Washington State Department of Labor and Industries Ambulatory Surgery Center Fee Schedule Ambulatory Surgery Center Effective July 1, 2019 CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 1 CPT ® HCPCS Code Jul 2019 ASC Payment Amount Subject To Multiple Procedure Discounting 10004 Bundled NA 10005 $238.89 Y 10006 Bundled NA 10007 $543.17 Y 10008 Bundled NA 10009 $485.08 Y 10010 Bundled NA 10011 $485.08 Y 10012 Bundled NA 10021 Not covered NA 10030 $495.74 Y 10035 Not covered NA 10036 Not covered NA 10040 Bundled NA 10060 $225.30 Y 10061 $389.73 Y 10080 $343.12 Y 10081 $512.09 Y 10120 $293.27 Y 10121 $901.87 Y 10140 $312.69 Y 10160 $247.31 Y 10180 $1,765.57 Y 11000 $104.23 Y 11001 Bundled NA 11010 $495.74 Y 11011 $495.74 Y 11012 $1,765.57 Y 11042 $268.96 Y 11043 $422.49 Y 11044 $901.87 Y 11045 Bundled NA 11046 Bundled NA 11047 Bundled NA 11055 Bundled NA 11056 Bundled NA 11057 $126.24 Y 11102 $187.75 Y 11103 Bundled NA 11104 $147.74 Y 11105 Bundled NA 11106 $285.50 Y 11107 Bundled NA 11200 Bundled NA 11201 Bundled NA 11300 Bundled NA 11301 Bundled NA 11302 Bundled NA 11303 Bundled NA 11305 Bundled NA 11306 Bundled NA
107
Embed
2019 Ambulatory Surgery Center Fee Schedule · Washington State Department of Labor and Industries Ambulatory Surgery Center Fee Schedule Ambulatory Surgery Center Effective July
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 1
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 56
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
53442 $2,918.85 Y53444 $27,763.19 Y53445 $28,751.38 Y53446 $2,918.85 N53447 $28,129.74 Y53449 $2,918.85 Y53450 $1,295.12 Y53460 $2,918.85 Y53502 $2,003.24 Y53505 $2,918.85 Y53510 $2,918.85 Y53515 $2,918.85 Y53520 $2,918.85 Y53600 $157.97 Y53601 Bundled NA53605 $1,295.12 Y53620 $221.41 Y53621 $209.11 Y53660 $135.31 N53661 Bundled NA53665 $1,295.12 Y53850 Not covered NA53852 Not covered NA53854 $1,277.05 N53860 Not covered NA54000 Not covered NA54001 Not covered NA54015 $901.87 Y54050 Bundled NA54055 $229.18 Y54056 Bundled NA54057 $1,357.31 Y54060 $1,357.31 Y54065 $1,357.31 Y54100 $901.87 Y54105 $1,765.57 Y54110 Not covered NA54111 Not covered NA54112 Not covered NA54115 $1,765.57 Y54120 $2,918.85 Y54150 Not covered NA54160 Not covered NA54161 $1,295.12 Y54162 Not covered NA54163 Not covered NA54164 Not covered NA54200 Not covered NA54205 Not covered NA54220 $198.63 Y54230 Bundled NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 57
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
54231 $269.32 Y54235 $174.15 Y54240 $200.69 N54250 $229.18 Y54300 Not covered NA54304 Not covered NA54308 Not covered NA54312 Not covered NA54316 Not covered NA54318 Not covered NA54322 Not covered NA54324 Not covered NA54326 Not covered NA54328 Not covered NA54340 Not covered NA54344 Not covered NA54348 Not covered NA54352 Not covered NA54360 Not covered NA54380 Not covered NA54385 Not covered NA54400 $28,042.53 N54401 $28,954.84 N54405 $29,008.12 N54406 $2,003.24 N54408 $2,918.85 Y54410 $28,517.26 N54415 $2,003.24 N54416 $28,142.65 N54420 $1,295.12 Y54435 $1,295.12 Y54437 $1,295.12 Y54440 $2,918.85 Y54450 Not covered NA54500 $1,765.57 Y54505 $2,003.24 Y54512 $1,295.12 Y54520 $2,003.24 Y54522 $2,003.24 Y54530 $2,213.83 Y54550 Not covered NA54560 Not covered NA54600 $2,003.24 Y54620 Not covered NA54640 $2,213.83 Y54660 $5,448.05 Y54670 $1,295.12 Y54680 $1,295.12 Y54690 $3,483.90 Y54692 Not covered NA54700 $1,295.12 Y
