The WBCCEDP will reimburse only the following CPT codes for services ...

[Pages:9]The Wyoming Breast & Cervical Cancer Screening Program will reimburse only the following CPT codes for services provided in

accordance with the program guidelines

January 2021

CPT CODE

99070

99202 99203 99204 99205 99211 99212 99213 99214 99385 99386 99387 99395 99396 99397 76098 76098-TC 76098-26 76641

76641-TC 76641-26 76642 76642-TC 76642-26 76942

76942-TC

76942-26

Service Description

Supplies and materials-over and above those usually included with the office visit (list drugs,trays,supplies, or materials provided) Office visit ? New patient- Expanded problem focused Office visit ? New patient- Detailed Office visit ? New patient-comprehensive history 45 min Office visit ? New Patient- comprehensive history 60 min Office visit ? New patient- Problem focused Office visit ? Established patient- Problem focused Office visit ? Established patient- Expanded problem focused Office visit ? Established patient ? Detailed History 25 min. Initial Preventive Medicine Evaluation-30-39 years Initial Preventive Medicine Evaluation-40-64 years Initial Preventive Medicine Evaluation-65 years and older Periodic Preventive Medicine Evaluation-30-39 years Periodic Preventive Medicine Evaluation-40-64 years Periodic Preventive Medicine Evaluation-65 years and older Radiological Examination Examination-surgical specimen Technical Component for performing- 76098 Professional Component for interpretation of -76098 Ultrasound, complete examination of breast including axilla, unilateral

2021 Max. Allowable Reimbursement Amount. $10.00

$73.97 $113.59 $170.44 $224.97 $23.83 $57.99 $92.95 $132.12 $132.12 $132.12 $132.12 $92.95 $92.95 $92.95 $43.40 $28.28 $15.15 $110.88

Technical Component of- 76641 Professional Component for interpretation of -76641 Ultrasound , Limited examination of breast including axilla, unilateral Technical component -76642 Professional component-76642 Ultrasonic Guidance for Needle Biopsy-radiological supervision and interpretation Technical Component for performing-76942

$75.72 $35.17 $90.76 $58.02 $32.74 $59.60

$28.97

Professional Component for interpretation-76942

$30.64

Revised 02.01.2022

The Wyoming Breast & Cervical Cancer Screening Program will reimburse only the following CPT codes for services provided in

accordance with the program guidelines

January 2021

77053 77053-TC

77053-26

77046 77046-TC 77046-26 77047

77047-TC 77047-26 77048

77048-TC 77048-26 77049

77049-TC 77049-26 77063 77063-TC 77063-26 G0279 G0279-TC G0279-26 77067 77067-TC 77067-26 77066

77066-TC 77066-26 77065

77065-TC

Mammary ductogram or galactogram, single duct Mammary ductogram or galactogram, single duct- Technical component Mammary ductogram or galactogram, single duct- Professional component Magnetic Resonance Imaging,breast,with without contrast, unilateral Technical Component of -77046 Professional Component for interpretation of -77046 Magnetic Resonance Imaging,breast, without contrast, bilateral

$57.87 $40.31

$17.57

$249.29 $179.04 $70.24 $255.50

Technical Component of - 77047 Professional Component for interpretation of- 77047 Magnetic Resonance Imaging,breast,without/with contrast, including CAD when performed-unilateral Technical Component of-77048 Professional Component for interpretation of-77048 Magnetic Resonance Imaging,breast,without/with contrast, including CAD when performed-bilateral Technical Component of-77049 Professional Component for interpretation of-77049 Screening Digital Breast Tomosynthesis Technical Component of - 77063 Professional Component for interpretation of- 77063 Tomosynthesis, Mammo Technical Component of ?G0279 Professional Component for interpretation of G0279 Screening Mammogram-bilateral including CAD Technical Component of-77067 Professional Component for interpretation of ?77067 Diagnostic Mammogram-bilateral including CAD

$178.34 $77.17 $396.47

$295.17 $101.29 $404.71

$293.77 $110.94 $55.14 $26.20 $28.95 $55.14 $26.20 $28.95 $135.22 $98.37 $36.85 $167.13

Technical Component of ?77066 Professional Component for interpretation of-77066 Diagnostic Mammogram-including CAD unilateral

$118.91 $48.22 $132.33

Technical Component of-77065

$93.06

Revised 02.01.2022

The Wyoming Breast & Cervical Cancer Screening Program will reimburse only the following CPT codes for services provided in

accordance with the program guidelines

January 2021

77065-26 87426 87635 87624 87625 88141 88142

88143 88164 88165

88172 88172-TC 88172-26 88173 88173-TC 88173-26 88174

88175

88177

88177-TC

Professional Component for interpretation of-77065

$39.27

COVID-19 infectious agent detection by nuclei acid DNA or RNA; amplified probe technique

$35.33

COVID-19 infectious agent antigen detection by immunoassay technique; qualitative or semi quantitative

$51.31

HPV-Papillomavirus, human, high risk types.

