Minnesota Administrative Rules

5221.4033 OUTPATIENT LIMITATION FOR MEDICAL/SURGICAL FACILITY FEE.

Subpart 1.

No facility fee.

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

Subp. 1a.

Payment of facility fee.

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

A.

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

(1)

nursing, technician, and related services;

(2)

use of the facilities where the surgical procedures are performed;

(3)

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

(4)

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

(5)

administrative, record keeping, and housekeeping items and services;

(6)

materials for anesthesia;

(7)

intraocular lenses (IOLs); and

(8)

supervision of the services of an anesthetist by the operating surgeon.

B.

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

(1)

physician services;

(2)

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

(3)

prosthetic devices, except IOLs;

(4)

ambulance services;

(5)

leg, arm, back, and neck braces and artificial limbs;

(6)

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

(7)

anesthetist services.

Subp. 2a.

[Repealed, 25 SR 1142]

Subp. 2b.

Procedure codes subject to limitation.

CPT/HCPCS Procedure Code	CPT/HCPCS Description
10040	Acne surgery
10060	Drainage of skin abscess
10061	Drainage of skin abscess
10080	Drainage of pilonidal cyst
10081	Drainage of pilonidal cyst
10120	Remove foreign body
10121	Remove foreign body
10140	Drainage of hematoma/fluid
10160	Puncture drainage of lesion
11000	Surgical cleansing of skin
11001	Additional cleansing of skin
11200	Removal of skin tags
11201	Removal of added skin tags
11300	Shave skin lesion
11301	Shave skin lesion
11302	Shave skin lesion
11303	Shave skin lesion
11305	Shave skin lesion
11306	Shave skin lesion
11307	Shave skin lesion
11308	Shave skin lesion
11310	Shave skin lesion
11311	Shave skin lesion
11312	Shave skin lesion
11313	Shave skin lesion
11400	Removal of skin lesion
11401	Removal of skin lesion
11402	Removal of skin lesion
11403	Removal of skin lesion
11420	Removal of skin lesion
11421	Removal of skin lesion
11422	Removal of skin lesion
11423	Removal of skin lesion
11440	Removal of skin lesion
11441	Removal of skin lesion
11442	Removal of skin lesion
11443	Removal of skin lesion
11600	Removal of skin lesion
11601	Removal of skin lesion
11602	Removal of skin lesion
11603	Removal of skin lesion
11620	Removal of skin lesion
11621	Removal of skin lesion
11622	Removal of skin lesion
11623	Removal of skin lesion
11640	Removal of skin lesion
11641	Removal of skin lesion
11642	Removal of skin lesion
11643	Removal of skin lesion
11730	Removal of nail plate
11732	Remove additional nail plate
11740	Drain blood from under nail
11750	Removal of nail bed
11752	Remove nail bed/finger tip
11760	Reconstruction of nail bed
11762	Reconstruction of nail bed
11765	Excision of nail fold, toe
11900	Injection into skin lesions
11901	Added skin lesion injections
12031	Layer closure of wound(s)
12032	Layer closure of wound(s)
12041	Layer closure of wound(s)
12042	Layer closure of wound(s)
12051	Layer closure of wound(s)
12052	Layer closure of wound(s)
15780	Abrasion treatment of skin
15781	Abrasion treatment of skin
15782	Abrasion treatment of skin
15783	Abrasion treatment of skin
15786	Abrasion treatment of lesion
15787	Abrasion, added skin lesions
15851	Removal of sutures
15852	Dressing change, not for burn
16000	Initial treatment of burn(s)
16020	Treatment of burn(s)
16025	Treatment of burn(s)
17000	Destroy benign/premal lesion
17106	Destruction of skin lesions
17107	Destruction of skin lesions
17110	Destruction of skin lesions
17250	Chemical cautery, tissue
17260	Destruction of skin lesions
17261	Destruction of skin lesions
17262	Destruction of skin lesions
17263	Destruction of skin lesions
17264	Destruction of skin lesions
17266	Destruction of skin lesions
