Spreadsheet: 0315becd-92af-4ede-8482-5c5ddf20c036
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | For Informational Purposes Only! | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | Unnamed: 17
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 10121 |  |  | INCISION/REMOVAL OF FORIEGN BODY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 10180 |  |  | INCISION AND DRAINAGE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11010 |  |  | DEBRIDEMENT INCLUDING REMOVAL OF |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11011 |  |  | DEBRIDEMENT INCLUDING REMOVAL OF |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11012 |  |  | DEBRIDEMENT INCLDING REMOVAL OF |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11042 |  |  | DEBRIDEMENT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11043 |  |  | DEBRIDEMENT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11044 |  |  | DEBRIDEMENT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11404 |  |  | EXCISION BENIGN LESION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 11406 |  |  | EXCISION BENIGN LESION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11420 |  |  | EXCISION BENIGN LESION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 11421 |  |  | EXCISION BENIGN LESION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 11422 |  |  | EXCISION BENIGN LESION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 11423 |  |  | EXCISION BENIGN LESION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 11424 |  |  | EXCSION BENIGN LESION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11426 |  |  | EXCISION BENIGN LESION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11440 |  |  | EXCISION OTHER BENIGN LESION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 11441 |  |  | EXCISION OTHER BENIGN LESION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 11442 |  |  | EXCISION OTHER BENIGN LESION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 11443 |  |  | EXCISION OTHER BENIGN LESION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 11444 |  |  | EXCISION OTHER BENIGN LESION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 11446 |  |  | EXCISION OTHER BENIGN LESION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11450 |  |  | EXCISION SKIN & SUBCUTANEOUS TISSUE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11451 |  |  | EXCISION SKIN & SUBCUTANEOUS TISSUE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11462 |  |  | EXCISION SKIN & SUBCUTANEOUS TISSUE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11463 |  |  | EXCISION SKIN & SUBCUTANEOUS TISSUE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11470 |  |  | EXCISION SKIN & SUBCUTANEOUS TISSUE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11471 |  |  | EXCISION SKIN & SUBCUTANEOUS TISSUE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11604 |  |  | EXCISION MALIGNANT LESION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11606 |  |  | EXCISION MALIGNANT LESION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11624 |  |  | EXCISION MALIGNANT LESION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11626 |  |  | EXCISION MALIGNANT LESION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11644 |  |  | EXCISION MALIGNANT LESION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11646 |  |  | EXCISION MALIGNANT LESION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11770 |  |  | EXCISION PILONIDAL CYST OR SINUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 11771 |  |  | EXCISION PILONIDAL CYST OR SINUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 11772 |  |  | EXCISION PILONIDAL CYST OR SINUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 11960 |  |  | INSERTION OF TISSUE EXPANDERS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 11970 |  |  | REPLACEMENT OF TISSUE EXPANDER |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 11971 |  |  | REMOVAL OF TISSUE EXPANDER(S) |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 12005 |  |  | SIMPLE REPAIR OF SUPERFICIAL WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12006 |  |  | SIMPLE REPAIR OF SUPERFICIAL WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12007 |  |  | SIMPLE REPAIR OF SUPERFICIAL WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 1 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 12016 |  |  | SIMPLE REPAIR OF SUPERFICIAL WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12017 |  |  | SIMPLE REPAIR OF SUPERFICIAL WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12018 |  |  | SIMPLE REPAIR OF SUPERFICIAL WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12020 |  |  | TREATMENT SUPERFICIAL WOUND |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 12021 |  |  | [NAME] |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 12034 |  |  | LAYER CLOSURE OF WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12035 |  |  | LAYER CLOSURE OF WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12036 |  |  | LAYER CLOSURE OF WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12037 |  |  | LAYER CLOSURE OF WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12044 |  |  | LAYER CLOSURE OF WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12045 |  |  | LAYER CLOSURE OF WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12046 |  |  | LAYER CLOSURE OF WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12047 |  |  | LAYER CLOSURE OF WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12054 |  |  | LAYER CLOSURE OF WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12055 |  |  | LAYER CLOSURE OF WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12056 |  |  | LAYER CLOSURE OF WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 12057 |  |  | LAYER CLOSURE OF WOUNDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 13100 |  |  | RECONSTRUCTIVE REPAIR, COMPLEX |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 13101 |  |  | RECONSTRUCTIVE REPAIR, COMPLEX |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 13102 |  |  | REPAIR COMPLEX |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 13120 |  |  | RECONSTRUCTIVE REPAIR, COMPLEX |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 13121 |  |  | RECONSTRUCTIVE REPAIR, COMPLEX |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 13122 |  |  | REPAIR, COMPLEX |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 13131 |  |  | RECONSTRUCTIVE REPAIR, COMPLEX |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 13132 |  |  | RECONSTRUCTIVE REPAIR, COMPLEX |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 13133 |  |  | REPAIR, COMPLEX-ADD ON |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 13150 |  |  | RECONSTRUCTIVE REPAIR, COMPLEX |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 13151 |  |  | RECONSTRUCTIVE REPAIR, COMPLEX |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 13152 |  |  | RECONSTRUCTIVE REPAIR, COMPLEX |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 13153 |  |  | REPAIR, COMPLEX-ADD ON |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 13160 |  |  | SECONDARY CLOSURE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 14000 |  |  | ADJACENT TISSUE TRANSFER/REARRANGE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 14001 |  |  | ADJACENT TISSUE TRANSFER/REARRANGE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 14020 |  |  | ADACENT TISSUE TRANSFER/REARRANGE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 14021 |  |  | ADJACENT TISSUE TRANSFER/REARRANGE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 14040 |  |  | ADJACENT TISSUE TRANSFER/REARRANGE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 14041 |  |  | ADJACENT TISSUE TRANSFER/REARRANGE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 14060 |  |  | ADJACENT TISSUE TRANSFER/REARRANGE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 14061 |  |  | ADJACENT TISSUE TRANSFER/REARRANGE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 14301 |  |  | ADJACENT TISSUE TRANSFER OR REARRA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 14302 |  |  | EACH ADDITIONAL 30.0 SQ CM, OR PAR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 14350 |  |  | FILLETED FINGER OR TOE FLAP |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15002 |  |  | SURGICAL PREPARATION OR CREATION O |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 2 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 15003 |  |  | SURGICAL PREPARATION/CREATION OF R |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 15004 |  |  | SURGICAL PREPARATION/CREATION OF S |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15005 |  |  | SURGICAL PREPARATION OR CREATION/S |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 15040 |  |  | HARVEST OF SKIN/TISSUE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15050 |  |  | PINCH GRAFT/SINGLE OR MULTIPLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15100 |  |  | SPLIT GRAFT/TRUNK,ARMS,LEGS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15101 |  |  | SPLIT SKIN GRAFT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15110 |  |  | EPIDERMAL AUTOGRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15111 |  |  | EPIDERMAL AUTOGRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15115 |  |  | EPIDERMAL AUTOGRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15116 |  |  | EPIDERMAL AUTOGRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15120 |  |  | [NAME],SCALP,EYELIDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15121 |  |  | SPLIT GRAFT/FACE,SCALP,EYELIDS, |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15130 |  |  | DERMAL AUTOGRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15131 |  |  | DERMAL AUTOGRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15135 |  |  | DERMAL AUTOGRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15136 |  |  | DERMAL AUTOGRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15150 |  |  | TISSUE CULTURED EPIDERMAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15151 |  |  | TISSUE CULTURED EPIDERMAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15152 |  |  | TISSUE CULTUR EPIDERMA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15155 |  |  | TISSUE CULTURE EPIDERMAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15156 |  |  | TISSUE CULTURE EPIDERMAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15157 |  |  | TISSUE CULTURED EPIDERMAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15170 |  |  | [NAME], TRUN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15171 |  |  | [NAME],TRUNK,ARM |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15175 |  |  | ACELLULAR DERMAL REPLACEMEN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15176 |  |  | [NAME] |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15200 |  |  | FULL THICKNESS GRAFT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15201 |  |  | FULL THICKNESS GRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15220 |  |  | FULL THICKNESS GRAFT,FREE INCLUDING |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15221 |  |  | FULL THICKNESS GRAFT,FREE INCLUDING |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15240 |  |  | FULL THICKNESS GRAFT,FREE,INCLUDING |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15241 |  |  | FULL THICKNESS GRAFT,FREE,INCLUDING |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15260 |  |  | FULL THICKNESS GRAFT,FREE,INCLUDING |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15261 |  |  | FULL THICKNESS GRAFT,FREE,INCLUDING |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15300 |  |  | ALLOGRAFT SKIN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15301 |  |  | ALLOGRAFT SKIN/TEMPORARY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15320 |  |  | ALLOGRAFT SKIN/TEMPORARY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15321 |  |  | ALLOGRAFT SKIN/TEMP WOUND |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15330 |  |  | [NAME] |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15331 |  |  | [NAME] ALLOGRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15335 |  |  | [NAME] ALLOGRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15336 |  |  | [NAME] ALLOGRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 3 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 15340 |  |  | TISSUE CULTURED ALLOGENIC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15341 |  |  | TISSUE CULTURED ALLOGENIC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15360 |  |  | TISSUE CULTURED ALLOGENIC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15361 |  |  | TISSUE CULTURED ALLOGENIC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15365 |  |  | TISSUE CULTURED ALLOGENIC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15366 |  |  | TISSUE CULT ALLOGEN DERMAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15400 |  |  | APPLICATION OF SENOGRAFT,SKIN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15401 |  |  | APPLICATION OF XENOGRAFT, SKIN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15420 |  |  | XENOGRAFT SKIN FOR TEM |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15421 |  |  | XENOGRAFT SKIN FOR TEMP WOUND CLOS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15430 |  |  | [NAME] IMPLAN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15431 |  |  | [NAME] IMPLANT, |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15570 |  |  | FORM OF DIRECT OR TUBED PEDICLE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15572 |  |  | FORM OF DIRECT OR TUBED PEDICLE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15574 |  |  | FORM OF DIRECT OR TUBED PEDICLE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15576 |  |  | FORM OF DIRECT OR TUBED PEDICLE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15600 |  |  | DELAY OF FLAP OR SECTIONING FLAP |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15610 |  |  | DELAY OF FLAP OR SECTIONING FLAP |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15620 |  |  | DELAY OF LAP OR SECTIONING OF FLAP |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 15630 |  |  | DELAY OF FLAP OR SECTIONING OF FLAP |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15650 |  |  | TRANSFER OF ANY PEDICLE FLAP |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 15731 |  |  | FOREHEAD FLAP WITH PRESERVATION OF |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15732 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15734 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15736 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15738 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15740 |  |  | FLAP; ISLAND PEDICLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15750 |  |  | FLAP; NEUROVASCULAR PEDICLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15760 |  |  | GRAFT; COMPOSITE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 15770 |  |  | GRAFT; COMPOSITE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15820 |  |  | BLEPHAROPLASTY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15821 |  |  | BLEPHAROPLASTY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15822 |  |  | BLEPHAROPLASTY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15823 |  |  | BLEPHAROPLASTY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 15829 |  |  | RHYTIDECTOMY |  |  |  |  | 5 |  |  | Y |  |  |  | Referral Required
 |  | 15830 |  |  | EXCISION, EXCESSIVE SKIN/SUBCUTANE |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 15833 |  |  | EXCISION |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 15836 |  |  | EXCISION |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 15840 |  |  | GRAFT FOR FACIAL NERVE PARALYSIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 15841 |  |  | GRAFT FOR FACIAL NERVE PARALYSIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 15845 |  |  | GRAFT FOR FACIAL NERVE PARALYSIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 15850 |  |  | REMOVAL OF SUTURES |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 15877 |  |  | SUCTION ASSISTED LIPECTOMY; |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 4 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 15920 |  |  | EXCISION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15922 |  |  | EXCISION |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 15931 |  |  | EXCISION, SACRAL PRESSURE ULCER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15933 |  |  | EXCISION, SACRAL PRESSURE ULCER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15934 |  |  | EXCISION, SACRAL PRESSURE ULCER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15935 |  |  | EXCISION, SACRAL PRESSURE ULCER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 15936 |  |  | EXCISION, SACRAL PRESSURE ULCER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 15937 |  |  | EXCISION, SACRAL PRESSURE ULCER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 15940 |  |  | EXCISION, ISCHIAL PRESSURE ULCER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15941 |  |  | EXCISION, ISCHIAL PRESSURE ULCER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15944 |  |  | EXCISION, ISCHIAL PRESSURE ULCER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15945 |  |  | EXCISION, ISCHIAL PRESSURE ULCER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 15946 |  |  | EXCISION, ISCHIAL PRESSURE ULCER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 15950 |  |  | EXCIS.TROCHANTERIC PRESSURE ULCER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15951 |  |  | EXCIS. TROCHANTERIC PRESSURE ULCER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 15952 |  |  | EXCIS. TROCHANTERIC PRESSURE ULCER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15953 |  |  | EXCIS. TROCHANTERIC PRESSURE ULCER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 15956 |  |  | EXCIS. TROCHANTERIC PRESSURE ULCER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 15958 |  |  | EXCIS. TROCHANTERIC PRESSURE ULCER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 17106 |  |  | DESTRUCTION |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 17107 |  |  | DESTRUCTION |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 17108 |  |  | DESTRUCTION |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 19020 |  |  | MASTOTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 19100 |  |  | BREAST BIOPSY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 19101 |  |  | BREAST BIOPSY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 19102 |  |  | BIOPSY OF BREAST |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 19103 |  |  | BIOPSY OF BREAST |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 19105 |  |  | ABLATION, CRYOSURGICAL, OF FIBROAD |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 19110 |  |  | NIPPLE EXPLORATION W/ OR W/O E |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 19112 |  |  | EXCISION OF LACTIFEROUS DUCT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 19120 |  |  | EXCISION, CYST, BREAST |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 19125 |  |  | EXCISION BREAST LESION IDENT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 19126 |  |  | EA ADDITIONAL LESION SEPARATELY IDE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 19290 |  |  | PRE-OPERATIVE PLACEMENT NEED |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 19291 |  |  | PREOP PLACE NEEDLE WIRE BREAST EA A |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 19295 |  |  | IMAGE GUIDED PLACEMENT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 19296 |  |  | PLACEMENT OF RADIOTHERAPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 19298 |  |  | PLACEMENT OF RADIOTHERAPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 19300 |  |  | MASTECTOMY FOR GYNECOMASTIA |  |  |  |  | 4 |  |  | Y |  |  |  | Referral Required
 |  | 19301 |  |  | MASTECTOMY, PARTIAL (EG, LUMPECTOM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 19302 |  |  | MASTECTOMY, PARTIAL ; W/ AXILLARY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 19303 |  |  | MASTECTOMY, SIMPLE, [NAME] |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 19304 |  |  | MASTECTOMY, SUBCUTANEOUS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 5 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 19316 |  |  | MASTOPEXY |  |  |  |  | 4 |  |  | Y |  |  |  | Referral Required
 |  | 19318 |  |  | REDUCTION MAMMAPLASTY |  |  |  |  | 4 |  |  | Y |  |  |  | Referral Required
 |  | 19324 |  |  | MAMMAPLASTY,AUGMENTATION W/O |  |  |  |  | 4 |  |  | Y |  |  |  | Referral Required
 |  | 19325 |  |  | MAMMAPLASTY WITH PROSTHETIC |  |  |  |  | 9 |  |  | Y |  |  |  | Referral Required
 |  | 19328 |  |  | REMOVAL OF INTACT MAMMARYIMP |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 19330 |  |  | REMOVAL, BREAST IMPLANT |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 19340 |  |  | IMMEDIATE INSERTION OF BREAS |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 19342 |  |  | DELAYED INSERTION OF BREAST |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 19350 |  |  | RECONSTRUCTION, NIPPLE |  |  |  |  | 4 |  |  | Y |  |  |  | Referral Required
 |  | 19357 |  |  | BREAST RECONSTRUCT W/TISSUE |  |  |  |  | 5 |  |  | Y |  |  |  | Referral Required
 |  | 19364 |  |  | BREAST RECONSTRUCTION WITH F |  |  |  |  | 5 |  |  | Y |  |  |  | Referral Required
 |  | 19366 |  |  | BREAST RECONSTRUCTION W/OTHE |  |  |  |  | 5 |  |  | Y |  |  |  | Referral Required
 |  | 19370 |  |  | OPEN PERIPROSTHETIC CAPULOTO |  |  |  |  | 4 |  |  | Y |  |  |  | Referral Required
 |  | 19371 |  |  | PERIPROSTHETIC CAPSULECTOMY |  |  |  |  | 4 |  |  | Y |  |  |  | Referral Required
 |  | 19380 |  |  | REVISION OF RECONSTRUCTED BR |  |  |  |  | 5 |  |  | Y |  |  |  | Referral Required
 |  | 20005 |  |  | INCISION OF SOFT TISSUE ABSC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 20200 |  |  | BIOPSY, [NAME] |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 20205 |  |  | BIOPSY, [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 20206 |  |  | [NAME] N |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 20220 |  |  | BIOPSY, BONE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 20225 |  |  | BIOPSY, BONE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 20240 |  |  | BIOPSY, BONE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 20245 |  |  | BIOPSY, BONE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 20250 |  |  | BIOPSY VERTEBRAL BODY OPEN T |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 20251 |  |  | BIOPSY VERTEBRAL BODY OPEN L |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 20520 |  |  | REMOVAL, FOREIGN BODY, MUSCL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 20525 |  |  | REMOVAL FB IN MUSCLE DEEP OR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 20612 |  |  | ASPIRATION &/OR INJECTION GANGLION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 20650 |  |  | INSERTION, PIN, SKELETAL TRA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 20670 |  |  | REMOVAL, PIN OR OTHER |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 20680 |  |  | REMOVAL, PIN OR OTHER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 20690 |  |  | APP OF A UNIPLANE UNILATERAL, EXTE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 20692 |  |  | APP OF MULTIPLANE (PINS OR WIRES M |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 20693 |  |  | ADJ/REVISION OF EXTERNAL FIX |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 20694 |  |  | REMOVAL,UNDER ANESTHESIA OF |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 20900 |  |  | BONE GRAFT, ANY DONOR AREA; MINOR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 20902 |  |  | BONE GRAFT, ANY DONOR AREA; MAJOR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 20910 |  |  | CARTILAGE GRAFT; COSTOCHONDRAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 20912 |  |  | CARTILAGE GRAFT, NASAL SEPTUM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 20920 |  |  | FASCIA LATA GRAFT; BY STRIPPER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 20922 |  |  | FASCIA LATA GRAFT; BY INCISION & A |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 20924 |  |  | TENDON GRAFT, FROM A DISTANCE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 20926 |  |  | TISSUE GRAFTS, OTHER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 6 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 20975 |  |  | ELECTRIC STIMULATION TO AID |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21010 |  |  | ARTHROTOMY,TEMPOROMANDIBULAR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21011 |  |  | AMB SURG CTR -ARTHRO TEMPOROM JNT B |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21012 |  |  | 2 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21013 |  |  | EXCISION, TUMOR SFT TISS OF FACE & |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21014 |  |  | 2 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21015 |  |  | RADICAL RESECTION TUMOR FACE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 21016 |  |  | 2 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21025 |  |  | EXCISION OF BONE, MANDIBLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21026 |  |  | EXCISION OF FACIAL BONES |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21029 |  |  | REMOVAL BY CONTOURING BENIGN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21030 |  |  | EXCISION, TUMOR, FACIAL BONE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 21034 |  |  | EXCISION MALIGNANT TUMOR OF |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 21040 |  |  | EXCISION, TUMOR, MANDIBLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21044 |  |  | EXCISION OF MALIGNANT TUMOR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21046 |  |  | EXCISION OF BEGNIGN TUMOR OR CYST |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21047 |  |  | EXCISION OF BENIGN TUMOR OR CYST |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21048 |  |  | EXCISION OF BENIGN TUMOR OR CYST |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 21049 |  |  | EXCISION OF BENIGN TUMOR OR CYST |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 21050 |  |  | ARTHRECTOMY, TEMP-MANDBLR JN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 21060 |  |  | MENISCECTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21070 |  |  | CORONOIDECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 21100 |  |  | APPLICATION, HALO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21120 |  |  | GENIOPLASTY; AUGMENTATION AU |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21121 |  |  | SLIDING OSTEOTOMY, SINGLE PI |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21122 |  |  | SLIDING OSTEOTOMIES TWO OR M |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21123 |  |  | GENIOPLASTY, AUGMENTATION SL |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21125 |  |  | AUGMENTATION MANDIBULAR BODY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21127 |  |  | AUGMENTATION,MANDIBULAR BODY |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 21181 |  |  | REMOVAL CONTOURING BENIGN TU |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21206 |  |  | OSTEOPLASY, MAXILLA, SEGMENT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 21208 |  |  | OSTEOPLASTY FACIAL BONES AUG |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21209 |  |  | OSTEOPLASTY, FACIAL BONES AU |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 21210 |  |  | GRAFT, FACIAL BONE |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21215 |  |  | BONE GRAFT, MANDIBLE |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21230 |  |  | GRAFT, CARTILAGE |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21235 |  |  | GRAFT, CARTILAGE |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21240 |  |  | ARTHROPLASTY, TEMP-MANDBL JN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 21242 |  |  | TEMP MAND JOINT ARTHROPLASTY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 21243 |  |  | ARTHROPLASTY TMJ W/PROSTHETI |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 21244 |  |  | RECONSTRUCT MANDIBLE EXTRAOR |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21245 |  |  | RECONSTRUCTION OF MANDIBLE O |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21246 |  |  | RECONSTRUCT MANDIBLE/MAXILLA |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 7 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 21248 |  |  | RECONSTRUCT MAXILLA/MANDIBLE |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21249 |  |  | RECONSTRUCT MANDIBLE/MAXILLA |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21267 |  |  | ORBITAL REPOSITION, PERIORBI |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21270 |  |  | MALAR AUGMENTATION PROSTHETI |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 21275 |  |  | SECONDARY REVISION FOR ORBIT |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21280 |  |  | MEDIAL CANTHOPEXY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 21282 |  |  | [NAME] CANTHOPEXY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 21295 |  |  | REDUCTION OF MASSETER MUSCLE & BONE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 21296 |  |  | REDUCTION OF MASSETER MUSCLE & BONE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 21310 |  |  | TREAT CLOSED/OPEN NASAL FX W |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21315 |  |  | FRACTURE, NASAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21320 |  |  | FRACTURE, NASAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21325 |  |  | FRACTURE, NASAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 21330 |  |  | FRACTURE, NASAL |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 21335 |  |  | FRACTURE, NASAL |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21336 |  |  | OPEN TX NASAL SEPTAL FX W/WO |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 21337 |  |  | TREATMENT OF CLOSED NASAL SE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21338 |  |  | OPEN TREATMENT NASOETHMOID F |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 21339 |  |  | TREATMENT OF NASOETHMOID FRA |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 21340 |  |  | TREAT CLOSED/OPEN NASOETHMOI |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 21345 |  |  | FRACTURE, NASO-MAXILLARY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 21355 |  |  | FRACTURE, MALAR AREA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 21400 |  |  | FRACTURE, ORBIT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21401 |  |  | FRACTURE, ORBIT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 21421 |  |  | FRACTURE, PALATAL RIDGE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 21440 |  |  | MANIPULATIVE TREATMENT OF AL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 21445 |  |  | OPEN