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 58
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
54800 $901.87 Y54830 $1,295.12 Y54840 $1,295.12 Y54860 $1,295.12 Y54861 $2,003.24 Y54865 $2,003.24 Y54900 $1,295.12 Y54901 $2,003.24 Y55000 $226.59 Y55040 $2,213.83 Y55041 $2,213.83 Y55060 $1,295.12 Y55100 $901.87 Y55110 $1,295.12 Y55120 $1,295.12 Y55150 Not covered NA55175 $2,003.24 Y55180 $2,918.85 Y55200 Not covered NA55250 Not covered NA55300 Not covered NA55400 Not covered NA55500 $2,003.24 Y55520 $2,003.24 Y55530 $2,003.24 Y55535 $2,213.83 Y55540 $2,213.83 Y55550 $3,483.90 Y55600 $1,295.12 Y55680 Not covered NA55700 $1,295.12 Y55705 $1,295.12 Y55706 Not covered NA55720 $1,295.12 Y55725 $1,295.12 Y55860 Not covered NA55870 $334.71 Y55874 $2,918.85 Y55875 Not covered NA55876 Not covered NA55920 Not covered NA56405 $204.58 Y56420 $230.47 Y56440 Not covered NA56441 Not covered NA56442 Not covered NA56501 Not covered NA56515 Not covered NA56605 $154.08 Y56606 Bundled NA56620 Not covered NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 59
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
56625 Not covered NA56700 Not covered NA56740 Not covered NA56800 $1,863.92 Y56805 Not covered NA56810 $1,863.92 Y56820 $211.05 Y56821 $277.09 Y57000 $1,863.92 Y57010 $1,863.92 Y57020 $1,863.92 Y57022 $901.87 Y57023 $1,765.57 Y57061 Not covered NA57065 Not covered NA57100 $167.68 Y57105 $1,863.92 Y57130 Not covered NA57135 Not covered NA57150 Bundled NA57155 Not covered NA57156 Not covered NA57160 $143.08 Y57170 Not covered NA57180 $139.07 Y57200 $1,863.92 Y57210 $1,863.92 Y57220 $3,055.46 Y57230 $1,863.92 Y57240 $3,055.46 Y57250 $3,055.46 Y57260 $3,055.46 Y57265 $3,055.46 Y57267 Bundled NA57268 $1,863.92 Y57287 $1,863.92 N57288 $3,055.46 Y57289 $4,280.91 Y57291 Not covered NA57300 $1,863.92 Y57320 $3,055.46 Y57400 Not covered NA57410 $1,863.92 Y57415 $1,863.92 Y57420 $221.41 Y57421 $295.21 Y57426 $4,280.91 Y57452 $203.93 Y57454 $284.21 Y57455 $266.73 Y57456 $251.84 Y
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 60
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
57460 $530.87 Y57461 $600.14 Y57500 $240.83 Y57505 $192.93 Y57510 Not covered NA57511 Not covered NA57513 Not covered NA57520 Not covered NA57522 Not covered NA57530 Not covered NA57550 $1,863.92 Y57556 $3,055.46 Y57558 $1,863.92 Y57700 Not covered NA57720 $1,863.92 Y57800 $112.65 Y58100 $203.28 Y58110 Not covered NA58120 $1,863.92 Y58145 Not covered NA58301 Not covered NA58321 Not covered NA58322 Not covered NA58323 Not covered NA58340 Not covered NA58345 Not covered NA58346 Not covered NA58350 Not covered NA58353 Not covered NA58356 Not covered NA58545 Not covered NA58546 Not covered NA58550 $3,483.90 Y58552 $5,595.74 Y58555 $1,863.92 Y58558 $1,863.92 Y58559 $3,055.46 Y58560 Not covered NA58561 Not covered NA58562 $1,863.92 Y58563 Not covered NA58565 Not covered NA58600 Not covered NA58615 Not covered NA58660 $3,483.90 Y58661 Not covered NA58662 Not covered NA58670 Not covered NA58671 Not covered NA58672 Not covered NA58673 Not covered NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 61
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