17270	Destruction of skin lesions
17271	Destruction of skin lesions
17272	Destruction of skin lesions
17273	Destruction of skin lesions
17274	Destruction of skin lesions
17276	Destruction of skin lesions
17280	Destruction of skin lesions
17281	Destruction of skin lesions
17282	Destruction of skin lesions
17283	Destruction of skin lesions
17284	Destruction of skin lesions
17286	Destruction of skin lesions
17340	Cryotherapy of skin
17360	Skin peel therapy
19000	Drainage of breast lesion
19001	Drain added breast lesion
20500	Injection of sinus tract
20520	Removal of foreign body
20550	Inject tendon/ligament/cyst
20600	Drain/inject joint/bursa
20605	Drain/inject joint/bursa
20610	Drain/inject joint/bursa
20615	Treatment of bone cyst
20974	Electrical bone stimulation
21029	Contour of face bone lesion
21030	Removal of face bone lesion
21031	Remove exostosis, mandible
21032	Remove exostosis, maxilla
21079	Prepare face/oral prosthesis
21080	Prepare face/oral prosthesis
21081	Prepare face/oral prosthesis
21082	Prepare face/oral prosthesis
21083	Prepare face/oral prosthesis
21084	Prepare face/oral prosthesis
21085	Prepare face/oral prosthesis
21086	Prepare face/oral prosthesis
21087	Prepare face/oral prosthesis
21088	Prepare face/oral prosthesis
21089	Prepare face/oral prosthesis
21110	Interdental fixation
23031	Drain shoulder bursa
24200	Removal of arm foreign body
24650	Treat radius fracture
25500	Treat fracture of radius
25530	Treat fracture of ulna
25600	Treat fracture radius/ulna
25622	Treat wrist bone fracture
25630	Treat wrist bone fracture
25650	Repair wrist bone fracture
26010	Drainage of finger abscess
26600	Treat metacarpal fracture
26720	Treat finger fracture, each
26725	Treat finger fracture, each
26740	Treat finger fracture, each
28001	Drainage of bursa of foot
28010	Incision of toe tendon
28011	Incision of toe tendons
28022	Exploration of a foot joint
28024	Exploration of a toe joint
28052	Biopsy of foot joint lining
28108	Removal of toe lesions
28124	Partial removal of toe
28126	Partial removal of toe
28153	Partial removal of toe
28160	Partial removal of toe
28190	Removal of foot foreign body
28220	Release of foot tendon
28230	Incision of foot tendon(s)
28232	Incision of toe tendon
28234	Incision of foot tendon
28270	Release of foot contracture
28272	Release of toe joint, each
28430	Treatment of ankle fracture
28450	Treat midfoot fracture, each
28455	Treat midfoot fracture, each
28470	Treat metatarsal fracture
28475	Treat metatarsal fracture
28490	Treat big toe fracture
28495	Treat big toe fracture
28510	Treatment of toe fracture
28515	Treatment of toe fracture
28530	Treat sesamoid bone fracture
28540	Treat foot dislocation
28570	Treat foot dislocation
28600	Treat foot dislocation
28630	Treat toe dislocation
29015	Application of body cast
29035	Application of body cast
29049	Application of shoulder cast
29065	Application of long arm cast
29075	Application of forearm cast
29085	Apply hand/wrist cast
29105	Apply long arm splint
29125	Apply forearm splint
29126	Apply forearm splint
29130	Application of finger splint
29131	Application of finger splint
29200	Strapping of chest
29260	Strapping of elbow or wrist
29280	Strapping of hand or finger
29345	Application of long leg cast
29355	Application of long leg cast
29358	Apply long leg cast brace
29365	Application of long leg cast
29405	Apply short leg cast
29425	Apply short leg cast
29435	Apply short leg cast
29440	Addition of walker to cast
29450	Application of leg cast
29515	Application lower leg splint
29520	Strapping of hip
29530	Strapping of knee
29540	Strapping of ankle
29550	Strapping of toes
29580	Application of paste boot
29700	Removal/revision of cast
29705	Removal/revision of cast
29710	Removal/revision of cast
29720	Repair of body cast
29730	Windowing of cast
29740	Wedging of cast
29750	Wedging of clubfoot cast
29850	Knee arthroscopy/surgery
30000	Drainage of nose lesion
