229 $333.09 Y 67250 $1,140.86 Y 67255 $1,301.49 Y 67299 $367.54 Y 67311 $1,474.58 Y 67312 $1,474.58 Y 67314 $1,474.58 Y 67316 $1,474.58 Y 67318 $1,474.58 Y 67320 $1,474.58 Y 67331 $1,474.58 Y 67332 $1,474.58 Y 67334 $1,474.58 Y 67335 $1,474.58 Y 67340 $1,474.58 Y 67343 $1,474.58 Y 67345 $202.73 Y 67346 $976.42 Y 67399 $1,474.58 Y 67400 $1,140.86 Y Procedure Code Allowed Amount Multiple Procedure Discounting 67405 $1,686.33 Y 67412 $1,140.86 Y 67413 $1,686.33 Y 67414 $2,451.08 Y 67415 $1,140.86 Y 67420 $2,451.08 Y 67430 $2,451.08 Y 67440 $2,451.08 Y 67445 $2,451.08 Y 67450 $2,451.08 Y 67500 $122.99 N 67505 $202.73 Y 67515 $202.73 Y 67550 $2,451.08 Y 67560 $1,686.33 Y 67570 $2,451.08 Y 67599 $202.73 Y 67700 $202.73 Y 67710 $480.15 Y 67715 $1,140.86 Y 67800 $202.73 Y 67801 $480.15 Y 67805 $202.73 Y 67808 $1,140.86 Y 67810 $202.73 Y 67820 $60.02 N 67825 $202.73 Y 67830 $480.15 Y 67835 $1,140.86 Y 67840 $480.15 Y 67850 $480.15 Y 67875 $480.15 Y 67880 $1,020.89 Y 67882 $1,140.86 Y 67900 $1,686.33 Y 67901 $1,140.86 Y 67902 $1,686.33 Y 67903 $1,140.86 Y CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 55
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Ambulatory Surgery Center Fee Sched
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