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Workers' compensation -- HIPAA 835 Health care claim payment/remittance advice



5221.4033 Outpatient limitation for medical/surgical facility fee

Subpart 1. No facility fee. Procedures whose codes are listed in subpart 2b are predominantly performed in office settings and, therefore, no additional facility fees are payable when the procedure is performed by the employee's treating health care provider, unless it is an emergency or medically necessary to perform the procedure in a nonoffice setting or after normal office hours. This part does not preclude payment of a facility fee where the employee is treated by emergency room or urgent care staff.

Subp. 1a. Payment of facility fee. Except where the facility fee is precluded from payment in subpart 1, fees for ambulatory surgical center and hospital outpatient surgical center are paid in accordance with part 5221.0500, subpart 2.

A. Services and supplies included in facility fee. The services in subitems (1) to (8) are included in the facility fee. There may be no separate payment for these services and supplies:

(1) nursing, technician, and related services;

(2) use of the facilities where the surgical procedures are performed;

(3) drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment directly related to the provision of surgical procedures;

(4) diagnostic or therapeutic services or items directly related to the provision of a surgical procedure;

(5) administrative, recordkeeping, and housekeeping items and services;

(6) materials for anesthesia;

(7) intraocular lenses (IOLs); and

(8) supervision of the services of an anesthetist by the operating surgeon.

B. Services and supplies in subitems (1) to (7) are paid separately from the facility fee:

(1) physician services;

(2) laboratory, X-ray, or diagnostic procedures, other than those directly related to performance of the surgical procedure;

(3) prosthetic devices, except IOLs;

(4) ambulance services;

(5) leg, arm, back, and neck braces and artificial limbs;

(6) durable medical equipment for use in the patient's home or take-home supplies; and

(7) anesthetist services.

Subp. 2b. Procedure codes subject to limitation.

CPT/HCPCS
procedure code
CPT/HCPCS
description
10040
Acne surgery
10060
Drainage of skin abscess
10061
Drainage of skin abscess
10080
Drainage of pilonidal cyst
10081
Drainage of pilonidal cyst
10120
Remove foreign body
10121
Remove foreign body
10140
Drainage of hematoma/fluid
10160
Puncture drainage of lesion
11000
Surgical cleansing of skin
11001
Additional cleansing of skin
11040
Surgical cleansing, abrasion
11041
Surgical cleansing of skin
11050
Trim skin lesion
11051
Trim 2 to 4 skin lesions
11052
Trim over 4 skin lesions
11100
Biopsy of skin lesion
11101
Biopsy, each added lesion
11200
Removal of skin tags
11201
Removal of added skin tags
11300
Shave skin lesion
11301
Shave skin lesion
11302
Shave skin lesion
11303
Shave skin lesion
11305
Shave skin lesion
11306
Shave skin lesion
11307
Shave skin lesion
11308
Shave skin lesion
11310
Shave skin lesion
11311
Shave skin lesion
11312
Shave skin lesion
11313
Shave skin lesion
11400
Removal of skin lesion
11401
Removal of skin lesion
11402
Removal of skin lesion
11403
Removal of skin lesion
11420
Removal of skin lesion
11421
Removal of skin lesion
11422
Removal of skin lesion
11423
Removal of skin lesion
11440
Removal of skin lesion
11441
Removal of skin lesion
11442
Removal of skin lesion
11443
Removal of skin lesion
11600
Removal of skin lesion
11601
Removal of skin lesion
11602
Removal of skin lesion
11603
Removal of skin lesion
11620
Removal of skin lesion
11621
Removal of skin lesion
11622
Removal of skin lesion
11623
Removal of skin lesion
11640
Removal of skin lesion
11641
Removal of skin lesion
11642
Removal of skin lesion
11643
Removal of skin lesion
11730
Removal of nail plate
11731
Removal of second nail plate
11732
Removal of additional nail plate
11740
Drain blood from under nail
11750
Removal of nail bed
11752
Removal of nail bed/finger tip
11760
Reconstruction of nail bed
11762
Reconstruction of nail bed
11765
Excision of nail fold, toe
11900
Injection into skin lesions
11901
Added skin lesion injections
12031
Layer closure of wound(s)
12032
Layer closure of wound(s)
12041
Layer closure of wound(s)
12042
Layer closure of wound(s)
12051
Layer closure of wound(s)
12052
Layer closure of wound(s)
15780
Abrasion treatment of skin
15781
Abrasion treatment of skin
15782
Abrasion treatment of skin
15783
Abrasion treatment of skin
15786
Abrasion treatment of lesion
15787
Abrasion, added skin lesions
15851
Removal of sutures
15852
Dressing change, not for burn
16000
Initial treatment of burn(s)
16010
Treatment of burn(s)
16020
Treatment of burn(s)
16025
Treatment of burn(s)
17000
Destroy benign/premal lesion
17001
Destruction of additional lesions
17002
Destruction of additional lesions
17010
Destruction of skin lesion(s)
17100
Destruction of skin lesion
17101
Destruction of second lesion
17102
Destruction of additional lesions
17104
Destruction of skin lesions
17105
Destruction of skin lesions
17106
Destruction of skin lesions
17107
Destruction of skin lesions
17110
Destruction of skin lesions
17200
Electrocautery of skin tags
17201
Electrocautery added lesions
17250
Chemical cautery, tissue
17260
Destruction of skin lesions
17261
Destruction of skin lesions
17262
Destruction of skin lesions
17263
Destruction of skin lesions
17264
Destruction of skin lesions
17266
Destruction of skin lesions
17270
Destruction of skin lesions
17271
Destruction of skin lesions
17272
Destruction of skin lesions
17273
Destruction of skin lesions
17274
Destruction of skin lesions
17276
Destruction of skin lesions
17280
Destruction of skin lesions
17281
Destruction of skin lesions
17282
Destruction of skin lesions
17283
Destruction of skin lesions
17284
Destruction of skin lesions
17286
Destruction of skin lesions
17304
Chemosurgery of skin lesion
17305
Second stage chemosurgery
17306
Third stage chemotherapy
17307
Follow-up skin lesion therapy
17310
Extensive skin chemosurgery
17340
Cryotherapy of skin
17360
Skin peel therapy
19000
Drainage of breast lesion
17001
Drain added breast lesion
20000
Incision of abscess
20500
Injection of sinus tract
20520
Removal of foreign body
20550
Inject tendon/ligament/cyst
20600
Drain/inject joint/bursa
20605
Drain/inject joint/bursa
20610
Drain/inject joint/bursa
20615
Treatment of bone cyst
20974
Electrical bone stimulation
21029
Contour of face bone lesion
21030
Removal of face bone lesion
21031
Remove exostosis, mandible
21032
Remove exostosis, maxilla
21079
Prepare face/oral prosthesis
21080
Prepare face/oral prosthesis
21081
Prepare face/oral prosthesis
21082
Prepare face/oral prosthesis
21083
Prepare face/oral prosthesis
21084
Prepare face/oral prosthesis
21085
Prepare face/oral prosthesis
21086
Prepare face/oral prosthesis
21087
Prepare face/oral prosthesis
21088
Prepare face/oral prosthesis
21089
Prepare face/oral prosthesis
21110
Interdental fixation
23031
Drain shoulder bursa
24200
Removal of arm foreign body
24650
Treat radius fracture
25500
Treat fracture of radius
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