PhilHealth Medical Case Rates (Annex A to PC2024-0037)
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PhilHealth Medical Case Rates (Annex A to PC2024-0037)
Annex A - List of Medical Case Rates Case Rate Health Facility Fee Professional Fee A00.0 CHOLERA DUE TO VIBRIO CHOLERAE 01, BIOVAR CHOLERAE 11,700.00
8,190.00
3,510.00
A00.1 CHOLERA DUE TO VIBRIO CHOLERAE 01, BIOVAR ELTOR 11,700.00
8,190.00
3,510.00
A00.9 CHOLERA, UNSPECIFIED 11,700.00
8,190.00
3,510.00
A01.0 TYPHOID FEVER 19,500.00
13,650.00
5,850.00
A01.0+ J17.0* PNEUMONIA IN TYPHOID FEVER 29,250.00
20,475.00
8,775.00
A01.1 PARATYPHOID FEVER A 19,500.00
13,650.00
5,850.00
A01.2 PARATYPHOID FEVER B 19,500.00
13,650.00
5,850.00
A01.3 PARATYPHOID FEVER C 19,500.00
13,650.00
5,850.00
A01.4 PARATYPHOID FEVER, UNSPECIFIED; INFECTION DUE TO SALMONELLA PARATYPHI NOS 19,500.00
13,650.00
5,850.00
A02.0 SALMONELLA ENTERITIS; SALMONELLOSIS 19,500.00
13,650.00
5,850.00
A02.1 SALMONELLA SEPTICAEMIA 19,500.00
13,650.00
5,850.00
A02.2 LOCALIZED SALMONELLA INFECTIONS 19,500.00
13,650.00
5,850.00
A02.2+ J17.0* PNEUMONIA IN SALMONELLA INFECTION 29,250.00
20,475.00
8,775.00
A02.8 OTHER SPECIFIED SALMONELLA INFECTIONS 19,500.00
13,650.00
5,850.00
A02.9 SALMONELLA INFECTION, UNSPECIFIED 19,500.00
13,650.00
5,850.00
A03.0 SHIGELLOSIS DUE TO SHIGELLA DYSENTERIAE; GROUP A SHIGELLOSIS [SHIGA-KRUSE DYSENTERY] 11,700.00
8,190.00
3,510.00
A03.1 SHIGELLOSIS DUE TO SHIGELLA FLEXNERI;GROUP B SHIGELLOSIS 11,700.00
8,190.00
3,510.00
A03.2 SHIGELLOSIS DUE TO SHIGELLA BOYDII; GROUP C SHIGELLOSIS 11,700.00
8,190.00
3,510.00
A03.3 SHIGELLOSIS DUE TO SHIGELLA SONNEI; GROUP D SHIGELLOSIS 11,700.00
8,190.00
3,510.00
A03.8 OTHER SHIGELLOSIS 11,700.00
8,190.00
3,510.00
A03.9 SHIGELLOSIS, UNSPECIFIED; ; BACILLARY DYSENTERY NOS 11,700.00
8,190.00
3,510.00
A04.0 ENTEROPATHOGENIC ESCHERICHIA COLI INFECTION 11,700.00
8,190.00
3,510.00
A04.1 ENTEROTOXIGENIC ESCHERICHIA COLI INFECTION 11,700.00
8,190.00
3,510.00
A04.2 ENTEROINVASIVE ESCHERICHIA COLI INFECTION 11,700.00
8,190.00
3,510.00
A04.3 ENTEROHAEMORRHAGIC ESCHERICHIA COLI INFECTION 11,700.00
8,190.00
3,510.00
A04.4 OTHER INTESTINAL ESCHERICHIA COLI INFECTIONS 11,700.00
8,190.00
3,510.00
A04.5 CAMPYLOBACTER ENTERITIS 11,700.00
8,190.00
3,510.00
A04.6 ENTERITIS DUE TO YERSINIA ENTEROCOLITICA 11,700.00
8,190.00
3,510.00
A04.7 ENTEROCOLITIS DUE TO CLOSTRIDIUM DIFFICILE; FOODBORNE INTOXICATION BY CLOSTRIDIUM DIFFICILE; PSEUDOMEMBRANOUS COLITIS 11,700.00
8,190.00
3,510.00
A04.8 OTHER SPECIFIED BACTERIAL INTESTINAL INFECTIONS 11,700.00
8,190.00
3,510.00
A04.9 BACTERIAL INTESTINAL INFECTION, UNSPECIFIED. BACTERIAL ENTERITIS NOS 11,700.00
8,190.00
3,510.00
A05.0 FOODBORNE STAPHYLOCOCCAL INTOXICATION 11,700.00
8,190.00
3,510.00
A05.1 BOTULISM; CLASSICAL FOODBORNE INTOXICATION DUE TO CLOSTRIDIUM BOTULINUM 9,360.00
6,552.00
2,808.00
A05.2
FOODBORNE CLOSTRIDIUM PERFRINGENS [CLOSTRIDIUM
WELCHII] INTOXICATION. ENTERITIS NECROTICANS.
PIG-BEL
11,700.00
8,190.00
3,510.00
A05.3 FOODBORNE VIBRIO PARAHAEMOLYTICUS INTOXICATION 11,700.00
8,190.00
3,510.00
A05.4 FOODBORNE BACILLUS CEREUS INTOXICATION 11,700.00
8,190.00
3,510.00
A05.8 OTHER SPECIFIED BACTERIAL FOODBORNE INTOXICATIONS 11,700.00
8,190.00
3,510.00
A05.9 BACTERIAL FOODBORNE INTOXICATION, UNSPECIFIED 11,700.00
8,190.00
3,510.00
A06.0 ACUTE AMOEBIC DYSENTERY; ACUTE AMOEBIASIS; INTESTINAL AMOEBIASIS NOS 11,700.00
8,190.00
3,510.00
A06.1 CHRONIC INTESTINAL AMOEBIASIS 11,700.00
8,190.00
3,510.00
A06.2 AMOEBIC NONDYSENTERIC COLITIS 11,700.00
8,190.00
3,510.00
A06.3 AMOEBOMA OF INTESTINE; AMOEBOMA NOS 11,700.00
8,190.00
3,510.00
A06.4+ K77.0* AMOEBIC LIVER ABSCESS; HEPATIC AMOEBIASIS 19,500.00
13,650.00
5,850.00
A06.7 CUTANEOUS AMOEBIASIS 11,700.00
8,190.00
3,510.00
A06.8 AMOEBIC APPENDICITIS 11,700.00
8,190.00
3,510.00
A07.0 BALANTIDIASIS; BALANTIDIAL DYSENTERY 11,700.00
8,190.00
3,510.00
A07.1 GIARDIASIS [LAMBLIASIS] 11,700.00
8,190.00
3,510.00
A07.2 CRYPTOSPORIDIOSIS 11,700.00
8,190.00
3,510.00
A07.3 ISOSPORIASIS; INFECTION DUE TO ISOSPORA BELLI AND ISOSPORA HOMINIS; INTESTINAL COCCIDIOSIS; ISOSPOROSIS 11,700.00
8,190.00
3,510.00
A07.8 OTHER SPECIFIED PROTOZOAL INTESTINAL DISEASES; INTESTINAL TRICHOMONIASIS; SARCOCYSTOSIS; SARCOSPORIDIOSIS 11,700.00
8,190.00
3,510.00
A07.9 PROTOZOAL INTESTINAL DISEASE, UNSPECIFIED;FLAGELLATE DIARRHOEA; PROTOZOAL COLITIS; PROTOZOAL DIARRHOEA; PROTOZOAL DYSENTERY 11,700.00
8,190.00
3,510.00
A08.0 ROTAVIRAL ENTERITIS 11,700.00
8,190.00
3,510.00
A08.1 ACUTE GASTROENTEROPATHY DUE TO NORWALK AGENT; SMALL ROUND STRUCTURED VIRUS ENTERITIS 11,700.00
8,190.00
3,510.00
A08.2 ADENOVIRAL ENTERITIS 11,700.00
8,190.00
3,510.00
A08.3 OTHER VIRAL ENTERITIS 11,700.00
8,190.00
3,510.00
A08.4 VIRAL INTESTINAL INFECTION, UNSPECIFIED; VIRAL ENTERITIS NOS; VIRAL GASTROENTERITIS NOS; VIRAL GASTROENTEROPATHY NOS 11,700.00
8,190.00
3,510.00
A08.5 OTHER SPECIFIED INTESTINAL INFECTIONS 11,700.00
8,190.00
3,510.00
A09.0 INFECTIOUS DIARRHEA 11,700.00
8,190.00
3,510.00
A09.9 ACUTE GASTROENTERITIS 11,700.00
8,190.00
3,510.00
A15.0 TUBERCULOSIS OF LUNG, CONFIRMED BY SPUTUM MICROSCOPY WITH OR WITHOUT CULTURE; TUBERCULOUS BRONCHIECTASIS, CONFIRMED BY SPUTUM MICROSCOPY WITH OR WITHOUT CULTURE; TUBERCULOUS FIBROSIS OF LUNG, CONFIRMED BY SPUTUM MICROSCOPY WITH OR WITHOUT CULTURE; TUBERCU 19,110.00
13,377.00
5,733.00
ICD Code Description First Case Rate Page 1 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate A15.1 TUBERCULOSIS OF LUNG, CONFIRMED BY CULTURE ONLY; TUBERCULOUS BRONCHIECTASIS, CONFIRMED BY CULTURE ONLY; TUBERCULOUS FIBROSIS OF LUNG, CONFIRMED BY CULTURE ONLY; TUBERCULOUS PNEUMONIA, CONFIRMED BY CULTURE ONLY; TUBERCULOUS PNEUMOTHORAX, CONFIRMED BY CUL 19,110.00
13,377.00
5,733.00
A15.2
TUBERCULOSIS OF LUNG, CONFIRMED HISTOLOGICALLY ONLY;
TUBERCULOUS BRONCHIECTASIS, CONFIRMED HISTOLOGICALLY
ONLY; TUBERCULOUS FIBROSIS OF LUNG, CONFIRMED
HISTOLOGICALLY ONLY; TUBERCULOUS PNEUMONIA,
CONFIRMED HISTOLOGICALLY ONLY; TUBERCULOUS
PNEUMOTHORAX
19,110.00
13,377.00
5,733.00
A15.3
TUBERCULOSIS OF LUNG, CONFIRMED BY UNSPECIFIED MEANS;
TUBERCULOUS BRONCHIECTASIS, CONFIRMED BUT UNSPECIFIED
WHETHER BACTERIOLOGICALLY OR HISTOLOGICALLY;
TUBERCULOUS FIBROSIS OF LUNG, CONFIRMED BUT
UNSPECIFIED WHETHER BACTERIOLOGICALLY OR
HISTOLOGICALLY
19,110.00
13,377.00
5,733.00
A15.4 TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, CONFIRMED BACTERIOLOGICALLY & HISTOLOGICALY; TUBERCULOSIS OF HILAR LYMPH NODES, CONFIRMED BACTERIOLOGICALLY & HISTOLOGICALY; TUBERCULOSIS OF MEDIASTINAL, LYMPH NODES, CONFIRMED BACTERIOLOGICALLY & HISTOLOGICALY; 23,205.00
16,243.50
6,961.50
A15.5 TUBERCULOSIS OF LARYNX, TRACHEA AND BRONCHUS, CONFIRMED BACTERIOLOGICALLY AND HISTOLOGICALLY ; TUBERCULOSIS OF BRONCHUS,CONFIRMED BACTERIOLOGICALLY AND HISTOLOGICALLY; TUBERCULOSIS OF GLOTTIS, CONFIRMED BACTERIOLOGICALLY AND HISTOLOGICALLY; TUBERCULO 23,205.00
16,243.50
6,961.50
A15.6 TUBERCULOUS PLEURISY, CONFIRMED BACTERIOLOGICALLY AND HISTOLOGICALLY [TUBERCULOSIS OF PLEURA, CONFIRMED BACTERIOLOGICALLY AND HISTOLOGICALLY; TUBERCULOUS EMPYEMA, CONFIRMED BACTERIOLOGICALLY & HISTOLOGICALLY 23,205.00
16,243.50
6,961.50
A15.7 PRIMARY RESPIRATORY TUBERCULOSIS, CONFIRMED BACTERIOLOGICALLY AND HISTOLOGICALLY 19,110.00
13,377.00
5,733.00
A15.8
OTHER RESPIRATORY TUBERCULOSIS, CONFIRMED
BACTERIOLOGICALLY AND HISTOLOGICALLY; MEDIASTINAL
TUBERCULOSIS, CONFIRMED BACTERIOLOGICALLY AND
HISTOLOGICALLY; NASOPHARYNGEAL TUBERCULOSIS,
CONFIRMED BACTERIOLOGICALLY AND HISTOLOGICALLY;
TUBERCULOSIS OF NOSE,
23,205.00
16,243.50
6,961.50
A15.9 RESPIRATORY TUBERCULOSIS UNSPECIFIED, CONFIRMED BACTERIOLOGICALLY AND HISTOLOGICALLY 19,110.00
13,377.00
5,733.00
A16.0
TUBERCULOSIS OF LUNG, BACTERIOLOGICALLY AND
HISTOLOGICALLY NEGATIVE;
TUBERCULOUS BRONCHIECTASIS , BACTERIOLOGICALLY AND
HISTOLOGICALLY NEGATIVE; TUBERCULOUS FIBROSIS OF LUNG,
BACTERIOLOGICALLY AND HISTOLOGICALLY NEGATIVE;
TUBERCULOUS PNEUMONIA, BAC
19,110.00
13,377.00
5,733.00
A16.1
TUBERCULOSIS OF LUNG, BACTERIOLOGICAL AND HISTOLOGICAL
EXAMINATION NOT DONE; TUBERCULOUS BRONCHIECTASIS,
BACTERIOLOGICAL AND HISTOLOGICAL EXAMINATION NOT DONE;
TUBERCULOUS FIBROSIS OF LUNG, BACTERIOLOGICAL AND
HISTOLOGICAL EXAMINATION NOT DONE; TUBERCULO
19,110.00
13,377.00
