N.Y. Comp. Codes R. & Regs. tit. 18 § 533.4

Current through Register Vol. 46, No. 45, November 2, 2024

Section 533.4 - Medicine

(a)Conversion factor.

The conversion factor for the services and procedures listed in subdivision (g) of this section shall be $5.

(b)Services and values.

For the numbered and described items of services or procedures set forth in subdivision (g) of this section, the maximum reimbursable fee shall be computed on the basis of the respective assigned value multiplied by the conversion factor of $5.

(c)Clinic services.

(1) Maximum reimbursable allowances established for payment to a physician for clinic services (items 9023, 9024, 9032, 9033, 9026, 9027, 9030, 9031) shall not apply when the physician receives any form of compensation from the facility for providing such services.

(2) Clinic fees (items 9023, 9024, 9032, 9033, 9026, 9027, 9030, 9031) shall be prorated according to the number of medical assistance patients treated as a percentage of the total number of patients seen during a clinic session.

(d)Hospital visits.

(1) Hospital visit fees shall not apply to preoperative consultations or follow-up visits as designated in accordance with the surgical fees listed in section 533.5 of this Part.

(2) Reimbursement for hospital visits shall only be made for care provided in accordance with the provisions of Part 505 of this Subchapter.

(e)Newborn care.

Newborn care (fee codes 9035 and 9038) is in addition to any appropriate fee for maternity care.

(f) Psychiatric services by a private practicing physician require prior approval of the local professional director when more than 15 visits within a continuous six-month period are required to complete the course of treatment.

(g)Maximum reimbursable medical fee schedule.

GENERAL PRACTITIONER

(or Specialist Providing Service in Nonspecialist Area)

