10-144-101 Me. Code R. § III-15
DEFINITIONS
CPT Codes: Current Procedural Terminology codes of medical procedures and services developed and published by the American Medical Association. Procedure codes and modifiers can be referenced on the American Medical Association's website at: http://www.ama-assn.org and the Centers for Medicare and Medicaid Services' website at: http://www.cms.hhs.gov.
Modifiers: A modifier is a two-character code added as a suffix to the procedure code. Use of a modifier indicates that a service has been altered by some specific circumstance, but there are no changes in its definition or code. The Department uses standard industry wide modifiers as identified in the American Medical Association's publication of Current Procedural Terminology and the Healthcare Common Procedure Coding System.
Pricing Modifiers:Radiology services are comprised of two parts, the professional component and the administrative and technical component. A provider may be reimbursed for supplying the professional component, the administrative and technical component, or both. When billing for the Professional component or the Administrative and Technical component, each of these radiology services must include an appropriate modifier in addition to the procedure code for payment. When billing for Total Professional, Administrative and Technical radiology services (global), modifiers TC and 26 shall be used when appropriate.
Evaluation and Management Codes : Evaluation and Management codes 99201-99215 are to be used for evaluations and management only. The rates are posted on the Physician Fee Schedule under MaineCare UCR at:
https://mainecare.maine.gov/Provider%20Fee%20Schedules/Forms/Publication.aspx?RootFolder=%2FProvider%20Fee%20Schedules%2FMaineCare%20UCR&FolderCTID=0x012000264D1FBA0C2BB247BF40A2C571600E81&View=%7B69CEE1D4%2DA5CC%2D4DAE%2D93B6%2D72A66DE366E0%7D
The Department is seeking and anticipates receiving CMS approval for this Section. Pending approval, the following rule will be applied.
FEE SCHEDULE
The following Fee Schedule represents the only procedure codes chiropractors may use to bill MaineCare. The member can be billed for any non-covered service only if the member has been informed that he/she is liable for payment for non-covered services. This must be done prior to the provision of services. Documentation of the prior notification must be included in the member's records.
ALLOWED AGE | PROC CODE | Modifier | DESCRIPTION | MAXIMUM ALLOWANCE | |
All Ages | 72020 | Radiologic Examination, Spine, Single View, Specify Level | $14.76 | ||
All Ages | 72020 | 26 | Radiologic Examination, Spine, Single View, Specify Level (Professional Component) | $5.26 | |
All Ages | 72020 | TC | Radiologic Examination, Spine, Single View, Specify Level (Technical Component) | $9.49 | |
All Ages | 72040 | Radiologic Examination, Spine, Cervical; Two or Three Views | $22.86 | ||
All Ages | 72040 | 26 | Radiologic Examination, Spine, Cervical; Two or Three Views (Professional Component) | $7.48 | |
All Ages | 72040 | TC | Radiologic Examination, Spine, Cervical; Two or Three Views (Technical Component) | $15.38 | |
All Ages | 72050 | Radiologic Examination, Spine, Cervical; Four or Five Views | $32.37 | ||
All Ages | 72050 | 26 | Radiologic Examination, Spine, Cervical; Four or Five Views (Professional Component) | $10.43 | |
All Ages | 72050 | TC | Radiologic Examination, Spine, Cervical; Four or Five Views (Technical Component) | $21.94 | |
All Ages | 72052 | Radiologic Examination, Spine, Cervical; Six or More Views | $40.52 | ||
All Ages | 72052 | 26 | Radiologic Examination, Spine, Cervical; Six or More Views (Professional Component) | $12.27 | |
All Ages | 72052 | TC | Radiologic Examination, Spine, Cervical; Six or More Views (Technical Component) | $28.25 | |
All Ages | 72070 | Radiologic Examination, Spine; Thoracic, Two Views | $21.06 | ||
All Ages | 72070 | 26 | Radiologic Examination, Spine; Thoracic, Two Views (Professional Component) | $7.48 | |
All Ages | 72070 | TC | Radiologic Examination, Spine; Thoracic, Two Views (Technical Component) | $13.57 | |
All Ages | 72072 | Radiologic Examination, Spine, Thoracic, Three Views | $23.88 | ||
All Ages | 72072 | 26 | Radiologic Examination, Spine, Thoracic, Three Views (Professional Component) | $7.48 | |
