June 3, 1999 - TEACH
DELTA HEALTHCARE
EXHIBIT A
COMPENSATION SCHEDULE
NON-SURGICAL ABORTION Methotrexate-
(less than 6 weeks by Ultrasound) Mifeprex (RU486) -
Global fee to include:
History and Physical
Counseling
Laboratory
Pregnancy Test
Hematocrit
Rh Typing
Ultrasound (Transvaginal)
All necessary medications to perform non-surgical abortion.
Methotrexate
Misoprostal
Follow – up visits with repeat transvaginal ultrasounds ( up to 5 visits )
*Mini-Rhogam (if indicated, will be an additional $85.00. Rhogam is not included in global fee)
FIRST TRIMESTER ABORTION
6 – 11 weeks + 6 days
w/ General anesthesia
Global fee to include:
History and Physical
Counseling (verbal & video)
Laboratory
Pregnancy Test
Dipstick Urinalysis
Rh Typing
Hematocrit
Specimen Pathology
Ultrasound
Anesthesia Services
Anesthesiologist Fee
Anesthesia evaluation and services
Introduction of intra-cath
Administration and maintenance of anesthetics and narcotic
Monitoring of patient intra-operatively, vital signs and oxygen saturation.
Exhibit A, continued
All narcotics and medications
Anesthesia
Antibiotics
Antimetics
Methergine (if indicated)
Pitocin (if indicated)
*Mini-Rhogam (if indicated, will be an additional $85.00. Rhogam is
is not included in global fee)
Surgery
Surgeon Fee
Paracervical Block
Phlebotomy and Supplies
Ancillary services
Room Charge
Monitoring Equipment
Sonography Fee
PAR Services
Should complications arise that fall outside the scope of the initial procedure,
Cigna Healthcare of California agrees to compensate Professional for Covered, Authorized Services.
EXCLUSIONS: Hospital Charges and Consulting Physician fees. The patient’s PCP will provide; two week follow-up visit and 24-hour after hours emergency care and follow-up.
ADDITIONAL SERVICES
If an abortion procedure is not performed, the following may be billed separately:
90742 Mini Rhogam 85.00
90384 Full Rhogam 110.00
59200 Laminaria 5.00 each
76815 Sonogram 80.00
81025 Pregnancy Test 10.00
86901 Rh Typing 10.00
85014 Hematocrit 10.00
99203 Office Visit 75.00
* Due to the high cost of Rhogam, it is not feasible to include it in the global fee.
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