OFFICE VISITS

Unit or Dollar Value
9000	First visit, new patient or new illness, history, examination and treatment .......	$7.80
9001	Subsequent visit, including treatment .......	$6.00
9002	Complete physical examination with special report .......	$12.00
HOME VISITS
9010	First visit, new patient or new illness, history, examination and treatment .......	1.6
9011	Subsequent visit, including treatment .......	1.4
9012	Complete physical examination with special report .......	2.25
9018	Home visit each additional member of same household .......	1.0
HOSPITAL VISITS
9020	First visit, new patient or new illness, history, examination and treatment .......	1.3
9021	Subsequent visit, including treatment .......	1.0
9022	Complete physical examination with special report .......	2.0
NURSING HOME VISITS
9003	First visit, new patient or new illness, history, examination and treatment .......	1.6
9005	Subsequent visit, including treatment .......	1.4
9014	Complete physical examination with special report .......	2.25
9019	Visit, each additional patient, same nursing home, same session .......	1.0
CLINIC VISITS, NONSPECIALIST
9023	One-hour session .......	3.0
9024	Two-hour session .......	5.0
9032	Three-hour session .......	7.0
9033	Each additional hour (per hour) .......	1.4
OSTEOPATHIC PHYSICIAN
9041	Osteopathic manipulation, where indicated, additional .......	.2
SPECIALIST PROCEDURES CONSULTATION BY SPECIALIST
9028G	Initial consultation (office) .......	$24.00
9029G	Subsequent consultation when required to complete diagnosis (office) .......	$18.00
9028J	Initial consultation (other than office) .......	4.0
9029J	Subsequent consultation when required to complete diagnosis (other than office) .......	3.0
INTERNIST
Office Visits
Comprehensive diagnostic history, physical examination and treatment, including screening test for anemia and urinary glucose and albumin, taking of blood specimens, and furnishing of reports when requested.
9002B	Up to 45 minutes .......	$15.00
9002M	46 minutes to one hour .......	$20.00
9002E	More than one hour .......	$25.00
9004	Follow-up visit, routine .......	$7.50
9006	Follow-up visit, prolonged (over 20 minutes) .......	$10.00
Home Visits
9012B	Initial home visit, routine, new patient or new illness, history and examination .......	3.0
9012M	Initial home visit, complete diagnostic history and physical examination, established patient or minor chronic illness, including initiation of diagnostic and treatment programs .......	4.0
9021E	Initial home visit, complete diagnostic history and physical examination, new patient or major illness, including initiation of diagnostic and treatment programs .......	5.0
9015	Examination or evaluation, routine .......	2.0
Hospital Visits
9020B	Initial hospital visit, brief history and physical examination, including initiation of diagnostic and treatment programs and preparation of hospital records .......	3.0
9021M	Initial hospital visit, complete diagnostic history and physical examination, established patient or minor chronic illness, including initiation of diagnostic and treatment programs and preparation of hospital records .......	4.0
9022E	Initial hospital visit, complete diagnostic history, and physical examination, new patient or major illness, including initiation of diagnostic and treatment programs and preparation of hospital records .......	5.0
9025	Examination or evaluation, routine follow-up .......	1.5
PEDIATRICIAN
Office Home and Hospital Visits
9007F	Comprehensive diagnostic history and physical examination, new patient or new illness, office .......	$12.00
9007R	Comprehensive diagnostic history and physical examination, new patient or new illness, home .......	2.0
9007H	Comprehensive diagnostic history and physical examination, new patient or new illness, hospital .......	2.0
9009F	Routine office visit, including treatment .......	$7.20
9009H	Routine hospital visit, including treatment .......	1.2
9013	Routine home visit, including treatment .......	1.8
9018P	Each additional child at home .......	1.0
9037	Pediatrician in attendance at problem deliveries .......	5.0
9038	Total newborn care in hospital, including physical examinations of the baby and discussion with the mother during the hospital stay (total fee for minimum 3-day stay) .......	4.0
OTOLARYNGOLOGIST
Office Visits
9042	Complete diagnosis, history, physical examination, new patient or new illness .......	$12.00
9043	Routine visit and treatment .......	$7.20
Hospital Visits
9044	Initial visit .......	2.0
9045	Follow-up visit, including treatment .......	1.2
UROLOGIST
Office Visits
9078	Complete diagnosis, history, physical examination, new patient or new illness .......	$12.00
9079	Routine visit, including treatment .......	$7.20
Hospital Visits
9080	Initial visit .......	2.0
9081	Follow-up visit, including treatment .......	1.2
DERMATOLOGIST
Office Visits
9065	Comprehensive diagnosis, history, physical examination, new patient or new illness .......	$12.00
9066	Routine visit, including treatment .......	$7.30