30020	Drainage of nose lesion
30100	Intranasal biopsy
30110	Removal of nose polyp(s)
30200	Injection treatment of nose
30210	Nasal sinus therapy
30220	Insert nasal septal button
30300	Remove nasal foreign body
30901	Control of nosebleed
31000	Irrigation maxillary sinus
31002	Irrigation sphenoid sinus
31505	Diagnostic laryngoscopy
31575	Diagnostic laryngoscopy
31579	Diagnostic laryngoscopy
36000	Place needle in vein
36400	Drawing blood
36405	Drawing blood
36406	Drawing blood
36410	Drawing blood
36430	Blood transfusion service
36450	Exchange transfusion service
36470	Injection therapy of vein
36471	Injection therapy of veins
36510	Insertion of catheter, vein
40490	Biopsy of lip
40800	Drainage of mouth lesion
40804	Removal foreign body, mouth
40808	Biopsy of mouth lesion
40810	Excision of mouth lesion
40812	Excise/repair mouth lesion
41100	Biopsy of tongue
41108	Biopsy of floor of mouth
41825	Excision of gum lesion
41826	Excision of gum lesion
42100	Biopsy roof of mouth
42330	Removal of salivary stone
42400	Biopsy of salivary gland
42650	Dilation of salivary duct
42660	Dilation of salivary duct
42800	Biopsy of throat
45300	Proctosigmoidoscopy
45303	Proctosigmoidoscopy
45330	Sigmoidoscopy, diagnostic
45520	Treatment of rectal prolapse
46083	Incise external hemorrhoid
46221	Ligation of hemorrhoid(s)
46230	Removal of anal tabs
46320	Removal of hemorrhoid clot
46500	Injection into hemorrhoids
46600	Diagnostic anoscopy
46604	Anoscopy and dilation
46606	Anoscopy and biopsy
46614	Anoscopy, control bleeding
46615	Anoscopy
46900	Destruction, anal lesion(s)
46910	Destruction, anal lesion(s)
46916	Cryosurgery, anal lesion(s)
46917	Laser surgery, anal lesion(s)
46940	Treatment of anal fissure
46942	Treatment of anal fissure
46945	Ligation of hemorrhoids
46946	Ligation of hemorrhoids
51700	Irrigation of bladder
51705	Change of bladder tube
51720	Treatment of bladder lesion
52265	Cystoscopy and treatment
53270	Removal of urethra gland
53600	Dilate urethra stricture
53601	Dilate urethra stricture
53620	Dilate urethra stricture
53621	Dilate urethra stricture
53660	Dilation of urethra
53661	Dilation of urethra
54050	Destruction, penis lesion(s)
54055	Destruction, penis lesion(s)
54056	Cryosurgery, penis lesion(s)
54200	Treatment of penis lesion
54230	Prepare penis study
54235	Penile injection
55000	Drainage of hydrocele
55250	Removal of sperm duct(s)
56420	Drainage of gland abscess
56501	Destruction, vulva lesion(s)
56606	Biopsy of vulva/perineum
57061	Destruction, vagina lesion(s)
57100	Biopsy of vagina
57150	Treat vagina infection
57160	Insertion of pessary
57170	Fitting of diaphragm/cap
57452	Examination of vagina
57454	Vagina examination and biopsy
57460	LEEP procedure
57500	Biopsy of cervix
57505	Endocervical curettage
57510	Cauterization of cervix
57511	Cryocautery of cervix
58100	Biopsy of uterus lining
58301	Remove intrauterine device
59200	Insert cervical dilator
59300	Episiotomy or vaginal repair
59425	Antepartum care only
59426	Antepartum care only
59430	Care after delivery
60100	Biopsy of thyroid
61001	Remove cranial cavity fluid
64400	Injection for nerve block
64405	Injection for nerve block
64408	Injection for nerve block
64418	Injection for nerve block
64435	Injection for nerve block
64445	Injection for nerve block
64450	Injection for nerve block
64505	Injection for nerve block
64553	Implant neuroelectrodes
64555	Implant neuroelectrodes
64612	Destroy nerve, face muscle
65205	Remove foreign body from eye
65210	Remove foreign body from eye
65220	Remove foreign body from eye
65222	Remove foreign body from eye
65286	Repair of eye wound
65430	Corneal smear
65435	Curette/treat cornea
65436	Curette/treat cornea
65600	Revision of cornea
65772	Correction of astigmatism
65855	Laser surgery of eye
65860	Incise inner eye adhesions
66761	Revision of iris
66770	Removal of inner eye lesion
67145	Treatment of retina
67210	Treatment of retinal lesion
67228	Treatment of retinal lesion