TREAT MANDIBULAR-MAXILL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 21450 |  |  | CLOSED TREAT MANDIBULAR FX W |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 21451 |  |  | CLOSED TREAT MANDIBULAR FX W |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 21452 |  |  | [NAME] TREAT MANDIBULA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21453 |  |  | TREATMENT OF OP MANDIBULAR F |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 21454 |  |  | OPEN TRTMNT CLCS/OPN MANDIBU |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 21461 |  |  | FRACTURE, MANDIBULAR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 21462 |  |  | FRACTURE, MANDIBULAR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 21465 |  |  | OPEN TREAT MANDIBULAR CONDYL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 21480 |  |  | DISLOCATN, TEMPORO-MANDIBULA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 21485 |  |  | CLOSED TREAT TEMPOROMANDIBUL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21490 |  |  | OPEN TREAT TEMPORMANDIBULAR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 21497 |  |  | INTERDENATAL WIRING FOR COND |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21501 |  |  | INCISN & DRNGE, ABSCESS, NEC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21502 |  |  | INCISN & DRNGE, ABSCESS, NEC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21552 |  |  | 3 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21554 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 8 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 21555 |  |  | EXCISION TUMOR SOFT TISSUE O |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21556 |  |  | EXCISN, TUMR, SUBFASCIAL, NE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21558 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21600 |  |  | EXCISION, RIB |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21610 |  |  | COSTOTRANSVERSECTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21685 |  |  | HYOID MYOTOMY AND SUSPENSION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21700 |  |  | DIVISION, SCALENUS ANTICUS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21720 |  |  | DIVISION, STERNOCLEIDOMASTOI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 21725 |  |  | DIVISION, STERNOCLEIDOMASTOI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 21742 |  |  | RECONSTRUCTIVE REPAIR OF PECTUS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 21743 |  |  | RECONSTRUCTIVE REPAIR OF PECTUS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 21800 |  |  | FRACTURE, RIB |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 21805 |  |  | RIB FX OPEN OR COMPLICATED |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21820 |  |  | STERNUM FX CLOSED |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 21925 |  |  | BIOPSY SOFT TISSUE BACK/FLAN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21930 |  |  | EXCISION TUMOR SOFT TISSUE B |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21931 |  |  | 3 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21932 |  |  | EXCISION, TUMOR, SOFT TISSUE OF BA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21933 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 21935 |  |  | RADICAL RESECTION OF TUMOR, |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 21936 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 22010 |  |  | INCISION AND DRAINAGE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 22015 |  |  | INCISION AND DRAINAGE, OPEN, |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 22305 |  |  | CLOSED TREAT VERTEBRAL PROCE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 22310 |  |  | CLOSED TREAT VERTEBRAL BODY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 22315 |  |  | CLOSED TREATMENT OF VERTEBRA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 22505 |  |  | SPINAL MANIPULATION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 22900 |  |  | EXCISION, TUMOR, ABDOMINL WA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 22901 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 22902 |  |  | EXCISION, TUMOR, SOFT TISSUE OF AB |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 22903 |  |  | 3 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 22904 |  |  | RADICAL RESECTION OF TUMOR SOFT TI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 22905 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23000 |  |  | REMOVAL SUBDELTOID CALCAREOU |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23020 |  |  | CAPSULAR CONTRACTURE RELEASE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23030 |  |  | DRAINAGE, ABSCESS, SHOULDER |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23031 |  |  | DRAINAGE, BURSA, INFECTED |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23035 |  |  | INCISION, SHOULDER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23040 |  |  | ARTHROTOMY, GLENOHUMERAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23044 |  |  | ARTHROTOMY, ACROMIOCAVICULAR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23066 |  |  | BIOPSY, SOFT TISSUE OF SHOUL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23071 |  |  | 3 CM OR GREATE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23073 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 9 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 23075 |  |  | EXCISION TUMOR SHOULDER AREA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23076 |  |  | EXCISION, TUMOR, SHOULDER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23077 |  |  | RADICAL RESECTION OF TUMOR, |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23078 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23100 |  |  | ARTHROTOMY, GLENOHUMERAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23101 |  |  | ARTHROTOMY FOR BX OR EXC TOR |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 23105 |  |  | SYNOVECTOMY, GLENOHUMERAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23106 |  |  | ARTHROTOMY, ACROMIOCAVICULAR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23107 |  |  | ARTHROTOMY, GLENOHUMERAL JOI |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23120 |  |  | CLAVICULECTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23125 |  |  | CLAVICULECTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23130 |  |  | ACROMIOPLASTY-ACROMIONECTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23140 |  |  | EXCISION, CYST, CLAVICLE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23145 |  |  | EXCISION, CYST, CLAVICLE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23146 |  |  | EXCISION, CYST, CLAVICLE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23150 |  |  | EXCISION, CYST, HUMERAL HEAD |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23155 |  |  | EXCISION, CYST, HUMERAL HEAD |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23156 |  |  | EXCISION, CYST, HUMERAL HEAD |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23170 |  |  | SEQUESTRECTOMY, CLAVICLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23172 |  |  | SEQUESTRECTOMY, SCAPULA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23174 |  |  | SEQUESTRECTOMY, HUMERAL HEAD |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23180 |  |  | EXCISION, PARTIAL, CLAVICLE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23182 |  |  | EXCISION, PARTIAL, SCAPULA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23184 |  |  | EXCISN, PTL, PROXIMAL HUMERU |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23190 |  |  | OSTECTOMY, SCAPULA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23195 |  |  | RESECTION, HUMERAL HEAD |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23330 |  |  | REMOVAL OF FEREIGN BODY; SUB |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23331 |  |  | REMOVAL, FGN BODY, SHOULDER |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23395 |  |  | TRANSFER, MUSCLE, SHOULDER |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23397 |  |  | TRANSFER, MUSCLE, SHOULDER |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 23400 |  |  | SCAPULOPEXY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 23405 |  |  | TENOMYOTOMY, SHOULDER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23406 |  |  | TENOMYOTOMY, SHOULDER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23410 |  |  | REPAIR, MUSCULOTENDINOUS CUF |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23412 |  |  | REPAIR, MUSCULOTENDINOUS CUFF |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 23415 |  |  | CORACOACROMIAL LIGAMNT RELEA |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23420 |  |  | REPAIR, SHOULDER CUFF AVULSI |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 23430 |  |  | TENODESIS, BICEPS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23440 |  |  | RESECTION, LONG TENDON, BICE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23450 |  |  | CAPSULORRHAPHY, SHOULDER JOI |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23455 |  |  | CAPSULORRHAPHY, SHOULDER JOI |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 23460 |  |  | CAPSULORRHAPHY, SHOULDER JOI |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23462 |  |  | CAPSULORRHAPHY, SHOULDER JOI |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 10 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 23465 |  |  | CAPSULORRHAPHY, SHOULDER JOI |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23466 |  |  | CAPSULORRHAPHY ANY TYPE MULT |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 23480 |  |  | OSTEOTOMY, CLAVICLE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23485 |  |  | OSTEOTOMY, CLAVICLE |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 23490 |  |  | PROPHYLACTIC TREATMENT; CLAV |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23491 |  |  | PROPHYLACTIC TREATMENT;PROXI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23500 |  |  | FRACTURE CLAVICLE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23505 |  |  | FRACTURE, CLAVICLE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23515 |  |  | FRACTURE, CLAVICLE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23520 |  |  | DISLOCATION, STERNOCLAVICULA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23525 |  |  | DISLOCATION, STERNOCLAVICULA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23530 |  |  | DISLOCATION, STERNOCLAVICULA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23532 |  |  | DISLOCATION, STERNOCLAVICULA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23540 |  |  | DISLOCATION, ACROMIOCLAVICUL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23545 |  |  | TREATMENT CLOSED ACROMIOCLAV |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23550 |  |  | DISLOCATION, ACROMIOCLAVICUL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23552 |  |  | DISLOCATION, ACROMIOCLAVICUL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23570 |  |  | CLOSED TX SCAPULAR FRACTURE; |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23575 |  |  | FRACTURE, SCAPULAR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23585 |  |  | FRACTURE, SCAPULAR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23600 |  |  | FRACTURE, HUMERAL NECK |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23605 |  |  | FRACTURE, HUMERAL NECK |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23615 |  |  | FRACTURE, HUMERAL NECK |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23616 |  |  | OPEN TREAT W/PROXIMAL HUMERA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23620 |  |  | FRACTURE, HUMERAL NECK |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23625 |  |  | FRACTURE, HUMERAL NECK |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23630 |  |  | FRACTURE, HUMERAL NECK |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 23650 |  |  | DISLOCATION, SHOULDER |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23655 |  |  | DISLOCATION, SHOULDER |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23660 |  |  | DISLOCATION, SHOULDER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23665 |  |  | DISLOCATION, SHOULDER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23670 |  |  | DISLOCATION, SHOULDER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23675 |  |  | DISLOCATION, SHOULDER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23680 |  |  | DISLOCATION, SHOULDER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23700 |  |  | MANIPULATION, SHOULDER |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23800 |  |  | FUSION, SHOULDER JOINT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 23802 |  |  | FUSION, SHOULDER JOINT |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 23921 |  |  | DISARTICULATION, SHOULDER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 23930 |  |  | DRAINAGE, ABSCESS, HUMERUS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 23931 |  |  | DRAINAGE ABSCESS ELBOW INFEC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 23935 |  |  | INCISION DEEP OPENING BONE C |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24000 |  |  | ARTHROTOMY, ELBOW |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24006 |  |  | ARTHROTOMY ELBOW W/CAPSULAR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 11 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 24066 |  |  | BIOPSY,SOFT TISSUE UPPER ARM |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24071 |  |  | 3 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24073 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24075 |  |  | EXCISION,TUMOR,UPPER ARM OR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24076 |  |  | EXCISION, TUMOR, HUMERUS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24077 |  |  | RADICAL RESECTION OF TUMOR; |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24079 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24100 |  |  | ARTHROTOMY, ELBOW |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 24101 |  |  | ARTHROTOMY W/JOINT EXPLORE W |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24102 |  |  | ARTHROTOMY, ELBOW |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24105 |  |  | EXCISION, BURSA, OLECRANON |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24110 |  |  | EXCISION, CYST, HUMERUS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24115 |  |  | EXCISION, CYST, HUMERUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24116 |  |  | EXCISION, CYST, HUMERUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24120 |  |  | EXCISION, CYST, HUMERUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24125 |  |  | EXCISION, CYST, HUMERUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24126 |  |  | EXCISION, CYST, HUMERUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24130 |  |  | EXCISION, RADIAL HEAD |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24134 |  |  | SEQUESTRECTOMY, HUMERUS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24136 |  |  | SEQUESTRECTOMY, RADIAL HEAD |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24138 |  |  | SEQUESTRECTOMY, OLECRANON PR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24140 |  |  | EXCISION, PARTIAL, HUMERUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24145 |  |  | EXCISION, PARTIAL, RADIAL HE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24147 |  |  | EXCISION, PTL, OLECRANON PRC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24155 |  |  | RESECTION, ELBOW JOINT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24160 |  |  | REMOVAL, IMPLANT, ELBOW JOIN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24164 |  |  | REMOVAL, IMPLANT, RADIAL JOI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24201 |  |  | REMOVAL FB UPPER ARM/ELBOW D |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24301 |  |  | TRANSFER, TENDON, ARM |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24305 |  |  | LENGTHENING, TENDON, UPPER A |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24310 |  |  | TENOTOMY, UPPER ARM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24320 |  |  | TENOPLASTY, UPPER ARM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24330 |  |  | FLEXOR-PLASTY, ELBOW |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24331 |  |  | FLEXOR-PLASTY, ELBOW |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24340 |  |  | TENODESIS, ELBOW |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24341 |  |  | REPAIR TENDON/[NAME], UPPER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24342 |  |  | REINSERTION, TENDON, UPPER A |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24345 |  |  | REPAIR MEDIAL COLLATERAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24346 |  |  | RECONSTRUCTION LIGAMENT, ELBOW |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24359 |  |  | TENOTOMY, ELBOW, [NAME] OR MEDIAL |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 24360 |  |  | ARTHROPLASTY, ELBOW |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 24361 |  |  | ARTHROPLASTY ELBOW W/DISTAL |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 24362 |  |  | ARTHROPLASTY ELBOW W/IMPLANT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 12 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 24363 |  |  | ARTHROPLASTY ELBOW W/IMPLANT |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 24365 |  |  | ARTHROPLASTY, RADIAL HEAD |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 24366 |  |  | ARTHROPLASTY, RADIAL HEAD |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 24400 |  |  | OSTEOTOMY, HUMERUS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24410 |  |  | OSTEOTOMY, HUMERUS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24420 |  |  | OSTEOPLASTY, HUMERUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24430 |  |  | REPAIR, MALUNION, HUMERUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24435 |  |  | REPAIR, MALUNION, HUMERUS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24470 |  |  | HEMI-EPIPHYSEAL ARREST, HUME |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24495 |  |  | DECOMPRESSION FASCIOTOMY FOR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24498 |  |  | PROPHYLACTIC TREATMENT; HUME |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24500 |  |  | FRACTURE, HUMERAL SHAFT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 24505 |  |  | FRACTURE, HUMERAL SHAFT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 24515 |  |  | FRACTURE, HUMERAL SHAFT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24516 |  |  | OPEN TREAT HUMERAL SHAFT FX |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24530 |  |  | FRACTURE, TRANSCONDYLAR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 24535 |  |  | FRACTURE, TRANSCONDYLAR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 24538 |  |  | FRACTURE, TRANSCONDYLAR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24545 |  |  | FRACTURE, TRANSCONDYLAR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24546 |  |  | CLOSED TREAT HUMERAL CONDYLA |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 24560 |  |  | FRACTURE, EPICONDYLAR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 24565 |  |  | FRACTURE, EPICONDYLAR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24566 |  |  | PERCUTANEOUS SKELETAL FIXATI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24575 |  |  | FRACTURE, EPICONDYLAR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24576 |  |  | FRACTURE, CONDYLAR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 24577 |  |  | FRACTURE, CONDYLAR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 24579 |  |  | FRACTURE, CONDYLAR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24582 |  |  | PERCUTANEOUS SKELETAL FIXATI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24586 |  |  | OPEN TREAT C/O ELBOW FX W/EL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24587 |  |  | OPEN TREAT CLOSED/OPEN ELBOW |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 24600 |  |  | DISLOCATION, ELBOW |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 24605 |  |  | DISLOCATION, ELBOW |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24615 |  |  | DISLOCATION, ELBOW |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24620 |  |  | FRACTURE-DISLOCATION, ELBOW |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 24635 |  |  | FRACTURE-DISLOCATION, ELBOW |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24655 |  |  | FRACTURE, RADIAL HEAD |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 24665 |  |  | FRACTURE, RADIAL HEAD |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24666 |  |  | FRACTURE, RADIAL HEAD |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24670 |  |  | FRACTURE, ULNAR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 24675 |  |  | FRACTURE, ULNAR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 24685 |  |  | FRACTURE, ULNAR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 24800 |  |  | FUSION, ELBOW JOINT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 24802 |  |  | FUSION, ELBOW JOINT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 13 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 24925 |  |  | AMPUTATION, ARM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25000 |  |  | TENOVAGINOTOMY, WRIST |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25020 |  |  | DECOMPRESSION FASCIOTOMY WRI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25023 |  |  | DECOMP FASCIOTOMY W/DEBRIDEM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25024 |  |  | DECOMPRESSION FASCIOTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25025 |  |  | DECOMPRESSION FASCIOTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25028 |  |  | INCISION DRAIN FOREARM/WRIST |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 25031 |  |  | INFECTED BURSA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25035 |  |  | INCISION DEEP W/OPENING BONE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25040 |  |  | ARTHROTOMY, WRIST JOINT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25066 |  |  | BIOPSY, SOFT TISSUES, DEEP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25071 |  |  | 3 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25073 |  |  | 3 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25075 |  |  | EXCISION, BENIGN TUMOR, SUBC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25076 |  |  | [NAME] FOREARM/WRIST |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25077 |  |  | RADICAL RESECTION TUMOR, SOF |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25078 |  |  | 3 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25085 |  |  | CAPSULECTOMY, WRIST |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25100 |  |  | ARTHROTOMY, WRIST JOINT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25101 |  |  | ARTHROTOMY WRIST JOINT,BIOPS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25105 |  |  | ARTHROTOMY, WRIST JOINT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25107 |  |  | ARTHROTOMY, DSTL RDO-ULNR JN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25109 |  |  | EXCISION OF TENDON, FOREARM AND/OR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25110 |  |  | EXCSN, LSN, TENDN SHEATH, WR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25111 |  |  | EXCISION, GANGLION, WRIST |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25112 |  |  | EXCISION, GANGLION, WRIST |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25115 |  |  | TENOSYNOVECTOMY, FOREARM |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25116 |  |  | TENOSYNOVECTOMY, FOREARM |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25118 |  |  | SYNOVECTOMY, EXTENSOR TENDON |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25119 |  |  | SYNOVECTOMY,DSTL RDO-ULNR JN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25120 |  |  | EXCISION, CYST, ULNA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25125 |  |  | EXCISION, CYST, ULNA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25126 |  |  | EXCISION, CYST, ULNA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25130 |  |  | EXCISION, CYST, CARPAL BONES |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25135 |  |  | EXCISION, CYST, CARPAL BONES |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25136 |  |  | EXCISION, CYST, CARPAL BONES |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25145 |  |  | SEQUESTRECTOMY, FOREARM |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25150 |  |  | EXCISION, PARTIAL, ULNA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25151 |  |  | EXCISION, PARTIAL, RADIUS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25210 |  |  | CARPECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25215 |  |  | CARPECTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25230 |  |  | RADIAL STYLOIDECTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25240 |  |  | EXCISION, DISTAL ULNA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 14 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 25248 |  |  | EXPLORATION REMOVAL DEEP FB |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25250 |  |  | REMOVAL OF WRIST PROSTHESIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 25251 |  |  | REMOVAL OF WRIST PROSTHESIS; |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 25260 |  |  | REPAIR, [NAME], FOREARM |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25263 |  |  | REPAIR, [NAME], FOREARM |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25265 |  |  | REPAIR TENDON-MUSCLE FOREARM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25270 |  |  | AMB SURG CTR-REPAIR,[NAME],F |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25272 |  |  | REPAIR, [NAME], FOREARM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25274 |  |  | REPAIR, [NAME], FOREARM |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25275 |  |  | REPAIR OF TENDON SHEATH |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25280 |  |  | LENGTHENING, TENDON, FOREARM |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25290 |  |  | TENOTOMY, FOREARM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25295 |  |  | TENOLYSIS, FOREARM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25300 |  |  | TENODESIS, DGT FLEXRS, AT WR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25301 |  |  | TENODESIS, DGT FLEXRS, AT WR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25310 |  |  | TRANSPLANT, TENDON, WRIST |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25312 |  |  | TRANSPLANT, TENDON, WRIST |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25315 |  |  | FLEXOR ORIGIN SLIDE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25316 |  |  | REPAIR WITH TENDON TRANSFER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25320 |  |  | CAPSULORRHAPHY/RECONST CAPSU |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25332 |  |  | ARTHROPLASTY WRIST;PSEUDOART |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25335 |  |  | CENTRALIZATION WRIST ON ULNA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25337 |  |  | RECONSTRUCT FOR STABILIZATIO |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25350 |  |  | OSTEOTOMY, RADIUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25355 |  |  | OSTEOTOMY, RADIUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25360 |  |  | OSTEOTOMY, ULNA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25365 |  |  | OSTEOTOMY, RADIUS & ULNA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25370 |  |  | MULTIPLE OSTEOTOMIES W/REALI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25375 |  |  | OSTEOTOMY, RADIUS AND/OR ULN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25390 |  |  | OSTEOPLASTY, RADIUS/ULNA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25391 |  |  | OSTEOPLASTY, RADIUS/ULNA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25392 |  |  | OSTEOPLASTY, RADIUS/ULNA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25393 |  |  | OSTEOPLASTY, RADIUS/ULNA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25400 |  |  | REPAIR, MALUNION, RADIUS/ULN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25405 |  |  | REPAIR, MALUNION, RADIUS/ULN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25415 |  |  | REPAIR, MALUNION, RADIUS/ULN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25420 |  |  | REPAIR, MALUNION, RADIUS/ULN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25425 |  |  | REPAIR, BONE DEFICIT, FOREAR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25426 |  |  | REPAIR, BONE DEFICIT, FOREAR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25440 |  |  | REPAIR, NON-UNION, NAVICULAR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25441 |  |  | REPLACEMENT, IMPLANT, WRIST |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25442 |  |  | REPLACEMENT, IMPLANT, WRIST |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25443 |  |  | REPLACEMENT, IMPLANT, WRIST |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 15 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 25444 |  |  | REPLACEMENT, IMPLANT, WRIST |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25445 |  |  | REPLACEMENT, IMPLANT, WRIST |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25446 |  |  | TOTAL WRIST REPLACEMENT |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 25447 |  |  | INTERPOSITION ARTHROPLASTY,I |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25449 |  |  | REVISION ARTHROPLASTY INC RE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25450 |  |  | EPIPHYSEAL ARREST, FOREARM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25455 |  |  | EPIPHYSEAL ARREST, FOREARM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25490 |  |  | PROPHYLACTIC TREATMENT; RADI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25491 |  |  | PROPHYLACTIC TREATMENT; ULNA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25492 |  |  | PROPHYLACTIC TREATMENT; RADI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25505 |  |  | FRACTURE, RADIAL SHAFT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 25515 |  |  | FRACTURE, RADIAL SHAFT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25520 |  |  | CLOSED TREAT RADIAL SHAFT FX |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 25525 |  |  | OPEN TREAT RADIAL SHAFT FX W |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25526 |  |  | OPEN TREAT RADIAL SHAFT FX O |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25535 |  |  | FRACTURE, ULNAR SHAFT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 25545 |  |  | FRACTURE, ULNAR SHAFT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25565 |  |  | TREAT CLOSED RADIAL/ULNAR SH |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25574 |  |  | OPEN TREAT RADIAL/ULNAR SHAF |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25575 |  |  | FRACTURE, RADIAL & ULNAR SHA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25605 |  |  | COLLES FRACTURE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25606 |  |  | PERCUTANEOUS SKELETAL FIXATION OF |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25607 |  |  | OPEN TREATMENT/DISTAL RAD EXTRA-AR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25608 |  |  | OPEN TREATMENT DIST/RAD INTRA-ARTI |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25609 |  |  | OPEN TREATMENT OF DISTAL RADIAL IN |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25624 |  |  | TREAT CLOSED CARPAL SCOPHOID |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25628 |  |  | OPEN TREATMENT OF CARPAL SCA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25635 |  |  | TX CLOSED CARPAL BONE FRACTU |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 25645 |  |  | FRACTURE, CARPAL BONE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25660 |  |  | [NAME] 1-M |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 25670 |  |  | DISLOCATION, INTERCARPAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25671 |  |  | PERCUTANEOUS SKELETAL FIXATION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 25675 |  |  | DISLOCATN, DISTAL RADIO-ULNA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 25676 |  |  | DISLOCATN, DISTAL RADIO-ULNA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25680 |  |  | FRACTURE, TRANS-SCAPHO-PERIL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25685 |  |  | FRACTURE, TRANS-SCAPHO-PERIL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25690 |  |  | DISLOCATION, LUNATE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 25695 |  |  | DISLOCATION, LUNATE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 25800 |  |  | ARTHRODESIS, WRIST JOINT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25805 |  |  | ARTHRODESIS, WRIST JOINT WIT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25810 |  |  | ARTHRODESIS, WRIST JOINT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25820 |  |  | INTERCARPAL FUSION; WITHOUT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 25825 |  |  | INTERCARPAL FUSION & AUTOGEN |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 16 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 25830 |  |  | RESECTION ULNA W/W/O BONE GR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 25907 |  |  | AMPUTATION, FOREARM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25922 |  |  | AMPUTATION, WRIST |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25929 |  |  | AMPUTATION, TRANSMETACARPAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 25999 |  |  | UNLISTED PROCEDURE, FOREARM/ |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26011 |  |  | DRAINAGE, ABSCESS, FINGER TI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 26020 |  |  | DRAINAGE, TENDON SHEATH, HAN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26025 |  |  | DRAINAGE, BURSA, PALMAR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 26030 |  |  | DRAIN PALMAR BURSA MULTIPLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26034 |  |  | INCISION, HAND |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26040 |  |  | FASCIOTOMY, PALMAR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26045 |  |  | FASCIOTOMY, PALMAR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26055 |  |  | TENDON SHEATH INCISION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26060 |  |  | TENOTOMY, FINGER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26070 |  |  | ARTHROTOMY, HAND JOINTS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26075 |  |  | ARTHROTOMY, HAND JOINTS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26080 |  |  | ARTHROTOMY, HAND JOINTS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26100 |  |  | BIOPSY, SYNOVIAL, HAND JOINT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26105 |  |  | BIOPSY, SYNOVIAL, HAND JOINT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 26110 |  |  | BIOPSY, SYNOVIAL, HAND JOINT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 26111 |  |  | 1.5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26113 |  |  | 1.5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26115 |  |  | EXCISION OF BENIGN TUMOR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26116 |  |  | EXCISION OF BENIGN TUMOR, DE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26117 |  |  | RADICAL RESECTION/TUMOR,SOFT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26118 |  |  | 3 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26121 |  |  | FASCIECTOMY PALMAR WITH OR W |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26123 |  |  | FACIECTOMY PARTIAL PALMAR EX |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26125 |  |  | PARTIAL EXCISION RELEASE EAC |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26130 |  |  | SYNOVECTOMY, HAND JOINTS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26135 |  |  | SYNOVECTOMY, HAND JOINTS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26140 |  |  | SYNOVECTOMY, FINGER JOINTS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26145 |  |  | SYNOVECTOMY, TNDN SHEATH, HA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26160 |  |  | EXCISN LSN,TNDN SHEATH HAND |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26170 |  |  | EXCISION, TENDON, HAND |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26180 |  |  | EXCISION, TENDON, HAND |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26185 |  |  | SESAMOIDECTOMY, THUMB OR FIN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26200 |  |  | EXCISION, CYST, METACARPAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26205 |  |  | EXCISION, CYST, METACARPAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26210 |  |  | EXCISION, CYST, PHALANX, FNG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26215 |  |  | EXCISION, CYST, PHALANX, FNG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26230 |  |  | EXCISION, PARTIAL, [NAME] |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 26235 |  |  | EXCISION, PARTL, PHALANX, FN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 17 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 26236 |  |  | EXCISION, PARTL, PHALANX, FN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26250 |  |  | OSTECTOMY, METACARPAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26260 |  |  | OSTECTOMY, PHALANX, FINGER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26262 |  |  | RADICAL RESECTION FOR TUMOR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26320 |  |  | REMOVAL, IMPLANT, HAND |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26350 |  |  | REPAIR, TENDON, FINGER |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 26352 |  |  | REPAIR, TENDON, FINGER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26356 |  |  | FLEXOR TENDON REPAIR OR ADVA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26357 |  |  | FLEXOR TENDON REPAIR/ADVANCE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26358 |  |  | FLEXOR TENDON REPAIR SECOUNDARY W/F |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26370 |  |  | [NAME] REPR OR ADVA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26372 |  |  | PROFUNDUS TENDON REPAIR SECO |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26373 |  |  | PROFUNDUS TENDON REPAIR/ADVA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26390 |  |  | EXCISION, FLEXOR TENDON, FIN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26392 |  |  | GRAFT, TENDON, FINGER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26410 |  |  | REPAIR, TENDON, DORSUM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26412 |  |  | REPAIR, TENDON, DORSUM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26415 |  |  | EXTENSOR TENDON EXCISION IMP |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26416 |  |  | REMOVAL TUBE/ROD INSERT OF E |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26418 |  |  | REPAIR, TENDON, DORSUM |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26420 |  |  | REPAIR, TENDON, DORSUM |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26426 |  |  | REPAIR, CENTRAL SLIP |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26428 |  |  | REPAIR, CENTRAL SLIP |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26432 |  |  | MALLET FINGER OPERATION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26433 |  |  | EXSTENSOR TENDON REPAIR, DIS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26434 |  |  | MALLET FINGER OPERATION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26437 |  |  | EXTENSOR TENDON REALIGNMENT, |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26440 |  |  | TENOLYSIS, PALM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26442 |  |  | TENOLYSIS, PALM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26445 |  |  | TENOLYSIS, FINGER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26449 |  |  | TENOLYSIS, FINGER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26450 |  |  | TENOTOMY, PALM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26455 |  |  | TENOTOMY, PALM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26460 |  |  | TENOTOMY, PALM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26471 |  |  | TENODESIS, FINGER JOINT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26474 |  |  | TENODESIS, FINGER JOINT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26476 |  |  | TENDON LENGTHENING EXTENSOR HAND/FI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 26477 |  |  | TENDON SHORTENING EXTENSOR HAND/FIN |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 26478 |  |  | TENDON LENGTHENING FLEXOR HAND/FING |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 26479 |  |  | TENDON SHORTENING FLEXOR HAND/FINGE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 26480 |  |  | TRANSPLANT, TENDON, HAND |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26483 |  |  | TRANSPLANT, TENDON, HAND |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26485 |  |  | TRANSPLANT, TENDON, HAND |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 18 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 26489 |  |  | TRANSPLANT, TENDON, HAND |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26490 |  |  | OPPONENS PLASTY, HAND |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26492 |  |  | OPPONENS PLASTY, HAND |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26494 |  |  | OPPONENS PLASTY, HAND |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26496 |  |  | OPPONENS PLASTY; OTHER METHO |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26497 |  |  | TENDON TRANSFER RESTORE INTR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26498 |  |  | TENDON TRANSFER TO RESTORE I |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26499 |  |  | CORRECTION CLAW FINGER, OTHE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26500 |  |  | TENDON PULLEY RECNSTRCTN, HN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26502 |  |  | TENDON PULLEY RECNSTRCTN, HN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26508 |  |  | THENAR [NAME] RELEASE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26510 |  |  | CROSS INTRINSIC TRANSFER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26516 |  |  | CAPSULODESIS M-P JOINT STABI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 26517 |  |  | CAPSULODESIS, FINGER JOINT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26518 |  |  | CAPSULODESIS, FINGER JOINT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26520 |  |  | CAPSULECTOMY, FINGER JOINT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26525 |  |  | CAPSULECTOMY, FINGER JOINT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26530 |  |  | ARTHROPLASTY, FINGER JOINT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26531 |  |  | ARTHROPLASTY, FINGER JOINT |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 26535 |  |  | ARTHROPLASTY, FINGER JOINT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 26536 |  |  | ARTHROPLASTY, FINGER JOINT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 26540 |  |  | RECNSTRCTN, LIGAMENT, FGR JN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26541 |  |  | RECNSTRCTN, LIGAMENT, FGR JN |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 26542 |  |  | REPAIR OF CALLATELAL LIGAMEN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26545 |  |  | RECNSTRCTN, LIGAMENT, FGR JNT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26546 |  |  | REPAIR NON-UNION, METACARPAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26548 |  |  | REPAIR/RECONSTRUCT, FINGER,V |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26550 |  |  | POLLICIZATION, FINGER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26555 |  |  | POSITIONAL CHANGE, FINGER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26560 |  |  | REPAIR, SYNDACTLY, FINGERS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26561 |  |  | REPAIR, SYNDACTLY, FINGERS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26562 |  |  | REPAIR SYNDACTYLY EA WEB SPA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26565 |  |  | OSTEOTOMY, FINGER |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 26567 |  |  | OSTEOTOMY, FINGER |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 26568 |  |  | OSTEOPLASTY TO LENGTHEN META |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26580 |  |  | REPAIR, CLEFT HAND |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 26587 |  |  | RECONSTRUCTION SUPERNUMERARY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 26590 |  |  | REPAIR, MACRODACTLY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 26591 |  |  | REPAIR INTRINSIC MUSCLES OF |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26593 |  |  | RELEASE, INTRINSIC MUSCLES O |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26596 |  |  | EXCISION CONSTRICTING RING O |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26605 |  |  | FRACTURE, METACARPAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26607 |  |  | TREATMENT CLOSED METACARPAL FRACTUR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 19 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 26608 |  |  | PERCUTANEOUS SKELETAL FIXATION META |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26615 |  |  | FRACTURE, METACARPAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26645 |  |  | FCTRE/DISLOC, CARPOMETACARPA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 26650 |  |  | FCTRE/DISLOC, CARPOMETACARPA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26665 |  |  | FCTRE/DISLOC, CARPOMETACARPA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26675 |  |  | FCTRE/DISLOC, CARPOMETACARPA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26676 |  |  | TREAT CLOSED CARPOMETACARPAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26685 |  |  | FCTRE/DISLOC, CARPOMETACARPA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26686 |  |  | OPEN TREAT OF C/O CARPOMETAC |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26705 |  |  | DISLOC, METACARPO-PHALANGEAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26706 |  |  | TREAT CLOSED METACARPOPHALAN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26715 |  |  | DISLOC, METACARPO-PHALANGEAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26727 |  |  | TRTMT UNSTABLE PHALANGEAL SHAFT F |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 26735 |  |  | FRACTURE, PHALANX, FINGER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26742 |  |  | TREATMENT CLOSED ARTICULAR FRACTURE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26746 |  |  | OPEN TX/ARTICULAR FX,METACARPAL-PHA |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 26756 |  |  | OPEN TREAT CLOSED/OPEN DISTAL PHALA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26765 |  |  | FRACTURE, PHALANX, FINGER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26776 |  |  | WITH PERCUTANEOUS PINNING |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26785 |  |  | DISLC, INTPHALANGEAL JNT, FG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26820 |  |  | FUSION IN OPPOSITION, THUMB |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 26841 |  |  | ARTHRODESIS, CARPOMTCRPL JNT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26842 |  |  | ARTHRODESIS, CARPOMTCRPL JNT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26843 |  |  | ARTHRODESIS, CARPOMTCRPL JNT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26844 |  |  | ARTHRODESIS, CARPOMTCRPL JNT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26850 |  |  | ARTHRODESIS, METCRPOPHALNGL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26852 |  |  | ARTHRODESIS, METCRPOPHALNGL JT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26860 |  |  | ARTHRODESIS, ITRPHLNGL JT, F |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26861 |  |  | ARTHRODESIS INTERPHALANGEAL JNT W/W |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26862 |  |  | ARTHRODESIS, ITRPHLNGL JT, F |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26863 |  |  | ARTHRODESIS W/AUTOGRAFT, EACH ADDIT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26910 |  |  | AMPUTATION, METACARPAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 26951 |  |  | AMPUTATION, FINGER/THUMB |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 26952 |  |  | AMPUTATION, FINGER/THUMB |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 26990 |  |  | DRAINAGE, ABSCESS, PELVIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 26991 |  |  | DRAINAGE, BURSA, HIP JOINT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27000 |  |  | TENOTOMY,[NAME] |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27001 |  |  | TENOTOMY ABDUCTOR SUBCUTAN,O |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27003 |  |  | TENOTOMY, ADDUCTOR, SUBCUTAN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27033 |  |  | ARTHROTOMY, HIP |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27035 |  |  | DENERVATION, HIP JOINT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27040 |  |  | BIOPSY, SOFT TISSUE OF PELVI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27041 |  |  | BIOPSY, SOFT TISSUES, DEEP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 20 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 27043 |  |  | 3 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27045 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27047 |  |  | EXCISION OF TUMOR PELVIS, HI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27048 |  |  | EXCISION, TUMOR, HIP |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27049 |  |  | RADICAL RESECTION TUMOR,SOFT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27050 |  |  | BIOPSY, SACROILIAC JOINT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27052 |  |  | BIOPSY, HIP JOINT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27059 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27060 |  |  | EXCISION, ISCHIAL BURSA |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27062 |  |  | EXCISION, TROCHANTERIC BURSA |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27065 |  |  | EXCISION, CYST, PELVIS |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27066 |  |  | EXCISION, CYST, PELVIS |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27067 |  |  | EXCISION OF BONE CYST/BENIGN |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27080 |  |  | COCCYGECTOMY-PRIMARY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27086 |  |  | REMOVAL FB PELVIS OR HIP SUB |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27087 |  |  | REMOVAL, FOREIGN BODY, HIP |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27096 |  |  | INJECTION FOR SACROILIAC JOINT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27097 |  |  | HAMSTRING RECESSION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27098 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27100 |  |  | TRANSFER, [NAME], OBLIQUE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27105 |  |  | TRANSFER, MUSCLE, PARASPINAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27110 |  |  | TRANSFER, ILIOPSOAS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27111 |  |  | TRANSFER,ILIOPSOAS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27193 |  |  | CLOSED TRTMENT OF PELVIC RIN |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27194 |  |  | CLOSED TREAT PELVIC RING FX |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27202 |  |  | OPEN TREATMENT OF CLOSED/OPE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27230 |  |  | FRACTURE, FEMUR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27238 |  |  | FRACTURE, INTERTROCHANTERIC |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27246 |  |  | FRACTURE, GREATER TROCHANTER |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27250 |  |  | DISLOCATION, HIP |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27252 |  |  | DISLOCATION, HIP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27257 |  |  | DISLOCATION, HIP |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27265 |  |  | TREATMENT ATRAUMATIC HIP DIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27266 |  |  | TREATMENT OF ATRAUMATIC HIP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27275 |  |  | MANIPULATION, HIP JOINTS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27301 |  |  | INCISION/DRAINAGE DEEP ABSCE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27305 |  |  | FASCIOTOMY, ILIO-TIBIAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27306 |  |  | TENOTOMY, DISTAL HAMSTRING |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27307 |  |  | TENOTOMY, DISTAL HAMSTRING |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27310 |  |  | ARTHROTOMY, KNEE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27323 |  |  | BIOPSY, SOFT TISSUE THIGH OR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27324 |  |  | BIOPSY SOFT TISSUE DEEP THIG |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27325 |  |  | NEURECTOMY, HAMSTRING MUSCLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 21 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 27326 |  |  | NEURECTOMY, POPLITEAL (GASTROCNEMI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27327 |  |  | EXCISION TUMOR THIGH OR KNEE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27328 |  |  | EXCISION TUMOR THIGH OR KNEE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27329 |  |  | RADICAL RESECTION OF TUMOR/S |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27330 |  |  | ARTHROTOMY, KNEE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27331 |  |  | ARTHROTOMY, KNEE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27332 |  |  | ARTHROTOMY, KNEE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27333 |  |  | ARTHROTOMY, KNEE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27334 |  |  | ARTHROTOMY, KNEE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27335 |  |  | ARTHROTOMY, KNEE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27337 |  |  | 3 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27339 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27340 |  |  | EXCISION, BURSA, PREPATELLAR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27345 |  |  | EXCISION, CYST, POPLITEAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27347 |  |  | EXCISION OF LESION OF MEN. OR [NAME]. |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27350 |  |  | PATELLECTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27355 |  |  | EXCISION, CYST, FEMUR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27356 |  |  | EXCISION BONE CYST BENIGN TU |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27357 |  |  | EXCISION, CYST, FEMUR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27358 |  |  | EXCISION/CURETTAGE BONE CYST |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27360 |  |  | EXCISION, PARTIAL, FEMUR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27364 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27372 |  |  | REMOVAL FB DEEP THIGH/KNEE |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 27380 |  |  | SUTURE, TENDON, INFRAPATELLA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27381 |  |  | SUTURE INFRAPATELLAR TENDON |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27385 |  |  | SUTURE, [NAME], QUADRICEPS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27386 |  |  | SUTURE, [NAME], QUADRICEPS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27390 |  |  | TENOTOMY, HAMSTRING |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27391 |  |  | TENOTOMY, HAMSTRING |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27392 |  |  | TENOTOMY, HAMSTRING,KNEE-HIP |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27393 |  |  | LENGTHENING, TENDON, HAMSTRI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27394 |  |  | LENGTHENING, TENDON, HAMSTRI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27395 |  |  | LENGTHENING OF HAMSTRING TEN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27396 |  |  | TRANSPLANT, TENDON, HAMSTRIN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27397 |  |  | TRANSPLANT, TENDON, HAMSTRIN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27400 |  |  | TRANSFER, [NAME], HAMSTRING |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27403 |  |  | ARTHROTOMY W/OPEN MENISCUS R |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27405 |  |  | REPAIR, LIGAMENT, KNEE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27407 |  |  | REPAIR, LIGAMENT, KNEE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27409 |  |  | REPAIR, LIGAMENT, KNEE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27418 |  |  | ANTERIOR TIBIAL TUBERCLEPLAS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27420 |  |  | RECONSTRUCTION, PATELLA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27422 |  |  | RECONSTRUCTION, PATELLA |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 22 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 27424 |  |  | RECONSTRUCTION, PATELLA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27425 |  |  | LATERAL RETINACULAR RELEASE |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 27427 |  |  | LIGAMENT RECONSTRUCTION KNEE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27428 |  |  | RECONSTRUCTION KNEE INTRAART |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27429 |  |  | RECONSTRUCTION KNEE INTRA AN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27430 |  |  | QUADRICEPSPLASTY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27435 |  |  | CAPSULOTOMY, KNEE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27437 |  |  | ARTHROPLASTY PATELLA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27438 |  |  | ARTHROPLASTY PATELLA W/PROST |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27441 |  |  | ARTHROPLASTY W/DEBRIDEMENT A |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27442 |  |  | ARTHROPLASTY, KNEE, FEMORAL |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27443 |  |  | ARTHROPLASTY W/DEBRIDEMENT & |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27496 |  |  | [NAME] |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27497 |  |  | DECOMPRESS FASCIOTOMY THIGH |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27498 |  |  | DECOMPRESSION FASCIOTOMY HIG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27499 |  |  | DECOMPRESS FASCIOTOMY THIGH |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27500 |  |  | FRACTURE, FEMUR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27501 |  |  | CLOSED TREAT SUPRACONDYLAR F |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27502 |  |  | FRACTURE, FEMUR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27503 |  |  | CLOSED TREAT SUPRACONDYLAR F |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27508 |  |  | FRACTURE, FEMUR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27509 |  |  | PERCUTANEOUS SKELETAL FIXATI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27510 |  |  | FRACTURE, FEMUR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27516 |  |  | FRACTURE, FEMUR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27517 |  |  | FRACTURE, FEMUR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27520 |  |  | FRACTURE, PATELLA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27530 |  |  | FRACTURE, TIBIA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27532 |  |  | FRACTURE, TIBIA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27538 |  |  | FRACTURE, TIBIA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27550 |  |  | DISLOCATION, KNEE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27552 |  |  | DISLOCATION, KNEE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27560 |  |  | TREAT CLOSED PATELLAR DISLOC |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27562 |  |  | DISLOCATION, PATELLA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27566 |  |  | DISLOCATION, PATELLA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27570 |  |  | MANIPULATION, KNEE JOINT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27594 |  |  | AMPUTATION, THIGH |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27600 |  |  | DECOMPRESSION FASCIOTOMY LEG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27601 |  |  | [NAME],LEG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27602 |  |  | FASCIOTOMY, LEG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27603 |  |  | INCISION/DRAIN LEG/ANKLE DEE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27604 |  |  | INCISION/DRAIONAGE LEG/ANKLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27605 |  |  | TENOTOMY, ACHILLES TENDON |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27606 |  |  | TENOTOMY, ACHILLES TENDON |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 23 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 27607 |  |  | INCISION DEEP W/OPENING BONE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27610 |  |  | ARTHROTOMY, ANKLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27612 |  |  | ARTHROTOMY, ANKLE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27614 |  |  | BX SOFT TISSUES, DEEP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27615 |  |  | RADICAL RECESTION OF TUMOR,S |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27616 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27618 |  |  | EXCISION, BENIGN TUMOR, SUBC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27619 |  |  | EXCISION, TUMOR, LEG OR ANKL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27620 |  |  | ARTHROTOMY, ANKLE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27625 |  |  | ARTHROTOMY, ANKLE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27626 |  |  | ARTHROTOMY, INCLUDING TENOSY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27630 |  |  | EXCISION, LESION, LEG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27632 |  |  | 3 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27634 |  |  | 5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27635 |  |  | EXCISION, CYST, TIBIA/FIBULA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27637 |  |  | EXCISION, CYST, TIBIA/FIBULA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27638 |  |  | EXCISION/CURETTAGE BONE CYST |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27640 |  |  | EXCISION, PARTIAL, TIBIA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27641 |  |  | EXCISION, PARTIAL, FIBULA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27647 |  |  | RESECTION, ASTRAGALUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27650 |  |  | REPAIR, ACHILLES TENDON |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27652 |  |  | REPAIR RUPTURED ACHILLES TEN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27654 |  |  | REPAIR, ACHILLES TENDON |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27656 |  |  | REPAIR, FASCIAL DEFECT, LEG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27658 |  |  | REPAIR, TENDON, LEG |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27659 |  |  | REPAIR, TENDON, LEG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27664 |  |  | REPAIR OF EXTENSOR TENDON OF LEG PR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27665 |  |  | SECONDARY WITH OR W/O GRAFT, SINGLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27675 |  |  | REPAIR DISLOCATING PERONAL T |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27676 |  |  | REPAIR, TENDON, LEG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27680 |  |  | TENOLYSIS, LEG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27681 |  |  | TENOLYSIS, LEG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27685 |  |  | LENGTHEN/SHORTEN TENDON, LEG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27686 |  |  | LENGTHEN/SHORTEN TENDON, LEG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27687 |  |  | GASTROCNEMIUS RECESSION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27690 |  |  | TRANSFER, TENDON, LEG |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27691 |  |  | TRANSFER, TENDON, LEG |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27692 |  |  | TRANSFER, TENDON, LEG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27695 |  |  | REPAIR, LIGAMENT, ANKLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27696 |  |  | REPAIR, LIGAMENT, ANKLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27698 |  |  | REPAIR, LIGAMENT, ANKLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27700 |  |  | ARTHROPLASTY, ANKLE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 27704 |  |  | REMOVAL OF ANKLE IMPLANT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 24 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 27705 |  |  | OSTEOTOMY, TIBIA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27707 |  |  | OSTEOTOMY, FIBULA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27709 |  |  | OSTEOTOMY, TIBIA/FIBULA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27730 |  |  | EPIPHYSEAL ARREST, LOWER LEG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27732 |  |  | EPIPHYSEAL ARREST, LOWER LEG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27734 |  |  | EPIPHYSEAL ARREST, LOWER LEG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27740 |  |  | EPIPHYSEAL ARREST, LOWER LEG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27742 |  |  | EPIPHYSEAL ARREST, LOWER LEG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27745 |  |  | PROPHYLACTIC TREATMENT, TIBI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27750 |  |  | FRACTURE, TIBIA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27752 |  |  | FRACTURE, TIBIA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27756 |  |  | FRACTURE, TIBIA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27758 |  |  | OPEN CLOSED TRIMENT TIBIAL S |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27759 |  |  | OPEN TREAT TIBIAL SHAFT FX B |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27760 |  |  | FRACTURE MEDIAL MALLEOLUS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27762 |  |  | FRACTURE, TIBIA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27766 |  |  | FRACTURE, TIBIA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27780 |  |  | FRACTURE, FIBULA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27781 |  |  | FRACTURE, FIBULA; WITH MANIP |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27784 |  |  | FRACTURE, FIBULA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27788 |  |  | FRACTURE, FIBULA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27792 |  |  | OPEN TREATMENT DISTAL FIBULA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27808 |  |  | FRACTURE, TIBIA AND FIBULA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27810 |  |  | FRACTURE, TIBIA AND FIBULA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27814 |  |  | FRACTURE, TIBIA AND FIBULA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27816 |  |  | TREAT CLOSED TRIMALLEOLAR AN |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27818 |  |  | FRACTURE, TIBIA AND FIBULA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27822 |  |  | FRACTURE, TIBIA AND FIBULA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27823 |  |  | FRACTURE, TIBIA AND FIBULA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27824 |  |  | CLOSED TREAT WEIGHT BEARING |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27825 |  |  | W/SKELETAL TRACTION OR [NAME] |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27826 |  |  | OPEN TREAT FX WT BEARING ART |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27827 |  |  | FRACTURE/DISLOCATION OF TIBIA ONLY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27828 |  |  | OF BOTH TIBIA AND FIBULA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27829 |  |  | OPEN TREAT DISTAL TIBIOFIBUL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27830 |  |  | DISLOCATION, TIBIO-FIBULAR J |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27831 |  |  | TREATMENT PROXIAML TIBIOFIBU |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27832 |  |  | DISLOCATION, TIBIO-FIBULAR J |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 27840 |  |  | DISLOCATION, ANKLE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27842 |  |  | DISLOCATION, ANKLE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 27846 |  |  | DISLOCATION, ANKLE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27848 |  |  | DISLOCATION, TIBIO-FIBULAR J |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27860 |  |  | MANIPULATION, ANKLE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 25 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 27870 |  |  | ARTHRODESIS, ANKLE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27871 |  |  | ARTHRODESIS TIBIOFIBULAR JOI |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 27884 |  |  | AMPUTATION, LEG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27889 |  |  | DISARTICULATION, ANKLE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27892 |  |  | DECOMPRESSION FASCIOTOMY LEG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27893 |  |  | POSTERIOR COMPARTMENTS ONLY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 27894 |  |  | ANTERIOR AND LATERAL COMPART |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28002 |  |  | DEEP DISSECTION BELOW FASCIA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28003 |  |  | DEEP DISSECTION BELOW FASCIA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28005 |  |  | INCISION, DEEP, W/OPENING OF BONE C |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28008 |  |  | FASCIOTOMY FOOT-TOE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28011 |  |  | TENOTOMY, TOE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28020 |  |  | ARTHROTOMY, TOE JOINTS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28022 |  |  | ARTHROTOMY, TOE JOINTS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28024 |  |  | ARTHROTOMY, TOE JOINTS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28035 |  |  | TARSAL TUNNEL RELEASE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28039 |  |  | 1.5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28041 |  |  | 1.5 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28043 |  |  | EXCISION TUMOR FOOT SUBCUTAN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28045 |  |  | EXCISION, TUMOR, FOOT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28046 |  |  | RADICAL RESECTION OF TUMOR, |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28047 |  |  | 3 CM OR GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28050 |  |  | ARTHROTOMY, FOOT JOINT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28052 |  |  | ARTHROTOMY, FOOT JOINT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28054 |  |  | ARTHROTOMY, FOOT JOINT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28055 |  |  | NEURECTOMY, INTRINSIC MUSCULATURE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28060 |  |  | FASCIECTOMY, PLANTAR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28062 |  |  | FASCIECTOMY EXCISION OF PLAN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28070 |  |  | SYNOVECTOMY, FOOT JOINTS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28072 |  |  | SYNOVECTOMY, FOOT JOINTS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28080 |  |  | EXCISION, MORTONS NEUROMA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28086 |  |  | SYNOVECTOMY, FOOT TENDONS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28088 |  |  | SYNOVECTOMY, FOOT TENDONS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28090 |  |  | EXCISION, LESION, FOOT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28092 |  |  | EXCISION LESION OF TENDON OR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28100 |  |  | EXCISION, TUMOR, FOOT BONES |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28102 |  |  | EXCISION, TUMOR, FOOT BONES |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28103 |  |  | EXCISION OF BONE CYST/BENIGN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28104 |  |  | EXCISION, TUMOR, FOOT BONES |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28106 |  |  | EXCISION, TUMOR, FOOT BONES |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28107 |  |  | EXCISION BONE CYST TARSAL/ME |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28108 |  |  | EXCISION, TUMOR, FOOT BONES |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28110 |  |  | OSTECTOMY PARTIAL EXCISION F |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 26 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 28111 |  |  | OSTECTOMY, METATARSAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28112 |  |  | OSTECTOMY, METATARSAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28113 |  |  | OSTECTOMY COMPLETE 5TH METAT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28114 |  |  | OSTECTOMY, METATARSAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28116 |  |  | EXCISION, TARSAL COALITION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28118 |  |  | EXCISION, OS CALCIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28119 |  |  | EXCISION, OS CALCIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28120 |  |  | EXCISION, PARTIAL, FOOT BONE |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 28122 |  |  | EXCISION, PARTIAL, FOOT BONE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28124 |  |  | EXCISION, PARTL, PHALANX, TO |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 28126 |  |  | CONDYLECTOMY, PHALANGEAL [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28130 |  |  | ASTRAGALECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28140 |  |  | METATARSECTOMY, FOOT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28150 |  |  | PHALANGECTOMY, FOOT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28153 |  |  | RESECTION, HEAD OF PHALANX, |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28160 |  |  | HEMIPHALANGECTOMY, FOOT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28171 |  |  | RADICAL RESECTION FOR TUMOR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28173 |  |  | RADICAL RESECTION FOR TUMOR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28175 |  |  | RADICAL RESECTION FOR TUMOR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28192 |  |  | REMOVAL FB FOOT DEEP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28193 |  |  | REMOVAL FB FOOT COMPLICATED |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28200 |  |  | REPAIR, TENDON, FOOT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28202 |  |  | REPAIR, TENDON, FOOT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28208 |  |  | REPAIR, TENDON, FOOT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28210 |  |  | REPAIR, TENDON, FOOT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28222 |  |  | TENOLYSIS, FOOT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 28225 |  |  | TENOLYSIS, FOOT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 28226 |  |  | TENOLYSIS, EXTENSOR, FOOT, MULTIPLE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 28232 |  |  | TENOTOMY, FOOT |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 28234 |  |  | TENOTOMY, FOOT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28238 |  |  | ADVANCEMENT, TENDON, FOOT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28240 |  |  | TENOTOMY, ABDUCTR HALLCS MSL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28250 |  |  | DIVISION, PLANTAR FASCIA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28260 |  |  | CAPSULOTOMY, FOOT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28261 |  |  | CAPSULOTOMY, FOOT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28262 |  |  | CAPSULOTOMY, FOOT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28264 |  |  | CAPSULOTOMY, FOOT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 28270 |  |  | CAPSULOTOMY, FOOT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28272 |  |  | CAPSULATOMY INTERPHALANGEAL JOINT, |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 28280 |  |  | WEBBING OPERATION, TOES |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28285 |  |  | ARTHRODESIS, INTRPHNGL JT, T |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28286 |  |  | PLASTIC PROCEDURE, FIFTH TOE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28288 |  |  | EXOSTECTOMY, METATARSAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 27 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 28289 |  |  | HALLUX RIGIDUS CORRECT [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28290 |  |  | HALLUX VALGUS CORRECTION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28292 |  |  | HALLUX VALGUS CORRECTION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28293 |  |  | HALLUX VALGUS CORRECTION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28294 |  |  | HALLUX VALGUS CORRECTION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28296 |  |  | HALLUX VALGUS CORRECTION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28297 |  |  | [NAME], BUNI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28298 |  |  | HALLUX VALGUS CORRECTION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28299 |  |  | OSTEOTOMY-HALLUS VALGUS |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 28300 |  |  | OSTEOTOMY, FOOT BONES |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28302 |  |  | OSTEOTOMY, FOOT BONES |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28304 |  |  | OSTEOTOMY, FOOT BONES |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28305 |  |  | OSTEOTOMY, FOOT BONES |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28306 |  |  | OSTEOTOMY, FOOT BONES |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28307 |  |  | OSTEOTOMY FIRST METATARSAL W |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28308 |  |  | OSTEOTOMY, FOOT BONES |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28309 |  |  | OSTEOTOMY [NAME] |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28310 |  |  | OSTEOTOMY, FOOT BONES |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28312 |  |  | OSTEOTOMY, FOOT BONES |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28313 |  |  | RECONSTRUCT ANGULAR DEFORMIT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28315 |  |  | SESAMOIDECTOMY, FIRST TOE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28320 |  |  | REPAIR, NON-UNION, FOOT BONE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28322 |  |  | REPAIR, NON-UNION, FOOT BONE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28340 |  |  | RECONSTRUCTION,TOE MACRODACT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28341 |  |  | RECONSTRUCTION,TOE,MACRODACT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28344 |  |  | RECONSTRUCTION, TOE, MACRODA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28345 |  |  | RECONSTRUCTION, TOES; SYNDAC |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28400 |  |  | FRACTURE, OS CALCIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 28405 |  |  | FRACTURE, OS CALCIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28406 |  |  | FRACTURE, OS CALCIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28415 |  |  | FRACTURE, OS CALCIS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28420 |  |  | FRACTURE, OS CALCIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28435 |  |  | FRACTURE, ASTRAGALUS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28436 |  |  | TREAT CLOSED TALUS FX W/MANI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28445 |  |  | FRACTURE, ASTRAGALUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28456 |  |  | TREAT CLOSED TARSAL BONE FX |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28465 |  |  | FRACTURE, TARSAL BONES |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28476 |  |  | TREATMENT OF CLOSED METATARS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28485 |  |  | FRACTURE, METATARSAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28496 |  |  | CLOSED FX GT TOE W/MANIP AND |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28505 |  |  | FRACTURE, PHALANX, TOE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28525 |  |  | FRACTURE, PHALANX, TOE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28531 |  |  | OPEN TREAT SESAMOID FX W/WO |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 28 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 28545 |  |  | DISLOCATION, TARSAL BONE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 28546 |  |  | DISLOCATION, TARSAL BONE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28555 |  |  | DISLOCATION, TARSAL BONE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28575 |  |  | DISLOC, ASTRAGALO-TARSAL JOI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 28576 |  |  | PERCUTANEOUS SKELETAL FIXATI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28585 |  |  | DISLOC, ASTRAGALO-TARSAL JOI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28605 |  |  | DISLOC, TARSO-METATARSAL JOI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 28606 |  |  | DISLOC, TARSO-METATARSAL JOI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28615 |  |  | DISLOC, TARSO-METATARSAL JOI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28635 |  |  | DISLOC, METATARSO-PHLNGL JNT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 28636 |  |  | PERCUTANEOUS SKELETAL FIXATI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28645 |  |  | DISLOC, METATARSO-PHLNGL JNT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28665 |  |  | CLOSED INTERPHALANGEAL JOINT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 28666 |  |  | PERCUTANEOUS SKELETAL FIXATI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28675 |  |  | DISLOC, INTERPHLNGL JNT, TOE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 28705 |  |  | ARTHRODESIS, PANTALAR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28715 |  |  | TRIPLE ARTHRODESIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28725 |  |  | ARTHRODESIS, SUBTALAR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28730 |  |  | ARTHRODESIS, MIDTARSAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28735 |  |  | FLATFOOT CORRECTION |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28737 |  |  | ARTHRODESIS, MIDTARSAL |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 28740 |  |  | ARTHRODESIS, MIDTARSAL OR TA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28750 |  |  | ARTHRODESIS, GREAT TOE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28755 |  |  | ARTHRODESIS, GREAT TOE, INTE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28760 |  |  | ARTHRODESIS, INTERPHALANGEAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 28810 |  |  | AMPUTATION, METATARSAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28820 |  |  | AMPUTATION, TOE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 28825 |  |  | AMPUTATION, TOE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 29710 |  |  | CAST REPAIR OR REMOVAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 29800 |  |  | ARTHROSCOPY,TMJ,DIAGNOSTIC W |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29804 |  |  | ARTHROSCOPY, TMJ, SURGICAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29805 |  |  | ARTHROSCOPY SHOULDER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29806 |  |  | ARTHROSCOPY SHOULDER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29807 |  |  | ARTHROSCOPY, SHOULDER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29819 |  |  | ARTHROSCOPY SHOULDER SURG W/ |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29820 |  |  | ARTHROSCOPY, SYNOVECTOMY, PA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29821 |  |  | SYNOVECTOMY COMPLETE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29822 |  |  | ARTHROSCOPY SHOULDER DEBRIDE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29823 |  |  | ARTHROSCOPY SHOULDER SURGICA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29824 |  |  | ARTHROSCOPY, SHOULDER |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 29825 |  |  | ARTHROSCOPY,SHOULDER W/LYSIS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29826 |  |  | ARTHROSCOPY SHOULDER [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29827 |  |  | ARTHROSCOPY- SHOULDER |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 29 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 29830 |  |  | ARTHROSCOPY ELBOW DIAGNOSTIC |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29834 |  |  | ARTHROSCOPY,ELBOW,SURGICAL;R |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29835 |  |  | ARTHROSCOPY ELBOW SURG SYNOV |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29836 |  |  | ARTHROSCOPY,ELBOW,SURGICAL;S |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29837 |  |  | ARTHROSCOPY,ELBOW,SURGICAL;D |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29838 |  |  | DEBRIDEMENT EXTENSIVE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29840 |  |  | ARTHROSCOPY WRIST DIAGNOSTIC |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29843 |  |  | ARTHROSCOPY WRIST SURG FOR I |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29844 |  |  | ARTHROSCOPY, SNYOVECTOMY, PA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29845 |  |  | SYNOVECTOMY COMPLETE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29846 |  |  | ARTHROSCOPY, WRIST, EXCISION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29847 |  |  | ARTHROSCOPY,WRIST,SURGICAL;I |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29848 |  |  | ARTHROSCOPY WRIST SURG/W/REL |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 29850 |  |  | ARTHROSCOPICALLY AIDED TREAT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 29851 |  |  | ARTHROSCOPICALLY AID TREAT W |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 29855 |  |  | ARTHROSCOPICALLY AIDED TXOF |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 29856 |  |  | BICONDYLAR,W/WO INTERNAL OR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 29860 |  |  | ARTHROSCOPY, HIP, DIAGNOSTIC |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 29861 |  |  | ARTHOSCOPY, HIP, SURGICAL,REM F/B |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 29862 |  |  | ARTHOSCOPY, HIP, SURGICAL,DEBRIDMEN |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 29863 |  |  | ARTHROSCOPY, HIP, SURGICAL;W/SYNOV |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 29870 |  |  | [NAME] DIAGNOSTIC |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29871 |  |  | ARTHROSCOPY, KNEE SURGICAL F |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29873 |  |  | ARTHROSCOPY - KNEE |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 29874 |  |  | [NAME] FOR REMOVAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29875 |  |  | [NAME] |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 29876 |  |  | [NAME] |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 29877 |  |  | [NAME] |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 29879 |  |  | [NAME] AR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29880 |  |  | [NAME] |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 29881 |  |  | ARTHROSCOPY KNEE W/MENISCECT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 29882 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29883 |  |  | ARTHROSCOPY WITH MENISCUS RE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29884 |  |  | ARTHROSCOPY KNEE W/LYSIS OF |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29885 |  |  | DRILLING FOR OSTEOCONDRITIS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29886 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29887 |  |  | [NAME] IN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29888 |  |  | ARTHROSCOPICALLY AIDED ANTER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29889 |  |  | ARTHROSCOPICALLY AIDED POSTE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29891 |  |  | ARTHROSCOPY, ANKLE, SURGICAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29892 |  |  | ARTHROSCOPICALLY AIDED REPAI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29893 |  |  | ENDOSCOPIC PLANTAR FASCIOTOM |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 29894 |  |  | [NAME] TIBIOTALAR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 30 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 29895 |  |  | ARTHROSCOPY ANKLE SYNOVECTOM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29897 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29898 |  |  | ARTHROSCOPY ANKLE TIB/FIB JO |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29899 |  |  | ARTHROSCOPY - ANKLE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29900 |  |  | ARTHROSCOPY, METACARPOPHALANGEAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29901 |  |  | ARTHROSCOPY, METACARPOPHALANGEAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 29902 |  |  | ARTHROSCOPY, METACARPOPHALANGEAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 30115 |  |  | NASAL POLYP EXCISION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 30117 |  |  | EXCISION/DESTRUCTION ANY MET |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 30118 |  |  | EXCISION/DESTRUCTION ANY MET |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 30120 |  |  | EXCISION, SKIN NOSE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 30125 |  |  | EXCISION DERMOID CYST COMPLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 30130 |  |  | EXCISION, TURBINATE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 30140 |  |  | RESECTION, TURBINATE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 30150 |  |  | RHINECTOMY; PARTIAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 30160 |  |  | RHINECTOMY; TOTAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 30220 |  |  | INSERT NASAL SEPTAL PROSTHES |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 30310 |  |  | REMOVAL FOREIGN BODY INTRANA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 30320 |  |  | REMOVAL FOREIGN BODY INTRANA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 30400 |  |  | RHINOPLASTY |  |  |  |  | 4 |  |  | Y |  |  |  | Referral Required
 |  | 30410 |  |  | RHINOPLASTY |  |  |  |  | 5 |  |  | Y |  |  |  | Referral Required
 |  | 30420 |  |  | RHINOPLASTY |  |  |  |  | 5 |  |  | Y |  |  |  | Referral Required
 |  | 30430 |  |  | RHINOPLASTY |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 30435 |  |  | RHINOPLASTY, SECONDARY INTER |  |  |  |  | 5 |  |  | Y |  |  |  | Referral Required
 |  | 30450 |  |  | RHINOPLASTY, MAJOR REVISION |  |  |  |  | 7 |  |  | Y |  |  |  | Referral Required
 |  | 30460 |  |  | RHINOPLASTY FOR NASAL DEFORM |  |  |  |  | 7 |  |  | Y |  |  |  | Referral Required
 |  | 30462 |  |  | TIP, SEPTUM, OSTEOTOMIES |  |  |  |  | 9 |  |  | Y |  |  |  | Referral Required
 |  | 30465 |  |  | REPAIR OF NASAL VESTIBULAR STENOSIS |  |  |  |  | 9 |  |  | Y |  |  |  | Referral Required
 |  | 30520 |  |  | SEPTOPLASTY |  |  |  |  | 4 |  |  | Y |  |  |  | Referral Required