58674 Not covered NA58800 Not covered NA58805 Not covered NA58820 Not covered NA58900 $1,863.92 Y58970 Not covered NA58974 Not covered NA58976 Not covered NA59000 $238.89 Y59001 $232.23 Y59012 $232.23 Y59015 $293.92 Y59020 $134.01 Y59025 $91.28 Y59070 $232.23 Y59072 $232.23 Y59076 $232.23 Y59100 Not covered NA59150 $3,483.90 Y59151 $3,483.90 Y59160 $1,863.92 Y59200 $136.60 Y59300 $365.78 Y59320 $1,863.92 Y59412 $1,863.92 Y59414 $1,863.92 Y59812 $1,863.92 Y59820 $1,863.92 Y59821 $1,863.92 Y59840 $1,863.92 Y59841 $1,863.92 Y59866 Not covered NA59870 Not covered NA59871 $1,863.92 N60000 Not covered NA60100 $212.99 Y60200 $3,483.90 Y60280 Not covered NA60281 Not covered NA60300 $224.65 Y61000 Not covered NA61001 Not covered NA61020 $581.70 Y61026 $470.24 Y61050 $211.76 Y61055 $211.76 Y61070 $470.24 Y61215 $3,377.49 Y61330 $1,581.85 Y61781 Bundled NA61782 Bundled NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 62
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 85
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
78805 $1,040.79 N78806 $1,040.79 N78807 $392.10 N78808 Bundled NA78811 Not covered NA78812 Not covered NA78813 Not covered NA78814 Not covered NA78815 $1,191.83 N78816 Not covered NA78999 $302.41 N79005 $258.96 N79101 $273.85 N79200 $253.13 N79300 $206.38 N79403 $365.78 N79440 $233.71 N79445 $206.38 N79999 $206.38 N90371 $111.96 N90375 $296.71 N90376 $296.34 N90385 Not covered NA90396 Not covered NA90476 Bundled NA90585 Not covered NA90632 Bundled NA90633 Not covered NA90634 Not covered NA90636 Bundled NA90647 Bundled NA90648 Bundled NA90672 Bundled NA90674 Bundled NA90675 $269.91 N90676 By Report N90680 Not covered NA90690 Not covered NA90691 Not covered NA90698 Bundled NA90700 Not covered NA90702 Not covered NA90707 Not covered NA90710 Not covered NA90713 Not covered NA90714 Not covered NA90715 Not covered NA90717 Bundled NA90733 Not covered NA90734 Not covered NA90749 Bundled NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 86
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
90756 Bundled NA91200 Not covered NA92071 Not covered NA93261 Not covered NA93355 Not covered NA93590 Not covered NA93591 Not covered NA93644 Not covered NA93895 Not covered NA95940 Not covered NA95941 Not covered NA99497 Not covered NA99498 Not covered NA0042T Not covered NA0100T Not covered NA0101T Not covered NA0102T Not covered NA0174T Not covered NA0175T Not covered NA0213T $581.70 Y0214T Bundled NA0215T Bundled NA0216T $581.70 Y0217T Bundled NA0218T Bundled NA0238T $22,551.20 Y0249T $1,892.29 Y0253T Not covered NA0313T Not covered NA0314T Not covered NA0315T Not covered NA0316T Not covered NA0335T Not covered NA0338T Not covered NA0339T Not covered NA0341T Not covered NA0342T Not covered NA0357T Not covered NA0376T Not covered NA0377T Not covered NA0379T Not covered NA0380T Not covered NA0394T Not covered NA0395T Not covered NA0402T Not covered NA0408T Not covered NA0409T Not covered NA0410T Not covered NA0411T Not covered NA0412T Not covered NA0413T Not covered NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 87
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
0414T Not covered NA0415T Not covered NA0416T Not covered NA0419T Not covered NA0420T Not covered NA0422T Not covered NA0437T Not covered NA0439T Bundled NA0440T Not covered NA0441T Not covered NA0442T Not covered NA0443T Bundled NA0444T Bundled NA0445T Bundled NA0446T Not covered NA0447T Not covered NA0448T Not covered NA0449T $2,944.19 Y0450T Bundled NA0471T Not covered NA0474T Not covered NA0479T Not covered NA0480T Not covered NA0482T Not covered NA0487T Not covered NA0491T Not covered NA0492T Not covered NA0493T Not covered NA0502T Not covered NA0503T Not covered NA0510T Not covered NA0511T Not covered NA0512T Not covered NA0513T Not covered NA0514T Bundled NA0523T Bundled NA0524T $2,122.91 Y0525T Not covered NA0526T Not covered NA0527T Not covered NA0530T Not covered NA0531T Not covered NA0532T Not covered NAA4218 Not covered NAA4220 Not covered NAA4248 Not covered NAA4262 Not covered NAA4263 Not covered NAA4270 Not covered NAA4300 Not covered NAA4301 Not covered NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 88