67345	Destroy nerve of eye muscle
67505	Inject/treat eye socket
67515	Inject/treat eye socket
67700	Drainage of eyelid abscess
67710	Incision of eyelid
67800	Remove eyelid lesion
67801	Remove eyelid lesions
67805	Remove eyelid lesions
67810	Biopsy of eyelid
67820	Revise eyelashes
67825	Revise eyelashes
67840	Remove eyelid lesion
67850	Treat eyelid lesion
67915	Repair eyelid defect
67922	Repair eyelid defect
67930	Repair eyelid wound
67938	Remove eyelid foreign body
68020	Incise/drain eyelid lining
68040	Treatment of eyelid lesions
68100	Biopsy of eyelid lining
68110	Remove eyelid lining lesion
68135	Remove eyelid lining lesion
68200	Treat eyelid by injection
68400	Incise/drain tear gland
68420	Incise/drain tear sac
68440	Incise tear duct opening
68530	Clearance of tear duct
68705	Revise tear duct opening
68760	Close tear duct opening
68761	Close tear duct opening
68770	Close tear system fistula
68840	Explore/irrigate tear ducts
69000	Drain external ear lesion
69005	Drain external ear lesion
69020	Drain outer ear canal lesion
69100	Biopsy of external ear
69105	Biopsy of external ear canal
69200	Clear outer ear canal
69210	Remove impacted ear wax
69220	Clean out mastoid cavity
69222	Clean out mastoid cavity
69420	Incision of eardrum
69433	Create eardrum opening
69540	Remove ear lesion
69610	Repair of eardrum
92002	Eye exam, new patient
92004	Eye exam, new patient
92012	Eye exam, established patient
92014	Eye exam and treatment
92019	Eye exam and treatment
92020	Special eye evaluation
92100	Serial tonometry exam(s)
92230	Eye exam with photos
92260	Ophthalmoscopy/dynamometry
92287	Internal eye photography
92311	Contact lens fitting
92312	Contact lens fitting
92313	Contact lens fitting
92315	Prescription of contact lens
92316	Prescription of contact lens
92317	Prescription of contact lens
92352	Special spectacles fitting
92353	Special spectacles fitting
92354	Special spectacles fitting
92371	Repair and adjust spectacles
92504	Ear microscopy examination
92507	Speech/hearing therapy
92508	Speech/hearing therapy
92511	Nasopharyngoscopy
92512	Nasal function studies
92516	Facial nerve function test
92520	Laryngeal function studies
92565	Stenger test, pure tone
92571	Filtered speech hearing test
92575	Sensorineural acuity test
92576	Synthetic sentence test
92577	Stenger test, speech
92582	Conditioning play audiometry
93797	Cardiac rehab
93798	Cardiac rehab/monitor
95056	Photosensitivity tests
95065	Nose allergy test
95144	Antigen therapy services
95145	Antigen therapy services
95146	Antigen therapy services
95147	Antigen therapy services
95148	Antigen therapy services
95149	Antigen therapy services
95165	Antigen therapy services
95170	Antigen therapy services
95180	Rapid desensitization
95851	Range of motion measurements
95852	Range of motion measurements
95857	Tensilon test
96405	Intralesional chemotherapy administration
96406	Intralesional chemotherapy administration
96450	Chemotherapy, into central nervous system
96542	Chemotherapy injection
98940	Chiropractor manip of spine
98941	Chiropractor manip of spine
98942	Chiropractor manip of spine
98943	Chiropractor manip extra spinal
99202	Office/outpatient visit, new
99203	Office/outpatient visit, new
99204	Office/outpatient visit, new
99205	Office/outpatient visit, new
99211	Office/outpatient visit, established
99212	Office/outpatient visit, established
99213	Office/outpatient visit, established
99214	Office/outpatient visit, established
99215	Office/outpatient visit, established
99241	Office consultation
99242	Office consultation
99243	Office consultation
99244	Office consultation
99245	Office consultation
99354	Prolonged service, office
99355	Prolonged service, office

Statutory Authority:

MS s 14.38; 14.386; 14.388; 175.171; 176.101; 176.135; 176.1351; 176.136; 176.231; 176.83

History:

18 SR 1472; 20 SR 530; 25 SR 1142; 38 SR 306; 47 SR 253

Published Electronically:

October 26, 2022