5,733.00
A16.2 TUBERCULOSIS OF LUNG, NOS, WITHOUT MENTION OF BACTERIOLOGICAL OR HISTOLOGICAL CONFIRMATION; TUBERCULOUS BRONCHIECTASIS, NOS, WITHOUT MENTION OF BACTERIOLOGICAL OR HISTOLOGICAL CONFIRMATION; TUBERCULOUS FIBROSIS OF LUNG, NOS, WITHOUT MENTION OF BACT 19,110.00
13,377.00
5,733.00
A16.3 TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, WITHOUT MENTION OF BACTERIOLOGICAL OR HISTOLOGICAL CONFIRMATION; TUBERCULOSIS OF HILAR LYMPH NODES NOS WITHOUT MENTION OF BACTERIOLOGICAL OR HISTOLOGICAL CONFIRMATION; TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, 23,205.00
16,243.50
6,961.50
A16.4 TUBERCULOSIS OF BRONCHUS, NOS, WITHOUT MENTION OF BACTERIOLOGICAL OR HISTOLOGICAL ONFIRMATION; TUBERCULOSIS OF GLOTTIS, NOS, WITHOUT MENTION OF BACTERIOLOGICAL OR HISTOLOGICAL ONFIRMATION; TUBERCULOSIS OF LARYNX, NOS, WITHOUT MENTION OF BACTERIOLOGIC 23,205.00
16,243.50
6,961.50
A16.5 TUBERCULOUS PLEURISY, WITHOUT MENTION OF BACTERIOLOGICAL OR HISTOLOGICAL CONFIRMATION; TUBERCULOSIS OF PLEURA, NOS, WITHOUT MENTION OF BACTERIOLOGICAL OR HISTOLOGICAL CONFIRMATION; TUBERCULOUS EMPYEMA, NOS, WITHOUT MENTION OF BACTERIOLOGICAL OR HIS 23,205.00
16,243.50
6,961.50
Page 2 of 105 of Annex A
Case Rate
Health Facility Fee
Professional Fee
ICD Code
Description
First Case Rate
A16.7
PRIMARY RESPIRATORY TUBERCULOSIS WITHOUT MENTION OF
BACTERIOLOGICAL OR HISTOLOGICAL CONFIRMATION; PRIMARY
RESPIRATORY TUBERCULOSIS NOS; PRIMARY TUBERCULOUS
COMPLEX
19,110.00
13,377.00
5,733.00
A16.8 OTHER RESPIRATORY TUBERCULOSIS, WITHOUT MENTION OF BACTERIOLOGICAL OR HISTOLOGICAL CONFIRMATION; MEDIASTINAL TUBERCULOSIS, NOS WITHOUT MENTION OF BACTERIOLOGICAL OR HISTOLOGICAL CONFIRMATION; NASOPHARYNGEAL TUBERCULOSIS, NOS WITHOUT MENTION OF BACTERIOLOG 23,205.00
16,243.50
6,961.50
A16.9 RESPIRATORY TUBERCULOSIS UNSPECIFIED, WITHOUT MENTION OF BACTERIOLOGICAL OR HISTOLOGICAL CONFIRMATION; RESPIRATORY TUBERCULOSIS NOS; TUBERCULOSIS NOS 19,110.00
13,377.00
5,733.00
A18.2 TUBERCULOUS PERIPHERAL LYMPHADENOPATHY; TUBERCULOUS ADENITIS 23,205.00
16,243.50
6,961.50
A18.3 TUBERCULOSIS OF INTESTINES, PERITONEUM AND MESENTERIC GLANDS; TUBERCULOSIS OF RETROPERITONEAL LYMPH NODES 23,205.00
16,243.50
6,961.50
A18.4
ERYTHEMA TUBERCULOUS INDURATUM, ; LUPUS EXEDENS;
LUPUS VULGARIS; LUPUS EXEDENS, NOS; LUPUS VULGARIS, NOS;
SCROFULODERMA
23,205.00
16,243.50
6,961.50
A19.0 ACUTE MILIARY TUBERCULOSIS OF A SINGLE SPECIFIED SITE 29,445.00
20,611.50
8,833.50
A19.1 ACUTE MILIARY TUBERCULOSIS OF MULTIPLE SITES 29,445.00
20,611.50
8,833.50
A19.2 ACUTE MILIARY TUBERCULOSIS, UNSPECIFIED 29,445.00
20,611.50
8,833.50
A19.8 OTHER MILIARY TUBERCULOSIS 29,445.00
20,611.50
8,833.50
A19.9 MILIARY TUBERCULOSIS 29,445.00
20,611.50
8,833.50
A20.0 BUBONIC PLAGUE 22,815.00
15,970.50
6,844.50
A20.9 PLAGUE, UNSPECIFIED 22,815.00
15,970.50
6,844.50
A21.0 ULCEROGLANDULAR TULARAEMIA; OPHTHALMIC TULARAEMIA 22,815.00
15,970.50
6,844.50
A21.1 OCULOGLANDULAR TULARAEMIA; OPHTHALMIC TULARAEMIA 22,815.00
15,970.50
6,844.50
A21.2 PULMONARY TULARAEMIA 22,815.00
15,970.50
6,844.50
A21.2+ J17.0* PNEUMONIA IN TULAREMIA 29,250.00
20,475.00
8,775.00
A21.3 GASTROINTESTINAL TULARAEMIA; ABDOMINAL TULARAEMIA 22,815.00
15,970.50
6,844.50
A21.9 TULARAEMIA, UNSPECIFIED 22,815.00
15,970.50
6,844.50
A22.0 CUTANEOUS ANTHRAX; MALIGNANT CARBUNCLE; MALIGNANT PUSTULE 22,815.00
15,970.50
6,844.50
A22.1+ J17.0* PNEUMONIA IN ANTHRAX 29,250.00
20,475.00
8,775.00
A22.2 GASTROINTESTINAL ANTHRAX 22,815.00
15,970.50
6,844.50
A22.7 ANTHRAX SEPTICAEMIA 22,815.00
15,970.50
6,844.50
A22.9 ANTHRAX, UNSPECIFIED 22,815.00
15,970.50
6,844.50
A23.1 BRUCELLOSIS DUE TO BRUCELLA ABORTUS 22,815.00
15,970.50
6,844.50
A23.9 BRUCELLOSIS, UNSPECIFIED 22,815.00
15,970.50
6,844.50
A24.0 GLANDERS; INFECTION DUE TO PSEUDOMONAS MALLEI; MALLEUS 22,815.00
15,970.50
6,844.50
A24.1 ACUTE AND FULMINATING MELIOIDOSIS; MELIOIDOSIS PNEUMONIA ; MELIOIDOSIS SEPTICAEMIA 22,815.00
15,970.50
6,844.50
A25.9 RAT-BITE FEVER, UNSPECIFIED 22,815.00
15,970.50
6,844.50
A26.8 OTHER FORMS OF ERYSIPELOID 22,815.00
15,970.50
6,844.50
A26.9 ERYSIPELOID, UNSPECIFIED 22,815.00
15,970.50
6,844.50
A27.0 LEPTOSPIROSIS ICTEROHAEMORRHAGICA; LEPTOSPIROSIS DUE TO LEPTOSPIRA INTERROGANS SEROVAR ICTEROHAEMORRHAGIAE 21,450.00
15,015.00
6,435.00
A27.8 OTHER FORMS OF LEPTOSPIROSIS 21,450.00
15,015.00
6,435.00
A27.9 LEPTOSPIROSIS, UNSPECIFIED 21,450.00
15,015.00
6,435.00
A28.0 PASTEURELLOSIS 22,815.00
15,970.50
6,844.50
A28.1 CAT-SCRATCH DISEASE; CAT-SCRATCH FEVER 22,815.00
15,970.50
6,844.50
A28.8 OTHER SPECIFIED ZOONOTIC BACTERIAL DISEASES, NOT ELSEWHERE CLASSIFIED 22,815.00
15,970.50
6,844.50
A28.9 ZOONOTIC BACTERIAL DISEASE, UNSPECIFIED 22,815.00
15,970.50
6,844.50
A30.0 HANSEN'S DISEASE: INDETERMINATE LEPROSY; I LEPROSY 17,160.00
12,012.00
5,148.00
A30.1 HANSEN'S DISEASE : TUBERCULOID LEPROSY; TT LEPROSY 17,160.00
12,012.00
5,148.00
A30.2 HANSEN'S DISEASE: BORDERLINE TUBERCULOID LEPROSY; BT LEPROSY 17,160.00
12,012.00
5,148.00
A30.4 HANSEN'S DISEASE: BORDERLINE LEPROMATOUS LEPROSY; BL LEPROSY 17,160.00
12,012.00
5,148.00
A30.5 HANSEN'S DISEASE: LEPROMATOUS LEPROSY; LL LEPROSY 17,160.00
12,012.00
5,148.00
A30.8 OTHER FORMS OF LEPROSY 17,160.00
12,012.00
5,148.00
A30.9 LEPROSY, UNSPECIFIED 17,160.00
12,012.00
5,148.00
A31.0 PULMONARY MYCOBACTERIAL INFECTION; INFECTION DUE TO MYCOBACTERIUM AVIUM, MYCOBACTERIUM INTRACELLULARE [BATTEY BACILLUS]; MYCOBACTERIUM KANSASII 29,250.00
20,475.00
8,775.00
A31.8 OTHER MYCOBACTERIAL INFECTIONS 17,355.00
12,148.50
5,206.50
A31.9
MYCOBACTERIAL INFECTION, UNSPECIFIED ; ATYPICAL
MYCOBACTERIUM INFECTION NOT OTHERWISE SPECIFIED;
MYCOBACTERIOSIS NOS; LISTERIOSIS (LISTERIAL FOODBORNE
INFECTION)
17,355.00
12,148.50
5,206.50
A33 TETANUS NEONATORUM 32,175.00
22,522.50
9,652.50
A34 OBSTETRICAL TETANUS 32,175.00
22,522.50
9,652.50
A35 OTHER TETANUS; TETANUS NOS 32,175.00
22,522.50
9,652.50
A36.0 PHARYNGEAL DIPHTHERIA; DIPHTHERITIC MEMBRANOUS ANGINA; TONSILLAR DIPHTHERIA 16,965.00
11,875.50
5,089.50
A36.3 CUTANEOUS DIPHTHERIA 16,965.00
11,875.50
5,089.50
A36.9 DIPHTHERIA, UNSPECIFIED 16,965.00
11,875.50
5,089.50
Page 3 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate A37.0 WHOOPING COUGH DUE TO BORDETELLA PERTUSSIS 20,670.00
14,469.00
6,201.00
A37.0+ J17.0* PNEUMONIA IN WHOOPING COUGH DUE TO BORDATELLA PERTUSIS 29,250.00
20,475.00
8,775.00
A37.1 WHOOPING COUGH DUE TO BORDETELLA PARAPERTUSSIS 20,670.00
14,469.00
6,201.00
A37.1+ J17.0* PNEUMONIA IN WHOOPING COUGH DUE TO BORDATELLA PARAPERTUSIS 29,250.00
20,475.00
8,775.00
A37.8 WHOOPING COUGH DUE TO OTHER BORDETELLA SPECIES 20,670.00
14,469.00
6,201.00
A37.8+ J17.0* PNEUMONIA IN WHOOPING COUGH DUE TO BORDATELLA SPECIES OTHER THAN PERTUSIS OR PARAPERTUSIS 29,250.00
20,475.00
8,775.00
A37.9 WHOOPING COUGH, UNSPECIFIED 20,670.00
14,469.00
6,201.00
A37.9+ J17.0* PNEUMONIA IN WHOOPING COUGH 29,250.00
20,475.00
8,775.00
A38 SCARLET FEVER; SCARLATINA 16,185.00
11,329.50
4,855.50
A39.2 ACUTE MENINGOCOCCAEMIA 38,610.00
27,027.00
11,583.00
A39.3 CHRONIC MENINGOCOCCAEMIA 38,610.00
27,027.00
11,583.00
A39.4 MENINGOCOCCAEMIA, UNSPECIFIED; MENINGOCOCCAL BACTERAEMIA NOS 38,610.00
27,027.00
11,583.00
A39.9 MENINGOCOCCAL INFECTION, UNSPECIFIED; MENINGOCOCCAL DISEASE NOS 38,610.00
27,027.00
11,583.00
A40.0 SEPTICAEMIA DUE TO STREPTOCOCCUS, GROUP A 62,400.00
43,680.00
18,720.00
A40.1 SEPTICAEMIA DUE TO STREPTOCOCCUS, GROUP B 62,400.00
43,680.00
18,720.00
A40.3 SEPTICAEMIA DUE TO STREPTOCOCCUS PNEUMONIAE; PNEUMOCOCCAL SEPTICAEMIA 62,400.00
43,680.00
18,720.00
A40.8 OTHER STREPTOCOCCAL SEPTICAEMIA 62,400.00
43,680.00
18,720.00
A40.9 STREPTOCOCCAL SEPTICAEMIA, UNSPECIFIED 62,400.00
43,680.00
18,720.00
A41.0 SEPTICAEMIA DUE TO STAPHYLOCOCCUS AUREUS 62,400.00
43,680.00
18,720.00
A41.1 SEPTICAEMIA DUE TO OTHER SPECIFIED STAPHYLOCOCCUS; SEPTICAEMIA DUE TO COAGULASE-NEGATIVE STAPHYLOCOCCUS 62,400.00
43,680.00
18,720.00
A41.2 SEPTICAEMIA DUE TO UNSPECIFIED STAPHYLOCOCCUS 62,400.00
43,680.00
18,720.00
A41.3 SEPTICAEMIA DUE TO HAEMOPHILUS INFLUENZAE 62,400.00
43,680.00
18,720.00
A41.4 SEPTICAEMIA DUE TO ANAEROBES 62,400.00
43,680.00
18,720.00
A41.5 SEPTICAEMIA DUE TO OTHER GRAM-NEGATIVE ORGANISMS; GRAM-NEGATIVE SEPTICAEMIA NOS 62,400.00
43,680.00
18,720.00
A41.8 OTHER SPECIFIED SEPTICAEMIA 62,400.00