 |  | 30540 |  |  | REPAIR, CHOANAL ATRESIA |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 30545 |  |  | REPAIR, CHOANAL ATRESIA |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 30560 |  |  | LYSIS, SYNECHIA, INTRANASAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 30580 |  |  | REPAIR, FISTULA, OROMAXILLAR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 30600 |  |  | REPAIR, FISTULA, ORONASAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 30620 |  |  | RECONSTRUCTION, INTERNAL NOS |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 30630 |  |  | REPAIR NASAL SEPTAL PERFORAT |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 30801 |  |  | [NAME] MUCOSA OF TURB |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 30802 |  |  | [NAME] MUCOSA OF TURB |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 30903 |  |  | CONTROL NASAL HEMORRHAGE ANTERIOR, |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 30905 |  |  | NASAL HEMORRHAGE CONTROL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 30906 |  |  | NASAL HEMORHAGE CONTROL, SUBSEQUENT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 30915 |  |  | LIGATION, ETHMOIDAL ARTERIES |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 30920 |  |  | LIGATION ARTERIES INTERNAL M |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 31 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 30930 |  |  | FRACTURE NASAL TRUBINATES TH |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31020 |  |  | ANTROTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31030 |  |  | ANTROTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 31032 |  |  | SINUSOTOMY RADICAL UNILAT W/ |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31050 |  |  | SINUSOTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31051 |  |  | SINUSOTOMY,SPHENOID,BIOPSY; |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31070 |  |  | SINUSOTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31075 |  |  | SINUSOTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31080 |  |  | SINUSOTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31081 |  |  | SINUSOTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31084 |  |  | SINUSOTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31085 |  |  | SINUSOTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31086 |  |  | SINUSOTOMY;NONOBLITERATIVE,W |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31087 |  |  | SINUSOTOMY;NONOBLITERATIVE,W |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31090 |  |  | SINUSOTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 31200 |  |  | ETHMOIDECTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31201 |  |  | ETHMOIDECTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 31205 |  |  | ETHMOIDECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 31233 |  |  | NASAL/SINUS ENDOSCOPY,DIAGNO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31235 |  |  | NASAL/SINUS ENDOSCOPY,DIAGNO |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31237 |  |  | NASAL/SINUS ENDOSCOPY W/BIOP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31238 |  |  | WITH CONTROL OF EPISTAXIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31239 |  |  | WITH DACRYOCYSTORHINOSTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31240 |  |  | WITH CONCHA BULLOSA RESECTIO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31254 |  |  | NASAL ENDOSCOPY W/ETHMOIDECT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 31255 |  |  | NASAL ENDOSCOPY & ETHMOIDECT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 31256 |  |  | NASAL ENDOSCOPY WITH MAXILLA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 31267 |  |  | MAXILLARY ENDOSCOPY SURG W/R |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 31276 |  |  | NASAL/SINUS ENDOSCOPY W/FRON |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 31287 |  |  | NASAL/SINUS ENDOSCOPY,SURGIC |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 31288 |  |  | WITH REMOVAL OF TISSUE FROM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 31300 |  |  | LARYNGOTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 31320 |  |  | LARYNGOTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31400 |  |  | ARYTENOIDECTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31420 |  |  | EPIGLOTTIDECTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31510 |  |  | LARYNGOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31511 |  |  | LARYNGOSCOPY, W/REMOVAL OF F |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31512 |  |  | LARYNGOSCOPY, W/REMOVAL OF L |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31513 |  |  | AMB SURG CTR -LARYNGOSCOPY I |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31515 |  |  | LARYNGOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31520 |  |  | LARYNGOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31525 |  |  | LARYNGOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31526 |  |  | LARYNGOSCOPY-DIAGNOSTIC W/OP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 32 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 31527 |  |  | AMB SURG CTR -LARYNGOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31528 |  |  | LARYNGOSCOPY, WITH DILATATIO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31529 |  |  | LARYNGOSCOPY DIRECT, W/DILAT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31530 |  |  | LARYNGOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31531 |  |  | LARYNGOSCOPY DIRECT;W/OPERAT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 31535 |  |  | LARYNGOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31536 |  |  | LARYNGOSCOPY DIRECT OPERATIV |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 31540 |  |  | LARYNGOSCOPY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 31541 |  |  | LARYNGOSCOPY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31545 |  |  | LARYNGOSCOPY, DIRECT, OPERATIVE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31546 |  |  | LARYNGOSCOPY, DIRECT, OPERATIVE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 31560 |  |  | LARYNGOSCOPY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 31561 |  |  | LARYNGOSCOPY W/ARYTENOIDECTO |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 31570 |  |  | LARYNGOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31571 |  |  | LARYNGOSCOPY W/INJECTION VOC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31576 |  |  | LARYNGOSCOPY FLEXIBLE FIBERS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31577 |  |  | LARYNGOSCOPY W/REMOVAL OF FO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31578 |  |  | LARYNGOSCOPY, WITH REMOVALL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31580 |  |  | LARYNGOPLASTY-2 STAGE, W/KEE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 31582 |  |  | LARYNGOPLASTY-FOR STENOSIS, |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 31588 |  |  | LARYNGOPLASTY, NOT OTHERWISE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 31590 |  |  | LARYNGEAL REINNERVATION NEUR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 31595 |  |  | SECTION RECURRENT LARYNGEAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31603 |  |  | TRACHEOSTOMY, EMERGENCY PROC |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31611 |  |  | CONSTR. OF T-E FISTULA&SUBSE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 31612 |  |  | TRACHEAL PUNCTURE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31613 |  |  | TRACHEOSTROMA REV SIMPLE W/O |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31614 |  |  | TRACHEOSTOMA REVISION;COMPLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31615 |  |  | TRACHEOBRONCHOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31620 |  |  | ENDOBRONCHIAL UNTRASOUND (EBUS) |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31622 |  |  | BRONCHOSCOPY,DIAGNOSTIC W/WO |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31623 |  |  | BRONCHOSCOPY W/ BRUSHING OR PROTEC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31624 |  |  | BRONCHOSCOPY W/BRONCHIAL LAVAGE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31625 |  |  | BRONCHOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31628 |  |  | BRONCHOSCOPY WITH TRANSBRONC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31629 |  |  | BRONCHOSCOPY,DIAGNOSTIC W/TR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31630 |  |  | BRONCHOSCOPY W TRANCHEAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31631 |  |  | BRONCHOSCOPY W/PLACEMENT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31632 |  |  | BRONCHOSCOPY, RIGID OR FLEXIBLE W/ |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31633 |  |  | BRONCHOSCOPY, RIGID OR FLEXIBLE W/ |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31635 |  |  | BRONCHOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31636 |  |  | BRONCHOSCOPY, RIGID OR FLEXIBLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31637 |  |  | BRONCHOSCOPY, RIGID OR FLEXIBLE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 33 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 31638 |  |  | BRONCHOSCOPY, RIGID OR FLEXIBLE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31640 |  |  | BRONCHOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31641 |  |  | W/DESTRUCTION TUMOR OR RELIE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31643 |  |  | BRONCHOSCOPY W/CATHETER PLACEMENT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31645 |  |  | BRONCHOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31646 |  |  | BRONCHOSCOPY W/THERAPEUTIC ASPIRATI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31656 |  |  | BRONCHOSCOPY WITH INJECTION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31717 |  |  | BRONCHIAL BRUSH BIOPSY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31720 |  |  | ASPIRATION, NASOTRACHEOBRONCHIAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31730 |  |  | TRANSTRACHEAL INTRODUCTION N |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31750 |  |  | TRACHEOPLASTY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 31755 |  |  | TRACHEOPHARYNGEAL FISTULIZAT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31820 |  |  | SURG CLOSE TRACHEOSTOMY/FIST |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 31825 |  |  | TRACHEOSTOMY CLOSURE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 31830 |  |  | REVISION, TRACHEOSTOMY SCAR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 32400 |  |  | BIOPSY, PLEURA, NEEDLE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 32405 |  |  | BIOPSY, LUNG/PLEURA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 32420 |  |  | PNEUMONOCENTESIS, PUNCTURE O |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 32553 |  |  | PLACEMENT OF INTERSTITIAL DEVICE(S |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 32998 |  |  | ABLATION THERAPY FOR REDUCTION/ERA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 33010 |  |  | PERICARDIOCENTESIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 33011 |  |  | PERICARDIOCENTESIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 33212 |  |  | INSERTION, PULSE GENERATOR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 33213 |  |  | DUAL CHAMBER |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 33215 |  |  | REPOSITIONING OF PACEMAKER |  |  |  |  | 6 |  |  | N |  |  |  | Referral Required
 |  | 33222 |  |  | REVISION OR RELOCATION OF SK |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 33223 |  |  | REVISION OR RELOCATION OF SK |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 33224 |  |  | INSERTION OF PACING ELECTRODE |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 33225 |  |  | INSERTION OF PACING ELECTRODE |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 33226 |  |  | REPOSITIONING OF CARDIAC ELECTRODE |  |  |  |  | 6 |  |  | N |  |  |  | Referral Required
 |  | 33233 |  |  | REMOVAL OF PERMANENT PACEMAK |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 33508 |  |  | ENDOSCOPY FOR CORONARY BYPASS |  |  |  |  | 6 |  |  | N |  |  |  | Referral Required
 |  | 33981 |  |  | REPLAC OF EXTRACORPOREAL VENTRICUL |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 33982 |  |  | REPLACEMENT OF VENTRICULAR PUMP(S) |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 33983 |  |  | IMPLANTABLE INTRACORPOREAL, SINGLE |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 35188 |  |  | REPAIR ACQUIRED TRAMATIC FIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 35206 |  |  | REPAIR BLOOD VESSEL, DIRECT, |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 35207 |  |  | REPAIR BLOOD VESSEL HAND |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 35236 |  |  | REPAIR BLOOD VESSEL W/VEIN G |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 35860 |  |  | EXPLORATION FOR POSTOP HEMOR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 35875 |  |  | THROMBECTOMY AND/OR REPAIR A |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 35876 |  |  | WITH REVISION OF ARTERIAL OR |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 36148 |  |  | ADDITIONAL ACCESS FOR THERAPEUTIC |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 34 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 36260 |  |  | INSERTION IMPLANTABLE INTRAVENOUS I |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36261 |  |  | REVISION IMPLANTED INTRA-ARTERIAL I |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 36262 |  |  | REMOVAL IMPLANTED INTRA-ARTERIAL IN |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 36475 |  |  | ENDOVENOUS ABLATION THERAPY OF VEI |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 36476 |  |  | ENDOVENOUS ABLATION THERAPY OF VEI |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 36478 |  |  | ENDOVENOUS ABLATION THERAPY OF VEI |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 36479 |  |  | ENDOVENOUS ABLATION THERAPY OF |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 36555 |  |  | INSERTION OF CENTRAL VENOUS CATH |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 36556 |  |  | INSERTION OF CENTRLY INSRTD CATH |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 36557 |  |  | INSRTN OF TUNLD CNTRL CATH |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36558 |  |  | INSERTION OF CENTRLY INSRTD CATH |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 36560 |  |  | INSRTN OF TUNLD CNTRL CATH |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36561 |  |  | INSRTN OF CNTRL VENUS CATH |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36563 |  |  | INSRTION OF TUNLED CNTRLY LOC CATH |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36565 |  |  | INSRTN OF CNTRL VENUS CATH |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36566 |  |  | INSERTION OF VENUS CATHINSRTN OF T |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36568 |  |  | INSRTN OF PERIPHERAL CATH |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 36569 |  |  | INSERTION OF PICC W/O PORT OR PUMP |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 36570 |  |  | INSERTION OF PICC |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36571 |  |  | INSERTION OF PICC W SUBCU PORT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36575 |  |  | REPAIR OF TUNLD OR NON-TUNLD CATH |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 36576 |  |  | REPAIR OF CNTRL VNUS CATH |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 36578 |  |  | REPLCMNT CATH ONLY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 36580 |  |  | RPLCMNT COMPLT, NON-TNLD CATH |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 36581 |  |  | RPLCMNT COMP, TUNLD CATH |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 36582 |  |  | RPLCMNT COMP TUNLD CATH |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36583 |  |  | RPLCMNT OF TUNLD CATH |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36584 |  |  | RPLCMNT COMP PERI CATH |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 36585 |  |  | RPLCMNT COMP PICC |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36589 |  |  | REMOVAL OF TUNLD CNTRL CATH |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 36590 |  |  | REMOVAL OF TUNLD CNTRL CATH |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 36640 |  |  | ARTERIAL CATHETERIZATION PRO |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 36800 |  |  | INSERT CANNULA FOR HEMODIALY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36810 |  |  | ARTERIOVENOUS CANNULIZATION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36815 |  |  | ARTERIOVENOUS EXTERNAL REVIS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36818 |  |  | [NAME], OPEN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36819 |  |  | [NAME], OPEN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36820 |  |  | ANASTOMOSIS, FOREARM VEIN TRANSPOS. |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36821 |  |  | ARTERIOVENOUS ANASTOMOSIS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36825 |  |  | ARTERIOVENOUS FISTULA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 36830 |  |  | ARTERIOVENOUS FISTULA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 36831 |  |  | THROMBECTOMY ARTERIOVENOUS FISTULA |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 36832 |  |  | REVISION OF ART FISTULA WITH |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 35 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 36833 |  |  | [NAME] |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 36835 |  |  | THOMAS SHUNT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 36860 |  |  | CANNULA DECLOTTING WO/BALLOO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 36861 |  |  | CANNULA DECLOTTING W/BALLOON |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 36870 |  |  | THROMBECTOMY |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 37203 |  |  | TRANSCATHETER RETRIEVAL INTR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 37500 |  |  | VASCULAR ENDOSCOPY |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 37607 |  |  | LIGATION OR BANDING OF ANGIO |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 37609 |  |  | LIGATION OR BIOPSY TEMPORAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 37650 |  |  | INTERRUPTION PART/COMP OF FE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 37700 |  |  | LIGATION & DIVISION, VEINS |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 37718 |  |  | LIGATION, DIVISION, AND STRIPPING, |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 37722 |  |  | LIGATION, DIVIDE/STRIP SAPHENOUS V |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 37735 |  |  | UNILATERAL LIGATION DIVISION |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 37760 |  |  | STRIPPING, SUBFASCIAL, RADIC |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 37761 |  |  | LIGATION OF PERFORATOR VEIN(S), SU |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 37780 |  |  | LIGATION & DIVISION, VEINS |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 37785 |  |  | VARICOSE VEINS, LIGTN & EXCS |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 37790 |  |  | PENILE VENOUS OCCLUSIVE PROC |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 38205 |  |  | BLOOD DERIVED HEMOTOPOIETIC CELL |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 38206 |  |  | BLOOD-DERIVED HEMATOPOIETIC CELL |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 38300 |  |  | DRAINAGE, LYMPHADENITIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 38305 |  |  | DRAINAGE LYMPHADENITIS EXTEN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 38308 |  |  | LYMPHANGIOTOMY OR OTHER OPER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 38500 |  |  | BIOPSY, LYMPH NODE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 38505 |  |  | BX OR EXC LYMPH NODE BY NEED |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 38510 |  |  | BIOPSY, LYMPH NODE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 38520 |  |  | BIOPSY, LYMPH NODE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 38525 |  |  | DEEP AXILLARY NODE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 38530 |  |  | BIOPSY, LYMPH NODE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 38542 |  |  | DISSECTION DEEP JUGULAR NODE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 38550 |  |  | EXCISION, CYSTIC HYGROMA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 38555 |  |  | EXCISION, CYSTIC HYGROMA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 38570 |  |  | [NAME] |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 38571 |  |  | [NAME] LYPMHADENECTOMY |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 38572 |  |  | LAPAROSCOPY PELVIC LYMPHADENECTOMY |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 38740 |  |  | AXILLARY LYMPHADENECTOMY, SU |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 38745 |  |  | LYMPHADENECTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 38760 |  |  | LYMPHADENECTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 40500 |  |  | VERMILIONECTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 40510 |  |  | RESECTION, LIP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 40520 |  |  | EXCISION, LIP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 40525 |  |  | LIP FULL-THICKNESS RECONSTRU |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 36 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 40527 |  |  | LIP-FULL THICKNESS RECONSTRU |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 40530 |  |  | RESECTION, LIP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 40650 |  |  | LIP REPAIR-FULL THICKNESS VE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 40652 |  |  | REPAIR LIP UP TO HALF VERTIC |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 40654 |  |  | REPAIR LIP OVER 1/2 VERTICAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 40700 |  |  | PLASTIC REPAIR, LIP |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 40701 |  |  | PLASTIC REPAIR, LIP |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 40720 |  |  | PLASTIC REPAIR, LIP |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 40761 |  |  | PLASTIC REPAIR CLEFT LIP-W/C |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 40801 |  |  | DRAIN ABSCESS,CYST,HEMATOMA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 40814 |  |  | EXCISION LESION MUCOSA-SUBMU |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 40816 |  |  | COMPLEX,WITH EXCISION OF UND |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 40818 |  |  | EXCISION MUCOSA OF VESTIBULE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 40819 |  |  | EXCISION OF FRENUM, LABIAL O |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 40831 |  |  | CLOSURE LACERATION MOUTH OVE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 40840 |  |  | VESTIBULOPLASTY; ANTERIOR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 40842 |  |  | VESTIBULOPLASTY, POSTERIOR, |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 40843 |  |  | VESTIBULOPLASTY, POSTERIOR B |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 40844 |  |  | VESTIBULOPLASTY, ENTIRE ARCH |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 40845 |  |  | VESTIBULOPLASTY, COMPLEX (IN |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 41005 |  |  | DRAINAGE, ABSCESS, SUBLINGUA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41006 |  |  | INTRAORAL INCISION SUBLINGUA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41007 |  |  | INTRAORAL I&D ABSCESS,CYST/H |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41008 |  |  | DRAIN ABCESS, CYST, HEMATOMA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41009 |  |  | INTRAORAL INCISION DRAIN ABS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41010 |  |  | INCISION, LINGUAL FRENUM |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41015 |  |  | EX RAORAL INCISION & DRAINAG |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41016 |  |  | EXTRORAL I&D ABSCESS,CYST/HE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41017 |  |  | EXTRAORAL INCISSION AND DRAI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41018 |  |  | EXTRAORAL I & D OF ABSCESS E |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41112 |  |  | EXCISION, LESION, TONGUE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 41113 |  |  | EXCISION LESION TONGUE W/CLO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 41114 |  |  | EXCISION LESSION TONGUE W/LO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 41116 |  |  | EXCISION LESION FLOOR OF MOU |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41120 |  |  | GLOSSECTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 41250 |  |  | REPAIR, LACERATION, TONGUE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 41251 |  |  | REPAIR, LACERATION, TONGUE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 41252 |  |  | REPAIR LACERATION TONGUE OVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 41500 |  |  | FIXATION, TONGUE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41510 |  |  | SUTURE, TONGUE TO LIP |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41520 |  |  | FRENOPLASTY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 41800 |  |  | DRNGE, CYST, DENTO ALVEOLAR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 41827 |  |  | EXCISION LESION/TUMOR,DENTOA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 37 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 41899 |  |  | UNLISTED PROC, DENTOALVEOLAR |  |  |  |  | 5 |  |  | N
 |  | 42000 |  |  | DRAINAGE, ABSCESS, PALATE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42107 |  |  | EXCISION LESION OF PALATE, U |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42120 |  |  | RESECTION, PALATE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 42140 |  |  | EXCISION, UVULA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42145 |  |  | PALATOPHARVNGOPLASTY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 42180 |  |  | REPAIR, LACERATION, PALATE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 42182 |  |  | REPAIR, LACERATION, PALATE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42200 |  |  | CLEFT PALATE REPAIR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 42205 |  |  | CLEFT PALATE REPAIR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 42210 |  |  | CLEFT PALATE REPAIR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 42215 |  |  | CLEFT PALATE REPAIR |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 42220 |  |  | CLEFT PALATE REPAIR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 42226 |  |  | LENGTHENING OF PALATE & PHAR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 42235 |  |  | REPAIR, PALATE, ANTERIOR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 42260 |  |  | REPAIR, FISTULA, NASOLABIAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 42280 |  |  | [NAME] FOR PAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 42300 |  |  | DRAINAGE, ABSCESS, PAROTID |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 42305 |  |  | DRAINAGE ABCESS PAROTID COMP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42310 |  |  | [NAME], ABSCESS, SUBMAXILLARY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 42320 |  |  | [NAME], ABSCESS, SUBMAXILLARY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 42340 |  |  | SIALOLITHOTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42405 |  |  | BIOPSY, SALIVARY GLAND |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42408 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 42409 |  |  | MARSUPIALIZATION SUBLINGIAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 42410 |  |  | EXCISION, PAROTID GLAND |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 42415 |  |  | EXCISION, PAROTID GLAND |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 42420 |  |  | EXCISION, PAROTID GLAND |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 42425 |  |  | EXCISION, PAROTID GLAND |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 42440 |  |  | EXCISION, SUBMANDIBULAR GLAN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 42450 |  |  | EXCISION, SUBLINGUAL GLAND |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42500 |  |  | SIALODOCHOPLASTY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 42505 |  |  | SIALODOCHOPLASTY SECOUNDARY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 42507 |  |  | PAROTID DUCT DIVERSION BILAT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 42508 |  |  | PAROTID DUCT DIVERSION W/EXC |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 42509 |  |  | PAROTID DUCT DIVERSION W/EXC |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 42510 |  |  | PAROTID DUCT DIVERSION W/LIG |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 42600 |  |  | CLOSURE, FISTULA, [NAME] |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 42665 |  |  | LIGATION, SALIVARY DUCT |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 42700 |  |  | INCISION & DRAINAGE ABSCESS; |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 42720 |  |  | INCISION DRAIN ABSCESS, RETR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 42725 |  |  | INCISION DRAIN ABSCESS, RETR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42802 |  |  | BIOPSY, PHARYNX |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 38 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 42804 |  |  | BIOPSY, PHARYNX |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 42806 |  |  | BIOPSY; [NAME] |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42808 |  |  | EXCISION OF LESION OF PHARNY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42810 |  |  | EXCISION, BRACHIAL CLEFT CYS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 42815 |  |  | EXCISION, BRACHIAL CLEFT CYS |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 42820 |  |  | TONSILLECTOMY AND ADENOIDECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 42821 |  |  | TONSILLECTOMY & ADENOIDECTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 42825 |  |  | TONSILLECTOMY PRI OR SEC UND |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 42826 |  |  | TONSILLECTOMY [NAME] AND SE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 42830 |  |  | ADENOIDECTOMY, PRIMARY UNDER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 42831 |  |  | ADENOIDECTOMY, PRIMARY, AGE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 42835 |  |  | ADENOIDECTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 42836 |  |  | ADENOIDECTOMY, SECONDARY, AG |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 42860 |  |  | EXCISION, TONSIL TAGS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 42870 |  |  | EXCISION, LINGUAL TONSIL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 42890 |  |  | LIMITED PHARYNGECTOMY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 42892 |  |  | [NAME] PHARYNGEAL |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 42900 |  |  | SUTURE, PHARYNX |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 42950 |  |  | PHARYNGOPLASTY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42955 |  |  | PHARYNGOSTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42960 |  |  | CNTRL OROPHARYNGEAL HEMORRHA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 42962 |  |  | CONTROL OROPHARYNGEAL HEMORR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 42972 |  |  | CONTROL NASOPHARYNGEAL HEMOR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 43200 |  |  | ESOPHAGOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43201 |  |  | ESOPHAGOSCOPY, RIGID OR FLEXIBLE; |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43202 |  |  | ESOPHAGOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43204 |  |  | ESOPHAGOSCOPY, RIGID OR FIBE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43205 |  |  | WITH BAND LIGATION OF ESOPHA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43215 |  |  | ESOPHAGOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43216 |  |  | W/REMOVAL TUMORS,POLYPS,OR O |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43217 |  |  | ESOPHAGOSCOPY FOR REMOVAL OF |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43219 |  |  | ESPOHAGOSCOPY FOR