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 96522 $118.17 N 96542 $70.55 N 96549 $23.93 N 96567 $175.81 N 96570 $96.83 N 96571 $96.83 N 96900 $33.31 N 96902 Packaged N 96904 Packaged N 96910 $33.31 N 96912 $33.31 N 96913 $168.32 N 96920 $96.83 Y 96921 $96.83 Y 96922 $96.83 Y 96999 $27.87 N 99143 Packaged N 99144 Packaged N 99145 Packaged N 99148 By Report N 99149 By Report N 99150 By Report N 99170 $8.29 Y 99174 By Report N 99175 Packaged N 99195 $38.53 N 0016T $367.54 Y 0017T $367.54 Y 0042T Packaged N 0071T $3,329.29 N 0072T $3,329.29 N 0073T $392.62 N 0085T Packaged N 0123T $1,533.18 Y 0124T $283.20 Y 0159T Packaged N 0173T By Report N 0174T By Report N Procedure Code Allowed Amount Multiple Procedure Discounting 0175T By Report N 0183T By Report N 0185T By Report N 0186T By Report N 0187T By Report N 0190T By Report N 0191T By Report N 0192T By Report N 0193T By Report N 0197T By Report N 0198T By Report N 0199T By Report N 0200T By Report N 0201T By Report N 0203T By Report N 0204T By Report N 0205T By Report N 0206T By Report N 0207T By Report N 0208T By Report N 0209T By Report N 0210T By Report N 0211T By Report N 0212T By Report N 0213T By Report N 0214T By Report N 0215T By Report N 0216T By Report N 0217T By Report N 0218T By Report N 0221T By Report N 0222T By Report N A4218 Packaged N A4220 Packaged N A4230 Packaged N A4231 Packaged N A4248 Packaged N A4252 Packaged N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 76
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 A4262 Packaged N A4263 Packaged N A4264 By Report N A4270 Packaged N A4300 Packaged N A4301 Packaged N A4305 Packaged N A4306 Packaged N A4336 Packaged N A4360 Packaged N A4456 Packaged N A4465 Packaged N A4466 Packaged N A4470 Packaged N A4480 Packaged N A4561 Packaged N A4562 Packaged N A4565 Packaged N A4641 Packaged N A4642 Packaged N A4648 Packaged N A4648 Packaged N A4649 Packaged N A4650 Packaged N A4650 Packaged N A4657 Packaged N A4660 Packaged N A4663 Packaged N A4680 Packaged N A4690 Packaged N A4706 Packaged N A4707 Packaged N A4708 Packaged N A4709 Packaged N A4714 Packaged N A4719 Packaged N A4720 Packaged N A4721 Packaged N Procedure Code Allowed Amount Multiple Procedure Discounting A4722 Packaged N A4723 Packaged N A4724 Packaged N A4725 Packaged N A4726 Packaged N A4730 Packaged N A4736 Packaged N A4737 Packaged N A4740 Packaged N A4750 Packaged N A4755 Packaged N A4760 Packaged N A4765 Packaged N A4766 Packaged N A4770 Packaged N A4771 Packaged N A4772 Packaged N A4773 Packaged N A4774 Packaged N A4802 Packaged N A4860 Packaged N A4870 Packaged N A4890 Packaged N A4911 Packaged N A4913 Packaged N A4918 Packaged N A4927 Packaged N A4928 Packaged N A4929 Packaged N A4930 Packaged N A4931 By Report N A5083 Packaged N A6413 Packaged N A6545 Packaged N A7027 By Report N A7028 By Report N A7029 By Report N A7042 Packaged N CPT® codes only are copyright 2012 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply Page | 77
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