43,680.00
18,720.00
A41.9 SEPTICAEMIA, UNSPECIFIED; SEPTIC SHOCK 62,400.00
43,680.00
18,720.00
A42.0 PULMONARY ACTINOMYCOSIS 17,355.00
12,148.50
5,206.50
A42.0+ J17.0* PNEUMONIA IN ACTINOMYCOSES 29,250.00
20,475.00
8,775.00
A42.1 ABDOMINAL ACTINOMYCOSIS 17,355.00
12,148.50
5,206.50
A42.2 CERVICOFACIAL ACTINOMYCOSIS 17,355.00
12,148.50
5,206.50
A42.7 ACTINOMYCOTIC SEPTICAEMIA 17,355.00
12,148.50
5,206.50
A42.8 OTHER FORMS OF ACTINOMYCOSIS 17,355.00
12,148.50
5,206.50
A42.9 ACTINOMYCOSIS, UNSPECIFIED 17,355.00
12,148.50
5,206.50
A43.1 CUTANEOUS NOCARDIOSIS 17,355.00
12,148.50
5,206.50
A43.9 NOCARDIOSIS, UNSPECIFIED 17,355.00
12,148.50
5,206.50
A44.1 CUTANEOUS AND MUCOCUTANEOUS BARTONELLOSIS; VERRUGA PERUANA 17,355.00
12,148.50
5,206.50
A44.9 BARTONELLOSIS, UNSPECIFIED 17,355.00
12,148.50
5,206.50
A46 ERYSIPELAS 18,720.00
13,104.00
5,616.00
A48.0
GAS GANGRENE; CLOSTRIDIAL CELLULITIS; CLOSTRIDIAL
MYONECROSIS
18,720.00
13,104.00
5,616.00
A48.1 LEGIONNAIRES' DISEASE 29,250.00
20,475.00
8,775.00
A48.3 TOXIC SHOCK SYNDROME 62,400.00
43,680.00
18,720.00
A48.8 OTHER SPECIFIED BACTERIAL DISEASES 17,355.00
12,148.50
5,206.50
A49.0 STAPHYLOCOCCAL INFECTION, UNSPECIFIED 17,355.00
12,148.50
5,206.50
A49.2 HAEMOPHILUS INFLUENZAE INFECTION, UNSPECIFIED 17,355.00
12,148.50
5,206.50
A49.3 MYCOPLASMA INFECTION, UNSPECIFIED 17,355.00
12,148.50
5,206.50
A49.8 OTHER BACTERIAL INFECTIONS OF UNSPECIFIED SITE 17,355.00
12,148.50
5,206.50
A49.9 BACTERIAL INFECTION, UNSPECIFIED; BACTERAEMIA NOS 17,355.00
12,148.50
5,206.50
A50.0
EARLY CUTANEOUS CONGENITAL SYPHILIS: , EARLY
MUCOCUTANEOUS CONGENITAL SYPHILIS, EARLY VISCERAL
CONGENITAL SYPHILIS; EARLY CONGENITAL SYPHILITIC
LARYNGITIS; EARLY CONGENITAL SYPHILITIC OCULOPATHY;
EARLY CONGENITAL SYPHILITIC OSTEOCHONDROPATHY; EAR
24,960.00
17,472.00
7,488.00
A50.2 EARLY CONGENITAL SYPHILIS, UNSPECIFIED; CONGENITAL SYPHILIS NOS LESS THAN TWO YEARS AFTER BIRTH. 24,960.00
17,472.00
7,488.00
A50.4 LATE CONGENITAL NEUROSYPHILIS [JUVENILE NEUROSYPHILIS]; DEMENTIA PARALYTICA JUVENILIS; JUVENILE GENERAL PARESIS ; JUVENILE TABES DORSALIS; JUVENILE TABOPARETIC NEUROSYPHILIS 24,960.00
17,472.00
7,488.00
A50.5 OTHER LATE CONGENITAL SYPHILIS, SYMPTOMATIC; SYPHILITIC SADDLE NOSE 24,960.00
17,472.00
7,488.00
A50.9 CONGENITAL SYPHILIS, UNSPECIFIED 24,960.00
17,472.00
7,488.00
A52.1 LATE SYMPTOMATIC NEUROSYPHILIS; TABES DORSALIS 10,725.00
7,507.50
3,217.50
A52.3 NEUROSYPHILIS, UNSPECIFIED; SYPHILITIC GUMMA OF CENTRAL NERVOUS SYSTEM NOS; LATE SYPHILIS OF CENTRAL NERVOUS SYSTEM NOS; SYPHILOMA OF CENTRAL NERVOUS SYSTEM NOS 10,725.00
7,507.50
3,217.50
A52.7 OTHER SYMPTOMATIC LATE SYPHILIS 10,725.00
7,507.50
3,217.50
A53.0 LATENT SYPHILIS, UNSPECIFIED AS EARLY OR LATE; LATENT SYPHILIS NOS; POSITIVE SEROLOGICAL REACTION FOR SYPHILIS 10,725.00
7,507.50
3,217.50
A53.0+ J17.0* PNEUMONIA IN NOCARDIOSIS 29,250.00
20,475.00
8,775.00
A54.1 GONOCOCCAL INFECTION OF LOWER GENITOURINARY TRACT WITH PERIURETHRAL AND ACCESSORY GLAND ABSCESS; GONOCOCCAL BARTHOLIN'S GLAND ABSCESS 10,725.00
7,507.50
3,217.50
A54.2 GONOCOCCAL PELVIPERITONITIS AND OTHER GONOCOCCAL GENITOURINARY INFECTIONS 10,725.00
7,507.50
3,217.50
A54.8 GONOCOCCAL SEPTICAEMIA; GONOCOCCAL SKIN LESIONS 10,725.00
7,507.50
3,217.50
Page 4 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate A54.8+ J17.0* PNEUMONIA IN GONORRHEA 29,250.00
20,475.00
8,775.00
A55 CHLAMYDIAL LYMPHOGRANULOMA (VENEREUM); CLIMATIC OR TROPICAL BUBO ; DURAND-NICOLAS-FAVRE DISEASE; ESTHIOMENE; LYMPHOGRANULOMA INGUINALE 10,725.00
7,507.50
3,217.50
A56.1 CHLAMYDIAL INFECTION OF PELVIPERITONEUM AND OTHER GENITOURINARY ORGANS; 10,725.00
7,507.50
3,217.50
A56.4 CHLAMYDIAL INFECTION OF PHARYNX 16,575.00
11,602.50
4,972.50
A59 TRICHOMONIASIS 10,725.00
7,507.50
3,217.50
A66.9 YAWS, UNSPECIFIED 17,160.00
12,012.00
5,148.00
A67.1 INTERMEDIATE LESIONS OF PINTA; ERYTHEMATOUS PLAQUES OF CARATE PINTA; HYPERCHROMIC LESIONS OF CARATE PINTA; HYPERKERATOSIS OF CARATE PINTA; PINTIDS OF CARATE PINTA 17,160.00
12,012.00
5,148.00
A68.9 RELAPSING FEVER, UNSPECIFIED 17,160.00
12,012.00
5,148.00
A69.0 NECROTIZING ULCERATIVE STOMATITIS; CANCRUM ORIS; FUSOSPIROCHAETAL GANGRENE; NOMA; STOMATITIS GANGRENOSA 17,160.00
12,012.00
5,148.00
A69.1
OTHER VINCENT'S INFECTIONS; FUSOSPIROCHAETAL
PHARYNGITIS ; ACUTE NECROTIZING ULCERATIVE GINGIVITIS;
ACUTE NECROTIZING ULCERATIVE GINGIVOSTOMATITIS;
SPIROCHAETAL STOMATITIS, TRENCH MOUTH; VINCENT'S
ANGINA; VINCENT’S GINGIVITIS
17,160.00
12,012.00
5,148.00
A69.2 LYME DISEASE; ERYTHEMA CHRONICUM MIGRANS DUE TO BORRELIA BURGDORFERI 17,160.00
12,012.00
5,148.00
A69.8+ J17.8* PNEUMONIA IN SPIROCHAETAL 29,250.00
20,475.00
8,775.00
A69.9 SPIROCHAETAL INFECTION, UNSPECIFIED 17,160.00
12,012.00
5,148.00
A70+ J17.8* PNEUMONIA IN ORNITHOSIS 29,250.00
20,475.00
8,775.00
A71.1 ACTIVE STAGE OF TRACHOMA; ACTIVE STAGE OF TRACHOMA; TRACHOMATOUS GRANULAR CONJUNCTIVITIS; TRACHOMATOUS FOLLICULAR CONJUNCTIVITIS; TRACHOMATOUS PANNUS 16,575.00
11,602.50
4,972.50
A71.9 TRACHOMA, UNSPECIFIED 16,575.00
11,602.50
4,972.50
A74.9 CHLAMYDIAL INFECTION, UNSPECIFIED; CHLAMYDIOSIS NOS 16,575.00
11,602.50
4,972.50
A75.0
EPIDEMIC LOUSE-BORNE TYPHUS FEVER DUE TO RICKETTSIA
PROWAZEKII; CL ASSICAL TYPHUS FEVER;
EPIDEMIC LOUSE-BORNE TYPHUS
13,650.00
9,555.00
4,095.00
A75.9 TYPHUS FEVER, UNSPECIFIED 13,650.00
9,555.00
4,095.00
A77.0 SPOTTED FEVER DUE TO RICKETTSIA RICKETTSII; ROCKY MOUNTAIN SPOTTED FEVER; SAO PAULO FEVER 13,650.00
9,555.00
4,095.00
A78+ J17.8* PNEUMONIA IN Q FEVER 29,250.00
20,475.00
8,775.00
A79.0 TRENCH FEVER ; QUINTAN FEVER; WOLHYNIAN FEVER 13,650.00
9,555.00
4,095.00
A79.9 RICKETTSIOSIS, UNSPECIFIED; RICKETTSIAL INFECTION NOS 13,650.00
9,555.00
4,095.00
A81.0 CREUTZFELDT-JAKOB DISEASE; SUBACUTE SPONGIFORM ENCEPHALOPATHY 41,145.00
28,801.50
12,343.50
A81.1 SUBACUTE SCLEROSING PANENCEPHALITIS; DAWSON'S INCLUSION BODY ENCEPHALITIS ; VAN BOGAERT'S SCLEROSING LEUKOENCEPHALOPATHY 41,145.00
28,801.50
12,343.50
A81.2 PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY; MULTIFOCAL LEUKOENCEPHALOPATHY NOS 41,145.00
28,801.50
12,343.50
A81.9 ATYPICAL VIRUS INFECTION OF CENTRAL NERVOUS SYSTEM, UNSPECIFIED; PRION DISEASE OF CENTRAL NERVOUS SYSTEM NOS 41,145.00
28,801.50
12,343.50
A82.0 SYLVATIC RABIES 41,145.00
28,801.50
12,343.50
A82.1 URBAN RABIES 41,145.00
28,801.50
12,343.50
A82.9 RABIES, UNSPECIFIED 41,145.00
28,801.50
12,343.50
A83.0 JAPANESE ENCEPHALITIS 41,145.00
28,801.50
12,343.50
A83.2 EASTERN EQUINE ENCEPHALITIS 41,145.00
28,801.50
12,343.50
A83.5 CALIFORNIA ENCEPHALITIS; CALIFORNIA MENINGOENCEPHALITIS LA CROSSE ENCEPHALITIS 41,145.00
28,801.50
12,343.50
A83.8 OTHER MOSQUITO-BORNE VIRAL ENCEPHALITIS 41,145.00
28,801.50
12,343.50
A83.9 MOSQUITO-BORNE VIRAL ENCEPHALITIS, UNSPECIFIED 41,145.00
28,801.50
12,343.50
A85.2 ARTHROPOD-BORNE VIRAL ENCEPHALITIS, UNSPECIFIED; 41,145.00
28,801.50
12,343.50
A85.8 OTHER SPECIFIED VIRAL ENCEPHALITIS; ENCEPHALITIS LETHARGIC; VON ECONOMO-CRUCHET DISEASE 41,145.00
28,801.50
12,343.50
A86 UNSPECIFIED VIRAL ENCEPHALITIS; VIRAL ENCEPHALOMYELITIS NOS; VIRAL MENINGOENCEPHALITIS NOS 41,145.00
28,801.50
12,343.50
A87.8 OTHER VIRAL MENINGITIS 50,115.00
35,080.50
15,034.50
A87.9 VIRAL MENINGITIS, UNSPECIFIED 50,115.00
35,080.50
15,034.50
A88.8 OTHER SPECIFIED VIRAL INFECTIONS OF CENTRAL NERVOUS SYSTEM 41,145.00
28,801.50
12,343.50
A89 UNSPECIFIED VIRAL INFECTION OF CENTRAL NERVOUS SYSTEM 41,145.00
28,801.50
12,343.50
A92.0 CHIKUNGUNYA VIRUS DISEASE; CHIKUNGUNYA (HAEMORRHAGIC) FEVER 15,795.00
11,056.50
4,738.50
A92.1 O'NYONG-NYONG FEVER 15,795.00
11,056.50
4,738.50
A92.2 VENEZUELAN EQUINE FEVER; VENEZUELAN EQUINE ENCEPHALITIS; VENEZUELAN ENCEPHALOMYELITIS VIRUS DISEASE 15,795.00
11,056.50
4,738.50
A92.8 OTHER SPECIFIED MOSQUITO-BORNE VIRAL FEVERS 15,795.00
11,056.50
4,738.50
A93.1 SANDFLY FEVER; PAPPATACI FEVER; PHLEBOTOMUS FEVER 15,795.00
11,056.50
4,738.50
A93.8 OTHER SPECIFIED ARTHROPOD-BORNE VIRAL FEVERS; PIRY VIRUS DISEASE; VESICULAR STOMATITIS VIRUS DISEASE [INDIANA FEVER] 15,795.00
11,056.50
4,738.50
Page 5 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate A94 UNSPECIFIED ARTHROPOD-BORNE VIRAL FEVER; UNSPECIFIED ARTHROPOD-BORNE VIRAL FEVER; ARBOVIRAL FEVER NOS; ARBOVIRUS INFECTION NOS 15,795.00
