CurrentAlaska MedicaidPolicy N/A

Physician Services — Anesthesia Base Rates and Procedure Fee Schedule

Governs calculation and published base rates for anesthesia services under Alaska Medicaid, describes base and time components and lists per-procedure payment and authorization indicators for covered CPT anesthesia and related procedure codes.

Policy Summary

PayerAlaska Medicaid

PolicyPhysician Services — Anesthesia Base Rates and Procedure Fee Schedule

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain and document medical justification or required Comagine/fiscal agent authorization for codes flagged as requiring prior authorization before submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$42.90Anesthesia base unit conversion

$3.60Anesthesia time conversion

$297.30Example base rate (00100)

$7,997.49Highest sample max allowable

multipleLines with authorization flags

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Billing Criteria

Fee schedule — wrist/forearm procedures

Fee schedule entries for wrist and forearm procedures. Listed entries show CPT code, brief description (OMK), authorization flags (Requires Medical Justification, Requires Comagine Authorization, Requires Fiscal Agent Authorization), NDC or Maximum Allowable when specified, and Billing Notes when present.

25136 — REMOVE & GRAFT WRIST LESION. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $842.77. Billing Notes = .

25145 — REMOVE FOREARM BONE LESION. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $883.07. Billing Notes = .

25150 — Partial removal of ulna. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $965.70. Billing Notes = .

25151 — Partial removal of radius. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $995.88. Billing Notes = .

25170 — RESECT RADIUS/ULNAR TUMOR. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $2,495.55. Billing Notes = .

25210 — Removal of wrist bone. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $837.98. Billing Notes = .

25215 — REMOVAL OF WRIST BONES. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $1,055.57. Billing Notes = .

25230 — PARTIAL REMOVAL OF RADIUS. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $737.68. Billing Notes = .

25240 — Partial removal of ulna. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $732.09. Billing Notes = .

25246 — INJECTION FOR WRIST X-RAY. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $302.31. Billing Notes = .

25248 — REMOVE FOREARM FOREIGN BODY. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $707.35. Billing Notes = .

25250 — Removal of wrist prosthesis. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $905.12. Billing Notes = .

25251 — Removal of wrist prosthesis. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $1,222.20. Billing Notes = .

25259 — MANIPULATE WRIST W/ANESTHES. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $701.15. Billing Notes = .

25260 — Repair forearm tendon/muscle. Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = $1,077.90. Billing Notes = .

25263 — Repair (entry truncated in source). Requires Medical Justification = . Requires Comagine Authorization = . Requires Fiscal Agent Authorization = . NDC = . Maximum Allowable = (see full fee schedule). Billing Notes = .

Source shows the list continues; clinicians should reference the full fee schedule for complete entries and amounts.

CPT / Fee Schedule & Anesthesia Rate Coding

Sample anesthesia base unit/value listingsCPTCovered

00100	ANESTH SALIVARY GLAND — Base Units 5; Per Unit $42.90; Base Value $214.50
00102	ANESTH REPAIR OF CLEFT LIP — Base Units 6; Per Unit $42.90; Base Value $257.40
00210	ANESTH CRANIAL SURG NOS — Base Units 11; Per Unit $42.90; Base Value $471.90

Anesthesia procedure base rates (examples)CPTCovered

01230	ANESTH SURGERY OF FEMUR; Base Units 6; Per Unit $42.90; Base Value $257.40
01234	ANESTH RADICAL FEMUR SURG.; Base Units 8; Per Unit $42.90; Base Value $343.20
01440	ANESTH KNEE ARTERIES SURG.; (example in brief) — minutes/value shown; Base Value $343.20
01634	ANESTH SHOULDER JOINT AMPUT.; Base Units 9; Per Unit $42.90; Base Value $386.10

Procedure codes with specified NDC reimbursementCPT

10004	FNA BX W/O IMG GDN EA ADDL; NDC $90.50
10005	FNA BX W/US GDN 1ST LES; NDC $219.18
10007	FNA BX W/FLUOR GDN 1ST LES; NDC $473.57

CPT procedural fee schedule entries (partial)CPTCovered

10005-11621 (selected CPT range shown across chunks)

Multiple CPT procedure codes for biopsies, incisions/drainage, debridement, excisions, skin lesion removals and related procedures are listed with descriptors and fee/authorization fields in this excerpt.