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
A4305 Not covered NAA4306 Not covered NAA4459 Not covered NAA4602 Not covered NAA4648 Not covered NAA4650 Not covered NAA7048 Not covered NAA9515 Not covered NAA9520 Bundled NAA9527 UR/BR NA9575 Bundled NAA9576 Bundled NAA9577 Bundled NAA9578 Bundled NAA9579 Bundled NAA9580 Bundled NAA9581 Bundled NAA9582 Not covered NAA9583 Bundled NAA9584 Bundled NAA9585 Bundled NAA9587 Not covered NAA9588 By Report NA9597 Not covered NAA9598 Not covered NAA9606 Not covered NAA9698 Bundled NAC1713 Bundled NAC1714 Bundled NAC1715 Bundled NAC1716 Not covered NAC1717 Not covered NAC1719 Not covered NAC1721 Bundled NAC1722 Bundled NAC1724 Bundled NAC1725 Bundled NAC1726 Bundled NAC1727 Bundled NAC1728 Bundled NAC1729 Bundled NAC1730 Bundled NAC1731 Bundled NAC1732 Bundled NAC1733 Bundled NAC1750 Bundled NAC1751 Bundled NAC1752 Bundled NAC1753 Bundled NAC1754 Bundled NAC1755 Bundled NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 89
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 90
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
C1885 Bundled NAC1887 Bundled NAC1888 Bundled NAC1889 Bundled NAC1891 Bundled NAC1892 Bundled NAC1893 Bundled NAC1894 Bundled NAC1895 Bundled NAC1896 Bundled NAC1897 Bundled NAC1898 Bundled NAC1899 Bundled NAC1900 Bundled NAC2613 Not covered NAC2614 Not covered NAC2615 Bundled NAC2616 UR/BR NC2617 Bundled NAC2618 Bundled NAC2619 Bundled NAC2620 Bundled NAC2621 Bundled NAC2622 Bundled NAC2624 Bundled NAC2625 Bundled NAC2626 Bundled NAC2627 Bundled NAC2628 Bundled NAC2629 Bundled NAC2630 Bundled NAC2631 Bundled NAC2634 Not covered NAC2635 Not covered NAC2636 Not covered NAC2638 Not covered NAC2639 Not covered NAC2640 Not covered NAC2641 Not covered NAC2642 Not covered NAC2643 Not covered NAC2698 Not covered NAC2699 Not covered NAC5271 Not covered NAC5272 Not covered NAC5273 Not covered NAC5274 Not covered NAC5275 Not covered NAC5276 Not covered NAC5277 Not covered NAC5278 Not covered NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 91
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
C8900 $218.72 NC8901 $212.22 NC8902 $394.94 NC8903 $218.72 NC8905 $394.94 NC8906 $394.94 NC8908 $394.94 NC8909 $218.72 NC8910 $212.22 NC8911 $394.94 NC8912 $394.94 NC8913 $212.22 NC8914 $394.94 NC8918 $218.72 NC8919 $212.22 NC8920 $394.94 NC9014 Not covered NAC9015 Not covered NAC9016 Not covered NAC9024 By Report NC9028 By Report NC9029 By Report NC9035 Not covered NAC9036 Not covered NAC9037 Not covered NAC9038 Not covered NAC9039 $37.80 NC9113 Bundled NAC9248 Bundled NAC9254 Bundled NAC9275 Not covered NAC9293 $344.56 NC9352 Bundled NAC9353 Bundled NAC9399 UR/BR NAC9407 Not covered NAC9447 Bundled NAC9460 By Report NC9488 $29.93 NC9492 Not Covered NAC9493 Not covered NAC9497 By Report NC9716 Not covered NAC9725 Not covered NAC9726 Not covered NAC9727 $984.97 YC9738 Bundled NAC9745 $6,448.39 YC9746 $24,185.08 YC9747 $11,544.96 YC9752 Not covered NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 92