Hospital Visits
9067	Initial visit .......	2.0
9068	Follow-up visit including treatment: .......	1.2
SURGEON (excluding neurosurgeon)
Office Visits
9074	Complete diagnosis, history, physical examination, new patient or new illness .......	$12.00
9075	Routine visit, including treatment: .......	$7.20
Hospital Visits
9076	Initial visit .......	2.0
9077	Follow-up visit, including treatment .......	1.2
PHYSIATRIST
9082	Complete diagnosis, history, physical examination, new patient or new illness, office .......	$12.00
9083	Routine visit, including treatment, office .......	$7.20
9084	Initial visit, hospital .......	2.0
9085	Follow-up visit, including treatment, hospital .......	1.2
FAMILY PRACTITIONER
Office Visits
Comprehensive diagnostic history and physical examination-new patient or now illness
9660	Child up to and including 16 years .......	$12.00
9661	Persons over 16 years .......	$12.50
Routine Office Visit, including treatment
9662	Child up to and including 16 years .......	$7.20
9663	Persons over 16 years .......	$7.50
Home Visits
Comprehensive diagnostic history and physical examination-new patient or new illness
9666	Child up to and including 16 years .......	2.0
9667	Persons over 16 years .......	2.5
Routine home visit including treatment .......
9668	Child up to and including 16 years .......	1.8
9669	Persons over 16 years .......	2.0
9670	Each additional person at home .......	1.0
Hospital Visits
Initial Visit
9671	Child up to and including 16 years .......	2.0
9672	Persons over 16 years .......	2.5
Follow-up visit, including treatment
9673	Child up to and including 16 years .......	1.2
9674	Persons over 16 years .......	1.5
ORTHOPEDIST
Office Visits
9086	Complete diagnosis, physical examination, history, new patient or new illness .......	$12.00
9087	Routine visit, including treatment .......	$7.20
Home Visits
9088	Home visit, including treatment .......	1.8
Hospital Visits
9089	Initial visit .......	2.0
9090	Follow-up visit, including treatment .......	1.2
OBSTETRICIAN-GYNECOLOGIST
Office Visits
9091	Pelvic examination, breast examination, Pap smear exclusive of laboratory charge, or new illness .......	$12.00
9092	Follow-up visit .......	$7.20
Hospital Visits
9093	Initial visit .......	2.0
9094	Follow-up visit, including treatment .......	1.2
NEUROLOGIST AND NEUROSURGEON
Office Visits
Comprehensive diagnostic history, physical examination and treatment
9500	Up to 45 minutes .......	$15.00
9501	46 minutes to one hour .......	$20.00
9502	More than one hour .......	$25.00
9503	Follow-up visit, routine .......	$7.50
9504	Follow-up visit, prolonged (over 20 minutes) .......	$10.00
Home Visits
9505	Initial home visit, routine, new patient or new illness, history and examination .......	3.0
9506	Initial home visit, complete diagnostic history and physical examination, established patient, including initiation of diagnostic and treatment programs .......	4.0
9507	Initial home visit, complete diagnostic history and physical examination, new patient, including initiation of diagnostic and treatment programs .......	5.0
9508	Examination or evaluation, routine follow-up .......	2.0
Hospital Visits
9509	Initial hospital visit, brief history and physical examination, including initiation of diagnostic and treatment programs and preparation of hospital records .......	3.0
9510	Initial hospital visit, complete diagnostic history and physical examination, established patient, including initiation of diagnostic and treatment programs and preparation of hospital records .......	4.0
9511	Initial hospital visit, complete diagnostic history and physical examination, new patient, including initiation of diagnostic and treatment programs and preparation of hospital records .......	5.0
9512	Examination or evaluation, routine follow-up .......	1.5
CLINIC VISITS, SPECIALISTS
9026	One-hour session .......	4.0
9027	Two-hour session .......	7.0
9030	Three-hour session .......	10.0
9031	Each additional hour (per hour) .......	2.0
CHAP (Child Health Assurance Program)
The following composite fee codes for use in the Medicaid program, effective April 1, 1974, include: office visit, 9040; immunization, 9998; average cost of materials, L112; hemoglobin or hematocrit; and L557 urinalysis for CHAP when performed by a pediatrician, internist, obstetrician-gynecologist, general practitioner or other specialist.
9008P	Pediatrician .......	$21.20
9008B	Internist .......	$21.20
9008Y	Obstetrician-Gynecologist .......	$21.20
9008G	General Practitioner or other specialist .......	$21.20
No provider shall be paid such a composite fee more than once annually per patient.
In addition to the above composite fee codes, optional tests, when indicated and when performed in accordance with criteria outlined in Item 44 of the State Medical Handbook, are eligible for additional payment on a fee-for-service basis at fees established in applicable fee schedules; e.g., 9340-audiometric hearing screening, etc.
For completion of the Child Health Care Status Report, effective Sept. 27, 1974:
