Independent Lab/Sleep Lab — Reimbursement Schedules Effective 11/1/12

Reimbursement Changes/Updates

Assistant Surgery allowable is 16% of the Surgery rate. Physician Assistants, Advance Nurse Practitioners, Registered Nurse First Assistants, Licensed Surgical Assistants, Clinical Nurse Specialists and Nurse Midwives will be reimbursed 85% of the rates posted on the internet except for Drugs, Clinical Lab, Other Lab, Durable Medical Equipment/Prosthetics and Orthotics. Drugs, Clinical Lab, Other Lab, Durable Medical Equipment/ Prosthetics and Orthotics will be reimbursed at 100% of the rates posted on the internet.

Facility Relative Values

Non-Facility Relative Values

Professional component for procedures listed on the Lab Schedules will be reimbursed at $5.00 for HMO and $5.50 for PPO.

Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.

Clinical Lab Schedule

Other Lab Codes Schedule

Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.

DME Schedule

Note: The Drug/Injectable Fee Schedule will be updated on the following dates: 9/1/12, 12/1/2012, 3/1/2013 and 6/1/2013.

Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.

CPT/HCPCS/Drug Schedule

Assistant Surgery allowable is 16% of the Surgery rate.

Physician Assistants, Advance Nurse Practitioners, Registered Nurse First Assistants, Licensed Surgical Assistants, Clinical Nurse Specialists and Nurse Midwives will be reimbursed 85% of the rates posted on the internet except for Drugs, Clinical Lab, Other Lab, Durable Medical Equipment/Prosthetics and Orthotics. Drugs, Clinical Lab, Other Lab, Durable Medical Equipment/ Prosthetics and Orthotics will be reimbursed at 100% of the rates posted on the internet.

Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.

Other Codes Schedule