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 88311 $9.71 N 88312 $15.59 N 88313 $15.59 N 88314 $15.59 N 88318 $15.59 N 88319 $50.44 N 88321 $15.59 N 88323 $33.31 N 88325 $50.44 N 88329 $15.59 N 88331 $33.31 N 88332 $15.59 N 88333 $15.59 N 88334 $15.59 N 88342 $33.31 N 88346 $33.31 N 88347 $33.31 N 88348 $153.62 N 88349 $153.62 N 88355 $33.31 N 88356 $50.44 N 88358 $33.31 N 88360 $33.31 N 88361 $50.44 N 88362 $50.44 N 88365 $50.44 N 88367 $50.44 N 88368 $50.44 N 88380 Packaged N 88381 Packaged N 88387 Packaged N 88388 Packaged N 88399 $9.71 N 88720 $9.20 N 88738 By Report N 88740 $9.20 N 88741 $9.20 N 89049 $9.71 N Procedure Code Allowed Amount Multiple Procedure Discounting 89100 $95.52 N 89105 $95.52 N 89130 $95.52 N 89132 $95.52 N 89135 $95.52 N 89136 $95.52 N 89140 $95.52 N 89141 $95.52 N 89230 $33.31 N 89240 $9.71 N 89264 $50.44 N 89322 By Report N 89331 By Report N 89398 By Report N 90284 By Report N 90296 Packaged N 90371 $114.20 N 90375 $150.91 N 90376 $140.06 N 90385 Packaged N 90393 By Report N 90396 $147.59 N 90470 $31.90 N 90471 $23.93 N 90472 $23.93 N 90473 $23.93 N 90474 $23.93 N 90476 By Report N 90477 By Report N 90581 By Report N 90585 $108.14 N 90632 Packaged N 90633 Packaged N 90634 Packaged N 90636 Packaged N 90644 By Report N 90645 Packaged N 90646 Packaged N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 68
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 90647 Packaged N 90648 Packaged N 90650 By Report N 90655 Packaged N 90656 Packaged N 90657 Packaged N 90658 Packaged N 90660 Packaged N 90661 By Report N 90662 By Report N 90663 Bundled N 90665 $0.93 N 90669 Packaged N 90670 By Report N 90675 $173.25 N 90676 $96.27 N 90680 $72.37 N 90681 $106.60 N 90690 By Report N 90691 By Report N 90692 By Report N 90696 Packaged N 90698 Packaged N 90700 Packaged N 90701 Packaged N 90702 Packaged N 90703 Packaged N 90704 Packaged N 90705 Packaged N 90706 Packaged N 90707 Packaged N 90708 Packaged N 90710 Packaged N 90712 Packaged N 90713 Packaged N 90714 Packaged N 90715 Packaged N 90717 By Report N Procedure Code Allowed Amount Multiple Procedure Discounting 90718 Packaged N 90719 Packaged N 90720 Packaged N 90721 Packaged N 90725 By Report N 90727 By Report N 90732 Packaged N 90733 $98.54 N 90734 $102.46 N 90735 $100.15 N 90738 By Report N 90740 Packaged N 90743 Packaged N 90744 Packaged N 90746 Packaged N 90747 Packaged N 90749 Packaged N 91000 $256.59 N 91010 $256.59 N 91011 $256.59 N 91012 $256.59 N 91020 $256.59 N 91022 $256.59 N 91030 $256.59 N 91034 $256.59 N 91035 $256.59 N 91037 $256.59 N 91038 $256.59 N 91040 $95.52 N 91052 $256.59 N 91055 $95.52 N 91065 $95.52 N 91105 $95.52 N 91110 $618.89 Y 91120 $68.85 Y 91122 $189.83 Y 91123 Packaged N 91132 $95.52 N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 69
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