9008R	Child Health Care Status Report (once per patient per period of eligibility) .......	$5.00
PSYCHIATRIC TREATMENT
9050G	Psychotherapy, office, verbal, drug augmented or other methods, one hour (office) .......	$30.00
9051G	Comprehensive psychiatric examination with written report (office) .......	$30.00
9053G	Group (maximum eight persons per group) one and one half hours, per person (office) .......	$9.00
9050J	Psychotherapy, hospital or home, verbal, drug augmented or other methods, one hour .......	5.0
9051J	Comprehensive psychiatric examination with written report (other than office) .......	5.0
9053J	Group (maximum eight persons per group) one and one half hours, per person (other than office) .......	1.5
9055	Electroshock (per treatment),
subconvulsive .......	4.0
9056	convulsive .......	5.0
for anesthetist .......	3.0+T
9057	Insulin shock (per treatment),
subcoma .......	4.0
9058	coma .......	6.0
9059	Metrazol convulsive shock (per treatment) .......	5.0
9060	Psychometric testing (one hour) with written report .......	5.0
9061G	Initial routine office visit to include general history, physical and treatment .......	$12.00
9062G	Routine follow-up visit .......	$7.20
9061J	Initial routine visit to include general history, physical and treatment (other than office) .......	2.0
9062J	Routine follow-up visit (other than office) .......	1.2
9064	Inpatient care, prolonged (chronic case) .......	by report
FAMILY PLANNING VISITS
Office Visits
9160	Family planning visit, specialist in obstetrics-gynecology, initial visit .......	$12.00
9161	Follow-up visit .......	$7.20
9165	Family planning visit, nonspecialist, initial visit .......	$7.80
9166	Follow-up visit .......	$6.00
OTHER SERVICES
In calculating fees please refer to general instructions, rules 10, 11, 12
9035	Total newborn care in hospital provided by a physician other than a pediatrician, including physical examinations of the baby and discussions with the mother during the hospital stay (total fee for minimum 3-day stay) .......	3.0
9040	Immunization(s), per visit (plus cost of materials) .......	0.4
9049	Therapeutic injectable material used for each injection may be charged at acquisition cost rounded to the nearest one-dollar amount, (effective 3/15/78).
9070	Mileage, per mile, one way, beyond 10 mile radius of point of origin (office or home) .......	0.1
9071	Night emergency: additional fee for service rendered between hours of 10 p.m. and 8 a.m. .......	1.0
9072	Intensive care, minimum of one hour .......	5.0
9073	each additional half hour .......	2.5
9998	costs of materials .......	by report
SPECIFIC DIAGNOSTIC AND THERAPEUTIC PROCEDURES
Listed values may be added to other significant services rendered at the same visit. Values for items 9101 to 9227 include laboratory procedure(s), interpretation and physicians' services (except surgical and anesthesia services as listed in the section on Surgery), unless otherwise stated. For other similar services, see appropriate sections.
9101	Electrocardiogram with interpretation and report .......	3.0
9102	tracing only, without interpretation and report .......	1.5
9103	interpretation and report only .......	1.5
9104	with exercise test .......	5.0
9105	tracing only without interpretation and report .......	2.5
9105	interpretation and report only .......	2.5
9107	single lead (for rhythm) with interpretation .......	1.0
Continuous EKG Monitoring
(e.g., Holter Monitor)
9109	Up to 12 hours .......	9.0
9110	Over 12 to 16 hours .......	10.0
9111	Over 16 hours .......	12.0
9112	Phonocardiogram with interpretation and report .......	4.0
9113	with indirect carotid artery tracing or similar study .......	5.0
9115	Vectorcardiogram (VCG), with or without EKG, interpretation and report .......	5.0
9116	when part of other diagnostic studies .......	4.0
9120	Venous pressure determination .......	1.0
9121	Circulation time, per test (not to exceed 2.0 units) .......	1.0
(For radioisotope tests, see 7836.)
9128	Recording of direct arterial pressure tracings (independent procedure) .......	4.0
(Recording of intracardiac pressures with evaluation and interpretation included as part of items 2330-2335.)
9126	Cardiac output (Fick) (independent procedure) (excluding cardiac catheterization-see 2330-2335) .......	5.0
(For radioisotope methods, see 7835.)
9127	Dye dilution studies, indicator dye curves .......	1.0
9128	cardiac output, initial (independent procedure) .......	5.0
9129	subsequent, same study period, each (independent procedure) .......	2.5
(When dye dilution studies are part of right heart catheterization, maximum units allowed will be 18; when part of combined right and left heart catheterization, maximum units allowed will be 22.)
9140	Screening throat culture .......	0.75
9190	Peripheral vascular disease studies .......	by report
9192	Plethysmography .......	by report
9193	Temperature gradient studies .......	by report
9194	Thermogram .......	by report
NONSURGICAL OPERATING ROOM SERVICES
9195	Operation of pump with oxygenator or heart exchanger, per hour pump time .......	6.0