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
C9754 $6,596.12 NC9755 $6,596.12 NE0616 Not covered NAE0749 Not covered NAE0782 Not covered NAE0783 Not covered NAE0785 Not covered NAE0786 Not covered NAG0104 $323.70 YG0105 $614.42 YG0121 $614.42 YG0127 Not covered NAG0130 $66.68 NG0186 $422.30 YG0247 Not covered NAG0259 Not covered NAG0260 $470.24 YG0268 Not covered NAG0269 Not covered NAG0276 Not covered NAG0288 Not covered NAG0289 Not covered NAG0339 Not covered NAG0340 Not covered NAG0453 Not covered NAG0458 Not covered NAG0464 Not covered NAG0472 Not covered NAG0516 Bundled NAG0517 Bundled NAG0518 Bundled NAJ0120 Not covered NAJ0129 $50.16 NJ0130 Bundled NAJ0131 Bundled NAJ0132 Bundled NAJ0133 Bundled NAJ0135 Not covered NAJ0153 Bundled NAJ0171 Bundled NAJ0178 Not covered NAJ0180 $172.19 NJ0185 $2.68 NJ0190 Not covered NAJ0200 Not covered NAJ0202 Not covered NAJ0205 Not covered NAJ0207 $948.18 NJ0210 Bundled NAJ0215 Not covered NAJ0220 Not covered NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 93
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
J0256 $4.45 NJ0278 Not covered NAJ0280 Bundled NAJ0282 Bundled NAJ0285 Bundled NAJ0287 $17.35 NJ0288 Not covered NAJ0289 $48.07 NJ0290 Bundled NAJ0295 Bundled NAJ0300 $219.91 NJ0330 Bundled NAJ0348 Bundled NAJ0360 Bundled NAJ0364 Not covered NAJ0365 Not covered NAJ0380 Not covered NAJ0390 Not covered NAJ0400 $0.70 NJ0401 $5.01 NJ0456 Bundled NAJ0461 Bundled NAJ0470 $50.91 N J0475 $178.38 NJ0476 $45.98 NJ0480 $3,550.39 NJ0485 $3.89 NJ0500 Bundled NAJ0515 Bundled NAJ0517 $190.08 NJ0520 Not covered NAJ0558 Bundled NAJ0561 $12.84 NJ0565 By Report NJ0567 Not covered NAJ0570 $1,229.98 NJ0583 Not covered NAJ0584 Not covered NAJ0585 $6.15 NJ0586 $8.23 NJ0587 $11.99 NJ0588 $5.08 NJ0592 Bundled NAJ0594 $27.95 NJ0595 Bundled NAJ0596 Not covered NAJ0597 Not covered NAJ0599 Not covered NAJ0600 $5,594.42 NJ0606 By Report NJ0610 Bundled NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 94
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
J0620 Not covered NAJ0630 $2,461.06 NJ0636 Not covered NAJ0637 $15.51 NJ0638 Not covered NAJ0640 Bundled NAJ0641 $0.36 NJ0670 Bundled NAJ0690 Bundled NAJ0692 Bundled NAJ0694 Bundled NAJ0695 $4.48 NJ0696 Bundled NAJ0697 Bundled NAJ0698 Bundled NAJ0702 Bundled NAJ0706 Not covered NAJ0710 Not covered NAJ0712 $2.62 NJ0713 Bundled NAJ0714 $78.64 NJ0715 Not covered NAJ0716 $5,305.50 NJ0717 Not covered NAJ0720 Bundled NAJ0725 Bundled NAJ0735 Bundled NAJ0740 $493.46 NJ0743 Bundled NAJ0744 Bundled NAJ0745 Not covered NAJ0770 Bundled NAJ0775 Not covered NAJ0780 Bundled NAJ0795 Not covered NAJ0800 $3,754.07 NJ0833 Bundled NAJ0834 Bundled NAJ0840 $3,086.28 NJ0841 Not covered NAJ0850 $1,129.12 NJ0875 $14.73 NJ0878 $0.42 NJ0881 $3.78 NJ0883 $45.60 NJ0884 $45.60 NJ0885 $13.00 NJ0888 $1.90 NJ0894 $16.42 NJ0895 Bundled NAJ0897 $17.94 N
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 95
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
J0945 Not covered NAJ1000 Not covered NAJ1020 Bundled NAJ1030 Bundled NAJ1040 Bundled NAJ1050 Bundled NAJ1071 Bundled NAJ1094 Not covered NAJ1100 Bundled NAJ1110 $83.35 NJ1120 Bundled NAJ1160 Bundled NAJ1162 $3,513.19 NJ1165 Bundled NAJ1170 Bundled NAJ1180 Not covered NAJ1190 $243.13 NJ1200 Bundled NAJ1205 Bundled NAJ1212 $549.34 NJ1230 Bundled NAJ1240 Bundled NAJ1245 Bundled NAJ1250 Bundled NAJ1260 Bundled NAJ1265 Bundled NAJ1267 Bundled NAJ1270 Not covered NAJ1290 Not covered NAJ1300 Not covered NAJ1301 Not covered NAJ1320 Not covered NAJ1322 Not covered NAJ1324 Not covered NAJ1325 Bundled NAJ1327 $31.29 NJ1330 Not covered NAJ1335 Bundled NAJ1364 $72.36 NJ1380 Not covered NAJ1410 Not covered NAJ1428 Not covered NAJ1430 Not covered NAJ1435 Not covered NAJ1436 Not covered NAJ1438 $521.34 NJ1439 $1.05 NJ1442 $1.02 NJ1447 $0.61 N J1450 Bundled NAJ1451 $11.33 N
