PROCEDURES/SERVICES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE

Some procedures/services are not accompanied by allowable fees. Procedures/services denoted "by report" (BR) in the maximum fee column are too unusual or variable in the nature of their performance, too new, or too infrequently performed to permit the assignment of a maximum fee. Fees for such procedures/services need to be justified "by report." The report should contain sufficient supportive information to permit proper identification. Pertinent information should be furnished concerning the nature, extent, and need for the procedure or service, the time, the skill, and equipment necessary, etc. For any procedure/service where the maximum fee is "BR," the health care provider shall establish a charge that is consistent with other maximum fees shown in the Schedule. The insurance carrier or selfinsured employer should review all submitted "BR" amounts to assure that an excessive charge for services provided is not occurring. Note also that for any procedures/services not listed within this Fee Schedule, the associated charge(s) will need to be substantiated "by report" (BR).

DEFINITIONS 

New Patient: One who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. 

Established Patient: One who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available. 

Note that no distinction is made between new and established patients in the emergency department. E / M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department. 

Modifiers: 

A modifier (located in Appendix A) provides the means by which the reporting physician can indicate that a service or procedure, that has been performed, has been altered by some specific circumstance but not changed in its definition or code. Only one modifier should be added to any single five-digit code submitted by an individual health care provider. The judicious application of modifiers obviates the necessity for separate procedure listings that may describe the modifying circumstance. Modifiers may be used to indicate to the recipient of a report that: 

 A service or procedure has both a professional and technical component. 

 A service or procedure was performed by more than one physician or in more than one location. 

 A service or procedure has been increased or reduced. 

 Only part of a service was performed.

 An adjunctive service was performed. 

 A bilateral procedure was performed. 

 A service or procedure was provided more than once. 

 Unusual events occurred.