$38.99

HPV-Papillomavirus, types 16 and 18 only

$40.55

Cytopathology, cervical, requiring interpretation by physician

$22.33

Cytopathology, cervical, collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision

$22.51

Cytopathology, cervical or vaginal, automated thin layer prep. Manual $23.04 screening and rescreening under physician supervision

Cytopathology ,smears up to three, screening by cytotechnologist under physician supervision, Bethesda System

$14.99

Cytopathology (conventional pap test),slides cervical or vaginal

$42.22

reported in Bethesda System, manual screening and rescreening under

physician supervision

Evaluation of Fine Needle Aspiration with or without preparation of $55.81 smears

Technical Component of-88172

$20.48

Professional Component for interpretation of-88172

$35.32

Interpretation and Report of fine Needle Aspiration

$158.63

Technical Component of-88173

$88.67

Professional Component for interpretation of-88173

$69.87

Cytopathology, cervical or vaginal, collected in preservative fluid, automated thin layer preparation, screening by automated system under physician supervision

$25.37

Cytopathology, cervical or vaginal, collected in preservative fluid, automated thin layer preparation, screening by automated system and manual screening, under physician supervision

Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen , each separate episode

Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen , each additional episode

$29.44 $29.23 $7.44

Revised 02.01.2022

The Wyoming Breast & Cervical Cancer Screening Program will reimburse only the following CPT codes for services provided in

accordance with the program guidelines

January 2021

88177-26

88305

88305-TC 88305-26 88307

88307-TC 88307-26 88331 88331-TC 88331-26 88332 88332-TC 88332-26 88341

88341-TC

88341-26

88342

Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen , each additional episode Surgical Pathology-Level IV-breast biopsy/cervical biopsy-per specimen Technical Component of-88305 Professional Component for interpretation of-88305 Breast-Excision of lesion-Surgical pathology, gross and microscopic examination requiring microscopic evaluation of surgical margins Technical Component of-88307 Professional Component for interpretation of-88307 Frozen section evaluation of biopsy during surgery Technical Component for performing-88331 Professional Component for interpretation of-88331 Each Additional Frozen Section Technical Component for performing-88332 Professional Component for interpretation of-88332 Immunohistochemistry or immunocytochemistry, per specimen; Initial single antibody stain procedure Immunohistochemistry or immunocytochemistry, per specimen; Initial single antibody stain procedure- Technical component Immunohistochemistry or immunocytochemistry, per specimen; Initial single antibody stain procedure- Professional component Immunohistochemistry

$21.80

$72.02

$34.99 $37.04 $296.09

$214.39 $81.70 $105.49 $43.85 $61.65 $55.56 $25.08 $30.48 $96.36

$68.33

$28.03

$108.19

88342-TC Technical Component for performing-88342

$73.59

88342-26 88360 88360-TC

Professional Component for performing-88342

$34.62

Morphometric analysis, tumor immunohistochemistry , per specimen; Manual

Technical Component for performing-88360

$127.50 $85.99

88360-26 Professional component for performing-88360

$41.53

88361

Morphometric analysis, tumor immunohistochemistry , per specimen; $127.05 using computer assisted technology

Revised 02.01.2022

The Wyoming Breast & Cervical Cancer Screening Program will reimburse only the following CPT codes for services provided in

accordance with the program guidelines

January 2021

88361-TC 88361-26

Technical Component for performing-88361 Professional component for performing-88361

$83.86 $43.19

88364

88364-TC 88364-26 88365

88365-TC 88365-26 88366

88366-TC 88366-26 88367

88367-TC 88367-26 88368

88368-TC 88368-26 88369

88369-TC 88369-26 88373

88373-TC 88373-26 88374

88374-TC 88374-26

In situ hybridization (eg,FISH), per specimen : each additional single

probe stain procedure

Technical Component for performing- 88364 Professional Component for performing-88364 In situ hybridization (eg,FISH), per specimen; initial single probe stain procedure Technical Component for performing-88365 Professional Component for performing-88365 In situ hybridization (eg,FISH), per specimen; each multiplex probe stain procedure Technical Component for performing-88366 Professional Component for performing-88366 Morphometric analysis, in situ hybridization, computer-assisted, per specimen, initial single probe stain procedure Technical Component for performing-88367 Professional Component for performing-88367 Morphometric analysis, in situ hybridization, manual, per specimen, initial single probe stain procedure Technical Component for performing-88368 Professional Component for performing-88368 Morphometric analysis, in situ hybridization, manual, per specimen, each additional probe stain procedure Technical Component for performing-88369 Professional Component for performing-88369 Morphometric analysis, in situ hybridization, computer-assisted, per specimen, each additional probe stain procedure Technical Component for performingProfessional Component for performingMorphometric analysis, in situ hybridization, computer-assisted, per specimen, each multiplex stain procedure Technical Component for performingProfessional Component for performing-