INSSERTION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43220 |  |  | ESOPHAGOSCOPY, RIGID OR FLEXIBLE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43226 |  |  | ESOPHAGOSCOPY FOR INSERTION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43227 |  |  | ESOPHAGOSCOPY FOR CONTROL OF |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43228 |  |  | FOR ABLATION OF TUMORS, POLY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43231 |  |  | ESOPHAGOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43232 |  |  | ESOPHAGOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43234 |  |  | UPPER GI ENDOSCOPY SIMPLE PR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43235 |  |  | ESOPHAGOGASTRODUODENOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43236 |  |  | UPPER GI ENDOSCOPY INC ESOPHAGUS, |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43237 |  |  | WITH ENDOSCOPIC ULTRASOUND EXAM |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43238 |  |  | WITH TRANSENDOSCOPIC ULTRASOUND |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 39 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 43239 |  |  | ESOPHAGOGASTROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43240 |  |  | UPPER GI ENDOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43241 |  |  | UPPER GASTROINTESTINAL ENDOS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43242 |  |  | UPPER GI ENDOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43243 |  |  | UPPER GASTROINTESTINAL ENDOS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43244 |  |  | UPPER GASTRO ENDOSCOPY W/BAN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43245 |  |  | UPPER GI ENDOSCOPY FOR DIL G |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43246 |  |  | UPPER GL ENDOSCOPY FOR PLACE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43247 |  |  | ESOPHAGOGASTRODUODENOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43248 |  |  | W/INSERT OF GUIDE WIRE FOLLO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43249 |  |  | GASTROINTESTINAL ENDOSCOPY W |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43250 |  |  | W/REMOVAL OF TUMORS,POLYPS,O |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43251 |  |  | REMOVAL POLYPOID LESION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43255 |  |  | UPPER GASTROINTESTINAL ENDOS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43256 |  |  | UPPER GI ENDOSCOPY W/STENT PLCMNT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 43257 |  |  | UPPER GASTROINTESTINAL ENDOSCOPY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 43258 |  |  | UPPER GASTRO ENDOSCOPY W/FUL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 43259 |  |  | W/ ENDOSCOPIC ULTRASOUND EXA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 43260 |  |  | ENDSCPIC RTRGRD CHOLANGIOPAN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43261 |  |  | WITH BIOPSY, SINGLE OR MULTI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43262 |  |  | ENDOSCOPIC RETROGRADE CHOLAN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43263 |  |  | ERCP FOR PRESSURE [NAME] OF |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43264 |  |  | UPPER GASTRO ENDOSCOPY INCL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43265 |  |  | ERCP FOR DESTRUCT LITHOTRIPS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43267 |  |  | ERCP FOR INSERTION OF NASOBI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43268 |  |  | ENDOSCOPIC RETROGRADE CHOLAN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43269 |  |  | ERCP, FOR REMOVAL OR CHANGE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43271 |  |  | ERCP FOR BALLOON DILATION OF |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43272 |  |  | ERCP FOR ABLATION OF TUMOR/M |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43273 |  |  | ENDO ANNULTN OF PAPILLA W/DIRECT V |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43281 |  |  | LAPAROSCOPY, SURGICAL, REPAIR OF P |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 43282 |  |  | WITH IMPLANTATION OF MESH |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 43450 |  |  | DILATION, ESOPHAGUS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43453 |  |  | DILATION OF ESOPHAGUS OVER G |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43456 |  |  | DILATION ESOPHAGUS BY BALLOO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43458 |  |  | DILATION ESOPHAGUS W/BALLOON |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 43600 |  |  | GASTRIC BIOPSY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43653 |  |  | [NAME] |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 43760 |  |  | CHANGE OF GASTROSTOMY TUBE; |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 43775 |  |  | LONGITUDINAL GASTRECTOMY (IE, SLEE |  |  |  |  | 4 |  |  | Y |  |  |  | Referral Required
 |  | 43870 |  |  | GASTROSTOMY CLOSURE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 44100 |  |  | BIOPSY, INTESTINES |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 44312 |  |  | ILEOSTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 40 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 44340 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 44360 |  |  | SM INTESTINAL ENDOSCOPY, BY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 44361 |  |  | SM. INTESTINAL ENDOSCOPY W/O |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 44363 |  |  | S INTESTINAL ENDOSCOPY W/FB |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 44364 |  |  | W/REMOVAL OF TUMORS,POLYPS,O |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 44365 |  |  | W/REMOVAL TUMORS,POLYPS,OR O |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 44366 |  |  | WITH CONTROL OF BLEEDING, AN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 44369 |  |  | W/ABLATION OF TUMORS,POLYPS, |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 44370 |  |  | SMALL INTESTINAL ENDOSCOPY |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 44372 |  |  | W/PLACEMENT PERCUTANEOUS JEJ |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 44373 |  |  | W/CONVERSION PERCUTANEOUS GA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 44376 |  |  | SM INTESTINAL ENDOSCOPY, ENT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 44377 |  |  | WITH BIOPSY, SINGLE OR MULTI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 44378 |  |  | WITH CONTROL OF BLEEDING, AN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 44379 |  |  | SMALL INTESTINAL ENDOSCOPY |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 44380 |  |  | ILEOSCOPY,THRU STOMA;DIAGNOS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 44382 |  |  | FIBEROPTJC ILEOSCOPY W/BIOPS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 44383 |  |  | ILEOSCOPY W/STENT |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 44385 |  |  | ENDOSCOPE EVALUATION OF SMAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 44386 |  |  | WITH BIOPSY, SINGLE OR MULTI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 44388 |  |  | COLONOSCOPY THRU STOMA;DIAGN |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 44389 |  |  | WITH BIOPSY, SINGLE OR MULTI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 44390 |  |  | WITH REMOVAL OF FOREIGN BODY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 44391 |  |  | WITH CONTROL OF BLEEDING ANY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 44392 |  |  | W/REMOVAL OF FOREIGN BODY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 44393 |  |  | W/ABLATION OF TUMORS,POLYPS, |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 44394 |  |  | COLONOSCOPY THROUGH STOMA; B |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 44397 |  |  | COLONOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45000 |  |  | DRAINAGE, ABSCESS, PELVIC |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45005 |  |  | INCISION & DRAINAGE OF SUBMU |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45020 |  |  | DRAINAGE, ABSCESS, PELVIRECT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45100 |  |  | BIOPSY, ANO-RECTAL WALL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45108 |  |  | MYOMECTOMY, ANORECTAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45150 |  |  | DIVISION, STRICTURE, RECTUM |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45160 |  |  | EXCISION RECTAL TUMOR BY PRO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45171 |  |  | EXCISION OF RECTAL TUMOR, TRANSANA |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 45172 |  |  | INCLUDING MUSCULARIS (IE, FULL THI |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 45190 |  |  | DESTRUCTION RECTAL TUMOR, TR |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 45305 |  |  | PROSCTOSIGMOIDOSCOPY WITH BI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45307 |  |  | PROCTOSIGMOIDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45308 |  |  | W/REMOVAL OF SINGLE TUMOR,PO |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45309 |  |  | W/REMOVAL OF SINGLE TUMOR,PO |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45315 |  |  | PROCTOSIGMOIDOSCOPY-REMOVE M |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 41 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 45317 |  |  | PROCTOSIGMOIDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45320 |  |  | PROCTOSIGMOIDOSCOPY W/ABLATI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45321 |  |  | PORSTOSIGMOIDOSCOPY FOR DECO |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45327 |  |  | PROCTOSIGMOIDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45331 |  |  | SIGMOIDOSCOPY, FLEX FIBEROPT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45332 |  |  | SIGMOIDOSCOPY, FLEXIBLE FIBE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45333 |  |  | SIGMOIDOSCOPY, FLEX FIBEROPT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45334 |  |  | WITH CONTROL OF BLEEDING, AN |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45335 |  |  | SIGMOIDOSCOPY, FLEXIBLE; W/DIRECTED |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45337 |  |  | WITH DECOMPRESSION OF VOLVUL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45338 |  |  | W/REMOVAL OF TUMORS,POLYPS, |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45339 |  |  | W/ABLATION OF TUMORS,POLYPS, |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45340 |  |  | SIGMOIDOSCOPY, FLEXIBLE; W/DILATION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45341 |  |  | SIGMOIDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45342 |  |  | SIGMOIDOSCOPY W/ULTRASOUND |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45345 |  |  | SIGMOIDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45355 |  |  | COLONOSCOPY,RIGID OR FLEXIBL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45378 |  |  | COLONOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45379 |  |  | COLONOSCOPY DIAGNOSTIC W/REM |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45380 |  |  | COLONOSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45381 |  |  | COLONOSCOPY, FLEXIBLE; PROXIMAL TO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45382 |  |  | COLONSCOPY W/CONTROL OF HEMO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45383 |  |  | W/ABLATION OF TUMORS,POLYPS, |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45384 |  |  | COLONOSCOPY WITH REMOVAL OF |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45385 |  |  | COLONSCOPY W/REMVL OF TUMOR, |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45386 |  |  | COLONOSCOPY, FLEXIBLE, PROXIMAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45387 |  |  | COLONOSCOPY W/STENT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45391 |  |  | COLONOSCOPY, FLEXIBLE, PROXIMAL TO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45392 |  |  | COLONOSCOPY, FLEXIBLE, PROXIMAL TO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45500 |  |  | PROCTOPLASTY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45505 |  |  | PROCTOPLASTY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45560 |  |  | REPAIR OF RECTOCELE (SEPARAT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 45900 |  |  | REDUCTION, PROCIDENTIA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45905 |  |  | DILATION OF ANAL SPHINCTER U |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45910 |  |  | DILATION OF RECTAL STRICTURE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 45915 |  |  | REMOVAL OF FECAL IMPACTION O |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46020 |  |  | PLACEMENT OF SETON |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46030 |  |  | REMOVAL, SETON |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46040 |  |  | DRAINAGE, ABSCESS, PERIRECTA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46045 |  |  | DRAINAGE, ABSCESS, TRANSANAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 46050 |  |  | DRAINAGE, ABSCESS, PERIANAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46060 |  |  | DRAINAGE, ABSCESS, INTRAMURA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 46080 |  |  | SPHINCTEROTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 42 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 46200 |  |  | FISSURECTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 46220 |  |  | PAPILLECTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46230 |  |  | EXCISION, HEMORRHOID TAGS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46250 |  |  | HEMORRHOIDECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46255 |  |  | HEMORRHOIDECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46257 |  |  | HEMORRHOIDECTOMY W/FISSURECT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46258 |  |  | HEMORRHOIDECTOMY W/FISTULECT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46260 |  |  | HEMORRHOIDECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46261 |  |  | HEMORRHOIDECTOMY INTERNAL/EX |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 46262 |  |  | HEMORRHOIDECTOMY COMPLEX W/F |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 46270 |  |  | FISTULECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46275 |  |  | FISTULECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46280 |  |  | FISTULECTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 46285 |  |  | FISTULECTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46288 |  |  | CLOSURE ANAL FISTULA W/ADVAN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 46608 |  |  | ANOSCOPY FOR REMOVAL OF FB |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46610 |  |  | ANOSCOPU FOR REMOVAL OF POLY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46611 |  |  | W/REMOVAL OF SINGLE TUMOR,PO |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46612 |  |  | ANOSCOPY FOR MULTI POLYP REM |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46615 |  |  | W/ABLATION OF TUMORS,POLYPS, |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 46700 |  |  | ANOPLASTY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46706 |  |  | REPAIR OF ANAL FISTULA W/ FIBRIN |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46707 |  |  | REPAIR OF ANORECTAL FISTULA W/PLUG |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46750 |  |  | SPHINCTEROPLASTY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46753 |  |  | GRAFT FOR RECTAL INCONTINENC |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46754 |  |  | REMOVAL THIERSCH WIRE OR SUT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 46760 |  |  | SPHINCTEROPLASTY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 46761 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 46762 |  |  | IMPLANTATION ARTIFICIAL SPHI |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 46917 |  |  | DESTRUCTION OF LESIONS ANUS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46922 |  |  | DESTRUCTION OF LESION, SURGI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46924 |  |  | DESTRUCTION LESION,ANUS, EXT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46930 |  |  | DESTRV OF INTNL HEMORRHOID BY THRM |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46945 |  |  | LIGATION OF INTERNAL HEMORRH |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 46947 |  |  | HEMORRHOIDOPEXY BY STAPLING |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 47000 |  |  | BIOPSY, [NAME] |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 47510 |  |  | INTRO OF PERCUTANEOUS TRANSH |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 47511 |  |  | INTRO TRANSHEPATIC STENT INT |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 47525 |  |  | CHANGE OF PERCUTANEOUS BILIA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 47530 |  |  | REVISION AND/OR REINSERTION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 47552 |  |  | BILIARY ENDOSCOPY PERCUTANEO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 47553 |  |  | BILIARY ENDOSCOPY FOR BIOPSY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 47554 |  |  | ENDOSCOPY W/REMOVAL OF STONE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 43 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 47555 |  |  | BILIARY ENDOSCOPY FOR DILATI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 47556 |  |  | BILIARY ENDOSCOPY,DILATIOBIL |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 47560 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 47561 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 47562 |  |  | [NAME] CHOLECYSTECTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 47563 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 47630 |  |  | STONE EXTRACTION, BILIARY DU |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 48102 |  |  | BIOPSY OF PANCREAS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 49080 |  |  | PERITONEOCENTESIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 49081 |  |  | PERITONEOCENTESIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 49180 |  |  | BIOPSY, ABDOMINAL/RETROPERIT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 49250 |  |  | UMBILECTOMY, OMPHALECTOMY, E |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49320 |  |  | LAPAROSCOPY/PERITONEOSCOPY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 49321 |  |  | LAPAROSCOPY/PERITONEOSCOPY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49322 |  |  | LAPAROSCOPY/PERITONEOSCOPY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49411 |  |  | PLACEMENT OF INTERSTITIAL DEVICE F |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 49419 |  |  | INSERTION INTRAPERITONEAL CANNULA/ |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 49420 |  |  | INTRAPERITONEAL CANNULA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 49421 |  |  | INSERT INTRAPERITONEAL CANNU |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 49422 |  |  | REMOVE PERMANENT INTRAPERITO |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 49426 |  |  | REVISION OF PERITONEAL VENOU |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 49495 |  |  | HERNIA REPAIR-INITIAL INGUIN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49496 |  |  | INCARCERATED OR STRANGULATED |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49500 |  |  | REPAIR INITIAL INGUINAL HERN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49501 |  |  | HERNIA REPAIR DIGESTIVE SYST |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 49505 |  |  | REPAIR INITIAL INGUINAL HERN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49507 |  |  | INCARCERATED OR STRANGULATED |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 49520 |  |  | REPAIR RECURRENT INGUINAL HE |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 49521 |  |  | INCARCERATED OR STRANGULATED |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 49525 |  |  | REPAIR INGUINAL HERNIA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49540 |  |  | HERNIA REPAIR DIGESTIVE SYST |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 49550 |  |  | REPAIR INITIAL FEMORAL HERNI |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 49553 |  |  | HERNIA REPAIR DIGESTIVE SYST |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 49555 |  |  | REPAIR RECURRENT FEMORAL HER |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 49557 |  |  | INCARCERATED OR STRANGULATED |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 49560 |  |  | REPAIR INITIAL INC ISIONAL H |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49561 |  |  | INCARCERATED OR STRANGULATED |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 49565 |  |  | REPAIR RECURRENT INCISIONAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49566 |  |  | INCARCERATED OR STRANGULATED |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 49568 |  |  | IPLANTATION OF MESH OR OTHER |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 49570 |  |  | REPAIR EPIGASTRIC HERNIA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49572 |  |  | INCARCERATED OR STRANGULATED |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 49580 |  |  | REPAIR UMBILICAL HERNIA-UNDE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 44 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 49582 |  |  | INCARCERATED OR STRANGULATED |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 49585 |  |  | REPAIR UMBILICAL HERNIA, AGE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49587 |  |  | INCARCERATED OR STRANGULATED |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 49590 |  |  | HERNIA REPAIR DIGESTIVE SYST |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 49600 |  |  | REPAIR OF SM OMPHALOCELE,WIT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49650 |  |  | [NAME] HERNIA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 49651 |  |  | [NAME] HERNIA |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 49652 |  |  | LAPARO SURG REP, VENTRAL, UMBIL SP |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 49653 |  |  | INCARCERATED OR STRANGULATED |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 49654 |  |  | LAPAROSURGICAL, REPAIR, INCISIONAL |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 49655 |  |  | INCARCERATED OR STRANGULATED |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 49656 |  |  | LAPAROSURGICAL, REPAIR, RECURRENT |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 49657 |  |  | INCARCERATED OR STRANGULATED |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 50200 |  |  | BIOPSY, RENAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50382 |  |  | REMOVAL AND REPLACEMENT OF INTERNA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50384 |  |  | REMOVAL OF INTERNALLY DWELLING UR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50390 |  |  | ASPIRATION, RENAL CYST |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50391 |  |  | INSTALLATION OF THERAPEUTIC AGENT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50392 |  |  | CATHETER, RENAL PELVIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50393 |  |  | INTRO URETERAL CATH OR STENT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50395 |  |  | INTRO OF GUIDE INTO RENAL PE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50396 |  |  | MANOMETRIC STUDIES, KINDEY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50398 |  |  | CHANGE NEPHROSTOMY TUBE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50551 |  |  | ENDOSCOPY, RENAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50553 |  |  | ENDOSCOPY, RENAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50555 |  |  | ENDOSCOPY, RENAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50557 |  |  | ENDOSCOPY, RENAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50561 |  |  | ENDOSCOPY, RENAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50562 |  |  | RENAL ENDOSCOPY; WITH RESECTION OF |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50688 |  |  | URETEROSTOMY TUBE CHANGE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50947 |  |  | LAPAROSCOPIC URETERONECYSTOSTOMY |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 50948 |  |  | LAPAROSCOPIC URETERONEOCYSTOSTOMY |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 50951 |  |  | URETERAL ENDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50953 |  |  | URETERAL ENDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50955 |  |  | URETERAL ENDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50957 |  |  | URETERAL ENDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50961 |  |  | URETERAL ENDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50970 |  |  | URETERAL ENDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50972 |  |  | URETERAL ENDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50974 |  |  | URETERAL ENDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50976 |  |  | URETERAL ENDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 50980 |  |  | URETERAL ENDOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 51020 |  |  | CYSTOTOMY/CYSTOSTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 45 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 51030 |  |  | CYSTOTOMY/CYSTOSTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 51040 |  |  | CYSTOTOMY/CYSTOSTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 51045 |  |  | CYSTOTOMY/CYSTOSTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 51050 |  |  | CYSTOLITHOTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 51065 |  |  | CYSTOTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 51080 |  |  | DRAINAGE, ABSCESS, PERIVESIC |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 51500 |  |  | EXCISION, CYST, URACHAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 51520 |  |  | CYSTOTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 51710 |  |  | CYSTOSTOMY TUBE CHANGE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 51715 |  |  | ENDOSCOPIC INJECTION OF IMPL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 51726 |  |  | COMPLEX CYSTOMETROGRAM |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 51727 |  |  | WITH URETHRAL PRESSURE PROFILE STU |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 51728 |  |  | WITH VOIDING PRESSURE STUDIES (IE, |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 51729 |  |  | WITH VOIDING PRESSURE STUDIES(IE, |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 51785 |  |  | NEEDLE ELECTROMYOGRAPHY STD |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 51880 |  |  | CLOSURE, CYSTOSTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 51992 |  |  | LAPAROSCOPY SLING OPERATION |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 52000 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 52001 |  |  | [NAME] W/ IRRIGATION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52005 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52007 |  |  | CYSTOURETHROSCOPY W/URETER C |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52010 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52204 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52214 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52224 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52234 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52235 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52240 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52250 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 52260 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52270 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52275 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52276 |  |  | [NAME] WITH DIREC |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52277 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52281 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52282 |  |  | CYSTOURETHROSCOPY, W/INSERT |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 52283 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52285 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52290 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52300 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52301 |  |  | CYSTOURETHROSCOPY W/RESECTIO |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52305 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52310 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 46 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 52315 |  |  | CYSTOURETHROSCOPY W/REMOVAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52317 |  |  | LITHOLAPAXY-CRUSHING OR FRAG |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 52318 |  |  | LITHOLAPAXY, COMPLICATED |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52320 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 52325 |  |  | CYSTOURETHROSCOPYC/WFRAGMENT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 52327 |  |  | CYSTOURETHROSCOPY; W/SUBURET |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52330 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52332 |  |  | CYSTOURETHROSCOPY, W/INSERT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52334 |  |  | CYSTOURETHROSCOPY W/INSERT U |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52341 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52342 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52343 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52344 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52345 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52346 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52351 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52352 |  |  | [NAME] |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 52353 |  |  | [NAME] |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 52354 |  |  | [NAME] |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 52355 |  |  | [NAME] |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 52400 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52402 |  |  | [NAME] WITH |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52450 |  |  | TRANSURETHRAL INCISION OF PR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52500 |  |  | RESECTION, VESICAL NECK |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 52601 |  |  | RESECTION, PROSTATE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 52630 |  |  | RESECTION, PROSTATE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 52640 |  |  | RESECTION, PROSTATE |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 52647 |  |  | NON-CONTACT LASER COAGULATIO |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 52648 |  |  | CONTACT LASER VAPORIZATION, |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 52700 |  |  | DRAINAGE, ABSCESS, PROSTATE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53000 |  |  | URETHROTOMY/URETHROSTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 53010 |  |  | URETHROTOMY/URETHROSTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 53020 |  |  | MEATOTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 53040 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53080 |  |  | DRAINAGE URINARY EXTRAVASATI |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 53200 |  |  | BIOPSY, URETHRA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 53210 |  |  | URETHRECTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 53215 |  |  | URETHRECTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 53220 |  |  | EXCISION, CARCINOMA, URETHRA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53230 |  |  | EXCISION URETHRAL DIVERTICUL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53235 |  |  | EXCISION URETHRAL DIVERTICUL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 53240 |  |  | MARSUP, URETHRAL DIVERTICULU |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53250 |  |  | EXCISION, BULBOURETHRAL GLAN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 47 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 53260 |  |  | EXCISION, URETHRAL POLYP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53265 |  |  | FULGURATION, URETHRAL CARUNC |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53270 |  |  | EXCISION, SKENES GLANDS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53275 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53400 |  |  | URETHROPLASTY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 53405 |  |  | URETHROPLASTY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53410 |  |  | URETHROPLASTY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53420 |  |  | URETHROPLASTY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 53425 |  |  | URETHROPLASTY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53430 |  |  | URETHROPLASTY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53431 |  |  | URETHROPLASTY FOR [NAME] |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53440 |  |  | [NAME] CORRECT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53442 |  |  | REMOVAL OF PERINEAL PROSTHES |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 53444 |  |  | INSERTION OF TANDEM CUFF |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53445 |  |  | PLACEMENT OF INFLATABLE SPHI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 53446 |  |  | REMOVAL INFLATABLE URETHRAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 53447 |  |  | REMOVAL, REPAIR, REPLACE INF |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 53449 |  |  | SURG CORRECT HYDRAULIC ABNOR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 53450 |  |  | URETHRAL MEATOPLASTY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 53460 |  |  | CYSTOSCOPY/URETHROSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 53500 |  |  | URETHROLYSIS, TRANSVAGINAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53502 |  |  | URETHRORRHAPHY SUTURE URETHR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53505 |  |  | URETHRORRHAPHY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53510 |  |  | URETHRORRHAPHY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53515 |  |  | URETHRORRHAPHY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53520 |  |  | URETHROSTOMY CLOSURE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53605 |  |  | DILATION, URETHRAL STRICTURE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 53665 |  |  | DILATION, URETHRA, FEMALE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 53850 |  |  | TRANSURETHRAL DESTRUCT PROSTATE |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 53855 |  |  | INSERTION OF A TEMPORARY PROSTATIC |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 54000 |  |  | DORSAL SLIT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 54001 |  |  | DORSAL SLIT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 54015 |  |  | INCISION & DRAINAGE, PENIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 54057 |  |  | DESTRUCTION OF LESION(S), PE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 54060 |  |  | CONDYLOMATA DESTRUCTION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 54065 |  |  | CONDYLOMATA DESTRUCTION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 54100 |  |  | BIOPSY, PENIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 54105 |  |  | BIOPSY, PENIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 54110 |  |  | EXCISION, PENILE PLAQUE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 54111 |  |  | EXCISION PENILE PLAQUE W/GRA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 54112 |  |  | BIOPSY PENIS W/GRAFT GREATER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 54115 |  |  | REMOVAL, FOREIGN BODY, PENIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 54120 |  |  | AMPUTATION, PENIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 48 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 54150 |  |  | CIRCUMCISION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 54160 |  |  | CIRCUMCISION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 54161 |  |  | CIRCUMCISION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 54162 |  |  | LYSIS/EXCISION PENILE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 54163 |  |  | REPAIR INCOMPLETE CIRCUMCISION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 54164 |  |  | FRENULOTOMY OF PENIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 54205 |  |  | INJECTION, PEYRONIES DISEASE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 54220 |  |  | IRRIGATION, CORPORA CAVERNOS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 54300 |  |  | STRAIGHTENING OF CHORDEE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54304 |  |  | PLASTIC OPERATION ON PENIS/C |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54308 |  |  | URETHROPLASTY FOR SECOND STA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54312 |  |  | URETHROPLASTY 2ND STAGE HYPO |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54316 |  |  | URETHROPLASTY 2ND STG HYPOSP |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54318 |  |  | URETHROPLASTY 3RD STAGE REPA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54322 |  |  | ONE STAGE DISTAL HYPOSPADIAS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54324 |  |  | HYPOSPADIAS REPAIR WITH URET |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54326 |  |  | ONE STAGE DISTAL HYPOSPADIAS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54328 |  |  | ONE STAGE DISTAL HYPOSPADIAS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54340 |  |  | REPAIR HYPOSPADIAS COMPLFIST |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54344 |  |  | REPAIR HYPOSPADIAS COMPLICAT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54348 |  |  | HYPO COMP REQUIRING MOBILIZA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54352 |  |  | REPAIR HYPOSPADIAS CRIPPLE R |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54360 |  |  | PLASTIC OPERATION ON PENIS T |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54380 |  |  | EPISPADIAS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54385 |  |  | PLASTIC OPERATION PENIS FOR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54420 |  |  | PRIAPISM OPERATION |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 54435 |  |  | CORPORA CAVERNOSA-GLANS PENI |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 54440 |  |  | REPAIR, PENILE INJURY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 54450 |  |  | FORESKIN MANIPULATION INC LY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 54500 |  |  | BIOPSY, TESTIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 54505 |  |  | BIOPSY, TESTIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 54512 |  |  | EXCISION OF TESTIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 54520 |  |  | ORCHIECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54522 |  |  | PARTIAL ORCHIECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54530 |  |  | ORCHIECTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 54550 |  |  | EXPLORATION UNDESCENDED TEST |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 54600 |  |  | REDUCTION, TORSION OF TESTIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 54620 |  |  | FIXATION, CONTRALATERAL TEST |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54640 |  |  | ORCHIOPEXY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 54670 |  |  | REPAIR, TESTICULAR INJURY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54680 |  |  | [NAME], TESTIS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54690 |  |  | [NAME] ORCHIECTOMY |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 54700 |  |  | DRAINAGE, TESTIS/EPIDIDYMIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 49 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 54800 |  |  | BIOPSY, EPIDIDYMIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 54830 |  |  | EXCISION, LESION, EPIDIDYMIS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54840 |  |  | EXCISION SPERMATOCELE W/WO E |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 54860 |  |  | EPIDIDYMECTOMY UNILATERAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 54861 |  |  | EPIDIDYMECTOMY BILATERAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 55040 |  |  | HYDROCELECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 55041 |  |  | HYDROCELECTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 55060 |  |  | RPR HYDROCELE TUNICA VAGINAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 55100 |  |  | DRAIN SCROTAL WALL ABSCESS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 55110 |  |  | SCROTAL EXPLORATION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 55120 |  |  | REMOVAL, FOREIGN BODY, SCROT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 55150 |  |  | RESECTION, SCROTUM |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 55175 |  |  | SCROTOPLASTY, SIMPLE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 55180 |  |  | SCROTOPLASTY; COMPLICATED |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 55200 |  |  | VASOTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 55250 |  |  | VASECTOMY |  |  |  |  | 2 |  |  | N
 |  | 55500 |  |  | HYDROCELECTOMY, SPERMATIC CO |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 55520 |  |  | EXCISION LESION SPERMATIC CO |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 55530 |  |  | EXCISION, VARICOCELE |  |  |  |  | 4 |  |  | Y |  |  |  | Referral Required
 |  | 55535 |  |  | EXCISION, VARICOCELE |  |  |  |  | 4 |  |  | Y |  |  |  | Referral Required
 |  | 55540 |  |  | EXCISION, VARICOCELE |  |  |  |  | 5 |  |  | Y |  |  |  | Referral Required
 |  | 55550 |  |  | [NAME] LIGATION OF SPERMATIC |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 55680 |  |  | EXCISION, CYST, MULLERIAN DU |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 55700 |  |  | BIOPSY, PROSTATE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 55705 |  |  | BIOPSY, PROSTATE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 55706 |  |  | BIOPS PROSTATE NDLE, TRNSPRINL, ST |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 55720 |  |  | PROSTATOTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 55725 |  |  | PROSTATOTOMY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 56440 |  |  | MARSUP, CYST, BARTHOLINS GLA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 56441 |  |  | LYSIS OF LABIAL ADHESIONS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 56515 |  |  | CONDYLOMATA DESTRUCTION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 56620 |  |  | VULVECTOMY SIMPL; PARTIAL |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 56625 |  |  | VULVECTOMY SIMPLE; [NAME] |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 56700 |  |  | HYMENECTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 56740 |  |  | EXCISION, CYST, BARTHOLINS G |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 56800 |  |  | REPAIR, VULVA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 56810 |  |  | PERINEOPLASTY REPAIR OF PERI |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 56820 |  |  | COLPOSCOPY OF THE [NAME] |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 56821 |  |  | COLPOSCOPY VULVA; W/BIOPSY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 57000 |  |  | COLPOTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 57010 |  |  | COLPOTOMY W/DRAINAGE OF PELV |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57020 |  |  | COLPOCENTESIS/CULDOCENTIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57022 |  |  | I & D OF VAGINAL HEMATOMA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 50 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 57023 |  |  | I & D OF VAGINAL HEMATOMA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 57065 |  |  | DESTRUCTION EXTENSIVE ANY ME |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 57105 |  |  | BIOPSY, VAGINAL MUCOSA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57130 |  |  | EXCISION, VAGINAL SEPTUM |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57135 |  |  | EXCISION, CYST, VAGINAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57155 |  |  | INSERTION UTERINE TANDEMS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57180 |  |  | INTRO ANY HEMOSTATIC AGENT/P |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 57200 |  |  | SUTURE, INJURY, VAGINA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 57210 |  |  | COLPOPERINEORRHAPHY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57220 |  |  | PLASTIC RPR URETHRAL SPHINCT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 57230 |  |  | PLASTIC REPAIR, URETHROCELE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 57240 |  |  | ANTERIOR COLPORRHAPHY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 57250 |  |  | POSTERIOR COLPORRHAPHY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 57260 |  |  | COLPORRHAPHY COMBINED |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 57265 |  |  | COLPORRHAPHY COMBINED |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 57267 |  |  | INSERTION OF MESH OR OTHER |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 57268 |  |  | ENTEROCELE REPAIR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 57288 |  |  | SLING OPERATION |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 57289 |  |  | PEREYRA PROCEDURE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 57300 |  |  | CLOSURE, FISTULA, RECTOVAGIN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 57400 |  |  | DILATION, VAGINA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57410 |  |  | PELVIC EXAM ANESTHESIA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57415 |  |  | REMOVAL IMPACTED VAGINAL FB |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57420 |  |  | COLPOSCOPY OF ENTIRE VAGINA W/ CERV |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 57421 |  |  | COLPOSCOPY OF ENTIRE VAGINA; WITH |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 57425 |  |  | LAPAROSCOPY, SURGICAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 57426 |  |  | REVISON (INCL. REMOVAL) OF PROSTHE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57455 |  |  | COLPOSCOPY CERVIX INC. UPPER VAGINA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 57456 |  |  | COLPOSCOPY CERVIX INC. UPPER VAGINA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 57461 |  |  | COLPOSCOPY CERVIX INC. UPPER VAGINA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 57513 |  |  | LASAR CAUTERY OF CERVIX |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57520 |  |  | CONIZATION OF CERVIX W/WO FU |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57522 |  |  | CONIZATION OF CERVIX; LOOP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 57530 |  |  | TRACHELECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 57550 |  |  | EXCISION, [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 57556 |  |  | EXCISION, [NAME] |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 57700 |  |  | CERCLAGE OF UTERINE CERVIX, |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 57720 |  |  | TRACHELORRHAPHY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 58120 |  |  | DILATION AND CURETTAGE DIAGN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 58145 |  |  | MYOMECTOMY, UTERINE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 58346 |  |  | INSERTION HEYMAN CAPSULES |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 58353 |  |  | ENDOMETRIAL THERMAL ABLATION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 58356 |  |  | EDOMETRIAL CRYOBLATION WITH |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 51 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 58545 |  |  | LAPAROSCOPY, MYOMECTOMY, EXCISION; |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 58546 |  |  | LAPAROSCOPY, MYOMECTOMY, EXCISION; |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 58550 |  |  | [NAME] |  |  |  |  | 9 |  |  | Y |  |  |  | Referral Required
 |  | 58555 |  |  | HYSTEROSCOPY DIAGNOSTIC |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 58558 |  |  | HYSTEROSCOPY, BIOPSY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 58559 |  |  | HYSTEROSCOPY LYSIS OF ADHESIONS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 58560 |  |  | HYSTEROSCOPY RESECT INTRAUTERINE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 58561 |  |  | HYSTEROSCOPY LEIMYOMATA REMOVAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 58562 |  |  | HYSTEROSCOPY FOREIGN BODY REMOVAL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 58563 |  |  | HYSTEROSCOPY ENDOMETRIAL ABLATION |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 58565 |  |  | HYSTEROSCOPY, SURGICAL; |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 58600 |  |  | TRANSECTION, FALLOPIAN TUBE |  |  |  |  | 4 |  |  | N
 |  | 58605 |  |  | TRANSECTION, FALLOPIAN TUBE |  |  |  |  | 4 |  |  | N
 |  | 58615 |  |  | OCCLUSION OF FALLOPIAN TUBE( |  |  |  |  | 4 |  |  | N
 |  | 58660 |  |  | [NAME] OF ADHESIONS |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 58661 |  |  | [NAME] OOPHORECTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 58662 |  |  | [NAME] |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 58670 |  |  | [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 58671 |  |  | [NAME] OCCLUSION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 58672 |  |  | [NAME] |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 58673 |  |  | [NAME] |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 58800 |  |  | DRAINAGE, CYST, OVARY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 58820 |  |  | DRAINAGE, ABSCESS, OVARY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 58900 |  |  | BIOPSY OF OVARY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 59150 |  |  | LAPAROSCOPIC TREATMENT ECTOP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 59151 |  |  | LAPAROSCOPIC TX ECTOPIC PREG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 59160 |  |  | CURETTAGE POSTPARTUM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 59320 |  |  | CERCLAGE CX VAGINAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 59409 |  |  | VAGINAL DELIVERY ONLY |  |  |  |  | 4 |  |  | N
 |  | 59812 |  |  | TREATMENT OF SPONT ABORTION |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 59820 |  |  | TREAT MISSED ABORTION COMPLE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 59821 |  |  | TREATMENT OF MISSED AB TREAT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 59840 |  |  | ABORTION INDUCED BY DILATIO |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 59841 |  |  | LEGAL(THERAPEUTIC) ABORTION |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 59870 |  |  | UTERINE EVAC + CURETTAGE FOR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 59871 |  |  | REMOVAL CERCLAGE SUTURE W/ANTETHESI |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 60000 |  |  | DRAINAGE, CYST, THYROGLOSSAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 60200 |  |  | EXCISION, CYST, THYROID |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 60280 |  |  | EXCSN, CYST, THYROGLOSSAL DU |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 60281 |  |  | EXCISION THYROGLOSSAL DUCT C |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 61020 |  |  | [NAME] |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 61026 |  |  | WITH INJECTION OF DRUG OR OT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 61050 |  |  | CISTERNAL PUNCTURES |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 52 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 61055 |  |  | INJECTION OF DRUG OR OTHER SUBSTANC |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 61070 |  |  | PUNCTURE, SHUNT TUBING |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 61215 |  |  | INSERTION OF SUB & RESERVOIR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 61790 |  |  | STEREOTAXIC LESION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 61791 |  |  | CREATION LESION STEREOTACTIC |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 61885 |  |  | INSERTION OR REPLACEMENT OF |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 61886 |  |  | PLACEMENT OF CRANIAL NEUROST |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 61888 |  |  | REVISION/REMOVAL CRANIAL NEU |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 62194 |  |  | IRRIGATION, SUBDURAL CATHETE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62225 |  |  | IRRIGATION VENTRICULAR CATHETE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62230 |  |  | REVISION, OBSTRUCTED VALVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 62252 |  |  | REPROGRAMMING OF CSF |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62263 |  |  | LYSIS OF EPIDURAL ADHESIONS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62264 |  |  | LYSIS OF EPIDURAL ADHESIONS; 1 DAY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62267 |  |  | PERC ASPIRATION W/IN NUCLEUS PULPO |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62268 |  |  | PERCUTANEOUS ASPIRATION, SPI |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62269 |  |  | BIOPSY OF SPINAL CORD, PERCU |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62270 |  |  | SPINAL PUNCTURE, LUMBAR DIAG |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62272 |  |  | SPINAL PUNCTURE THERAPEUTIC |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62273 |  |  | INJECTION, BLOOD/CLOT PATCH |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62280 |  |  | INJECTION NEUROLYTIC SUBSTAN |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62281 |  |  | NJ NEUROLYTIC SUBSTANCE EPID |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62282 |  |  | INJECTION NEUROLYTIC SUBSTAN |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62287 |  |  | ASPIRATION, [NAME], AN |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | 62294 |  |  | ARTERIAL INJECTION PROCEDURE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 62310 |  |  | EPIDURAL OR SUBARACHNOID INJECTION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62311 |  |  | EPIDURAL OR SUBARACHNOID INJECTION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62318 |  |  | EPIDURAL OR SUBARACHNOID INJECTION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62319 |  |  | EPIDURAL OR SUBARACHNOID INJECTION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 62350 |  |  | IMPLANTATION CATHETER,RESERV |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 62355 |  |  | REMOVAL IMPLANTED INTRATHECA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 62360 |  |  | IMPLANT/REPLACE DEVICE FOR D |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 62361 |  |  | IMPLANT/REPLACE DEVICE,DRUG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 62362 |  |  | IMPLANT/REPLACE DEVICE,DRUG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 62365 |  |  | REMOVAL SUBCUTANEOUS RESERVO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 63600 |  |  | STEREOTAXIC LESION SPINAL CO |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 63610 |  |  | STEREOTAXIC LESION SPINAL CO |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 63650 |  |  | PERCUTANEOUS IMPLANT NEUROST |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 63661 |  |  | REMOVAL OF SPINAL NEUROSTIMULATOR |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 63662 |  |  | REMOVAL OF SPINAL NEUROSTIMULATOR |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 63663 |  |  | REVISION INCL REPLACEMENT, WHEN PE |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 63664 |  |  | REVISION INCL REPLACEMENT, WHEN PE |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 63685 |  |  | INSERTION OR REPLACEMENT OF |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 53 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 63688 |  |  | REVISION OR REMOVAL |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 63744 |  |  | SHUNT, LUMBAR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 63746 |  |  | SHUNT, LUMBAR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64410 |  |  | SOMATIC NERVE BLOCK |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64415 |  |  | SOMATIC NERVE BLOCK |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64417 |  |  | SOMATIC NERVE BLOCK |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64420 |  |  | SOMATIC NERVE BLOCK |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64421 |  |  | SOMATIC NERVE BLOCK |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64430 |  |  | SOMATIC NERVE BLOCK |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64479 |  |  | TRANSFORAMINAL CERVICAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64480 |  |  | TRANSFORAMINAL CERVICAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64483 |  |  | TRANSFORAMINAL LUMBAR OR SACRAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64484 |  |  | TRANSFORAMINAL LUMBAR OR SACRAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64490 |  |  | INJECTION(S), DIAGNOSTIC OR THERAP |  |  |  |  | 1 |  |  | N
 |  | 64491 |  |  | SECOND LEVEL (SP) |  |  |  |  | 1 |  |  | N
 |  | 64492 |  |  | THIRD AND ANY ADDITIONAL LEVEL(S) |  |  |  |  | 1 |  |  | N
 |  | 64493 |  |  | INJECTION(S) DIAGNOSTIC/THERAPEUTI |  |  |  |  | 1 |  |  | N
 |  | 64494 |  |  | SECOND LEVEL (LIST SEPARATELY IN A |  |  |  |  | 1 |  |  | N
 |  | 64495 |  |  | THIRD AND ANY ADDITIONAL LEVEL(S) |  |  |  |  | 1 |  |  | N
 |  | 64510 |  |  | SYMPATHETIC NERVE BLOCK |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64517 |  |  | SUPERIOR HYPOGASTRIC PLEXUS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64520 |  |  | SYMPATHETIC NERVE BLOCK |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64530 |  |  | [NAME] |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64553 |  |  | PURCUTANEOUS IMPLANT OF NEUB |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 64561 |  |  | [NAME] IMPLANTAION |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 64573 |  |  | INCISE FOR IMPLANT OF NEURO |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 64575 |  |  | IMPLANTATION NEUROSTIMULATOR |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 64577 |  |  | AUTONOMIC NERVE |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 64580 |  |  | NEUROMUSCULAR |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 64581 |  |  | INCISION NEUROSTIMULATOR |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 64585 |  |  | REVISE/REMOVE PERIPHERAL NEU |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 64590 |  |  | INSERTION OR REPLACEMENT OF |  |  |  |  | 2 |  |  | Y |  |  |  | Referral Required
 |  | 64595 |  |  | REVISE/REMOVE PERIPHERAL NEU |  |  |  |  | 1 |  |  | Y |  |  |  | Referral Required