Selected CPTs and payments (partial list)CPTCovered

11471	CPT in segment; payment and billing notes present
11600	CPT in segment; OMK descriptors and Maximum Allowable listed
11621	Repeated entry with OMK 'EXC S/N/H/F/G MAL+MRG 0.6-1' and Maximum Allowable $370.26
11772	Remove pilonidal cyst complex — Maximum Allowable $1,234.34
11901	Inject skin lesions >7 — Maximum Allowable $116.27

Procedure code ranges presentCPTCovered

11740-11765	Nail procedures (excision, biopsy, repair, reconstruction, excision of nail fold)
11900-11920	Injection of skin lesions; tissue expander insertion and related procedures
12001-12020	Repair and reconstruction codes (skin/nail/trunk/limb wound repair ranges)

listed procedure codes and descriptionsCPT | mixedCovered

15116-16025 (range shown across chunks)

Procedure codes and associated descriptors/OMK entries covering grafts, flaps, debridement, dermabrasion, excisions, and burn treatment

microvascular/free flap codesCPTCovered

15756-15758

free flap / microvascular procedures with high NDC amounts

Selected surgical/anesthesia codesCPTCovered

15946	Procedure entry with Maximum Allowable $2,718.02
15950	Procedure entry with Maximum Allowable $1,066.55
15951	Procedure entry with Maximum Allowable $1,505.90

Dermatology / breast procedure examplesCPTCovered

17340	Cryotherapy for acne - shows Comagine authorization flagged and two fee values ($90.55 $205.49)
19368	Breast reconstruction 2 pedicle TRAM flap - Maximum Allowable $3,699.38

sample CPT entries with payment amounts and flagsCPT | mixedCovered

19350	Nipple/areola reconstruction; NDC $1,365.95; Requires Medical Justificatio = X
19367	Breast reconstruction TRAM flap; NDC $3,013.60; Requires Medical Justificatio = X
20705	I-artic RX device insertion/removal; NDC $4,661.61
20808	Replantation hand complete; NDC $6,699.39
20969	Bone/skin graft microvascular; Maximum Allowable $4,687.36

sample surgical/prosthetic codes and feesCPTCovered

20969	BONE/SKIN GRAFT MICROVASC. — Maximum Allowable $4,687.36
21215	LOWER JAW BONE GRAFT — Maximum Allowable $6,061.57
21082	IMPRES&PREP PALTL AUG PROSTH — Maximum Allowable $2,505.06 (Fiscal Agent Authorization = X)

Selected facial/craniofacial CPTs shownCPTCovered

21263	Facial/craniofacial procedure entry with associated rate
21267	Revise eye sockets / OMK indicated
21270	Augmentation cheek bone

Orbit/orbital CPTs shownCPTCovered

21400	Closed treatment orbit without manipulation
21406	Open treatment orbit fracture without implant
21408	Open treatment orbit fracture with bone graft

Thoracic CPTs shownCPTCovered

21601	Excision chest wall tumor with ribs
21602	Excision chest wall tumor with/without lymphadenectomy

Selected sternum, rib, and back procedure CPTsCPTCovered

21742	Repair sternum/Nuss without scope; Maximum Allowable = By Report
21811	Open treatment of rib fracture with fixation scope; Maximum Allowable = $1,013.32
21930	Excision back lesion subcutaneous < 3 cm; Maximum Allowable = $812.19

Sample CPTs and fees (spine/soft tissue)CPTCovered

21813	Treatment of rib fracture; Maximum Allowable = $1,669.65
21920	Biopsy soft tissue of back; Maximum Allowable = $405.94
21930	Excision back lesion SC <3 cm; Maximum Allowable = $812.19

Spinal fusion/fixation CPTsCPTCovered

22804	ARTHRD PST DFRM 13+ VRT SGM; Maximum Allowable = $4,074.10
22840	Insert spine fixation device; Maximum Allowable = $1,260.84
22849	Insert pelvic fixation device / reinsert spinal fixation; Maximum Allowable entries include $602.93 and $2,181.17 for reinsert

Spine arthroplasty and related proceduresCPTCovered

22855	Removal anterior instrument; Maximum Allowable = $1,843.32
22856	Total disc arthroplasty interspace cervical; Maximum Allowable = $2,706.40
22857	Total disc arthroplasty interspace lumbar; Maximum Allowable = $556.68
22859	Insertion biomechanical device; Maximum Allowable = $556.68
22861	Revision/replacement arthroplasty interspace cervical; Maximum Allowable = $3,790.52
22862	Revision/replacement arthroplasty interspace lumbar; Maximum Allowable = $3,785.23