$157.70

$119.63 $38.07 $202.94

$155.03 $47.91 $320.36

$252.24 $68.11 $126.43

$89.52 $36.92 $149.63

$104.34 $45.31 $129.11

$93.71 $35.40 $79.99

$51.46 $28.52 $384.89

$336.93 $47.97

Revised 02.01.2022

The Wyoming Breast & Cervical Cancer Screening Program will reimburse only the following CPT codes for services provided in

accordance with the program guidelines

January 2021

88377

88377-TC 88377-26 57452

Morphometric analysis, in situ hybridization, manual, per specimen, each multiplex stain procedure Technical Component for performingProfessional Component for performingColposcopy - Procedure by Physician

$463.69

$393.29 $70.40 $130.89

57454 57455 57456 57460 57461 57500 57505 19000 19001 19081 19082

19083 19084

19085

19086

19100

Colposcopy with biopsy (s) of cervix and/or cervical curettage Procedure by Physician

Colposcopy with biopsy(s) of the cervix-Procedure by Physician

Colposcopy with endocervical curettage-Procedure by Physician

Colposcopy of cervix with loop electrode biopsy(s) of the cervix Procedure by Physician

Colposcopy with loop electrode conization of the cervix-Procedure by Physician

Biopsy, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)-Procedure by Physician

Endocervical curettage (not done as part of a dilation and curettage)Procedure by Physician

Puncture aspiration of cyst of breast-Procedure by Physician

Puncture aspiration of cyst of breast-each additional cyst-Procedure by Physician

Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; stereotactic guidance; first lesion

Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; stereotactic guidance; each additional lesion

Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; ultrasonic guidance; first lesion

Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; ultrasonic guidance; each additional lesion

Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; magnetic resonance guidance; first lesion

Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; magnetic resonance guidance; each additional lesion

Biopsy of breast-Needle Core-Surgical Procedure by Physician

$175.19 $167.75 $157.80 $342.09 $380.13 $164.71 $156.58 $112.15 $27.24 $602.16 $484.83

$603.49 $476.25

$930.18

$740.11

$552.99

Revised 02.01.2022

The Wyoming Breast & Cervical Cancer Screening Program will reimburse only the following CPT codes for services provided in

accordance with the program guidelines

January 2021

19101 19120 19125

19126 19281 19282 19283 19284 19285 19286 19287 19288 10021 10004 10005 10006 10007 10008 10009 10010 10011 10012

Incisional biopsy of breast-Surgical Procedure by Physician

Excision of Cyst-Breast-Procedure by Physician

Excision of Breast Lesion-Identified by pre-op placement of radiological marker, single lesion-Procedure by Physician

Excision of Breast Lesion-Identified by pre-operative placement of radiological marker, each additional.

Placement of breast localization device, percutaneous; mammographic guidance; first lesion

Placement of breast localization device, percutaneous; mammographic guidance; each additional lesion

Placement of breast localization device, percutaneous; stereotactic guidance; first lesion

Placement of breast localization device, percutaneous; stereotactic guidance; each additional lesion

Placement of breast localization device, percutaneous; ultrasonic guidance; first lesion

Placement of breast localization device, percutaneous; ultrasonic guidance; each additional lesion

Placement of breast localization device, percutaneous; magnetic resonance; first lesion Placement of breast localization device, percutaneous; magnetic resonance; each additional lesion Fine needle aspiration-Without imaging guidance

Fine needle aspiration biopsy without imaging guidance, each additional lesion Fine needle aspiration biopsy including ultrasound guidance, first lesion. Fine needle aspiration biopsy including ultrasound guidance-each additional lesion Fine needle aspiration biopsy including fluoroscopic guidance, first lesion.

Fine needle aspiration biopsy including fluoroscopic guidance, each additional lesion. Fine needle aspiration biopsy including CT guidance, first lesion-

Fine needle aspiration biopsy including CT guidance, each additional lesion Fine needle aspiration biopsy including MRI guidance, first lesion-

Fine needle aspiration biopsy including MRI guidance, first lesion-

$1073.03 $1073.03 $1073.03

$160.85 $256.81 $184.37 $283.90 $217.78 $455.03 $385.99 $782.43 $620.82 $107.94 $52.34 $141.05 $61.74 $326.29 $172.63 $500.55 $293.46 $500.55 $293.40

Revised 02.01.2022

The Wyoming Breast & Cervical Cancer Screening Program will reimburse only the following CPT codes for services provided in

accordance with the program guidelines

January 2021

99156 99157

Moderate anesthesia, 10-22 Minutes for individuals age 5+ Moderate anesthesia, for each additional 15 min.

$83.66 $69.09

Revised 02.01.2022

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