11,056.50
4,738.50
A96.0 JUNIN HAEMORRHAGIC FEVER; ARGENTINIAN HAEMORRHAGIC FEVER 15,405.00
10,783.50
4,621.50
A96.1 MACHUPO HAEMORRHAGIC FEVER; BOLIVIAN HAEMORRHAGIC FEVER 15,405.00
10,783.50
4,621.50
A97.0 DENGUE WITHOUT WARNING SIGNS; DENGUE FEVER (DF) DENGUE HAEMORRHAGIC FEVER GRADES 1 AND 2; DENGUE HAEMORRHAGIC FEVER WITHOUT WARNING SIGNS 19,500.00
13,650.00
5,850.00
A97.1 DENGUE WITH WARNING SIGNS; DENGUE HAEMORRHAGIC FEVER WITH WARNING SIGNS 19,500.00
13,650.00
5,850.00
A98.8 OTHER SPECIFIED VIRAL HAEMORRHAGIC FEVERS 15,405.00
10,783.50
4,621.50
A99 UNSPECIFIED VIRAL HAEMORRHAGIC FEVER 15,405.00
10,783.50
4,621.50
B01.2+ J17.1* PNEUMONIA IN VARICELLA 29,250.00
20,475.00
8,775.00
B01.9 VARICELLA [CHICKENPOX] WITHOUT COMPLICATION 7,800.00
5,460.00
2,340.00
B05.0+ G05.1* MEASLES COMPLICATED BY ENCEPHALITIS; ENCEPHALITIS, MYELITIS AND ENCEPHALOMYELITIS IN VIRAL DISEASES CLASSIFIED ELSEWHERE 42,120.00
29,484.00
12,636.00
B05.1+ G02.0* MEASLES COMPLICATED BY MENINGITIS; MENINGITIS IN VIRAL DISEASES CLASSIFIED ELSEWHERE 50,115.00
35,080.50
15,034.50
B05.2+ J17.1* PNEUMONIA IN MEASLES 29,250.00
20,475.00
8,775.00
B05.3+ H67.1* MEASLES COMPLICATED BY OTITIS MEDIA; OTITIS MEDIA IN VIRAL DISEASES CLASSIFIED ELSEWHERE 15,210.00
10,647.00
4,563.00
B05.4 MEASLES WITH INTESTINAL COMPLICATIONS 18,525.00
12,967.50
5,557.50
B05.8 MEASLES WITH OTHER COMPLICATIONS 15,015.00
10,510.50
4,504.50
B05.9 MEASLES WITHOUT COMPLICATIONS 15,015.00
10,510.50
4,504.50
B06.8 RUBELLA WITH OTHER COMPLICATIONS 7,800.00
5,460.00
2,340.00
B06.8+ J17.1* PNEUMONIA IN RUBELLA 29,250.00
20,475.00
8,775.00
B06.9 RUBELLA WITHOUT COMPLICATION 7,800.00
5,460.00
2,340.00
B09 VIRAL EXANTHEM 7,800.00
5,460.00
2,340.00
B15.0 ACUTE HEPATITIS A WITH HEPATIC COMA 23,010.00
16,107.00
6,903.00
B15.9 ACUTE HEPATITIS A WITHOUT HEPATIC COMA; HEPATITIS A (ACUTE)(VIRAL) NOS 23,010.00
16,107.00
6,903.00
B16.0 ACUTE HEPATITIS B WITH DELTA-AGENT (COINFECTION) WITH HEPATIC COMA 23,010.00
16,107.00
6,903.00
B16.1 ACUTE HEPATITIS B WITH DELTA-AGENT (COINFECTION) WITHOUT HEPATIC COMA 23,010.00
16,107.00
6,903.00
B16.2 ACUTE HEPATITIS B WITHOUT DELTA-AGENT WITH HEPATIC COMA 23,010.00
16,107.00
6,903.00
B16.9 ACUTE HEPATITIS B WITHOUT DELTA-AGENT AND WITHOUT HEPATIC COMA; HEPATITIS B (ACUTE)(VIRAL) NOS 23,010.00
16,107.00
6,903.00
B17.0 ACUTE DELTA-(SUPER)INFECTION OF HEPATITIS B CARRIER 23,010.00
16,107.00
6,903.00
B17.1 ACUTE HEPATITIS C 23,010.00
16,107.00
6,903.00
B17.2 ACUTE HEPATITIS E 23,010.00
16,107.00
6,903.00
B17.8 OTHER SPECIFIED ACUTE VIRAL HEPATITIS; HEPATITIS NON-A NON-B (ACUTE)(VIRAL) NEC 23,010.00
16,107.00
6,903.00
B18.0 CHRONIC VIRAL HEPATITIS B WITH DELTA-AGENT 23,010.00
16,107.00
6,903.00
B18.1 CHRONIC VIRAL HEPATITIS B WITHOUT DELTA-AGENT; CHRONIC (VIRAL) HEPATITIS B 23,010.00
16,107.00
6,903.00
B18.2 CHRONIC VIRAL HEPATITIS C 23,010.00
16,107.00
6,903.00
B18.8 OTHER CHRONIC VIRAL HEPATITIS 23,010.00
16,107.00
6,903.00
B18.9 CHRONIC VIRAL HEPATITIS, UNSPECIFIED 23,010.00
16,107.00
6,903.00
B19.0 UNSPECIFIED VIRAL HEPATITIS HEPATIC WITH COMA 23,010.00
16,107.00
6,903.00
B19.9 UNSPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA; VIRAL HEPATITIS NOS 23,010.00
16,107.00
6,903.00
B20.1 HIV DISEASE RESULTING IN OTHER BACTERIAL INFECTIONS 17,355.00
12,148.50
5,206.50
B21.0 HUMAN IMMUNODEFICIENCY VIRUS [HIV] DISEASE RESULTING IN KAPOSI'S SARCOMA 23,400.00
16,380.00
7,020.00
B21.1 HUMAN IMMUNODEFICIENCY VIRUS [HIV] DISEASE RESULTING IN BURKITT'S LYMPHOMA 27,105.00
18,973.50
8,131.50
B21.2 HUMAN IMMUNODEFICIENCY VIRUS [HIV] DISEASE RESULTING IN OTHER TYPES OF NON-HODGKIN'S LYMPHOMA 27,105.00
18,973.50
8,131.50
B21.3 HUMAN IMMUNODEFICIENCY VIRUS [HIV] DISEASE RESULTING IN OTHER MALIGNANT NEOPLASMS OF LYMPHOID, HAEMATOPOIETIC AND RELATED TISSUE 27,105.00
18,973.50
8,131.50
B22.0 HUMAN IMMUNODEFICIENCY VIRUS [HIV] DISEASE RESULTING IN ENCEPHALOPATHY; HUMAN IMMUNODEFICIENCY VIRUS [HIV] DEMENTIA 43,290.00
30,303.00
12,987.00
B25.0+ J17.1* PNEUMONIA IN CYTOMEGALOVIRUS DISEASE 29,250.00
20,475.00
8,775.00
B34.1 ECHOVIRUS INFECTION NOS 7,800.00
5,460.00
2,340.00
B34.2 CORONAVIRUS INFECTION, UNSPECIFIED 7,800.00
5,460.00
2,340.00
B34.3 PARVOVIRUS INFECTION, UNSPECIFIED 7,800.00
5,460.00
2,340.00
B34.4 PAPOVAVIRUS INFECTION, UNSPECIFIED 7,800.00
5,460.00
2,340.00
B34.8 OTHER VIRAL INFECTIONS OF UNSPECIFIED SITE 7,800.00
5,460.00
2,340.00
B34.9 VIRAL INFECTION, UNSPECIFIED; 7,800.00
5,460.00
2,340.00
B37.1+ J17.2* PNEUMONIA IN CANDIDIASIS 29,250.00
20,475.00
8,775.00
B38.0+ J17.2* PNEUMONIA IN ACUTE PULMONARY COCCIDIOMYCOSIS 29,250.00
20,475.00
8,775.00
B38.1+ J17.2* PNEUMONIA IN CHRONIC PULMONARY COCCIDIOMYCOSIS 29,250.00
20,475.00
8,775.00
B38.2+ J17.2* PNEUMONIA IN PULMONARY COCCIDIOIDOMYCOSIS 29,250.00
20,475.00
8,775.00
B39.0+ J17.2* PNEUMONIA IN ACUTE PULMONARY HISTOPLASMOSIS CAPSULATI 29,250.00
20,475.00
8,775.00
B39.1+ J17.2* PNEUMONIA IN CHRONIC PULMONARY HISTOPLASMOSIS CAPSULATI 29,250.00
20,475.00
8,775.00
Page 6 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate B39.2+ J17.2* PNEUMONIA IN PULMONARY HISTOPLASMOSIS CAPSULATI 29,250.00
20,475.00
8,775.00
B39.9+ J17.2* PNEUMONIA IN HISTOPLASMOSIS 29,250.00
20,475.00
8,775.00
B44.0+ J17.2* PNEUMONIA IN INVASIVE PULMONARY ASPERGILLOSIS 29,250.00
20,475.00
8,775.00
B44.1+ J17.2* PNEUMONIA IN OTHER PULMONARY ASPERGILLOSIS 29,250.00
20,475.00
8,775.00
B50.9 PLASMODIUM FALCIPARUM MALARIA 7,800.00
5,460.00
2,340.00
B51.9 PLASMODIUM VIVAX MALARIA WITHOUT COMPLICATIONS 7,800.00
5,460.00
2,340.00
B52.9 PLASMODIUM MALARIAE MALARIA WITHOUT COMPLICATIONS 7,800.00
5,460.00
2,340.00
B58.3+ J17.3* PNEUMONIA IN TAXOPLASMOSIS 29,250.00
20,475.00
8,775.00
B65.0+ J17.3* PNEUMONIA IN SCHISTOSOMIASIS DUE TO SCHISTOSOMA HEMATOBIUM 29,250.00
20,475.00
8,775.00
B65.1 SCHISTOSOMIASIS DUE TO SCHISTOSOMA MANSONI [INTESTINAL SCHISTOSOMIASIS] 7,800.00
5,460.00
2,340.00
B65.1+ J17.3* PNEUMONIA IN SCHISTOSOMIASIS DUE TO SCHISTOSOMA MANSONI 29,250.00
20,475.00
8,775.00
B65.2 SCHISTOSOMIASIS DUE TO SCHISTOSOMA JAPONICUM 7,800.00
5,460.00
2,340.00
B65.2+ J17.3* PNEUMONIA IN SCHISTOSOMIASIS DUE TO SCHISTOSOMA JAPONICUM 29,250.00
20,475.00
8,775.00
B65.3 CERCARIAL DERMATITIS; SWIMMER'S ITCH 7,800.00
5,460.00
2,340.00
B65.8
INFECTION DUE TO SCHISTOSOMA INTERCALATUM,
SCHISTOSOMA MATTHEEI , SCHISTOSOMA MEKONGI
7,800.00
5,460.00
2,340.00
B65.8+ J17.3* PNEUMONIA IN SCHISTOSOMIASIS DUE TO SCHISTOSOMA INTERCALATUM; MATTHEEI; MEKONGI 29,250.00
20,475.00
8,775.00
B65.9 SCHISTOSOMIASIS, UNSPECIFIED 7,800.00
5,460.00
2,340.00
B65.9+ J17.3* PNEUMONIA IN SCHISTOSOMIASIS 29,250.00
20,475.00
8,775.00
B77.8+ J17.3* PNEUMONIA IN ASCARIASIS 29,250.00
20,475.00
8,775.00
B77.9 ASCARIASIS 7,800.00
5,460.00
2,340.00
B82.0 INTESTINAL HELMINTHIASIS, UNSPECIFIED 7,800.00
5,460.00
2,340.00
B82.9 INTESTINAL PARASITISM, UNSPECIFIED 7,800.00
5,460.00
2,340.00
B90.0 SEQUELAE OF CENTRAL NERVOUS SYSTEM TUBERCULOSIS 20,865.00
14,605.50
6,259.50
B90.8 SEQUELAE OF TUBERCULOSIS OF OTHER ORGANS 20,865.00
14,605.50
6,259.50
B90.9 SEQUELAE OF RESPIRATORY AND UNSPECIFIED TUBERCULOSIS; SEQUELAE OF TUBERCULOSIS NOS 20,865.00
14,605.50
6,259.50
B94.1 SEQUELAE OF VIRAL ENCEPHALITIS 20,865.00
14,605.50
6,259.50
B94.2 SEQUELAE OF VIRAL HEPATITIS 20,865.00
14,605.50
6,259.50
B94.8 SEQUELAE OF OTHER SPECIFIED INFECTIOUS AND PARASITIC DISEASES 20,865.00
14,605.50
6,259.50
B94.9 SEQUELAE OF UNSPECIFIED INFECTIOUS OR PARASITIC DISEASE 20,865.00
14,605.50
6,259.50
C00.0 MALIGNANT NEOPLASM OF EXTERNAL UPPER LIP; MALIGNANT NEOPLASM OF UPPER LIP NOS; MALIGNANT NEOPLASM OF UPPER LIP; MALIGNANT NEOPLASM OF LIPSTICK AREA; MALIGNANT NEOPLASM OF UPPER LIP, VERMILION BORDER 22,425.00
15,697.50
6,727.50
C00.9 MALIGNANT NEOPLASM OF LIP, UNSPECIFIED 22,425.00
15,697.50
6,727.50
C01 MALIGNANT NEOPLASM OF BASE OF DORSAL SURFACE OF TONGUE ; MALIGNANT NEOPLASM OF FIXED PART OF TONGUE NOS; MALIGNANT NEOPLASM OF POSTERIOR THIRD OF TONGUE 22,425.00
15,697.50
6,727.50
C02.0 MALIGNANT NEOPLASM OF DORSAL SURFACE OF BASE OF TONGUE; MALIGNANT NEOPLASM OF ANTERIOR TWO-THIRDS OF DORSAL SURFACE OF TONGUE 22,425.00
15,697.50
6,727.50
C02.1 MALIGNANT NEOPLASM OF BORDER OF TONGUE; MALIGNANT NEOPLASM OF TIP OF TONGUE 22,425.00
15,697.50
6,727.50