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 96
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
J1453 $2.10 NJ1454 $612.00 NJ1455 $15.00 NJ1457 Not covered NAJ1458 Not covered NAJ1459 $39.65 NJ1460 $38.79 NJ1555 By Report NJ1556 Not covered NAJ1559 Not covered NAJ1560 $387.93 NJ1561 $39.15 NJ1562 Not covered NAJ1566 $35.53 NJ1568 $41.41 NJ1569 $39.69 NJ1570 Bundled NAJ1571 $62.21 NJ1572 $35.15 NJ1573 $69.12 NJ1575 Not covered NAJ1580 Bundled NAJ1595 Not covered NAJ1599 Bundled NAJ1600 Not covered NAJ1602 $24.04 NJ1610 $211.73 NJ1620 Not covered NAJ1626 Bundled NAJ1627 $4.34 NJ1628 $1,219.00 NJ1630 Bundled NAJ1631 Bundled NAJ1640 $22.36 NJ1642 Bundled NAJ1644 Bundled NAJ1645 Bundled NAJ1650 Bundled NAJ1652 Bundled NAJ1655 Not covered NAJ1670 $451.51 NJ1700 Not covered NAJ1710 Not covered NAJ1720 Bundled NAJ1726 Not covered NAJ1729 Not covered NAJ1730 Not covered NAJ1740 $74.24 NJ1741 Bundled NAJ1742 $321.30 NJ1743 Not covered NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 97
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
J1744 Not covered NAJ1745 $83.29 NJ1746 $101.20 NJ1756 Bundled NAJ1786 $41.58 NJ1790 Bundled NAJ1800 Bundled NAJ1815 Bundled NAJ1817 Bundled NAJ1830 $346.17 NJ1833 $0.96 NJ1835 Not covered NAJ1840 Not covered NAJ1850 Not covered NAJ1885 Bundled NAJ1890 Not covered NAJ1930 Not covered NAJ1931 $30.61 NJ1940 Bundled NAJ1942 $2.43 NJ1945 Not covered NAJ1950 $1,089.22 NJ1953 Not covered NAJ1956 Bundled NAJ1960 Not covered NAJ1980 Bundled NAJ1990 Not covered NAJ2001 Bundled NAJ2010 Bundled NAJ2020 Bundled NAJ2060 Bundled NAJ2062 $18.00 NJ2150 Bundled NAJ2170 Not covered NAJ2175 Bundled NAJ2180 Not covered NAJ2182 $15.00 NJ2185 Bundled NAJ2210 Not covered NAJ2212 Bundled NAJ2248 Bundled NAJ2250 Bundled NAJ2260 Bundled NAJ2270 Bundled NAJ2274 Not covered NAJ2278 $7.44 NJ2280 Bundled NAJ2300 Bundled NAJ2310 Bundled NAJ2315 $3.26 NJ2320 Not covered NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 98
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
J2323 Not covered NAJ2325 Not covered NAJ2326 Not covered NAJ2350 Not covered NAJ2353 $190.68 NJ2354 Bundled NAJ2355 $467.22 NJ2357 $36.38 NJ2358 Bundled NAJ2360 Bundled NAJ2370 Bundled NAJ2400 Bundled NAJ2405 Bundled NAJ2407 $23.49 NJ2410 Bundled NAJ2425 Not covered NAJ2426 $10.38 NJ2430 Bundled NAJ2440 Bundled NAJ2469 $20.02 NJ2501 Bundled NAJ2502 $246.17 NJ2503 Not covered NAJ2504 Not covered NAJ2505 Not covered NAJ2510 Bundled NAJ2513 Not covered NAJ2515 Not covered NAJ2540 Bundled NAJ2543 Bundled NAJ2547 $0.10 NJ2550 Bundled NAJ2560 Bundled NAJ2562 $314.44 NJ2590 Not covered NAJ2597 $13.02 NJ2650 Not covered NAJ2670 Not covered NAJ2675 Not covered NAJ2680 Bundled NAJ2690 Bundled NAJ2700 Bundled NAJ2704 Bundled NAJ2710 Bundled NAJ2720 Bundled NAJ2724 $15.20 NJ2725 Not covered NAJ2730 Bundled NAJ2760 $255.00 NJ2765 Not covered NAJ2770 $419.20 N
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 99
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