Abdominal and shoulder surgical proceduresCPTCovered

22901	Excise abdominal tumor deep >5 cm (OMK) — Maximum Allowable = $1,131.35
23030	Drain shoulder lesion — Maximum Allowable examples present
23410	Repair rotator cuff acute — Maximum Allowable = $1,391.61
23335	Shoulder prosthesis removal — entry present with NDC/allowable

selected CPT codes and descriptionsCPT

23500	Closed treatment clavicular fracture without manipulation — Maximum Allowable = $380.03
23505	Closed treatment clavicular fracture with manipulation — NDC $611.41
23515	Open treatment clavicular fracture with internal fixation — NDC $1,222.22
23616	Open treatment proximal humeral fracture fixation/repair — NDC $2,100.06
24363	Replacement of elbow joint — NDC $2,470.26
24371	Revision of reconstructed elbow joint — NDC $3,013.54

Elbow and humerus proceduresCPTCovered

24360-24371

Elbow reconstruction/replacement and related procedures with associated NDC dollar values

Fracture/dislocation proceduresCPTCovered

24400-24666

Humerus and elbow fracture/dislocation treatment codes with listed NDC amounts

Forearm/wrist proceduresCPTCovered

25001-25248

Forearm, wrist, and hand procedure codes including biopsies, excisions, grafts, removals with NDC or Maximum Allowable amounts

selected CPT-like procedure lines and amountsmixedCovered

25136	Removal & graft wrist lesion; Maximum Allowable = $842.77
25150	Partial removal of ulna; Maximum Allowable = $965.70
25210	Removal of wrist bone; Maximum Allowable = $837.98
25391	Shorten/Lengthen radius or ulna; Maximum Allowable = $1,311.71 / $1,692.11
25449	Revision arthroplasty wrist joint; Maximum Allowable appears as $1,761.58
25500	Closed treatment radial shaft fracture w/o manipulation; Maximum Allowable = $481.59

inv-42: Rounding rule

Rounding ruleRBRVS-based rates are rounded to the nearest cent after adjustments

Rounding contextReimbursement may vary slightly from published rates as a result of rounding

Authorization, Documentation, and Billing Actions

Prior Authorization

Authorization and documentation required

Prior authorization and documentation requirements are flagged throughout the fee schedule. Providers must review code-specific authorization indicators (Comagine prior authorization, Fiscal Agent authorization, and requests for medical justification) before submitting claims to avoid denials or delays.

Codes marked "Requires Comagine Authorization = X" require prior review/authorization from Comagine prior to service.
Codes marked "Requires Fiscal Agent Authorization = X" require authorization via the fiscal agent process before billing.
Codes with "Requires Medical Justificatio = X" require clinical documentation in the member record to support medical necessity; include operative reports, imaging, prior treatments, and rationale.
Fee-schedule entries may show NDC/amount entries or "By Report" — when present include supporting invoice/cost documentation as noted.

Prior Authorization

Cellular therapy & device codes — dual requirements

Certain procedure codes (including many cellular therapy and implant/device related codes) carry both prior-authorization and medical-justification flags. For these codes, obtain the required Comagine authorization AND retain supporting clinical documentation demonstrating medical necessity.

Definitions and Calculation Notes

inv-84: Anesthesia base and minutes value calculation

Anesthesia Base Rate formulaAnesthesia Base Rate = (Base Value) + (Minutes Value)

Base Value calculationBase Value = (Base Value Conversion Factor $42.90) x (Code's Base Units)

Minutes Value calculationMinutes Value = (Anesthesia Time Conversion Factor $3.60) x (Allowed Minutes)

inv-85: Anesthesia Base Rate = (Base Value) + (Minutes Value)

Summary formulaAnesthesia Base Rate = (Base Value) + (Minutes Value)

Used to compute per-procedure anesthesia reimbursementCombine base units converted by $42.90 and minutes converted by $3.60

Policy Summary

PayerAlaska Medicaid

PolicyPhysician Services — Anesthesia Base Rates and Procedure Fee Schedule

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain and document medical justification or required Comagine/fiscal agent authorization for codes flagged as requiring prior authorization before submitting claims.

