Sage Screening Program Reimbursement Rates*
(EFFECTIVE JAN 1, 2016 THROUGH DEC 31, 2016)
CPT Code
Office Visit
99201
99202
99203
99211
99212
99213
99214
G0101
Preventive Visit Codes
Office Consultation
99241-99245
Pap Smear(Conventional)
88150, 88164, P3000
Pap Smear (Liquid Based)
88142, G0123
88143
88174, G0144
88175, G0145
4/14/2016
Service Description
New Patient (new to clinic), problem focused exam (10 minutes)
New Patient (new to clinic), expanded problem focused exam (20 minutes)
New Patient (new to clinic), detailed exam (30 minutes)
Established Patient, problem focused exam (5 minutes)
Established Patient, problem focused exam (10 minutes)
Established Patient, expanded problem focused exam (15 minutes)
Established Patient, detailed exam (25 minutes)
Pelvic exam with breast exam
Although preventive visit codes will be accepted (99385; 99386; 99387; 99395; 99396; 99397), Medicare
does not establish a rate for these codes. Sage will pay 99385 - 99387 at the rate for code 99203. Codes
99395 - 99397 will be paid at the rate for code 99213.
Allowable Rate
$43.72
$74.43
$106.68
$20.08
$43.60
$72.46
$106.78
$37.89
These codes have been discontinued by CMS. Use the EM Office Visit codes above.
Screening Pap (Conventional)
$14.39
Screening Pap (Liquid-based, thin layer prep)
Screening Pap (Liquid-based, thin layer prep) manual screening and rescreening under physician
supervision.
Screening Pap (Liquid-based, thin layer prep) screening by automated system.
Screening Pap (Liquid-based, thin layer prep) screening by automated system and manual rescreening.
$27.60
$27.60
$29.11
$36.09
CPT Code
Pap Smear/Pathology with
Additional Interpretation
88141, G0124
P3001
Mammography - Conventional
77057
77057-TC
77057-26
77055
77055-TC
77055-26
77056
77056-TC
77056-26
Mammography - Digital
G0202
G0202-TC
G0202-26
G0206
G0206-TC
G0206-26
G0204
G0204-TC
G0204-26
Mammography – ComputerAided Detection (CAD)
77052
77052-TC
4/14/2016
Service Description
(Providers will only be reimbursed for one Pap Smear/Pathology with interpretation CPT code per
Screening Pap Smear)
Cytopathology, cervical / vaginal; requiring physician interpretation
Screening Pap Smear, requiring interpretation by physician
Allowable Rate
$32.45
$32.45
ScreeningMammogram, Global
Screening Mammogram, technical component
Screening Mammogram, professional component
Diagnostic Mammogram (Unilateral), Global
Diagnostic Mammogram (Unilateral), technical component
Diagnostic Mammogram (Unilateral), professional component
Diagnostic Mammogram (Bilateral), Global
Diagnostic Mammogram (Bilateral), technical component
Diagnostic Mammogram (Bilateral), professional component
$83.03
$47.99
$35.04
$90.70
$55.66
$35.04
$116.64
$73.20
$43.44
ScreeningMammogram, Global
Screening Mammogram, technical component
Screening Mammogram, professional component
Diagnostic Mammogram (Unilateral), Global
Diagnostic Mammogram (Unilateral), technical component
Diagnostic Mammogram (Unilateral), professional component
Diagnostic Mammogram (Bilateral), Global
Diagnostic Mammogram (Bilateral), technical component
Diagnostic Mammogram (Bilateral), professional component
$136.02
$101.34
$34.67
$130.53
$95.86
$34.67
$165.97
$122.54
$43.44
CAD add-on code for Screening Mammogram Global code 77057
CAD add-on code for Screening Mammogram, technical component
$8.36
$5.48
CPT Code
77052-26
77051
77051-TC
77051-26
HPV Test
87625
87624
Colposcopy & Associated
Pathology
57420
57421
57452
57454
57455
57456
88305
88305-TC
88305-26
Endometrial Biopsy &
Associated Pathology
58100
58110
88305
88305-TC
88305-26
Fine Needle Aspiration &
Associated Cytology
4/14/2016
Service Description
CAD add-on code for Screening Mammogram, prof. component
CAD add-on code for Diagnostic Mammogram Global codes 77056 and 77055
CAD add-on code for Diagnostic Mammogram, technical component
CAD add-on code for Diagnostic Mammogram, prof. component
Allowable Rate
$2.88
$8.36
$5.48
$2.88
Human Papillomavirus (HPV) Test – types 16 & 18 only
Human Papillomavirus (HPV) Test – high-risk types
(Only visit charge 99213 may be billed in addition)
$47.80
$47.80
Colposcopy of entire vagina, with cervix if present-Without Biopsy
(this cpt code is for vaginoscopy for patients with an ABNORMAL PAP and who have had a hysterectomy)
Colposcopy of entire vagina, with cervix if present-With Biopsy(s)
(this cpt code is for vaginoscopy for patients with an ABNORMAL PAP and who have had a hysterectomy)
Colposcopy - Without Cervical Biopsy
Colposcopy - With Cervical Biopsy(s) and Endocervical Curettage
Colposcopy - With Cervical Biopsy(s)
Colposcopy - With Endocervical Curettage
Surgical Cervical Pathology, Global
Surgical Cervical Pathology, technical component
Surgical Cervical Pathology, professional component
For a Sage Screening Program covered AGC Pap (Atypical Glandular Cells) (Only visit charge 99213 may
be billed in addition)
Endometrial Biopsy
Endometrial Biopsy performed in conjunction with Colposcopy
Surgical Pathology, Global
Surgical Pathology, technical component
Surgical Pathology, professional component
$115.00
$153.97
$107.19
$149.90
$140.30
$132.50
$74.36
$34.83
$39.52
$107.05
$46.89
$74.36
$34.83
$39.52
CPT Code
10021
10022
88172
88172-TC
88172-26
88173
88173-TC
88173-26
19000
Breast Ultrasound
76641
76641-TC
76641-26
76642
76642-TC
76642-26
Outpatient Breast Diagnostic
Procedures
Itemized charges for each
procedure code
4/14/2016
Service Description
Fine Needle Aspiration (without imaging guidance)
Fine Needle Aspiration (with imaging guidance)
Evaluation of Fine Needle Aspirate
Evaluation of Fine Needle Aspirate, technical component
Evaluation of Fine Needle Aspirate, professional component
Interpretation and Report
Interpretation and Report, technical component
Interpretation and Report, professional component
Aspiration of Cyst
Allowable Rate
$122.73
$141.64
$57.95
$20.21
$37.74
$156.35
$82.45
$73.90
$113.94
Breast Ultrasound, complete, unilateral – Global
Breast Ultrasound, complete, unilateral - technical component
Breast Ultrasound, complete, unilateral – professional component
Breast Ultrasound, limited, unilateral - Global
Breast Ultrasound, limited, unilateral - technical component
Breast Ultrasound, limited, unilateral - professional component
(special arrangements must be made with SAGE prior to offering these services)
$109.32
$72.84
$36.48
$89.62
$55.66
$33.96
Patient Breast Diagnostic Procedures (must receive prior authorization for each procedure). Please call
for instructions.
Varies