C02.2 MALIGNANT NEOPLASM OF VENTRAL SURFACE OF TONGUE; MALIGNANT NEOPLASM OF ANTERIOR TWO-THIRDS OF VENTRAL SURFACE OF TONGUE; MALIGNANT NEOPLASM OF FRENULUM LINGUAE 22,425.00
15,697.50
6,727.50
C02.3 MALIGNANT NEOPLASM OF ANTERIOR TWO-THIRDS OF TONGUE, PART UNSPECIFIED; MALIGNANT NEOPLASM OF MIDDLE THIRD OF TONGUE NOS; MALIGNANT NEOPLASM OF MOBILE PART OF TONGUE NOS 22,425.00
15,697.50
6,727.50
C02.4 MALIGNANT NEOPLASM OF LINGUAL TONSIL 22,425.00
15,697.50
6,727.50
C02.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF TONGUE 22,425.00
15,697.50
6,727.50
C02.9 MALIGNANT NEOPLASM OF TONGUE, UNSPECIFIED 22,425.00
15,697.50
6,727.50
C03.0 MALIGNANT NEOPLASM OF UPPER GUM 22,425.00
15,697.50
6,727.50
C03.1 MALIGNANT NEOPLASM OF LOWER GUM 22,425.00
15,697.50
6,727.50
C03.9 MALIGNANT NEOPLASM OF GUM, UNSPECIFIED 22,425.00
15,697.50
6,727.50
C04.9 MALIGNANT NEOPLASM OF FLOOR OF MOUTH, UNSPECIFIED 22,425.00
15,697.50
6,727.50
C05.0 MALIGNANT NEOPLASM OF HARD PALATE 22,425.00
15,697.50
6,727.50
C05.1 MALIGNANT NEOPLASM OF SOFT PALATE 22,425.00
15,697.50
6,727.50
C05.9 MALIGNANT NEOPLASM OF PALATE, UNSPECIFIED 22,425.00
15,697.50
6,727.50
C06.0 MALIGNANT NEOPLASM OF CHEEK MUCOSA; MALIGNANT NEOPLASM OF BUCCAL MUCOSA NOS; MALIGNANT NEOPLASM OF INTERNAL CHEEK 22,425.00
15,697.50
6,727.50
C06.1 MALIGNANT NEOPLASM OF VESTIBULE OF MOUTH; MALIGNANT NEOPLASM OF UPPER BUCCAL SULCUS; MALIGNANT NEOPLASM OF LOWER BUCCAL SULCUS; MALIGNANT NEOPLASM OF UPPER LABIAL SULCUS; MALIGNANT NEOPLASM OF LOWER LABIAL SULCUS 22,425.00
15,697.50
6,727.50
C06.2 MALIGNANT NEOPLASM OF RETROMOLAR AREA 22,425.00
15,697.50
6,727.50
C06.9
MALIGNANT NEOPLASM OF MOUTH, UNSPECIFIED; MINOR
MALIGNANT NEOPLASM OF MINOR SALIVARY GLAND,
UNSPECIFIED SITE; MALIGNANT NEOPLASM OF ORAL CAVITY NOS
22,425.00
15,697.50
6,727.50
C07 MALIGNANT NEOPLASM OF PAROTID GLAND 22,425.00
15,697.50
6,727.50
Page 7 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate C08.0 MALIGNANT NEOPLASM OF SUBMANDIBULAR GLAND; MALIGNANT NEOPLASM OF SUBMAXILLARY GLAND 22,425.00
15,697.50
6,727.50
C08.1 MALIGNANT NEOPLASM OF SUBLINGUAL GLAND 22,425.00
15,697.50
6,727.50
C08.9 MALIGNANT NEOPLASM OF MAJOR SALIVARY GLAND, UNSPECIFIED; MALIGNANT NEOPLASM OF MAJOR SALIVARY GLAND NOS 22,425.00
15,697.50
6,727.50
C09.0 MALIGNANT NEOPLASM OF TONSILLAR FOSSA 22,425.00
15,697.50
6,727.50
C09.9 MALIGNANT NEOPLASM OF TONSIL, UNSPECIFIED; MALIGNANT NEOPLASM OF TONSIL NOS; MALIGNANT NEOPLASM OF FAUCIAL TONSIL; MALIGNANT NEOPLASM OF PALATINE TONSIL 22,425.00
15,697.50
6,727.50
C10.0 MALIGNANT NEOPLASM OF VALLECULA 22,425.00
15,697.50
6,727.50
C10.3 MALIGNANT NEOPLASM OF POSTERIOR WALL OF OROPHARYNX 22,425.00
15,697.50
6,727.50
C10.4 MALIGNANT NEOPLASM OF BRANCHIAL CLEFT; MALIGNANT NEOPLASM OF BRANCHIAL CYST 22,425.00
15,697.50
6,727.50
C10.9 MALIGNANT NEOPLASM OF OROPHARYNX, UNSPECIFIED 22,425.00
15,697.50
6,727.50
C11.0
MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX;
MALIGNANT NEOPLASM OF ROOF OF NASOPHARYNX
22,425.00
15,697.50
6,727.50
C11.1
MALIGNANT NEOPLASM OF POSTERIOR WALL OF NASOPHARYNX;
MALIGNANT NEOPLASM OF ADENOID; MALIGNANT NEOPLASM OF
PHARYNGEAL TONSIL
22,425.00
15,697.50
6,727.50
C11.2 MALIGNANT NEOPLASM OF LATERAL WALL OF NASOPHARYNX; MALIGNANT NEOPLASM OF FOSSA OF ROSENMüLLER; MALIGNANT NEOPLASM OF OPENING OF AUDITORY TUBE; MALIGNANT NEOPLASM OF PHARYNGEAL RECESS 22,425.00
15,697.50
6,727.50
C11.3
MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX;
MALIGNANT NEOPLASM OF A NTERIOR NASOPHARYNGEAL
SURFACE OF SOFT PALATE; MALIGNANT NEOPLASM OF POSTERIOR
NASOPHARYNGEAL SURFACE OF SOFT PALATE; MALIGNANT
NEOPLASM OF POSTERIOR MARGIN OF NASAL CHOANA; M
22,425.00
15,697.50
6,727.50
C11.9 MALIGNANT NEOPLASM OF NASOPHARYNX, UNSPECIFIED 22,425.00
15,697.50
6,727.50
C13.1
MALIGNANT NEOPLASM OF ARYEPIGLOTTIC FOLD,
HYPOPHARYNGEAL ASPECT HYPOPHARYNX ; MALIGNANT
NEOPLASM OF ARYEPIGLOTTIC FOLD, HYPOPHARYNX NOS;
MALIGNANT NEOPLASM OF ARYEPIGLOTTIC FOLD, MARGINAL
ZONE, HYPOPHARYNX
22,425.00
15,697.50
6,727.50
C13.9 MALIGNANT NEOPLASM OF HYPOPHARYNX, UNSPECIFIED; MALIGNANT NEOPLASM OF HYPOPHARYNGEAL WALL NOS 22,425.00
15,697.50
6,727.50
C14.0 MALIGNANT NEOPLASM OF PHARYNX, UNSPECIFIED 22,425.00
15,697.50
6,727.50
C14.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF LIP, ORAL CAVITY AND PHARYNX 22,425.00
15,697.50
6,727.50
C15.0 MALIGNANT NEOPLASM OF CERVICAL PART OF OESOPHAGUS 27,690.00
19,383.00
8,307.00
C15.2 MALIGNANT NEOPLASM OF ABDOMINAL PART OF OESOPHAGUS 27,690.00
19,383.00
8,307.00
C15.3 MALIGNANT NEOPLASM OF UPPER THIRD OF OESOPHAGUS 27,690.00
19,383.00
8,307.00
C15.4 MALIGNANT NEOPLASM OF MIDDLE THIRD OF OESOPHAGUS 27,690.00
19,383.00
8,307.00
C15.5 MALIGNANT NEOPLASM OF LOWER THIRD OF OESOPHAGUS 27,690.00
19,383.00
8,307.00
C15.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF OESOPHAGUS 27,690.00
19,383.00
8,307.00
C15.9 MALIGNANT NEOPLASM OF OESOPHAGUS, UNSPECIFIED 27,690.00
19,383.00
8,307.00
C16 DERMATO(POLY)MYOSITIS IN MALIGNANT NEOPLASM OF STOMACH 27,690.00
19,383.00
8,307.00
C16.0
MALIGNANT NEOPLASM OF CARDIA; MALIGNANT NEOPLASM OF
CARDIAC ORIFICE; MALIGNANT NEOPLASM OF CARDIO-
OESOPHAGEAL JUNCTION; MALIGNANT NEOPLASM OF
GASTRO-OESOPHAGEAL JUNCTION; MALIGNANT NEOPLASM OF
OESOPHAGUS AND STOMACH
27,690.00
19,383.00
8,307.00
C16.1 MALIGNANT NEOPLASM OF FUNDUS OF STOMACH 27,690.00
19,383.00
8,307.00
C16.2 MALIGNANT NEOPLASM OF BODY OF STOMACH 27,690.00
19,383.00
8,307.00
C16.3 MALIGNANT NEOPLASM OF PYLORIC ANTRUM; MALIGNANT NEOPLASM OF GASTRIC ANTRUM 27,690.00
19,383.00
8,307.00
C16.4 MALIGNANT NEOPLASM OF PYLORUS; MALIGNANT NEOPLASM OF PREPYLORUS; MALIGNANT NEOPLASM OF PYLORIC CANAL 27,690.00
19,383.00
8,307.00
C16.5 MALIGNANT NEOPLASM OF LESSER CURVATURE OF STOMACH, UNSPECIFIED 27,690.00
19,383.00
8,307.00
C16.6 MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH, UNSPECIFIED 27,690.00
19,383.00
8,307.00
C16.9 MALIGNANT NEOPLASM OF STOMACH, UNSPECIFIED 27,690.00
19,383.00
8,307.00
C17.0 MALIGNANT NEOPLASM OF DUODENUM 27,690.00
19,383.00
8,307.00
C17.1 MALIGNANT NEOPLASM OF JEJUNUM 27,690.00
19,383.00
8,307.00
C17.2 MALIGNANT NEOPLASM OF ILEUM 27,690.00
19,383.00
8,307.00
C17.9 MALIGNANT NEOPLASM OF SMALL INTESTINE, UNSPECIFIED 27,690.00
19,383.00
8,307.00
C18.0 MALIGNANT NEOPLASM OF CAECUM; MALIGNANT NEOPLASM OF ILEOCAECAL VALVE 27,690.00
19,383.00
8,307.00
C18.1 MALIGNANT NEOPLASM OF APPENDIX 27,690.00
19,383.00
8,307.00
C18.2 MALIGNANT NEOPLASM OF ASCENDING COLON 27,690.00
19,383.00
8,307.00
C18.3 MALIGNANT NEOPLASM OF HEPATIC FLEXURE 27,690.00
19,383.00
8,307.00
C18.4 MALIGNANT NEOPLASM OF TRANSVERSE COLON 27,690.00
19,383.00
8,307.00
Page 8 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate C18.5 MALIGNANT NEOPLASM OF SPLENIC FLEXURE 27,690.00
19,383.00
8,307.00
C18.6 MALIGNANT NEOPLASM OF DESCENDING COLON 27,690.00
19,383.00
8,307.00
C18.7 MALIGNANT NEOPLASM OF SIGMOID COLON; MALIGNANT NEOPLASM OF SIGMOID FLEXURE 27,690.00
19,383.00
8,307.00
C18.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF COLON 27,690.00
19,383.00
8,307.00
C18.9 MALIGNANT NEOPLASM OF COLON, UNSPECIFIED; MALIGNANT NEOPLASM OF LARGE INTESTINE NOS 27,690.00
19,383.00
8,307.00
C19 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION; MALIGNANT NEOPLASM OF COLON WITH RECTUM; MALIGNANT NEOPLASM OF RECTOSIGMOID COLON 27,690.00
19,383.00
8,307.00
C20 MALIGNANT NEOPLASM OF RECTUM; MALIGNANT NEOPLASM OF RECTAL AMPULLA 27,690.00
19,383.00
8,307.00
C21.0 MALIGNANT NEOPLASM OF ANUS, UNSPECIFIED 27,690.00
19,383.00
8,307.00
C21.1 MALIGNANT NEOPLASM OF ANAL CANAL; MALIGNANT NEOPLASM OF ANAL SPHINCTER 27,690.00
19,383.00
8,307.00
C21.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF RECTUM, ANUS AND ANAL CANAL; MALIGNANT NEOPLASM OF ANORECTAL JUNCTION; MALIGNANT NEOPLASM OF ANORECTUM 27,690.00
19,383.00
8,307.00
C22.0 LIVER CELL CARCINOMA; HEPATOCELLULAR CARCINOMA HEPATOMA 27,690.00
19,383.00
8,307.00
C22.1 INTRAHEPATIC BILE DUCT CARCINOMA; CHOLANGIOCARCINOMA 27,690.00
19,383.00
8,307.00
C22.2 HEPATOBLASTOMA 27,690.00
19,383.00
8,307.00
C22.3 ANGIOSARCOMA OF LIVER; KUPFFER CELL SARCOMA 27,690.00
19,383.00
8,307.00
C22.4 OTHER SARCOMAS OF LIVER 27,690.00
19,383.00
8,307.00
C22.7 OTHER SPECIFIED CARCINOMAS OF LIVER 27,690.00