SourceLink

On This Page

Rounding basisApplies to RBRVS-based rates after conversion factors and calculation of base/minutes components

inv-43: Minutes value

Anesthesia base unit conversion factor$42.90 per base unit

Anesthesia time conversion factor (per minute)$3.60 per allowed minute

Example minutes value shownUsed repeatedly in per-code listings (e.g., chunks showing minutes value $42.90)

inv-44: Maximum Allowable

Maximum Allowable (general)Dollar amounts listed per procedure where shown and used as payment limits (examples below)

Example: 11012Maximum Allowable = $1,048.11

Example: 15946Maximum Allowable = $2,718.02

inv-45: Maximum Allowable example values

11622Maximum Allowable = $410.51

11771Maximum Allowable = $1,007.16

11772Maximum Allowable = $1,234.34

inv-46: examples_of_high_fee

High-fee example11960 Maximum Allowable = $1,686.43

Related note11960 marked 'Requires Medical Justificatio = X'

inv-47: example maximum allowable

Example maximum allowable16000 Maximum Allowable = $131.85

Context16000 = INITIAL TREATMENT OF BURN(S) in burn treatment section

inv-48: Maximum allowable fee range

Observed fee range (sample chunks)Values in document include as low as $10.53 and as high as $3,699.38 in the cited segments

Example high within range19368 NDC = $3,699.38

Example low within range(document shows low values in other chunks; range noted across segments)

inv-49: Maximum Allowable examples

20969Maximum Allowable = $4,687.36

21215Maximum Allowable = $6,061.57

20974Maximum Allowable = $135.31

inv-50: Maximum Allowable range observed

Observed Maximum Allowable rangeDocumented ranges include $92.33 up to $6,061.57 across sections

Example high21215 = $6,061.57

Example low20979 = $92.33

inv-51: Maximum Allowable = By Report

By Report entriesSome codes list 'Maximum Allowable = By Report' requiring documentation to determine allowable

Example codes21742 and 21743 show 'Maximum Allowable = By Report'

inv-52: Notable high maximum allowance

Notable high maximum allowance22513 Maximum Allowable entries include $7,997.49 (also $2,827.32 listed alongside)

Context22513 relates to percutaneous vertebral augmentation entries with dual values shown

inv-53: Maximum Allowable

23500Maximum Allowable = $380.03

23505NDC (payment) = $611.41

23515NDC (payment) = $1,222.22

inv-54: Maximum allowable present

Specific wrist/forearm examples25136 Maximum Allowable = $842.77; 25246 Maximum Allowable = $302.31

Additional example25210 Maximum Allowable = $837.98

Cellular therapy and harvest codes (for example 0263T–0265T) show both medical justification and Comagine authorization flags — secure prior approval and document indications.
Device and implant-related codes (for example 0266T–0273T, and many spine/arthroplasty codes) frequently require Comagine authorization and medical justification — follow device-specific prior authorization procedures.
When a code lists NDC amounts or "By Report," include supplier invoices and cost documentation with authorization/claim as directed.

Note

Authorization field structure and usage

The fee schedule uses three distinct authorization/documentation indicators: Comagine Authorization (prior authorization vendor), Fiscal Agent Authorization, and Medical Justification required. Treat each indicator as operationally separate — compliance with one does not substitute for another.

Comagine Authorization = X indicates a prior authorization request must be submitted to Comagine before the service.
Fiscal Agent Authorization = X indicates authorization must be obtained through the fiscal agent workflow prior to billing.
Medical Justificatio = X indicates clinical documentation must be present in the medical record to support payment; include with prior authorization when applicable.

Prior Authorization

Comagine authorization examples

Examples from the schedule illustrate how Comagine flags are used in practice. Use these examples to identify similar cases in the full schedule and follow the same prior-authorization steps.

0095T and 0098T — Comagine Authorization = X for specific revision procedures — submit clinical rationale and prior-treatment history.
15271 and 15272 — skin graft add-on codes flagged for Comagine authorization — include graft size and indication in request.
22102–22103, 22110 — spine procedures with Comagine = X — provide imaging, conservative therapy history, and neurologic findings.

Prior Authorization

Authorization flags for listed CPTs

Authorization flags appear on many CPT ranges and individual codes. Providers should consult the fee-schedule entry for each billed code to determine whether Comagine, Fiscal Agent, and/or medical justification is required and act accordingly.

CPTs 23500 and 23505–23532 — authorization flags present for clavicle/shoulder procedures; check NDC and Maximum Allowable fields when applicable.
CPTs 24360–24363 — reconstruct/replace elbow joint entries show NDC amounts and authorization flags; submit documentation supporting device/implant.
CPTs in reconstructive series (19301–19307, 19350, 19355, 19367) show medical justification flags for reconstruction and nipple/areola procedures—retain operative and consult notes.

