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 67904 $1,140.86 Y 67906 $1,140.86 Y 67908 $1,140.86 Y 67909 $1,140.86 Y 67911 $1,140.86 Y 67912 $1,140.86 Y 67914 $1,140.86 Y 67915 $1,140.86 Y 67916 $1,140.86 Y 67917 $1,140.86 Y 67921 $1,140.86 Y 67922 $1,140.86 Y 67923 $1,140.86 Y 67924 $1,140.86 Y 67930 $1,140.86 Y 67935 $1,140.86 Y 67938 $122.99 N 67950 $1,140.86 Y 67961 $1,140.86 Y 67966 $1,140.86 Y 67971 $1,140.86 Y 67973 $1,686.33 Y 67974 $1,140.86 Y 67975 $1,140.86 Y 67999 $202.73 Y 68020 $202.73 Y 68040 $60.02 N 68100 $283.20 Y 68110 $976.42 Y 68115 $1,140.86 Y 68130 $1,020.89 Y 68135 $480.15 Y 68200 $60.02 N 68320 $1,686.33 Y 68325 $1,686.33 Y 68326 $1,140.86 Y 68328 $1,686.33 Y 68330 $1,533.18 Y Procedure Code Allowed Amount Multiple Procedure Discounting 68335 $1,686.33 Y 68340 $1,140.86 Y 68360 $1,533.18 Y 68362 $1,533.18 Y 68371 $1,020.89 Y 68399 $202.73 Y 68400 $202.73 Y 68420 $1,140.86 Y 68440 $202.73 Y 68500 $1,686.33 Y 68505 $1,686.33 Y 68510 $1,140.86 Y 68520 $1,686.33 Y 68525 $1,140.86 Y 68530 $202.73 Y 68540 $1,140.86 Y 68550 $1,686.33 Y 68700 $1,140.86 Y 68705 $202.73 Y 68720 $1,686.33 Y 68745 $1,686.33 Y 68750 $1,686.33 Y 68760 $202.73 N 68761 $202.73 N 68770 $1,686.33 Y 68801 $60.02 N 68810 $202.73 N 68811 $1,140.86 Y 68815 $1,140.86 Y 68816 $1,140.86 Y 68840 $122.99 N 68850 Packaged N 68899 $202.73 Y 69000 $91.46 Y 69005 $1,219.29 Y 69020 $91.46 Y 69100 $215.19 Y 69105 $1,079.91 Y CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 56
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 69110 $1,099.36 Y 69120 $1,568.46 Y 69140 $1,568.46 Y 69145 $1,099.36 Y 69150 $478.74 Y 69200 $42.05 N 69205 $1,469.46 Y 69210 $42.05 N 69220 $55.22 Y 69222 $1,079.91 Y 69300 $1,568.46 Y 69310 $2,700.59 Y 69320 $2,700.59 Y 69399 $72.39 Y 69400 $215.19 Y 69401 $215.19 Y 69405 $478.74 Y 69420 $215.19 Y 69421 $1,079.91 Y 69424 $1,079.91 Y 69433 $478.74 Y 69436 $1,079.91 Y 69440 $1,568.46 Y 69450 $2,700.59 Y 69501 $2,700.59 Y 69502 $1,568.46 Y 69505 $2,700.59 Y 69511 $2,700.59 Y 69530 $2,700.59 Y 69540 $1,079.91 Y 69550 $2,700.59 Y 69552 $2,700.59 Y 69601 $2,700.59 Y 69602 $2,700.59 Y 69603 $2,700.59 Y 69604 $2,700.59 Y 69605 $2,700.59 Y 69610 $1,568.46 Y Procedure Code Allowed Amount Multiple Procedure Discounting 69620 $1,568.46 Y 69631 $2,700.59 Y 69632 $2,700.59 Y 69633 $2,700.59 Y 69635 $2,700.59 Y 69636 $2,700.59 Y 69637 $2,700.59 Y 69641 $2,700.59 Y 69642 $2,700.59 Y 69643 $2,700.59 Y 69644 $2,700.59 Y 69645 $2,700.59 Y 69646 $2,700.59 Y 69650 $1,568.46 Y 69660 $2,700.59 Y 69661 $2,700.59 Y 69662 $2,700.59 Y 69666 $2,700.59 Y 69667 $2,700.59 Y 69670 $2,700.59 Y 69676 $2,700.59 Y 69700 $2,700.59 Y 69711 $2,700.59 Y 69714 $7,462.11 Y 69715 $7,462.11 Y 69717 $7,462.11 Y 69718 $7,462.11 Y 69720 $2,700.59 Y 69725 $2,700.59 Y 69740 $2,700.59 Y 69745 $2,700.59 Y 69799 $72.39 Y 69801 $1,568.46 Y 69802 $1,568.46 Y 69805 $2,700.59 Y 69806 $2,700.59 Y 69820 $2,700.59 Y 69840 $2,700.59 Y CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 57
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