19,383.00
8,307.00
C22.9 LIVER, UNSPECIFIED 27,690.00
19,383.00
8,307.00
C23 MALIGNANT NEOPLASM OF GALLBLADDER 27,690.00
19,383.00
8,307.00
C24.0 MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCT; MALIGNANT NEOPLASM OF BILIARY DUCT OR PASSAGE NOS; MALIGNANT NEOPLASM OF COMMON BILE DUCT; MALIGNANT NEOPLASM OF CYSTIC DUCT; MALIGNANT NEOPLASM OF HEPATIC DUCT 27,690.00
19,383.00
8,307.00
C24.1 MALIGNANT NEOPLASM OF AMPULLA OF VATER 27,690.00
19,383.00
8,307.00
C24.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF BILIARY TRACT 27,690.00
19,383.00
8,307.00
C24.9 MALIGNANT NEOPLASM OF BILIARY TRACT, UNSPECIFIED 27,690.00
19,383.00
8,307.00
C25.0 MALIGNANT NEOPLASM OF HEAD OF PANCREAS 27,690.00
19,383.00
8,307.00
C25.1 MALIGNANT NEOPLASM OF BODY OF PANCREAS 27,690.00
19,383.00
8,307.00
C25.2 MALIGNANT NEOPLASM OF TAIL OF PANCREAS 27,690.00
19,383.00
8,307.00
C25.3 MALIGNANT NEOPLASM OF PANCREATIC DUCT 27,690.00
19,383.00
8,307.00
C25.4 MALIGNANT NEOPLASM OF ENDOCRINE PANCREAS; MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS 27,690.00
19,383.00
8,307.00
C25.7 MALIGNANT NEOPLASM OF OTHER PARTS OF PANCREAS; MALIGNANT NEOPLASM OF NECK OF PANCREAS 27,690.00
19,383.00
8,307.00
C25.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF PANCREAS 27,690.00
19,383.00
8,307.00
C25.9 MALIGNANT NEOPLASM OF PANCREAS, UNSPECIFIED 27,690.00
19,383.00
8,307.00
C26.0 MALIGNANT NEOPLASM OF INTESTINAL TRACT, PART UNSPECIFIED; MALIGNANT NEOPLASM OF INTESTINE NOS 27,690.00
19,383.00
8,307.00
C26.1 MALIGNANT NEOPLASM OF SPLEEN 27,690.00
19,383.00
8,307.00
C26.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF DIGESTIVE SYSTEM 27,690.00
19,383.00
8,307.00
C26.9 MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE SYSTEM; MALIGNANT NEOPLASM OF ALIMENTARY CANAL OR TRACT NOS; MALIGNANT NEOPLASM OF GASTROINTESTINAL TRACT NOS 27,690.00
19,383.00
8,307.00
C30.0
MALIGNANT NEOPLASM OF NASAL CAVITY; MALIGNANT
NEOPLASM OF CARTILAGE OF NOSE; MALIGNANT NEOPLASM OF
NASAL CONCHA; MALIGNANT NEOPLASM OF INTERNAL NOSE;
MALIGNANT NEOPLASM OF SEPTUM OF NOSE; MALIGNANT
NEOPLASM OF VESTIBULE OF NOSE
20,085.00
14,059.50
6,025.50
C30.1
MALIGNANT NEOPLASM OF MIDDLE EAR; MALIGNANT NEOPLASM
OF EUSTACHIAN TUBE; MALIGNANT NEOPLASM OF INNER EAR;
MALIGNANT NEOPLASM OF
MASTOID AIR CELLS
20,085.00
14,059.50
6,025.50
C31.0 MALIGNANT NEOPLASM OF MAXILLARY SINUS; MALIGNANT NEOPLASM OF ANTRUM (HIGHMORE); MALIGNANT NEOPLASM OF ANTRUM (MAXILLARY) 22,425.00
15,697.50
6,727.50
C31.1 MALIGNANT NEOPLASM OF ETHMOIDAL SINUS 22,425.00
15,697.50
6,727.50
C31.2 MALIGNANT NEOPLASM OF FRONTAL SINUS 22,425.00
15,697.50
6,727.50
C31.3 MALIGNANT NEOPLASM OF SPHENOIDAL SINUS 22,425.00
15,697.50
6,727.50
C31.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF ACCESSORY SINUSES 22,425.00
15,697.50
6,727.50
C31.9 MALIGNANT NEOPLASM OF ACCESSORY SINUS, UNSPECIFIED 22,425.00
15,697.50
6,727.50
C32.0 MALIGNANT NEOPLASM OF GLOTTIS; MALIGNANT NEOPLASM OF INTRINSIC LARYNX; MALIGNANT NEOPLASM OF TRUE VOCAL CORD NOS 28,470.00
19,929.00
8,541.00
C32.1
MALIGNANT NEOPLASM OF SUPRAGLOTTIS: MALIGNANT
NEOPLASM OF ARYEPIGLOTTIC FOLD, LARYNGEAL ASPECT;
MALIGNANT NEOPLASM OF EPIGLOTTIS (SUPRAHYOID PORTION)
NOS; MALIGNANT NEOPLASM OF EXTRINSIC LARYNX; MALIGNANT
NEOPLASM OF FALSE VOCAL CORD; MALIGNANT NEOPLASM
28,470.00
19,929.00
8,541.00
C32.2 MALIGNANT NEOPLASM OF SUBGLOTTIS 28,470.00
19,929.00
8,541.00
C32.3 MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGE 28,470.00
19,929.00
8,541.00
Page 9 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate C32.9 MALIGNANT NEOPLASM OF LARYNX, UNSPECIFIED 28,470.00
19,929.00
8,541.00
C33 MALIGNANT NEOPLASM OF TRACHEA 28,470.00
19,929.00
8,541.00
C34.0 MALIGNANT NEOPLASM OF MAIN BRONCHUS; MALIGNANT NEOPLASM OF CARINA; MALIGNANT NEOPLASM OF HILUS OF LUNG 28,470.00
19,929.00
8,541.00
C34.1 MALIGNANT NEOPLASM OF UPPER LOBE, BRONCHUS OR LUNG 28,470.00
19,929.00
8,541.00
C34.2 MALIGNANT NEOPLASM OF MIDDLE LOBE, BRONCHUS OR LUNG 28,470.00
19,929.00
8,541.00
C34.3 MALIGNANT NEOPLASM OF LOWER LOBE, BRONCHUS OR LUNG 28,470.00
19,929.00
8,541.00
C34.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF BRONCHUS AND LUNG 28,470.00
19,929.00
8,541.00
C34.9 MALIGNANT NEOPLASM OF BRONCHUS OR LUNG, UNSPECIFIED 28,470.00
19,929.00
8,541.00
C37 MALIGNANT NEOPLASM OF THYMUS 28,470.00
19,929.00
8,541.00
C38.0 MALIGNANT NEOPLASM OF HEART; MALIGNANT NEOPLASM OF PERICARDIUM 28,470.00
19,929.00
8,541.00
C38.1 MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM 28,470.00
19,929.00
8,541.00
C38.3 MALIGNANT NEOPLASM OF MEDIASTINUM, PART UNSPECIFIED 28,470.00
19,929.00
8,541.00
C38.4 MALIGNANT NEOPLASM OF PLEURA 28,470.00
19,929.00
8,541.00
C38.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF HEART, MEDIASTINUM AND PLEURA 28,470.00
19,929.00
8,541.00
C39.0 MALIGNANT NEOPLASM OF UPPER RESPIRATORY TRACT, PART UNSPECIFIED 28,470.00
19,929.00
8,541.00
C39.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF RESPIRATORY AND INTRATHORACIC ORGANS 28,470.00
19,929.00
8,541.00
C39.9 MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE RESPIRATORY SYSTEM; RESPIRATORY TRACT NOS 28,470.00
19,929.00
8,541.00
C40.0 MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB 32,175.00
22,522.50
9,652.50
C40.1 MALIGNANT NEOPLASM OF SHORT BONES OF UPPER LIMB 32,175.00
22,522.50
9,652.50
C40.2 MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB 32,175.00
22,522.50
9,652.50
C40.3 MALIGNANT NEOPLASM OF SHORT BONES OF LOWER LIMB 32,175.00
22,522.50
9,652.50
C40.9 MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE OF LIMB, UNSPECIFIED 32,175.00
22,522.50
9,652.50
C41.0 MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE; MALIGNANT NEOPLASM O F SUPERIOR MAXILLA; MALIGNANT NEOPLASM OF ORBITAL BONE 32,175.00
22,522.50
9,652.50
C41.1 MALIGNANT NEOPLASM OF MANDIBLE; MALIGNANT NEOPLASM OF LOWER JAW BONE 32,175.00
22,522.50
9,652.50
C41.2 MALIGNANT NEOPLASM OF VERTEBRAL COLUMN 32,175.00
22,522.50
9,652.50
C41.3 MALIGNANT NEOPLASM OF RIBS, STERNUM AND CLAVICLE 32,175.00
22,522.50
9,652.50
C41.4 MALIGNANT NEOPLASM OF PELVIC BONES, SACRUM AND COCCYX 32,175.00
22,522.50
9,652.50
C41.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF BONE AND ARTICULAR CARTILAGE 32,175.00
22,522.50
9,652.50
C41.9 MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE, UNSPECIFIED 32,175.00
22,522.50
9,652.50
C45.0 MESOTHELIOMA OF PLEURA 20,670.00
14,469.00
6,201.00
C45.1 MESOTHELIOMA OF PERITONEUM; MESOTHELIOMA OF MESENTERY; MESOTHELIOMA OF MESOCOLON; MESOTHELIOMA OF OMENTUM; MESOTHELIOMA OF PARIETAL PERITONEUM; MESOTHELIOMA OF PELVIC PERITONEUM 27,690.00
19,383.00
8,307.00
C45.2 MESOTHELIOMA OF PERICARDIUM 20,670.00
14,469.00
6,201.00
C45.7 MESOTHELIOMA OF OTHER SITES 20,670.00
14,469.00
6,201.00
C45.9 MESOTHELIOMA, UNSPECIFIED 20,670.00
14,469.00
6,201.00
C46.9 KAPOSI'S SARCOMA, UNSPECIFIED 23,400.00
16,380.00
7,020.00
C47.0 MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF HEAD, FACE AND NECK 25,935.00
18,154.50
7,780.50
C47.1 MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF UPPER LIMB, INCLUDING SHOULDER 25,935.00
18,154.50
7,780.50
C47.2 MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF LOWER LIMB, INCLUDING HIP 25,935.00
18,154.50
7,780.50
C47.3 MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF THORAX 25,935.00
18,154.50
7,780.50
C47.4 MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF ABDOMEN 25,935.00
18,154.50
7,780.50
C47.5 MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF PELVIS 25,935.00
18,154.50
7,780.50
C47.6 MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF TRUNK, UNSPECIFIED 25,935.00
18,154.50
7,780.50
C47.9 MALIGNANT NEOPLASM OF PERIPHERAL NERVES AND AUTONOMIC NERVOUS SYSTEM, UNSPECIFIED 25,935.00
18,154.50
7,780.50
C48.0 MALIGNANT NEOPLASM OF RETROPERITONEUM 20,670.00
14,469.00
6,201.00
C48.1 MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM; MALIGNANT NEOPLASM OF MESENTERY; MALIGNANT NEOPLASM OF MESOCOLON; MALIGNANT NEOPLASM OF OMENTUM; MALIGNANT NEOPLASM OF PARIETAL PERITONEUM; MALIGNANT NEOPLASM OF PELVIC PERITONEUM 27,690.00
19,383.00
8,307.00
C48.2 MALIGNANT NEOPLASM OF PERITONEUM, UNSPECIFIED 27,690.00
19,383.00
8,307.00