Billing Rule

Maximum allowable and billing considerations

Some entries include Maximum Allowable amounts alongside authorization indicators. Even when an authorization flag is not set to X, review Maximum Allowable values and billing notes — overbilling against the listed maximum can result in claim adjustment or denial.

Entries such as 11471/11600, 11600–11604 display Maximum Allowable values; ensure charges align with these limits.
Codes with explicit Maximum Allowable values (for example many skin/excision and reconstruction codes) should be billed at or below the stated amounts.
When an entry includes both an authorization flag and a Maximum Allowable, obtain authorization first and then bill consistent with the allowable amount.

Billing Rule

Billing authorization notes and NDC documentation

Billing notes and schedule anomalies: occasionally the NDC column contains dollar amounts or 'By Report' — attach supplier invoices and document any reported amounts in authorization/claim submissions. Where the schedule repeats authorization indicators across multiple adjacent codes, treat each code as individually flagged unless documentation says otherwise.

NDC fields with dollar amounts (examples: 10005–10010 series, 24360 series) require cost documentation when billing; include invoices with prior authorization if requested.
Repeated flags across a code range (e.g., 11600–11604, 23500 series) imply each code in the range may have identical requirements but verify each code's entry before submission.
If a fee-schedule entry uses 'By Report' for NDC or maximum, provide supporting documentation as part of the claim or prior authorization packet.

inv-86: National Drug Code reimbursement amount shown for certain procedure entries

NDC field usageSome procedure lines list 'Requires NDC' with a dollar amount representing payment (e.g., 10005 NDC = $219.18; 15116 NDC = $260.84)

NoteIn this document 'NDC' is used as the pricing/payment field rather than strictly National Drug Code

inv-87: Anesthesia Base Rate

Anesthesia Base Rate (definition)Calculated as Base Value plus Minutes Value per the stated formula

Documented in multiple code listingsFormula repeated across anesthesia code entries in this section

inv-88: Anesthesia Base Rate

Anesthesia Base Rate repeatedAnesthesia Base Rate = (Base Value) + (Minutes Value) appears throughout code and fee listings

Practical useUsed when associating anesthesia-related payments with listed CPT base units and minutes

inv-89: OMK

OMK (descriptor)OMK appears as a short procedure descriptor (examples visible in many entries, e.g., 'EXC TR-EXT MAL+MARG 0.6-1 CM')

UsageOMK accompanies CPT lines to summarize procedure site/size/context

inv-90: Maximum Allowable

Maximum Allowable usageWhere present, 'Maximum Allowable' dollar values are shown per CPT line and serve as payment limits (examples across sections)

Example11012 Maximum Allowable = $1,048.11; 25136 Maximum Allowable = $842.77

inv-91: Authorization indicators

Requires Medical Justification flagMany entries include 'Requires Medical Justificatio' field; 'X' indicates requirement for specific codes

Examples19350 marked 'Requires Medical Justificatio = X'; other codes similarly flagged

inv-92: OMK (present as short descriptor field for procedure/context)

OMK as short descriptorOMK appears as a short descriptor field for procedure (e.g., 'OMK = INITIAL TREATMENT OF BURN(S)' and many reconstructive entries)

Examples24360 OMK entries and burn/treatment OMK lines demonstrate usage

inv-93: NDC used here to represent the dollar amount/pricing field for each procedure line (not National Drug Code in this context)

NDC used as payment amountEntries list 'Requires NDC = $...' where the dollar value is the payment amount for the procedure line (e.g., 10005 NDC = $219.18; 23505 NDC = $611.41)

ClarificationThis NDC field functions as the listed monetary reimbursement for those lines

inv-94: OMK appears as a short descriptor field for procedure (e.g., 'OMK = INITIAL TREATMENT OF BURN(S)')

OMK exampleOMK = INITIAL TREATMENT OF BURN(S) shown with 16000 and related codes

Usage in reconstructionOMK fields accompany reconstruction and grafting CPTs to provide brief context

inv-95: An authorization flag; 'X' indicates that Comagine authorization is required for that code in these entries

Comagine authorization flag'X' in the Comagine Authorization field denotes that Comagine authorization is required for that code

Examples0095T and multiple reconstructive codes show 'X' in various entries across the schedule

inv-96: Anesthesia Base Rate = (Base Value) + (Minutes Value)

Anesthesia Base Rate formula restatedAnesthesia Base Rate = (Base Value) + (Minutes Value)

Base/Minutes factorsBase units converted at $42.90; minutes converted at $3.60

inv-97: Per-code payment amount listed as 'Requires NDC = $...' or 'Maximum Allowable = $...'