 |  | 64600 |  |  | DESTRUCTION, SOMATIC NERVE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64605 |  |  | DESTRUCTION, SOMATIC NERVE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64610 |  |  | DESTRUCTION, SOMATIC NERVE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64620 |  |  | DESTRUCTION, SOMATIC NERVE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64622 |  |  | DESTRUCTION-PARAVERTEBRALFAC |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64623 |  |  | DESTRUCT NEUROLYTIC AGENT;JO |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64626 |  |  | PARAVERTEBRAL FACETJOINT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64627 |  |  | PARAVERTEBRAL FACET JOINT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64630 |  |  | DESTRUCTION BY NEUROLYTIC AG |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64680 |  |  | DESTRUCTION, SYMPATHETIC NER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 54 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 64681 |  |  | SUPERIOR HYPOGASTRIC PLEXUS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64702 |  |  | NEUROLYSIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64704 |  |  | NEUROLYSIS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64708 |  |  | NEUROLYSIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64712 |  |  | NEUROLYSIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64713 |  |  | NEUROLYSIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64714 |  |  | NEUROLYSIS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64716 |  |  | NEUROLYSIS AND/OR TRANSPOSIT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64718 |  |  | NEUROPLASTY &/OR TRANSPOSE: |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64719 |  |  | NEUROPLASTY &/OR TRANSPOSE: |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64721 |  |  | NEUROPLASTY &/OR TRANSPOSE: |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64722 |  |  | NERVE DECOMPRESSION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64726 |  |  | NERVE DECOMPRESSION |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64727 |  |  | INTERNAL NEUROLYSIS; REQUIRE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64732 |  |  | TRANSECTION, NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64734 |  |  | TRANSECTION, NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64736 |  |  | TRANSECTION, NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64738 |  |  | TRANSECTION, NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64740 |  |  | TRANSECTION OR AVULSION LING |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64742 |  |  | TRANSECTION, NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64744 |  |  | TRANSECTION, NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64746 |  |  | TRANSECTION, NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64771 |  |  | TRANSECTION/AVULSION OF OTHE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64772 |  |  | TRANSECTION OF OTHER SPINAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64774 |  |  | EXCISION, NEUROMA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64776 |  |  | EXCISION, NEUROMA, DIGITAL N |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64778 |  |  | EXCISION, NEUROMA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64782 |  |  | EXCISION, NEUROMA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64783 |  |  | EXCISION, NEUROMA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64784 |  |  | EXCISION, NEUROMA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64786 |  |  | EXCISION, NEUROMA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64787 |  |  | IMPLANTATION OF NERVE END IN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64788 |  |  | EXCISION, NEUROFIBROMA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64790 |  |  | EXCISION, NEUROFIBROMA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64792 |  |  | EXCISION, NEUROFIBROMA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64795 |  |  | BIOPSY, NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64802 |  |  | EXCISION, NERVES, SYMPATHETI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64821 |  |  | SYMPATHECTOMY; RADIAL ARTERY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 64831 |  |  | SUTURE DIGITAL NERVE HAND/FO |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 64832 |  |  | SUTURE, NERVE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64834 |  |  | SUTURE, NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64835 |  |  | SUTURE, NERVE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64836 |  |  | SUTURE, NERVE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 55 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 64837 |  |  | SUTURE EACH ADDITIONAL NERVE HAND O |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64840 |  |  | SUTURE POST TIBIAL NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64856 |  |  | SUTURE, NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64857 |  |  | SUTURE MAJOR PERIPHERAL NERV |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64858 |  |  | SUTURE OF SCIATIC NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64859 |  |  | SUTURE EACH ADDITIONAL MAJOR PERIPH |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 64861 |  |  | SUTURE, NERVE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64862 |  |  | SUTURE LUMBAR PLEXUS |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64864 |  |  | SUTURE FACIAL NERVE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64865 |  |  | SUTURE, NERVE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 64870 |  |  | SUTURE, NERVE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 64872 |  |  | SUTURE, NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64874 |  |  | SUTURE NERVE REQUIRING EXTEN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64876 |  |  | SUTURE NERVE; REQUIRING SHOR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64885 |  |  | NERVE GRAFT HEAD OR NECK UP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64886 |  |  | NERVE GRAFT HEAD OR NECK MOR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64890 |  |  | NERVE GRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64891 |  |  | NERVE GRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64892 |  |  | NERVE GRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64893 |  |  | NERVE GRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64895 |  |  | NERVE GRAFT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64896 |  |  | NERVE GRAFT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64897 |  |  | NERVE GRAFT ARM OR LEG UP TO |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64898 |  |  | NERVE GRAFT MORE THAN 4 CM |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 64901 |  |  | NERVE GRAFT EA ADDITIONAL NERVE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64902 |  |  | NERVE GRAFT; MULTIPLE [NAME] |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64905 |  |  | NERVE PEDICLE TRANSFER |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 64907 |  |  | NERVE PEDICLE TRANSFER |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 65091 |  |  | EVISCERATION, [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 65093 |  |  | EVISCERATION, [NAME] |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 65101 |  |  | ENUCLEATION, EYE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 65103 |  |  | ENUCLEATION, EYE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 65105 |  |  | ENUCLEATION, EYE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 65110 |  |  | EXENTERATION, ORBIT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 65112 |  |  | EXTENTERATION-ORBIT; W/THERA |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 65114 |  |  | EXENTERATION, ORBIT |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 65130 |  |  | INSERTION, OCULAR IMPLANT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 65135 |  |  | INSERTION, OCULAR IMPLANT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 65140 |  |  | INSERTION, OCULAR IMPLANT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 65150 |  |  | REINSERTION, OCULAR IMPLANT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 65155 |  |  | REINSERTION OF OCULAR IMPLAN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 65175 |  |  | REMOVAL, OCULAR IMPLANT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 65235 |  |  | FOREIGN BODY, EYEBALL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 56 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 65260 |  |  | FOREIGN BODY, EYEBALL |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 65265 |  |  | FOREIGN BODY, EYEBALL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 65270 |  |  | REPAIR, LACERATION, EYEBALL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 65272 |  |  | REPAIR LACERATION CONJUNCTIV |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 65275 |  |  | REPAIR LACERATION CORNEA W/W |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 65280 |  |  | REPAIR LACERATION CORNEA PER |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 65285 |  |  | REPAIR LACERATION CORNEA W/R |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 65290 |  |  | REPAIR, WOUND, EXTRAOCULAR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 65400 |  |  | EXCISION, LESION, CORNEA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 65410 |  |  | BIOPSY, CORNEA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 65420 |  |  | TRANSPOSITION, PTERYGIUM |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 65426 |  |  | EXICSION TRANSPOSITION OF PT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 65710 |  |  | KERATOPLASTY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 65730 |  |  | KERATOPLASTY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 65750 |  |  | KERATOPLASTY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 65755 |  |  | KERATOPLASTY; PENETRATING (I |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 65756 |  |  | ENDOTHELIAL |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 65770 |  |  | KERATOPROSTHESIS |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 65772 |  |  | CORNEAL RELAXING INCISION |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 65775 |  |  | CORNEAL WEDGE RESECTION NO A |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 65780 |  |  | OCULAR SURFACE RECONSTRUCTION |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 65781 |  |  | LIMBAL STEM CELL ALLOGRAFT |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 65782 |  |  | LIMBAL CONJUNCTIVAL AUTOGRAFT |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 65800 |  |  | PARACENTESIS EYE ANTE CHAMBE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 65805 |  |  | PARACENTESIS EYE ANTE CHAMBE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 65810 |  |  | PARACENTESIS EYE ANTE CHAMBE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 65815 |  |  | PARACENTESIS EYE ANTE CHAMBE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 65820 |  |  | GONIOTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 65850 |  |  | TRABECULOTOMY AB EXTERNO |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 65855 |  |  | TRABECULOPLASTY BY LASAR SUR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 65865 |  |  | LYSIS, ADHESIONS, EYE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 65870 |  |  | LYSIS, ADHESIONS, EYE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 65875 |  |  | LYSIS, ADHESIONS, EYE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 65880 |  |  | LYSIS, ADHESIONS, EYE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 65900 |  |  | REMOVAL EPITHELIAL DOWNGROWT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 65920 |  |  | REMOVAL IMPLANT MATERIAL, AN |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 65930 |  |  | REMOVAL, BLOOD CLOT, EYE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 66020 |  |  | INJECTION, EYE, ANTE CHAMBER |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 66030 |  |  | INJECTION, EYE, ANTE CHAMBER |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 66130 |  |  | EXCISION, LESION, SCLERA |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 66150 |  |  | FISTULIZATION, SCLERA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 66155 |  |  | THERMOCAUTERY, SCLERA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 66160 |  |  | THERMOCAUTERY, SCLERA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 57 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 66165 |  |  | IRIDENCLEISIS/IRIDOTASIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 66170 |  |  | TRABECULECTOMY AB EXTERNO |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 66172 |  |  | TRABECULECTOMY AB EXTERNO W/ |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 66180 |  |  | AQUEOUS SHUNT TO EXTRAOCULAR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 66185 |  |  | REVISION AQUEOUS SHUNT EXTRA |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 66220 |  |  | REPAIR, SCLERAL STAPHYLOMA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 66225 |  |  | REPAIR, SCLERAL STAPHYLOMA |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 66250 |  |  | REVISION, OPERATIVE WOUND, E |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 66500 |  |  | IRIDOTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 66505 |  |  | TRANSFIXION IRIDOTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 66600 |  |  | IRIDECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 66605 |  |  | IRIDECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 66625 |  |  | IRIDECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 66630 |  |  | IRIDECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 66635 |  |  | IRIDECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 66680 |  |  | REPAIR, IRIS/CILIARY BODY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 66682 |  |  | SUTURE OF IRIS, [NAME] |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 66700 |  |  | [NAME]; DI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 66710 |  |  | CYCLOPHOTOAGULATION TRANS |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 66711 |  |  | [NAME] |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 66720 |  |  | [NAME]; CRY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 66740 |  |  | [NAME]; CY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 66821 |  |  | DISCISSION SECONDARY MEMBRAN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 66825 |  |  | REPOSITION INTRAOCULAR LENS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 66830 |  |  | REMOVAL SECONDARY MEMBRANOUS CATAR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 66840 |  |  | LENS MATERIAL REMOVAL |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 66850 |  |  | PHACOFRAGMENTATION, LENS |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 66852 |  |  | REMOVAL LENS MATERIAL, PARS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 66920 |  |  | EXTRACTION LENS (CATARACT) I |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 66930 |  |  | EXTRACTION LENS (CATARACT) I |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 66940 |  |  | EXTRACTION LENS (CATARACT) E |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 66982 |  |  | EXTRACAPSULAR CATARACT |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 66983 |  |  | INTRACAPSULAR CATARACT EXTRA |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 66984 |  |  | EXTRA CAPSULAR CATARACT REMO |  |  |  |  | 8 |  |  | N |  |  |  | Referral Required
 |  | 66985 |  |  | INSERTION LENS PROSTHESIS SE |  |  |  |  | 6 |  |  | N |  |  |  | Referral Required
 |  | 66986 |  |  | EXCHANGE OF INTRAOCULAR LENS |  |  |  |  | 6 |  |  | N |  |  |  | Referral Required
 |  | 67005 |  |  | REMOVAL VITREOUS ANTERIOR AP |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67010 |  |  | REMOVAL VITREOUS, SUBTOTAL R |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67015 |  |  | ASPIRATION, VITREOUS |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 67025 |  |  | INJECTION, [NAME] |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 67027 |  |  | IMPLANT/REPLACE INTRAVITREAL DRUG |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67030 |  |  | DISCISSION, [NAME] |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 67031 |  |  | SEVERING VITREOUS STRANDS ON |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 58 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 67036 |  |  | VITRECTOMY, MECHANICAL, PARS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67039 |  |  | VITRECTOMY W/FOCAL ENDOLASER |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 67040 |  |  | VITRECTOMY W/ANDOLASAR PANRE |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 67041 |  |  | VITRECTOMY, MECHANICAL, PARS PLANA |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 67042 |  |  | VITRECTOMY, MECHANICAL, PARS PLANA |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 67043 |  |  | VITRECTOMY, MECHANICAL, PARS PLANA |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 67107 |  |  | REPAIR, RETINAL DETACHMENT |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 67108 |  |  | REPAIR, RETINAL DETACHMENT |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 67110 |  |  | RETINAL DETACH BY INJ OF AIR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 67112 |  |  | REPAIR, RETINAL DETACHMENT |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 67113 |  |  | REPAIR OF COMPLEX RETINAL DETACHME |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 67115 |  |  | RELEASE OF ENCIRCLING MATERI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 67120 |  |  | REMOVAL IMPLANTED MATERIAL P |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 67121 |  |  | REMOVAL IMPLANTED MATERIAL P |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 67141 |  |  | PROPHYLAXIS RETINAL DETACHME |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 67210 |  |  | DESTRUCTION OF LOCALIZED LES |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 67218 |  |  | DESTRUCITON-RADIATION BY IMP |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 67227 |  |  | DESTRUCTION EXTENSIVE RETINO |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 67228 |  |  | DESTRUCTION RETINOPATHY 1 OR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 67250 |  |  | SCLERAL REINFORCEMENT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67255 |  |  | SCLERAL REINFORCEMENT |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67299 |  |  | UNLISTED PROCEDURE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 67311 |  |  | STRABISMUS SURGERY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67312 |  |  | STRABISMUS SURGERY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67314 |  |  | ONE VERTICAL [NAME]/EXCLUDIN |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67316 |  |  | [NAME] TWO OR MORE VE |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67318 |  |  | STRABISMUS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67320 |  |  | TRANSPOSITION, EYE MUSCLES |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67331 |  |  | STRABISMUS SURGERY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67332 |  |  | STRABISMUS SURGERY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67334 |  |  | STRABISMUS SURG BY POSTERIOR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67335 |  |  | OCULAR ADNEXA ADJ SUTURO TEC |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67340 |  |  | STRABISMUS SURG W/EXPLOR AND |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67343 |  |  | RELEASE EXTENSIVE SCAR TISSU |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 67346 |  |  | BIOPSY OF EXTRAOCULAR MUSCLE |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 67400 |  |  | ORBITOTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67405 |  |  | ORBITOTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67412 |  |  | ORBITOTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 67413 |  |  | ORBITOTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 67415 |  |  | BIOPSY, ORBIT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 67420 |  |  | ORBITOTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 67430 |  |  | ORBITOTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 67440 |  |  | ORBITOTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 59 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 67445 |  |  | ORBITOTOMY W/REMOVAL OF BONE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 67450 |  |  | ORBITOTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 67550 |  |  | INSERTION, ORBITAL IMPLANT |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67560 |  |  | REVISION, ORBITAL IMPLANT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 67570 |  |  | OPTIC NERVE DECOMPRESSION |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67715 |  |  | CANTHOTOMY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 67808 |  |  | EXCISION, CHALAZION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 67830 |  |  | TRICHIASIS CORRECTION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 67835 |  |  | TRICHIASIS CORRECTION |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 67880 |  |  | TARSORRHAPHY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67882 |  |  | TARSORRHAPHY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67900 |  |  | REPAIR OF BROW PTOSIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67901 |  |  | REPAIR, BLEPHAROPTOSIS |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 67902 |  |  | REPAIR, BLEPHAROPTOSIS |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 67903 |  |  | REPAIR, BLEPHAROPTOSIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67904 |  |  | REPAIR, BLEPHAROPTOSIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67906 |  |  | REPAIR, BLEPHAROPTOSIS |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 67908 |  |  | REPAIR, BLEPHAROPTOSIS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67909 |  |  | REDUCTION OVERCORRECTED PTOS |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67911 |  |  | CORRECTION, LID RETRACTION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67912 |  |  | CORRECTION LID RETRACTION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67914 |  |  | ECTROPION REPAIR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67916 |  |  | ECTROPION REPAIR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67917 |  |  | ECTROPION REPAIR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67921 |  |  | ENTROPION REPAIR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67923 |  |  | ENTROPION REPAIR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67924 |  |  | ENTROPION REPAIR |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 67935 |  |  | SUTURE, EYELID WOUND |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 67950 |  |  | CANTHOPLASTY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 67961 |  |  | EXCISION & REPAIR, EYELID |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67966 |  |  | EXCISION & REPAIR, EYELID |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67971 |  |  | RECONSTRUCTION, EYELID |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67973 |  |  | RECONSTRUCTION, EYELID |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67974 |  |  | RECONSTRUCTION, EYELID |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 67975 |  |  | RECONSTRUCTION, EYELID |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 68115 |  |  | EXCISION, LESION, CONJUNCTIV |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 68130 |  |  | EXCISION, LESION, CONJUNCTIV |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 68320 |  |  | CONJUNCTIVOPLASTY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 68325 |  |  | CONJUNCTIVOPLASTY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 68326 |  |  | CONJUNCTIVOPLASTY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 68328 |  |  | CONJUNCTIVOPLASTY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 68330 |  |  | CONJUNCTIVOPLASTY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 68335 |  |  | CONJUNCTIVOPLASTY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 60 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 68340 |  |  | DIVISION SYMBLEPHARON W/WO I |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 68360 |  |  | CONJUNCTIVAL FLAP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 68362 |  |  | CONJUNCTIVAL FLAP |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 68371 |  |  | HARVESTING CONJUNCTIVAL ALLOGRAFT |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 68500 |  |  | EXCISION, LACRIMAL GLAND |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 68505 |  |  | EXCISION, LACRIMAL GLAND |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 68510 |  |  | BIOPSY, LACRIMAL GLAND |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 68520 |  |  | EXCISION, LACRIMAL SAC |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 68525 |  |  | BIOPSY, LACRIMAL SAC |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 68530 |  |  | REMOVAL FB/DACRYOLITHA, LACR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 68540 |  |  | EXCISION, TUMOR LACRIMAL GLA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 68550 |  |  | EXCISION, TUMOR LACRIMAL GLA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 68700 |  |  | PLASTIC REPAIR, CANALICULI |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 68720 |  |  | DACRYOCYSTORHINOSTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 68745 |  |  | CONJUNCTIVO-RHINOSTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 68750 |  |  | CONJUNCTIVO-RHINOSTOMY |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 68770 |  |  | CLOSURE, FISTULA, LACRIMAL S |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 68810 |  |  | PROBING OF NASOLACRINAL DUCT |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 68811 |  |  | PROBING-NASOLACRIMAL DUCT RE |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 68815 |  |  | PROBING-NASOLACRIMAL DUCT W/ |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 69110 |  |  | EXCISION, EAR |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 69120 |  |  | EXCISION, EAR |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 69140 |  |  | EXOSTOSIS, AUDITORY CANAL |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 69145 |  |  | EXCISION LESION AUDITORY CAN |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 69150 |  |  | EXCISION LESION AUDITORY CAN |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 69205 |  |  | FOREIGN BODY, AUDITORY CANAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 69222 |  |  | DEBRIDEMENT, MASTOIDECTOMY C |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 69300 |  |  | OTOPLASTY |  |  |  |  | 3 |  |  | Y |  |  |  | Referral Required
 |  | 69310 |  |  | RECONSTRUCTION OF EXTERNAL A |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 69320 |  |  | RECONSTRUCTION, AUDITORY CAN |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69421 |  |  | MYRINGOTOMY INCLUDING ASPIRA |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 69436 |  |  | TYMPANOSTOMY GENERAL ANESTHE |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 69440 |  |  | EXPLORATION, MIDDLE EAR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 69450 |  |  | TYMPANALYSIS, TRANSCANAL |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 69501 |  |  | TRANSMASTOID ANTROTOMY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69502 |  |  | MASTOIDECTOMY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69505 |  |  | MASTOIDECTOMY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69511 |  |  | MASTOIDECTOMY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69530 |  |  | [NAME] |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69550 |  |  | EXCISION, AURAL GLOMUS TUMOR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69552 |  |  | EXCISION, AURAL GLOMUS TUMOR |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69601 |  |  | REVISION MASTOIDECTOMY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69602 |  |  | REVISION MASTOIDECTOMY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 61 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 69603 |  |  | REVISION MASTOIDECTOMY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69604 |  |  | REVISION MASTOIDECTOMY, RESU |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69605 |  |  | REVISION MASTOIDECTOMY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69610 |  |  | REPAIR OF EARDRUM |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 69620 |  |  | MYRINGOPLASTY |  |  |  |  | 2 |  |  | N |  |  |  | Referral Required
 |  | 69631 |  |  | TYMPANOPLASTY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69632 |  |  | TYMPANOPLASTY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69633 |  |  | TYMPANOPLASTY W/OSSICULAR RE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69635 |  |  | TYMPANOPLASTY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69636 |  |  | TYMPANOPLASTY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69637 |  |  | TYMPANOPLASTY WITH OSSICULAR |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69641 |  |  | TYMPANOPLASTY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69642 |  |  | TYMPANOPLASTY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69643 |  |  | TYMPANOPLASTY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69644 |  |  | TYMPANOPLASTY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69645 |  |  | TYMPANOPLASTY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69646 |  |  | TYMPANOPLASTY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69650 |  |  | STAPES MOBILIZATION |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69660 |  |  | STAPEDECTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69661 |  |  | STAPEDECTOMY/OTOMY W/FOOTPLA |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69662 |  |  | REVISION OF STAPEDECTOMY OR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69666 |  |  | REPAIR, FISTULA, OVAL WINDOW |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 69667 |  |  | REPAIR, FISTULA, ROUND WINDO |  |  |  |  | 4 |  |  | N |  |  |  | Referral Required
 |  | 69670 |  |  | MASTOID OBLITERATION |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 69676 |  |  | TYMPANIC NEURECTOMY |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 69700 |  |  | CLOSURE, POST AURICULAR |  |  |  |  | 3 |  |  | N |  |  |  | Referral Required
 |  | 69711 |  |  | REMOVAL/REPAIR ELECTROMAGNET |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 69714 |  |  | OSSEOINTEGRATED INPLANT |  |  |  |  | 9 |  |  | Y |  |  |  | Referral Required
 |  | 69715 |  |  | OSSEOINTEGRATED IMPLANT |  |  |  |  | 9 |  |  | Y |  |  |  | Referral Required
 |  | 69717 |  |  | OSSEOINTEGRATED IMPLANT |  |  |  |  | 9 |  |  | Y |  |  |  | Referral Required
 |  | 69718 |  |  | OSSEOINTEGRATED IMPLANT |  |  |  |  | 9 |  |  | Y |  |  |  | Referral Required
 |  | 69720 |  |  | DECOMPRESSION, FACIAL NERVE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69725 |  |  | DECOMPRESS FACIAL NERVE INC |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69740 |  |  | SUTURE, FACIAL NERVE |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69745 |  |  | SUTURE FACIAL NERVE INC MEDI |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69801 |  |  | LABYRINTHOTOMY |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69802 |  |  | LABYRINTHOTOMY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69805 |  |  | ENDOLYMPHATIC SAC OPERATION |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69806 |  |  | ENDOLYMPHATIC SAC OPERATION |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69820 |  |  | FENESTRATION SEMICIRCULAR CN |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69840 |  |  | REV, FENESTRATION, INNER EAR |  |  |  |  | 5 |  |  | N |  |  |  | Referral Required
 |  | 69905 |  |  | LABYRINTHECTOMY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69910 |  |  | LABYRINTHECTOMY |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 62 of 63
 |  |  |  |  |  | For Informational Purposes Only!
 | Idaho Medicaid Fee Schedule |  |  |  |  |  |  |  |  |  |  |  |  | Current as of July 2014
 |  | Procedure C |  |  | Procedure Code Description |  |  |  | ASC Level |  |  |  | PA Indicat |  |  |  | HC Referr
 |  | 69915 |  |  | VESTIBULAR NERVE SECTION |  |  |  |  | 7 |  |  | N |  |  |  | Referral Required
 |  | 69930 |  |  | COCHLEAR DEVICE IMPLANT; W/W |  |  |  |  | 7 |  |  | Y |  |  |  | Referral Required
 |  | 75901 |  |  | MECHANICAL REMOVAL CENTRAL VENOUS |  |  |  |  | 1 |  |  | N
 |  | 75902 |  |  | REMOVAL OF INRALUMINAL MATERIAL |  |  |  |  | 1 |  |  | N
 |  | 90870 |  |  | [NAME] |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 92018 |  |  | OPTHALMOLOGICAL EXAM/EVAL UNDER GEN |  |  |  |  | 1 |  |  | N
 |  | 92502 |  |  | OTOSCOPY |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 95990 |  |  | REFILLING AND MAINTENANCE OF IMPLAN |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 95991 |  |  | REFILLING AND MAINTENANCE OF IMPLA |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 96920 |  |  | LASER TREATMENT FOR [NAME] |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 96921 |  |  | LASER TREATMENT INFLAMMATORY SKIN |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | 96922 |  |  | LASER TREATMENT FOR [NAME] |  |  |  |  | 1 |  |  | N |  |  |  | Referral Required
 |  | G0105 |  |  | COLORECTAL CANCER SCREENING |  |  |  |  | 2 |  |  | N
 |  | G0121 |  |  | COLORECTAL CANCER SCREENING |  |  |  |  | 2 |  |  | N
 |  | G0256 |  |  | PROSTATE BRACHYTHERAPY |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  | G0261 |  |  | PROSTATE BRACHYTHERAPY |  |  |  |  | 9 |  |  | N |  |  |  | Referral Required
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Page 63 of 63