MBC-F11 -------------- MBC-F11 contains twelve fields separated by tabs. If a field is null, the concept does not apply to the particular code. For example, Anesthesia codes do not have RVUs associated with them since these codes are not reimbursed under the Medicare Resource Based Relative Value System. Field 1 CPT CPT code (5 CHAR) Field 2 MOD Modifier (2 CHAR) Field 3 SDESCR 35-character CPT description (up to 35 characters) Field 4 MDESCR 100-character CPT description (up to 100 characters) Field 5 LDESCR Full CPT description (unlimited length) Field 6 FTOT Transitioned Facility Relative Value Unit total for Medicare billing (can be less than NTOT) Field 7 NTOT Transitioned Non-Facility Relative Value Unit total for Medicare billing Beginning in 2007, CMS used a bottom-up methodology for direct costs, use supplementary survey data for indirect costs, and eliminate the nonphysician workpool in order to calculate the practice expense RVUs. Field 8 STATUS Billing status code for Medicare billing purposes A = Active Code. These codes are paid separately under the physician fee schedule, if covered. There will be RVUs for codes with this status. The presence of an "A" indicator does not mean that Medicare has made a national coverage determination regarding the service; carriers remain responsible for coverage decisions in the absence of a national Medicare policy. B = Bundled Code. Payment for covered services are always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient). C = Carriers price the code. Carriers will establish RVUs and payment amounts for these services, generally on an individual case basis following review of documentation such as an operative report. D = Deleted Codes. These codes are deleted effective with the beginning of the applicable year. These codes will not appear on the 2006 file as the grace period for deleted codes is no longer applicable. E = Excluded from Physician Fee Schedule by regulation. These codes are for items and/or services that CMS chose to exclude from the fee schedule payment by regulation. No RVUs are shown, and no payment may be made under the fee schedule for these codes. Payment for them, when covered, generally continues under reasonable charge procedures. F = Deleted/Discontinued Codes. (Code not subject to a 90 day grace period). These codes will not appear on the 2006 file as the grace period for deleted codes is no longer applicable. G = Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. (Code subject to a 90 day grace period.) These codes will not appear on the 2006 file as the grace period for deleted codes is no longer applicable. H = Deleted Modifier. This code had an associated TC and/or 26 modifier in the previous year. For the current year, the TC or 26 component shown for the code has been deleted, and the deleted component is shown with a status code of "H". These codes will not appear on the 2006 file as the grace period for deleted codes is no longer applicable. I = Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. (Code NOT subject to a 90 day grace period.) J = Anesthesia Services. There are no RVUs and no payment amounts for these codes. The intent of this value is to facilitate the identification of anesthesia services. M = Measurement codes. Used for reporting purposes only. N = Non-covered Services. These services are not covered by Medicare. P = Bundled/Excluded Codes. There are no RVUs and no payment amounts for these services. No separate payment should be made for them under the fee schedule. --If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident. (An example is an elastic bandage furnished by a physician incident to physician service.) --If the item or service is covered as other than incident to a physician service, it is excluded from the fee schedule (i.e., colostomy supplies) and should be paid under the other payment provision of the Act. R = Restricted Coverage. Special coverage instructions apply. If covered, the service is carrier priced. (NOTE: The majority of codes to which this indicator will be assigned are the alpha-numeric dental codes, which begin with "D". We are assigning the indicator to a limited number of CPT codes which represent services that are covered only in unusual circumstances.) T = Injections. There are RVUS and payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made. (NOTE: This is a change from the previous definition, which states that injection services are bundled into any other services billed on the same date.) X = Statutory Exclusion. These codes represent an item or service that is not in the statutory definition of "physician services" for fee schedule payment purposes. No RVUS or payment amounts are shown for these