Reduction Reason
| Description
|
Certified Diabetic Educator (CDE)
| Allowed at 75% of PPS
Exceptions are 100% of PPS for:
- 97802-97804, 98960 – 98962, G0108, G0109 and S9145
|
Certified Registered Nurse Anesthetist (CRNA)
| Allowed at 85% of PPS for non-anesthesia services
|
Chiropractor
| Allowed at 85% of PPS
Exceptions are 100% of PPS for:
- Laboratory/Pathology services, DME and Prosthetics, Physical and Occupational Therapies/Modalities, Radiology services, and Diagnostic tests.
|
Clinical Nurse Specialist (CNS
| Allowed at 85% of PPS
Exceptions are 100% of PPS for:
- Laboratory/Pathology services, Blood and Blood products, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
- H0020 and H2010
|
Nurse Midwife (CNM)
| Allowed at 85% of PPS
Exceptions are 100% of PPS for:
- Laboratory/Pathology services, Blood and Blood products, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
- G0108 and G0109
|
Nurse Practitioner (NP)
Physician Assistant (PA)
| Allowed at 85% of PPS
Exceptions are 100% of PPS for:
- Laboratory/Pathology services, Blood and Blood products, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
- G0108, G0109, H0020, H2010, and S9145
|
Licensed Addiction Counselor (LAC)
| Allowed at 75% of PPS
Exceptions are 100% of PPS for:
- Laboratory/Pathology services
- H0004, H0005, H0020, H2010, H2019, and H2035
Exceptions are 50% of PPS for
- 90791, 90832, 90834, 90837, 90839, 90840 and H0001
|
Licensed Clinical Social Worker (LCSW)
Licensed Professional Clinical Counselor (LPCC)
Licensed Professional Counselor (LPC)
| Allowed at 75% of PPS
Exceptions are 100% of PPS for: H0020, H2010, H2019
|
Licensed Marriage Family Therapist (LMFT)
| Allowed at 75% of PPS
|
Licensed Associate Professional Counselor (LAPC)
Licensed Master Social Worker (LMSW)
| Allowed at 65% of PPS
Exceptions are 100% of PPS for: H0020, H2010, H2019
|
Licensed Registered Dietician (LRD)
| Allowed at 75% of PPS
Exceptions are 100% of PPS for:
97802-97804, 98960 – 98962, G0108, G0109, and S9470
|
Local Public Health Unit (LPHU)
| Allowed at 75% of PPS
Exceptions are 100% of PPS for:
- Laboratory/Pathology services, Blood and Blood products, Injectables or infused drugs including administration, DME and Prosthetics, Radiology services, and Diagnostic tests
|
Naturopath
| Allowed at 65% of PPS
|
Peer Support Specialist
| Allowed at 100% of PPS for H0038
|
Pharmacist
| Allowed at 85% of PPS
Exceptions are 100% of PPS for:
- Vaccines and administration
|
Psychologist (PhD)
| Allowed at 85% of PPS
Exceptions are 100% of PPS for (as defined in the CPT/HCPCS codebook)
- Psychiatry codes (except for 90867-90870; 90880-90885; 90899)
- Health Behavior Assessment and Intervention
- Development/Behavioral Screening and Testing
- Psychological/Neuropsychological Testing
- Adaptive Behavior Assessments/Treatments
- Psychiatric Collaboration Care Management
- Alcohol and Drug Abuse Treatment Services (Hxxxx HCPCS) (except for H0031, H0033, H0041-H0045, H2012, H2014-H2016, H2021-H2031, H2034, H2035)
- Additional codes may or may not be reduced based on diagnosis code billed and/or benefit categorization.
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