J2778 Not covered NAJ2780 Bundled NAJ2783 Not covered NAJ2785 Bundled NAJ2786 $0.84 NJ2788 Bundled NAJ2790 Bundled NAJ2791 Bundled NAJ2792 $24.31 NJ2794 $8.98 NJ2795 Bundled NAJ2796 $68.50 NJ2797 By Report NJ2800 Bundled NAJ2805 Not covered NAJ2810 Bundled NAJ2820 $37.48 NJ2840 Not covered NAJ2850 Not covered NAJ2860 Not covered NAJ2910 Not covered NAJ2916 Bundled NAJ2920 Bundled NAJ2930 Bundled NAJ2941 Not covered NAJ2950 Not covered NAJ2993 Not covered NAJ2995 Not covered NAJ2997 $84.58 NJ3000 Bundled NAJ3010 Bundled NAJ3030 Bundled NAJ3060 Not covered NAJ3070 $108.39 NJ3090 $1.38 NJ3095 $5.39 NJ3101 $111.63 NJ3105 Bundled NAJ3121 Bundled NAJ3145 $0.54 N J3230 Bundled NAJ3240 $1,598.00 NJ3243 $2.63 NJ3246 $11.18 NJ3250 Bundled NAJ3260 Bundled NAJ3262 $4.54 NJ3265 Bundled NAJ3280 Not covered NAJ3285 Not covered NAJ3300 $3.87 N
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 100
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
J3301 Bundled NAJ3302 Not covered NAJ3303 Bundled NAJ3304 $18.88 NJ3310 Not covered NAJ3315 Not covered NAJ3316 Not covered NAJ3320 Not covered NAJ3350 Not covered NAJ3355 Not covered NAJ3357 $184.94 NJ3358 By Report NJ3360 Bundled NAJ3364 Not covered NAJ3365 Not covered NAJ3370 Bundled NAJ3380 $19.13 NJ3385 Not covered NAJ3396 Not covered NAJ3397 Not covered NAJ3398 Not covered NAJ3400 Not covered NAJ3410 Bundled NAJ3411 Bundled NAJ3415 Bundled NAJ3420 Bundled NAJ3430 Bundled NAJ3465 $2.10 NJ3470 Bundled NAJ3471 Bundled NAJ3472 Bundled NAJ3473 Bundled NAJ3475 Bundled NAJ3480 Bundled NAJ3485 Bundled NAJ3486 Bundled NAJ3489 Bundled NAJ3490 Bundled NAJ3530 Not covered NAJ3590 Bundled NAJ7030 Bundled NAJ7040 Bundled NAJ7042 Bundled NAJ7050 Bundled NAJ7060 Bundled NAJ7070 Bundled NAJ7100 Bundled NAJ7110 Not covered NAJ7120 Bundled NAJ7131 Bundled NAJ7170 Not covered NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 101
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
J7175 $9.86 NJ7177 Not covered NAJ7178 $0.93 NJ7179 $3.50 NJ7181 $18.29 NJ7185 $1.25 NJ7186 $0.99 NJ7187 $1.13 NJ7188 $12.20 NJ7189 $2.06 NJ7190 $1.04 NJ7191 Not covered NAJ7192 $1.28 NJ7193 $1.13 NJ7194 $1.40 NJ7195 $1.50 NJ7196 Not covered NAJ7197 $3.59 NJ7198 $1.99 NJ7200 $1.31 NJ7201 $3.03 NJ7202 $6.34 NJ7203 Not covered NAJ7205 $2.05 NJ7207 By Report NJ7209 By Report NJ7210 By Report NJ7211 By Report NJ7308 Not covered NAJ7309 Not covered NAJ7310 Not covered NAJ7311 $20,166.50 NJ7312 $200.36 NJ7313 $490.28 NJ7315 Bundled NAJ7316 Not covered NAJ7318 $6.50 NJ7321 $88.65 NJ7322 $7.26 NJ7323 $149.92 NJ7324 $149.40 NJ7325 $12.08 NJ7326 $527.87 NJ7327 $812.55 NJ7336 $3.15 NJ7340 By Report NJ7342 Not covered NAJ7345 Not covered NAJ7500 Bundled NAJ7501 Not covered NAJ7502 Bundled NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 102
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
J7504 $1,937.64 NJ7505 Not covered NAJ7507 Bundled NAJ7508 Bundled NAJ7509 Bundled NAJ7510 Bundled NAJ7511 $713.84 NJ7513 Not covered NAJ7515 Bundled NAJ7516 Bundled NAJ7517 Bundled NAJ7518 Not covered NAJ7520 Bundled NAJ7525 $192.81 NJ7527 Bundled NAJ7599 Bundled NAJ7674 Bundled NAJ7799 Bundled NAJ8501 Not covered NAJ8510 Bundled NAJ8520 Bundled NAJ8521 Bundled NAJ8530 Bundled NAJ8540 Bundled NAJ8560 $74.66 NJ8562 Not covered NAJ8597 Bundled NAJ8600 Bundled NAJ8610 Bundled NAJ8655 $366.82 NJ8670 $2.27 NJ8700 Bundled NAJ8705 $103.73 NJ9000 Bundled NAJ9015 $2,342.00 NJ9017 $71.82 NJ9019 $409.06 NJ9020 Not covered NAJ9022 By Report NJ9023 Not covered NAJ9025 Not covered NAJ9027 Not covered NAJ9031 $137.67 NJ9032 $36.27 NJ9033 $30.21 NJ9034 $23.75 NJ9035 $77.17 NJ9039 $107.47 NJ9040 Bundled NAJ9041 $46.66 NJ9042 Not covered NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 103
