Effective January 1, 2018

Susana Martinez, Governor

Darin A. Childers, Director

2410 Centre Ave SE, PO Box 27198 Albuquerque, NM 87125-7198 (505) 841-6000

Effective January 1, 2018

Issued Pursuant to NMSA 1978, ? 52-5-4 and Rule 11.4.7 NMAC 9(A)(1)

COPYRIGHT NOTICE

Please be advised that this publication contains material that is copyrighted by the American Medical Association (AMA). You are forbidden to download the materials unless you read, agree to and abide by the provisions of the copyright statement. The five character codes included in the New Mexico Health Care Providers' Fee Schedule are obtained from the 2017 Current Procedural Terminology (CPT), copyright 2016 by the AMA. CPT? is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. The responsibility for the content of the New Mexico Health Care Providers' Fee Schedule is with the New Mexico Workers' Compensation Administration and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the New Mexico Health Care Providers' Fee Schedule. Fee Schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Any use of CPT outside of the New Mexico Health Care Providers' Fee Schedule should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. CPT is a registered trademark of the American Medical Association.

CPT only Copyright 2016 American Medical Association. All rights reserved.

HCP Fee Schedule & Billing Instructions

Effective January 01, 2018

TABLE OF CONTENTS

DEFINITIONS .................................................................................................................................................................. 4 HCP FEE SCHEDULE ..................................................................................................................................................... 7

Anesthesia ..................................................................................................................................................................... 7 Modifiers ................................................................................................................................................................... 7

Durable Medical Equipment (DME) ............................................................................................................................. 8 Evaluation and Management (E/M) Services................................................................................................................ 8 Explanation of Benefits (EOBs) .................................................................................................................................... 9

Standard EOBs .......................................................................................................................................................... 9 Inaccurate Billing/Billing Errors ............................................................................................................................... 9 Specific EOB Reductions .......................................................................................................................................... 9 Facility Fees .................................................................................................................................................................. 9 Failed Appointments ...................................................................................................................................................10 Free-Standing Ambulatory Surgery Centers and Outpatient Surgery .........................................................................10 Global Surgery ............................................................................................................................................................11 Hospital Ratios ............................................................................................................................................................11 Implants, Hardware & Instrumentation.......................................................................................................................13 Materials and Supplies ................................................................................................................................................13 Medical Cannabis ........................................................................................................................................................14 Miscellaneous Fees......................................................................................................................................................14 Copies ...................................................................................................................................................................... 14 Form Letter to Health Care Provider.......................................................................................................................14 New Mexico Gross Receipts Tax (NMGRT) ..........................................................................................................14 Radiographic Files...................................................................................................................................................15 Referrals and Consultations.....................................................................................................................................15 Pharmacy ..................................................................................................................................................................... 15 Average Wholesale Price (AWP)............................................................................................................................15 Compound Medications ..........................................................................................................................................16 Physical Therapy .........................................................................................................................................................16

CPT only Copyright 2016 American Medical Association. All rights reserved. Relative Value Guide? is a registered trademark of the American Society of Anesthesiologists. "Official Disability Guidelines" and "ODG" are registered trademarks of Work Loss Data Institute.

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HCP Fee Schedule & Billing Instructions

Effective January 01, 2018

Platelet Rich Plasma (PRP) Injection..........................................................................................................................17 Provider's Report of Physical Ability .........................................................................................................................17 Service Component Modifiers for Hospitals, FASCs and Outpatient Services ..........................................................17 Surgical Modifiers for Hospitals, FASCs and Outpatient Services.............................................................................17 Urine Drug Testing......................................................................................................................................................18 BILLING INSTRUCTIONS ...........................................................................................................................................20 Instructions for Completing Forms .............................................................................................................................20

Form CMS-1500 (02/12) .........................................................................................................................................20 Form UB-04 CMS 1450 ..........................................................................................................................................23 APPENDIX A ? CPT-CODED HCP FEE SCHEDULE ................................................................................................25

CPT only Copyright 2016 American Medical Association. All rights reserved. Relative Value Guide? is a registered trademark of the American Society of Anesthesiologists. "Official Disability Guidelines" and "ODG" are registered trademarks of Work Loss Data Institute.

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HCP Fee Schedule & Billing Instructions

Effective January 01, 2018

DEFINITIONS

For the purposes of this document, the following definitions apply to the provision of all services:

A. "ASA Relative Value Guide?" means a document published by the American Society of Anesthesiologists (ASA) which includes only CPT descriptive terms, identifying codes and modifiers for reporting medical services and procedures that relate to the practice of anesthesiology. The current calendar year edition of the ASA Relative Value Guide? applies.

B. "Assistant Surgeon" means a surgeon who provides full assistance to the primary surgeon and is capable of taking over the surgery should the primary surgeon become incapacitated and is billed using modifier "80". When billed using modifier "82" it means an assistant who provides surgery when a qualified resident surgeon is not available. Modifier "82" is used primarily in teaching hospitals to indicate that a qualified resident surgeon is unavailable.

C. the Act.

"Authorized Health Care Provider (HCP)" means the Health Care Provider selected in accordance with

D. "Average Wholesale Price (AWP)" means the average national price paid by pharmacies for pharmaceutical products, as determined and published at least monthly by any nationally recognized pricing guide.

E. "By-report (BR)" means a maximum amount for a service has not been established in the HCP Fee Schedule.

F. "Centers for Medicare & Medicaid Services (CMS)" means part of the Federal Department of Health and Human Services which administers programs including Medicare, Medicaid, the Children's Health Insurance Program (CHIP) and the Health Insurance Marketplace.

G. "Failed appointment" means an appointment with an HCP or caregiver for which the patient fails to show or arrives too late to be treated on the same day.

H. "Forms" means a bill for services that is rendered by an HCP, caregiver, or supplier submitted on one of the following forms as outlined in this document: (1) CMS-1500 (02/12); (2) UB-04 CMS 1450 (OMB No. 09380997).

I.

"HCP Fee Schedule" means this Health Care Provider Fee Schedule & Billing Instructions document

and is used for ease of reference.

J. "Implants, instrumentation and hardware" means: surgical implants are defined as any single-use item that is surgically inserted, deemed to be medically necessary and approved by the payer which the physician does not specify to be removed in less than six weeks, such as bone, cartilage, tendon or other anatomical material obtained from a source other than the patient; plates, screws, pins, cages; internal fixators; joint replacements; anchors; permanent neurostimulators; pain pumps; and disposable instrumentation which includes ports, single-use temporary pain pumps, external fixators and temporary neurostimulators and other single-use items intended to be removed from the body in less than six (6) weeks.

CPT only Copyright 2016 American Medical Association. All rights reserved. Relative Value Guide? is a registered trademark of the American Society of Anesthesiologists. "Official Disability Guidelines" and "ODG" are registered trademarks of Work Loss Data Institute.

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