All Ages | 72072 | TC | Radiologic Examination, Spine, Thoracic, Three Views (Technical Component) | $16.40 | |
All Ages | 72074 | Radiologic Examination, Spine, Thoracic; Minimum of Four Views | $27.84 | ||
All Ages | 72074 | 26 | Radiologic Examination, Spine, Thoracic; Minimum of Four Views (Professional Component) | $7.48 | |
All Ages | 72074 | TC | Radiologic Examination, Spine, Thoracic; Minimum of Four Views (Technical Component) | $20.36 | |
All Ages | 72080 | Radiologic Examination, Spine, Thoracolumbar Junction, Minimum of Two Views | $21.96 | ||
All Ages | 72080 | 26 | Radiologic Examination, Spine, Thoracolumbar Junction, Minimum of Two Views (Professional Component) | $7.48 | |
All Ages | 72080 | TC | Radiologic Examination, Spine, Thoracolumbar Junction, Minimum of Two Views (Technical Component) | $14.48 | |
All Ages | 72081 | Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view | $25.40 | ||
All Ages | 72081 | 26 | Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); One view (Professional Component) | $9.14 | |
All Ages | 72081 | TC | Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); One View (Technical Component) | $16.27 | |
All Ages | 72082 | Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); Two or Three Views | $40.69 | ||
All Ages | 72082 | 26 | Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); Two or Three Views (Professional Component) | $11.08 | |
All Ages | 72082 | TC | Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); Two or Three Views (Technical Component) | $29.61 | |
All Ages | 72083 | Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); Four or Five Views | $44.23 | ||
All Ages | 72083 | 26 | Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); Four or Five Views (Professional Component) | $12.08 | |
All Ages | 72083 | TC | Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); Four or Five Views (Technical Component) | $32.14 | |
All Ages | 72084 | Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); Minimum of Six Views | $52.86 | ||
All Ages | 72084 | 26 | Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); Minimum of Six Views (Professional Component) | $14.05 | |
All Ages | 72084 | TC | Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); Minimum of Six Views (Technical Component) | $38.82 | |
All Ages | 72100 | Radiologic Examination, Spine; Lumbosacral; Two or Three Views | $23.99 | ||
All Ages | 72100 | 26 | Radiologic Examination, Spine; Lumbosacral; Two or Three Views (Professional Component) | $7.48 | |
All Ages | 72100 | TC | Radiologic Examination, Spine; Lumbosacral; Two or Three Views (Technical Component) | $16.51 | |
All Ages | 72110 | Radiologic Examination, Spine, Lumbosacral; Minimum of Four Views | $33.50 | ||
All Ages | 72110 | 26 | Radiologic Examination, Spine, Lumbosacral; Minimum of Four Views (Professional Component) | $10.43 | |
All Ages | 72110 | TC | Radiologic Examination, Spine, Lumbosacral; Minimum of Four Views (Technical Component) | $23.07 | |
All Ages | 72114 | Radiologic Examination, Spine, Lumbosacral; Complete, Including Bending Views, minimum of 6 views | $43.67 | ||
All Ages | 72114 | 26 | Radiologic Examination, Spine, Lumbosacral; Complete, Including Bending Views, minimum of 6 views (Professional Component) | $12.27 | |
All Ages | 72114 | TC | Radiologic Examination, Spine, Lumbosacral; Complete, Including Bending Views, minimum of 6 views (Technical Component) | $31.41 | |
All Ages | 72120 | Radiologic Examination, Spine; Lumbosacral; Bending Views Only, Two or Three Views | $29.87 | ||
All Ages | 72120 | 26 | Radiologic Examination, Spine; Lumbosacral; Bending Views Only, Two or Three Views (Professional Component) | $7.48 | |
All Ages | 72120 | TC | Radiologic Examination, Spine; Lumbosacral; Bending Views Only, Two or Three Views (Technical Component) | $22.39 | |
All Ages | 98940 | Chiropractic Manipulative Treatment (CMT); Spinal, One to Two Regions | $19.40 | ||
All Ages | 98941 | Chiropractic Manipulative Treatment (CMT); Spinal, Three to Four Regions | $19.40 | ||
All Ages | 98942 | Chiropractic Manipulative Treatment (CMT); Spinal, Five Regions | $24.23 |
10-144 C.M.R. ch. 101, § III-15
August 26, 2016 - filing 2016-140
4/12/2019 - filing 2019-061