Per-code payment labelingSome lines present payment as 'Requires NDC = $...' or 'Maximum Allowable = $...' to indicate the payable amount for that CPT

Examples19350 Requires NDC = $1,365.95; 19367 Requires NDC = $3,013.60

inv-98: Anesthesia Base Rate

Anesthesia Base Rate (definition)Repeated across document as the formula used to compute anesthesia payments

ApplicationApplied when mapping base units and allowed minutes to a dollar base rate per CPT

inv-99: Fiscal Agent Authorization = X

Fiscal Agent Authorization = X'X' in the Fiscal Agent Authorization field denotes requirement for fiscal agent prior authorization for that code

Examples21082 and reconstruction codes (21147, 21150, 21154, etc.) show Fiscal Agent Authorization = X in entries

inv-100: Anesthesia Base Rate

Anesthesia Base Rate formula (repeat)Anesthesia Base Rate = (Base Value) + (Minutes Value)

Used in facial/craniofacial and other surgical entriesMultiple entries (21263, 21270, etc.) reference this calculation basis

inv-101: Maximum allowable payment amount for the listed procedure (some entries show specific dollar values, others 'By Report')

Maximum Allowable usage noteMany entries show a specific dollar Maximum Allowable; some entries are labeled 'By Report' requiring documentation

Examples21742 Maximum Allowable = By Report; 21811 Maximum Allowable = $1,013.32

inv-102: Maximum Allowable

Maximum Allowable entries presentPer-code lines include Maximum Allowable or NDC payment amounts (examples throughout the schedule)

Example listing11012 Maximum Allowable = $1,048.11; 23500 Maximum Allowable = $380.03

inv-103: Comagine Authorization

Comagine Authorization occurrencesCertain procedure entries are explicitly marked 'Requires Comagine Authorization = X', indicating prior authorization by Comagine may be required

Examples22102, many reconstructive and cellular therapy codes show Comagine Authorization markers

inv-104: Maximum Allowable

Maximum Allowable / NDC valuesEntries show either 'Requires NDC' dollar amounts or 'Maximum Allowable' values to represent payment amounts for the procedure line

Examples24360 NDC = $1,531.53; 25136 Maximum Allowable = $842.77

inv-105: Comagine Authorization

Comagine Authorization flags repeatedComagine Authorization field appears across many craniofacial and reconstruction entries; 'X' indicates requirement

Examples21235 marked 'Requires Comagine Authorization = X'

inv-106: Anesthesia Base Rate

Anesthesia Base Rate formula (document-wide)Anesthesia Base Rate = (Base Value) + (Minutes Value) — repeated as the pricing methodology for anesthesia codes

Implementation noteApply conversion factors ($42.90 and $3.60) to base units and minutes when computing per-case anesthesia reimbursement

inv-107: NDC / Maximum Allowable

NDC / Maximum Allowable fieldsMany procedure lines list either 'Requires NDC = $...' or 'Maximum Allowable = $...' to indicate the payment amount for that CPT line

Examples10005 NDC = $219.18; 23505 NDC = $611.41; 11012 Maximum Allowable = $1,048.11

inv-108: Anesthesia Base Rate = (Base Value) + (Minutes Value)

Anesthesia Base Rate formula restatedAnesthesia Base Rate = (Base Value) + (Minutes Value)

Repeated usageFormula appears in header and before many code groups indicating consistent calculation approach

inv-109: Monetary values listed as 'Requires NDC' or 'Maximum Allowable' represent the payment amount associated with the listed procedure in this excerpt.

Monetary field interpretationMonetary values listed as 'Requires NDC' or 'Maximum Allowable' represent the payment amount associated with the listed procedure in this excerpt

Provider actionUse the listed dollar amount as the payment limit when processing claims for the specific CPT line

inv-110: Anesthesia Base Rate formula

Canonical anesthesia formulaAnesthesia Base Rate = (Base Value) + (Minutes Value)

Computation componentsBase Value = $42.90 x Base Units; Minutes Value = $3.60 x Allowed Minutes