9196	Monitoring E.K.G., pressures, etc., in intrathoracic or other critical surgery, per hour .......	5.0
PULMONARY
9201	Spirometry, complete (respirometer) including graphic record, total and timed vital capacity and maximal breathing capacity, with written report .......	3.0
9203	Branchospirometry; expired gas analysis, (independent procedure) (for insertion of tube see 2126) .......	5.0
9206	Bronchospasm evaluation; spirometry as in 9201 before and after bronchodilator (aerosol or parenteral) .......	5.0
9215	Vital capacity, total .......	0.6
9216	total and timed .......	1.0
9220	Maximal breathing capacity .......	2.0
9221	Maximal expiratory flow rate measurement or equivalent (independent procedure) .......	1.0
9224	Residual air (helium method) including equilibration time, initial .......	3.0
9225	subsequent .......	2.0
9228	Residual air (open circuit method) including alveolar nitrogen, initial .......	6.0
9229	subsequent .......	4.0
9235	Nitrogen washout curve (continuous) .......	by report
9268	Oxygen uptake, expired gas analysis rest and exercise (direct) .......	5.0
9269	rest (indirect) .......	1.5
9272	Carbon monoxide diffusing capacity .......	by report
9275	Pulmonary compliance .......	by report
9277	Carbon dioxide, expired gas determination by infrared analyzer .......	by report
ALLERGY TESTING AND TREATMENT
The following values are based on the type and number of tests performed, and must include observation and interpretation of the tests by a physician. In routine office practice, the following items may be added to fee code items 9004 or 9009F.
9300	Scratch or puncture tests, up to 60 tests, per 10 tests (minimum-1.0 unit) .......	1.0
9301	in excess of first 60 tests, per 20 tests .......	1.0
9302	Intradermal tests, up to total of 60 tests, per 10 tests (minimum-1.0 unit) .......	1.5
9303	in excess of first 60 tests, per 20 tests .......	1.5
9304	Patch tests, each (minimum-1.0 unit) .......	0.2
9305	Direct opththalmic tests, each (minimum-1.0 unit) .......	0.4
9306	Direct nasal tests, each (minimum-1.0 unit) .......	0.4
9307	Passive transfer tests (including cost of recipient) per 10 tests (minimum-10.0 units) .......	3.0
9308	Maximum allowable for allergy testing; reserved for allergic conditions necessitating unusually extensive testing .......	22.0
9550	Antigens-treatment sets prepared by allergist for administration by or under the supervision of another physician; solutions of increasing concentration. e.g., ragweed, dust, feathers, four vials .......	4.0
9551	five vials .......	5.0
9552	one vial or one refill .......	2.0
9553	Injection(s) of antigens prepared by allergists for own patients allow maximum of 0.5 unit plus immunization fee (code 9040) .......	0.5
MISCELLANEOUS
9320	Skin test with bacterial, viral or fungal extracts (includes reading test), e.g., brucella, tuberculin, histoplasma, coccidioidin, Frel. etc. each .......	1.0
9321	Tine test, includes injection and reading .......	0.375
9323	Exclusion test for pheochromocytoma, e.g., regitine, benzodiozane, histamine, each .......	2.0
9330	Electroencephalogram, awake, asleep (natural or induced) and activation .......	7.0
9331	at surgery .......	by report
9332	Electroencephalogram, interpretation and report only .......	1.5
9333	Electroencephalogram, tracing only, without interpretation and report .......	5.0
9340	Audiometric hearing screening, pure tone (air only) .......	1.0
9341	air and bone, with or without masking .......	2.0
9342	Air, bone and speech audiometry (includes reception and discrimination tests) .......	3.0
9343	Vestibular function test .......	3.0
9350	Muscle testing, manual or electrical, with report, one extremity .......	1.5
9351	four extremities and trunk .......	4.0
9354	Range of motion measurements and report, two extremities .......	1.0
9358	Electromyography, one extremity and related areas of the back .......	7.0
9362	Nerve velocity determination, each nerve (independent procedure) .......	3.0
(For vision testing see 5400-5411.)
9400	Phlebotomy, therapeutic (independent procedure) .......	2.0
9404	Intermittent positive pressure treatment, initial or subsequent .......	0.6
9412	Chemotherapy for malignant disease .......	by report
9413	Perfusion for malignant disease .......	by report
9415	Desensitization, e.g., horse serum .......	by report
9417	Gastric lavage, treatment, e.g., ingested poisons, etc. .......	8v.
9420	Cardioversion .......	10.0
9420a	Cardioversion, anesthesia fee .......	3.0+T
Professional Dialysis Fees for Physician in Personal Attendance*
9405	Peritoneal dialysis (hospital) .......	15.0
9407	Patient's first hemodialysis .......	20.0
9408	See item 9405 above
9410	Home hemodialysis .......	3.0
(This fee is applicable when physican participates in a training session in the home. In all other other instances, the regular home visit fee will apply.)

Footnotes

* For corresponding surgical prodecures see codes 2590-2592.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 533.4