codes, and no payment may be made under the physician fee schedule. (Examples are ambulance services and clinical diagnostic laboratory services.) Field 9 MALE Male only flag -- this flag is 1 for procedures that are performed on males only, otherwise it is 0. Field 10 FEMALE Female only flag -- this flag is 1 for procedures that are performed on females only, otherwise it is 0. Field 11 COMP Correct Coding Initiative comprehensive flag -- this flag is 1 if the code is comprehensive per CCI guidelines, otherwise it is 0. Field 12 MN Medical necessity flag -- this flag is 1 if the procedure appears in any local Medicare coverage decision, otherwise it is 0. CPT MOD SDESCR MDESCR LDESCR FTOT NTOT STATUS MALE FEMALE COMP MN 0001F HEART FAILURE COMPOSITE HRT FAILURE ASSESSED HEART FAILURE ASSESSED (INCLUDES ASSESSMENT OF ALL THE FOLLOWING COMPONENTS) (CAD, HF): BLOOD PRESSURE MEASURED (2000F) LEVEL OF ACTIVITY ASSESSED (1003F) CLINICAL SYMPTOMS OF VOLUME OVERLOAD (EXCESS) ASSESSED (1004F) WEIGHT, RECORDED (2001F) CLINICAL SIGNS OF VOLUME OVERLOAD (EXCESS) ASSESSED (2002F) 0 0 I 0 0 0 0 0005F OSTEOARTHRITIS COMPOSITE OSTEOARTHRITIS ASSESSED OSTEOARTHRITIS ASSESSED (OA) INCLUDES ASSESSMENT OF ALL THE FOLLOWING COMPONENTS: OSTEOARTHRITIS SYMPTOMS AND FUNCTIONAL STATUS ASSESSED (1006F) USE OF ANTI-INFLAMMATORY OR OVER-THE-COUNTER (OTC) ANALGESIC MEDICATIONS ASSESSED (1007F) INITIAL EXAMINATION OF THE INVOLVED JOINT(S) (INCLUDES VISUAL INSPECTION, PALPATION, RANGE OF MOTION) (2004F) 0 0 I 0 0 0 0 00100 ANESTH SALIVARY GLAND ANESTHESIA SALIVARY GLANDS WITH BIOPSY ANESTHESIA FOR PROCEDURES ON SALIVARY GLANDS, INCLUDING BIOPSY 0 0 J 0 0 1 1 00102 ANESTH REPAIR OF CLEFT LIP ANESTHESIA CLEFT LIP INVOLVING PLASTIC REPAIR ANESTHESIA FOR PROCEDURES INVOLVING PLASTIC REPAIR OF CLEFT LIP 0 0 J 0 0 1 1 00103 ANESTH BLEPHAROPLASTY ANESTHESIA EYELID RECONSTRUCTIVE PROCEDURE ANESTHESIA FOR RECONSTRUCTIVE PROCEDURES OF EYELID (EG, BLEPHAROPLASTY, PTOSIS SURGERY) 0 0 J 0 0 1 1 00104 ANESTH ELECTROSHOCK ANESTHESIA ELECTROCONVULSIVE THERAPY ANESTHESIA FOR ELECTROCONVULSIVE THERAPY 0 0 J 0 0 1 1 00120 ANESTH EAR SURGERY ANESTHESIA EXTERNAL MIDDLE & INNER EAR W/BIOPSY ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING BIOPSY; NOT OTHERWISE SPECIFIED 0 0 J 0 0 1 1 00124 ANESTH EAR EXAM ANES EXTERNAL MIDDLE & INNER EAR W/BX OTOSCOPY ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING BIOPSY; OTOSCOPY 0 0 J 0 0 1 1 00126 ANESTH TYMPANOTOMY ANES XTRNL MID & INNER EAR W/BX TYMPANOTOMY ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING BIOPSY; TYMPANOTOMY 0 0 J 0 0 1 1 0012F CAP BACTERIAL ASSESS COMMUNITY-ACQUIRED BACTERIAL PNEUMONIA ASSMT COMMUNITY-ACQUIRED BACTERIAL PNEUMONIA ASSESSMENT (INCLUDES ALL OF THE FOLLOWING COMPONENTS) (CAP): CO-MORBID CONDITIONS ASSESSED (1026F) VITAL SIGNS RECORDED (2010F) MENTAL STATUS ASSESSED (2014F) HYDRATION STATUS ASSESSED (2018F) 0 0 I 0 0 0 0 00140 ANESTH PROCEDURES ON EYE ANESTHESIA EYE NOT OTHERWISE SPECIFIED ANESTHESIA FOR PROCEDURES ON EYE; NOT OTHERWISE SPECIFIED 0 0 J 0 0 1 1 00142 ANESTH LENS SURGERY ANESTHESIA EYE LENS SURGERY ANESTHESIA FOR PROCEDURES ON EYE; LENS SURGERY 0 0 J 0 0 1 1 00144 ANESTH CORNEAL TRANSPLANT ANESTHESIA EYE CORNEAL TRANSPLANT ANESTHESIA FOR PROCEDURES ON EYE; CORNEAL TRANSPLANT 0 0 J 0 0 1 1 00145 ANESTH VITREORETINAL SURG ANESTHESIA EYE VITREORETINAL SURGERY ANESTHESIA FOR PROCEDURES ON EYE; VITREORETINAL SURGERY 0 0 J 0 0 1 1 00147 ANESTH IRIDECTOMY ANESTHESIA EYE IRIDECTOMY ANESTHESIA FOR PROCEDURES ON EYE; IRIDECTOMY 0 0 J 0 0 1 1 00148 ANESTH EYE EXAM ANESTHESIA EYE OPHTHALMOSCOPY ANESTHESIA FOR PROCEDURES ON EYE; OPHTHALMOSCOPY 0 0 J 0 0 1 1 0014F COMP PREOP ASSESS CAT SURG COMP PREOP ASSESS CATARACT SURG W/ IOL PLACEMNT COMPREHENSIVE PREOPERATIVE ASSESSMENT PERFORMED FOR CATARACT SURGERY WITH INTRAOCULAR LENS (IOL) PLACEMENT (INCLUDES ASSESSMENT OF ALL OF THE FOLLOWING COMPONENTS) (EC): DILATED FUNDUS EVALUATION PERFORMED WITHIN 12 MONTHS PRIOR TO CATARACT SURGERY (2020F) PRE-SURGICAL (CATARACT) AXIAL LENGTH, CORNEAL POWER MEASUREMENT AND METHOD OF INTRAOCULAR LENS POWER CALCULATION DOCUMENTED (MUST BE PERFORMED WITHIN 12 MONTHS PRIOR TO SURGERY) (3073F) PREOPERATIVE ASSESSMENT OF FUNCTIONAL OR MEDICAL INDICATION(S) FOR SURGERY PRIOR TO THE CATARACT SURGERY WITH INTRAOCULAR LENS PLACEMENT (MUST BE PERFORMED WITHIN 12 MONTHS PRIOR TO CATARACT SURGERY) (3325F) 0 0 I 0 0 0 0 0015F MELAN FOLLOW-UP COMPLETE MELANOMA FOLLOW UP COMPLETED MELANOMA FOLLOW UP COMPLETED (INCLUDES ASSESSMENT OF ALL OF THE FOLLOWING COMPONENTS) (ML): HISTORY OBTAINED REGARDING NEW OR CHANGING MOLES (1050F) COMPLETE PHYSICAL SKIN EXAM PERFORMED (2029F) PATIENT COUNSELED TO PERFORM A MONTHLY SELF SKIN EXAMINATION (5005F) 0 0 I 0 0 0 0