C49.0 MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF HEAD, FACE AND NECK; MALIGNANT NEOPLASM OF CONNECTIVE TISSUE OF EAR; MALIGNANT NEOPLASM OF CONNECTIVE TISSUE OF EYELID 23,400.00
16,380.00
7,020.00
Page 10 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate C49.1 MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF UPPER LIMB, INCLUDING SHOULDER 23,400.00
16,380.00
7,020.00
C49.2 MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF LOWER LIMB, INCLUDING HIP 23,400.00
16,380.00
7,020.00
C49.3 MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF THORAX; MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF AXILLA; MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF DIAPHRAGM; MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF GREAT VESSELS 23,400.00
16,380.00
7,020.00
C49.4 MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF ABDOMEN; MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF ABDOMINAL WALL; MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF HYPOCHONDRIUM 23,400.00
16,380.00
7,020.00
C49.5 MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF PELVIS; MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF BUTTOCK; MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF GROIN; MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF PERINEUM 23,400.00
16,380.00
7,020.00
C49.6 MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF TRUNK, UNSPECIFIED; MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE OF BACK NOS 23,400.00
16,380.00
7,020.00
C49.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF CONNECTIVE AND SOFT TISSUE 23,400.00
16,380.00
7,020.00
C49.9 MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE, UNSPECIFIED 23,400.00
16,380.00
7,020.00
C50.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA, BREAST 23,010.00
16,107.00
6,903.00
C50.1 MALIGNANT NEOPLASM OF CENTRAL PORTION OF BREAST 23,010.00
16,107.00
6,903.00
C50.2 MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF BREAST 23,010.00
16,107.00
6,903.00
C50.3 MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF BREAST 23,010.00
16,107.00
6,903.00
C50.4 MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF BREAST 23,010.00
16,107.00
6,903.00
C50.6 MALIGNANT NEOPLASM OF AXILLARY TAIL OF BREAST 23,010.00
16,107.00
6,903.00
C50.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF BREAST 23,010.00
16,107.00
6,903.00
C50.9 MALIGNANT NEOPLASM OF BREAST, UNSPECIFIED 23,010.00
16,107.00
6,903.00
C51.0 MALIGNANT NEOPLASM OF LABIUM MAJUS; MALIGNANT NEOPLASM OF BARTHOLIN'S [GREATER VESTIBULAR] GLAND 22,230.00
15,561.00
6,669.00
C51.1 MALIGNANT NEOPLASM OF LABIUM MINUS 22,230.00
15,561.00
6,669.00
C51.2 MALIGNANT NEOPLASM OF CLITORIS 22,230.00
15,561.00
6,669.00
C51.9 MALIGNANT NEOPLASM OF VULVA, UNSPECIFIED; MALIGNANT NEOPLASM OF EXTERNAL FEMALE GENITALIA NOS; MALIGNANT NEOPLASM OF PUDENDUM 22,230.00
15,561.00
6,669.00
C52 MALIGNANT NEOPLASM OF VAGINA 22,230.00
15,561.00
6,669.00
C53.0 MALIGNANT NEOPLASM OF ENDOCERVIX 22,230.00
15,561.00
6,669.00
C53.1 MALIGNANT NEOPLASM OF EXOCERVIX 22,230.00
15,561.00
6,669.00
C53.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF CERVIX UTERI 22,230.00
15,561.00
6,669.00
C53.9 MALIGNANT NEOPLASM OF CERVIX UTERI, UNSPECIFIED 22,230.00
15,561.00
6,669.00
C54.0 MALIGNANT NEOPLASM OF ISTHMUS UTERI; MALIGNANT NEOPLASM OF LOWER UTERINE SEGMENT 22,230.00
15,561.00
6,669.00
C54.1 MALIGNANT NEOPLASM OF ENDOMETRIUM 22,230.00
15,561.00
6,669.00
C54.2 MALIGNANT NEOPLASM OF MYOMETRIUM 22,230.00
15,561.00
6,669.00
C54.3 MALIGNANT NEOPLASM OF FUNDUS UTERI 22,230.00
15,561.00
6,669.00
C54.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF CORPUS UTERI 22,230.00
15,561.00
6,669.00
C54.9 CORPUS UTERI, UNSPECIFIED 22,230.00
15,561.00
6,669.00
C55 MALIGNANT NEOPLASM OF UTERUS, PART UNSPECIFIED 22,230.00
15,561.00
6,669.00
C56 MALIGNANT NEOPLASM OF OVARY 22,230.00
15,561.00
6,669.00
C57.0 MALIGNANT NEOPLASM OF FALLOPIAN TUBE; MALIGNANT NEOPLASM OF OVIDUCT; MALIGNANT NEOPLASM OF UTERINE TUBE 22,230.00
15,561.00
6,669.00
C57.3 MALIGNANT NEOPLASM OF PARAMETRIUM; MALIGNANT NEOPLASM OF UTERINE LIGAMENT NOS 22,230.00
15,561.00
6,669.00
C57.4 MALIGNANT NEOPLASM OF UTERINE ADNEXA, UNSPECIFIED 22,230.00
15,561.00
6,669.00
C57.7 MALIGNANT NEOPLASM OF OTHER SPECIFIED FEMALE GENITAL ORGANS; MALIGNANT NEOPLASM OF WOLFFIAN BODY OR DUCT 22,230.00
15,561.00
6,669.00
C57.8
MALIGNANT NEOPLASM OF OVERLAPPING LESION OF FEMALE
GENITAL ORGANS; MALIGNANT NEOPLASM OF TUBO-OVARIAN;
MALIGNANT NEOPLASM OF UTERO-OVARIAN
22,230.00
15,561.00
6,669.00
C57.9 MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN, UNSPECIFIED; MALIGNANT NEOPLASM OF FEMALE GENITOURINARY TRACT NOS 22,230.00
15,561.00
6,669.00
C58 MALIGNANT NEOPLASM OF PLACENTA; CHORIOCARCINOMA NOS; CHORIONEPITHELIOMA NOS 22,230.00
15,561.00
6,669.00
C60.9 MALIGNANT NEOPLASM OF PENIS, UNSPECIFIED; MALIGNANT NEOPLASM OF SKIN OF PENIS NOS 26,130.00
18,291.00
7,839.00
C61 MALIGNANT NEOPLASM OF PROSTATE 26,130.00
18,291.00
7,839.00
C62.0 MALIGNANT NEOPLASM OF UNDESCENDED TESTIS; ECTOPIC TESTIS ; MALIGNANT NEOPLASM OF RETAINED TESTIS 26,130.00
18,291.00
7,839.00
Page 11 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate C62.1 MALIGNANT NEOPLASM OF DESCENDED TESTIS; MALIGNANT NEOPLASM OF SCROTAL TESTIS 26,130.00
18,291.00
7,839.00
C62.9 MALIGNANT NEOPLASM OF TESTIS, UNSPECIFIED 26,130.00
18,291.00
7,839.00
C63.0 MALIGNANT NEOPLASM OF EPIDIDYMIS 26,130.00
18,291.00
7,839.00
C63.1 MALIGNANT NEOPLASM OF SPERMATIC CORD 26,130.00
18,291.00
7,839.00
C63.2 MALIGNANT NEOPLASM OF SCROTUM; MALIGNANT NEOPLASM OF SKIN OF SCROTUM 26,130.00
18,291.00
7,839.00
C63.7 MALIGNANT NEOPLASM OF SEMINAL VESICLE; MALIGNANT NEOPLASM OF TUNICA VAGINALIS 26,130.00
18,291.00
7,839.00
C63.9 MALIGNANT NEOPLASM OF MALE GENITAL ORGAN, UNSPECIFIED; MALE GENITOURINARY TRACT NOS 26,130.00
18,291.00
7,839.00
C64 MALIGNANT NEOPLASM OF KIDNEY, EXCEPT RENAL PELVIS & RENAL CALYCES 27,495.00
19,246.50
8,248.50
C65 MALIGNANT NEOPLASM OF RENAL PELVIS; MALIGNANT NEOPLASM OF PELVIURETERIC JUNCTION; MALIGNANT NEOPLASM OF RENAL CALYCES 27,495.00
19,246.50
8,248.50
C66 MALIGNANT NEOPLASM OF URETER 27,495.00
19,246.50
8,248.50
C67.0 MALIGNANT NEOPLASM OF TRIGONE OF BLADDER 27,495.00
19,246.50
8,248.50
C67.1 MALIGNANT NEOPLASM OF DOME OF BLADDER 27,495.00
19,246.50
8,248.50
C67.2 MALIGNANT NEOPLASM OF LATERAL WALL OF BLADDER 27,495.00
19,246.50
8,248.50
C67.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF BLADDER 27,495.00
19,246.50
8,248.50
C67.5 MALIGNANT NEOPLASM OF BLADDER NECK; MALIGNANT NEOPLASM OF INTERNAL URETHRAL ORIFICE 27,495.00
19,246.50
8,248.50
C67.6 MALIGNANT NEOPLASM OF URETERIC ORIFICE 27,495.00
19,246.50
8,248.50
C67.7 MALIGNANT NEOPLASM OF URACHUS 27,495.00
19,246.50
8,248.50
C67.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF BLADDER 27,495.00
19,246.50
8,248.50
C67.9 MALIGNANT NEOPLASM OF BLADDER, UNSPECIFIED 27,495.00
19,246.50
8,248.50
C68.0 MALIGNANT NEOPLASM OF URETHRA 27,495.00
19,246.50
8,248.50
C68.9
MALIGNANT NEOPLASM OF URINARY ORGAN, UNSPECIFIED;
MALIGNANT NEOPLASM OF URINARY SYSTEM NOS
27,495.00
19,246.50
8,248.50
C69.1 MALIGNANT NEOPLASM OF CORNEA 32,955.00
23,068.50
9,886.50
C69.2 MALIGNANT NEOPLASM OF RETINA 32,955.00
23,068.50
9,886.50
C69.3 MALIGNANT NEOPLASM OF CHOROID 32,955.00
23,068.50
9,886.50
C69.4 MALIGNANT NEOPLASM OF CILIARY BODY; MALIGNANT NEOPLASM OF EYEBALL 32,955.00
23,068.50
9,886.50
C69.5
MALIGNANT NEOPLASM OF LACRIMAL GLAND AND DUCT;
MALIGNANT NEOPLASM OF LACRIMAL SAC; MALIGNANT
NEOPLASM OF NASOLACRIMAL DUCT
32,955.00
23,068.50
9,886.50
C69.6 MALIGNANT NEOPLASM OF ORBIT; MALIGNANT NEOPLASM OF CONNECTIVE TISSUE OF ORBIT; MALIGNANT NEOPLASM OF EXTRAOCULAR MUSCLE; MALIGNANT NEOPLASM OF PERIPHERAL NERVES OF ORBIT; MALIGNANT NEOPLASM OF RETROBULBAR TISSUE; MALIGNANT NEOPLASM OF RETRO-OCULAR 32,955.00
23,068.50
9,886.50
C69.9 MALIGNANT NEOPLASM OF EYE, UNSPECIFIED 32,955.00
23,068.50
9,886.50
C70.0 MALIGNANT NEOPLASM OF CEREBRAL MENINGES 32,955.00
23,068.50
9,886.50
C70.1 MALIGNANT NEOPLASM OF SPINAL MENINGES 32,955.00
23,068.50
9,886.50
C70.9 MALIGNANT NEOPLASM OF MENINGES, UNSPECIFIED 32,955.00
23,068.50
9,886.50
C71.0 MALIGNANT NEOPLASM OF CEREBRUM, EXCEPT LOBES AND VENTRICLES; MALIGNANT NEOPLASM OF SUPRATENTORIAL NOS 32,955.00