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
J9044 Not covered NAJ9045 Bundled NAJ9047 $34.11 NJ9050 $3,854.59 NJ9055 Not covered NAJ9057 Not covered NAJ9060 Bundled NAJ9065 $22.62 NJ9070 Not covered NAJ9098 $628.37 NJ9100 Bundled NAJ9120 $1,580.57 NJ9130 Bundled NAJ9145 $50.39 NJ9150 $41.58 NJ9151 Not covered NAJ9153 Not covered NAJ9160 Not covered NAJ9171 $1.66 NJ9173 Not covered NAJ9175 Not covered NAJ9176 $6.35 NJ9178 Bundled NAJ9179 $111.28 NJ9181 Bundled NAJ9185 $76.62 N J9190 Bundled NAJ9200 Bundled NAJ9201 Bundled NAJ9202 $397.59 NJ9203 By Report NJ9205 $42.59 NJ9206 Bundled NAJ9207 $72.11 NJ9208 Bundled NAJ9209 Bundled NAJ9211 $34.28 NJ9212 Bundled NAJ9213 Not covered NAJ9214 $31.09 NJ9215 Not covered NAJ9216 $1,342.37 NJ9217 $209.30 NJ9218 $25.79 NJ9219 Not covered NAJ9225 Not covered NAJ9226 Not covered NAJ9229 Not covered NAJ9230 $292.48 NJ9245 $1,117.99 NJ9250 Bundled NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 104
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
J9260 Bundled NAJ9261 $151.90 NJ9262 Not covered NAJ9263 Bundled NAJ9264 $11.12 NJ9266 $14,977.05 NJ9267 Bundled NAJ9268 $2,066.03 NJ9270 Not covered NAJ9271 $48.71 NJ9280 $140.08 NJ9285 Not covered NAJ9293 $32.14 NJ9295 $5.36 NJ9299 Not covered NAJ9301 Not covered NAJ9302 $56.59 NJ9303 Not covered NAJ9305 $66.17 NJ9306 $11.51 NJ9307 $262.32 NJ9308 $56.93 NJ9310 $883.68 NJ9311 Not covered NAJ9312 $112.74 NJ9315 Not covered NAJ9320 $342.79 NJ9325 By Report NJ9328 $9.48 NJ9330 $71.69 NJ9340 $1,080.00 NJ9351 Bundled NAJ9352 By Report NJ9354 Not covered NAJ9355 $101.05 NJ9357 Not covered NAJ9360 Bundled NAJ9370 Bundled NAJ9371 $2,807.15 NJ9390 Bundled NAJ9395 Not covered NAJ9400 $8.12 NJ9600 $12,256.00 NJ9999 Bundled NAL8600 Bundled NAL8603 Bundled NAL8604 Bundled NAL8606 Bundled NAL8609 Not covered NAL8610 Bundled NAL8612 Bundled NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 105
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 106
CPT ®
HCPCS Code
Jul 2019 ASC Payment Amount
Subject To Multiple
Procedure Discounting
Q4114 Bundled NAQ4118 Not covered NAQ4121 Not covered NAQ4131 Not covered NAQ4132 Not covered NAQ4133 Not covered NAQ4137 Not covered NAQ4138 Not covered NAQ4139 Not covered NAQ4140 Not covered NAQ4141 Not covered NAQ4142 Not covered NAQ4143 Not covered NAQ4145 Not covered NAQ4146 Not covered NAQ4147 Not covered NAQ4148 Not covered NAQ4149 Not covered NAQ4150 Not covered NAQ4151 Not covered NAQ4152 Not covered NAQ4153 Not covered NAQ4154 Not covered NAQ4155 Not covered NAQ4156 Not covered NAQ4157 Not covered NAQ4158 Not covered NAQ4159 Not covered NAQ4160 Not covered NAQ4166 Not covered NAQ4167 Not covered NAQ4168 Not covered NAQ4169 Not covered NAQ4170 Not covered NAQ4171 Not covered NAQ4173 Not covered NAQ4174 Not covered NAQ4175 Not covered NAQ4176 Not covered NAQ4177 Not covered NAQ4178 Not covered NAQ4179 Not covered NAQ4180 Not covered NAQ4181 Not covered NAQ4182 Not covered NAQ9950 Bundled NAQ9951 Bundled NAQ9953 Bundled NAQ9954 Bundled NAQ9955 Bundled NAQ9956 Bundled NA
Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule
Ambulatory Surgery CenterEffective July 1, 2019
CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions Page 107