23,068.50
9,886.50
C71.1 MALIGNANT NEOPLASM OF FRONTAL LOBE 32,955.00
23,068.50
9,886.50
C71.2 MALIGNANT NEOPLASM OF TEMPORAL LOBE 32,955.00
23,068.50
9,886.50
C71.3 MALIGNANT NEOPLASM OF PARIETAL LOBE 32,955.00
23,068.50
9,886.50
C71.4 MALIGNANT NEOPLASM OF OCCIPITAL LOBE 32,955.00
23,068.50
9,886.50
C71.5 MALIGNANT NEOPLASM OF CEREBRAL VENTRICLE 32,955.00
23,068.50
9,886.50
C71.6 MALIGNANT NEOPLASM OF CEREBELLUM 32,955.00
23,068.50
9,886.50
C71.7 MALIGNANT NEOPLASM OF BRAIN STEM; MALIGNANT NEOPLASM OF FOURTH VENTRICLE; MALIGNANT NEOPLASM OF INFRATENTORIAL NOS 32,955.00
23,068.50
9,886.50
C71.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF BRAIN 32,955.00
23,068.50
9,886.50
C71.9 MALIGNANT NEOPLASM OF BRAIN, UNSPECIFIED 32,955.00
23,068.50
9,886.50
C72.0 MALIGNANT NEOPLASM OF SPINAL CORD 32,955.00
23,068.50
9,886.50
C72.1 MALIGNANT NEOPLASM OF CAUDA EQUINA 32,955.00
23,068.50
9,886.50
C72.2 MALIGNANT NEOPLASM OF OLFACTORY NERVE; MALIGNANT NEOPLASM OF OLFACTORY BULB 32,955.00
23,068.50
9,886.50
C72.3 MALIGNANT NEOPLASM OF OPTIC NERVE 32,955.00
23,068.50
9,886.50
C72.4 MALIGNANT NEOPLASM OF ACOUSTIC NERVE 32,955.00
23,068.50
9,886.50
C72.5 MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED CRANIAL NERVES; MALIGNANT NEOPLASM OF CRANIAL NERVE NOS 32,955.00
23,068.50
9,886.50
C72.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF BRAIN AND OTHER PARTS OF CENTRAL NERVOUS SYSTEM 32,955.00
23,068.50
9,886.50
C72.9 MALIGNANT NEOPLASM OF CENTRAL NERVOUS SYSTEM, UNSPECIFIED; MALIGNANT NEOPLASM OF NERVOUS SYSTEM NOS 32,955.00
23,068.50
9,886.50
C73 MALIGNANT NEOPLASM OF THYROID GLAND 22,230.00
15,561.00
6,669.00
C74.0 MALIGNANT NEOPLASM OF CORTEX OF ADRENAL GLAND 22,230.00
15,561.00
6,669.00
C74.1 MALIGNANT NEOPLASM OF MEDULLA OF ADRENAL GLAND 22,230.00
15,561.00
6,669.00
C74.9 MALIGNANT NEOPLASM OF ADRENAL GLAND, UNSPECIFIED 22,230.00
15,561.00
6,669.00
C75.0 MALIGNANT NEOPLASM OF PARATHYROID GLAND 22,230.00
15,561.00
6,669.00
C75.1 MALIGNANT NEOPLASM OF PITUITARY GLAND 22,230.00
15,561.00
6,669.00
C75.3 MALIGNANT NEOPLASM OF PINEAL GLAND 22,230.00
15,561.00
6,669.00
C75.5 MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA 22,230.00
15,561.00
6,669.00
Page 12 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate C75.9 MALIGNANT NEOPLASM OF ENDOCRINE GLAND, UNSPECIFIED 22,230.00
15,561.00
6,669.00
C76.0 MALIGNANT NEOPLASM OF HEAD, FACE AND NECK; MALIGNANT NEOPLASM OF CHEEK NOS; MALIGNANT NEOPLASM OF NOSE NOS 22,425.00
15,697.50
6,727.50
C76.1
MALIGNANT NEOPLASM OF THORAX; MALIGNANT NEOPLASM OF
AXILLA NOS; MALIGNANT NEOPLASM OF INTRATHORACIC NOS;
MALIGNANT NEOPLASM OF THORACIC NOS
28,470.00
19,929.00
8,541.00
C76.2 MALIGNANT NEOPLASM OF ABDOMEN 27,690.00
19,383.00
8,307.00
C76.3
MALIGNANT NEOPLASM OF PELVIS; MALIGNANT NEOPLASM OF
GROIN NOS; MALIGNANT NEOPLASM OF
SITES OVERLAPPING SYSTEMS WITHIN THE PELVIS, SUCH AS
RECTOVAGINAL (SEPTUM) & RECTOVESICAL (SEPTUM)
31,395.00
21,976.50
9,418.50
C76.4 MALIGNANT NEOPLASM OF UPPER LIMB 31,395.00
21,976.50
9,418.50
C76.5 MALIGNANT NEOPLASM OF LOWER LIMB 31,395.00
21,976.50
9,418.50
C76.7 MALIGNANT NEOPLASM OF OTHER ILL-DEFINED SITES 31,395.00
21,976.50
9,418.50
C76.8 MALIGNANT NEOPLASM OF OVERLAPPING LESION OF OTHER AND ILL-DEFINED SITES 31,395.00
21,976.50
9,418.50
C77.0 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD, FACE AND NECK; MALIGNANT NEOPLASM OF SUPRACLAVICULAR LYMPH NODES 22,425.00
15,697.50
6,727.50
C77.1 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRATHORACIC LYMPH NODES 28,470.00
19,929.00
8,541.00
C77.2 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRA- ABDOMINAL LYMPH NODES 27,690.00
19,383.00
8,307.00
C77.3 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF AXILLARY AND UPPER LIMB LYMPH NODES; SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF PECTORAL LYMPH NODES 31,395.00
21,976.50
9,418.50
C77.9 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODE, UNSPECIFIED 31,395.00
21,976.50
9,418.50
C78.0 SECONDARY MALIGNANT NEOPLASM OF LUNG 28,470.00
19,929.00
8,541.00
C78.1 SECONDARY MALIGNANT NEOPLASM OF MEDIASTINUM 28,470.00
19,929.00
8,541.00
C78.2 SECONDARY MALIGNANT NEOPLASM OF PLEURA; MALIGNANT PLEURAL EFFUSION NOS 28,470.00
19,929.00
8,541.00
C78.3 SECONDARY MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED RESPIRATORY ORGANS 28,470.00
19,929.00
8,541.00
C78.4 SECONDARY MALIGNANT NEOPLASM OF SMALL INTESTINE 27,690.00
19,383.00
8,307.00
C78.5 SECONDARY MALIGNANT NEOPLASM OF LARGE INTESTINE AND RECTUM 27,690.00
19,383.00
8,307.00
C78.6 SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM; MALIGNANT ASCITES NOS 27,690.00
19,383.00
8,307.00
C78.7 SECONDARY MALIGNANT NEOPLASM OF LIVER 27,690.00
19,383.00
8,307.00
C78.8 SECONDARY MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED DIGESTIVE ORGANS 27,690.00
19,383.00
8,307.00
C79.0 SECONDARY MALIGNANT NEOPLASM OF KIDNEY AND RENAL PELVIS 27,495.00
19,246.50
8,248.50
C79.1 SECONDARY MALIGNANT NEOPLASM OF BLADDER AND OTHER AND UNSPECIFIED URINARY ORGANS 27,495.00
19,246.50
8,248.50
C79.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND CEREBRAL MENINGES 32,955.00
23,068.50
9,886.50
C79.4 SECONDARY MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED PARTS OF NERVOUS SYSTEM 32,955.00
23,068.50
9,886.50
C79.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW 32,175.00
22,522.50
9,652.50
C79.6 SECONDARY MALIGNANT NEOPLASM OF OVARY 22,230.00
15,561.00
6,669.00
C79.7 SECONDARY MALIGNANT NEOPLASM OF ADRENAL GLAND 31,395.00
21,976.50
9,418.50
C79.8 SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES 31,395.00
21,976.50
9,418.50
C80 MALIGNANT NEOPLASM WITHOUT SPECIFICATION OF SITE; UNSPECIFIED SITE WHETHER PRIMARY OR SECONDARY [CANCER, CARCINOMA, CARCINOMATOSIS, GENERALIZED CANCER, GENERALIZED MALIGNANCY, MALIGNANCY, MULTIPLE CANCER]; MALIGNANT CACHEXIA; MALIGNANT NEOPLASM OF PRIMARY 31,395.00
21,976.50
9,418.50
C81.0 HODGKIN'S DISEASE (LYMPHOCYTIC PREDOMINANCE); HODGKIN'S DISEASE (LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE) 27,105.00
18,973.50
8,131.50
C81.1 HODGKIN'S DISEASE( NODULAR SCLEROSIS) 27,105.00
18,973.50
8,131.50
C81.9 HODGKIN'S DISEASE, UNSPECIFIED 27,105.00
18,973.50
8,131.50
C82.0 SMALL CLEAVED CELL, FOLLICULAR NON-HODGKIN'S LYMPHOMA 27,105.00
18,973.50
8,131.50
C82.1 MIXED SMALL CLEAVED NON-HODGKIN'S LYMPHOMA AND LARGE CELL, FOLLICULAR NON-HODGKIN'S LYMPHOMA 27,105.00
18,973.50
8,131.50
C82.2 LARGE CELL, FOLLICULAR NON-HODGKIN'S LYMPHOMA 27,105.00
18,973.50
8,131.50
C82.7 OTHER TYPES OF FOLLICULAR NON-HODGKIN'S LYMPHOMA 27,105.00
18,973.50
8,131.50
C82.9 FOLLICULAR NON-HODGKIN'S LYMPHOMA, UNSPECIFIED; NODULAR NON-HODGKIN'S LYMPHOMA NOS 27,105.00
18,973.50
8,131.50
C83.0 SMALL CELL DIFFUSE NON-HODGKIN'S LYMPHOMA 27,105.00
18,973.50
8,131.50
C83.2 MIXED SMALL AND LARGE CELL DIFFUSE NON-HODGKIN'S LYMPHOMA 27,105.00
18,973.50
8,131.50
C83.3 LARGE CELL DIFFUSE NON-HODGKIN'S LYMPHOMA 27,105.00
18,973.50
8,131.50
C83.4 IMMUNOBLASTIC DIFFUSE NON-HODGKIN'S LYMPHOMA 27,105.00
18,973.50
8,131.50
C83.5 LYMPHOBLASTIC DIFFUSE NON-HODGKIN'S LYMPHOMA 27,105.00
18,973.50
8,131.50
C83.7 BURKITT'S TUMOUR 27,105.00
18,973.50
8,131.50
C83.8 OTHER TYPES OF DIFFUSE NON-HODGKIN'S LYMPHOMA 27,105.00
18,973.50
8,131.50
Page 13 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate C83.9 DIFFUSE NON-HODGKIN'S LYMPHOMA, UNSPECIFIED 27,105.00
18,973.50
8,131.50
C84.0 MYCOSIS FUNGOIDES 27,105.00
18,973.50
8,131.50
C84.1 SéZARY'S DISEASE 27,105.00
18,973.50
8,131.50
C84.3 LYMPHOEPITHELIOID LYMPHOMA; LENNERT'S LYMPHOMA 27,105.00
18,973.50
8,131.50
C84.4 PERIPHERAL T-CELL LYMPHOMA 27,105.00
18,973.50
8,131.50
C84.5 OTHER AND UNSPECIFIED T-CELL LYMPHOMAS 27,105.00
18,973.50
8,131.50
C85.0 LYMPHOSARCOMA 27,105.00
18,973.50
8,131.50
C85.1 B-CELL LYMPHOMA, UNSPECIFIED 27,105.00
18,973.50
8,131.50
C85.7 OTHER SPECIFIED TYPES OF NON-HODGKIN'S LYMPHOMA; MALIGNANT RETICULOENDOTHELIOSIS; MALIGNANT RETICULOSIS; MICROGLIOMA 27,105.00
18,973.50
8,131.50
C85.9 NON-HODGKIN'S LYMPHOMA, UNSPECIFIED TYPE; LYMPHOMA NOS 27,105.00
18,973.50
8,131.50
C90.0 MULTIPLE MYELOMA; KAHLER'S DISEASE; MYELOMATOSIS 27,105.00
18,973.50
8,131.50
C90.1 PLASMA CELL LEUKAEMIA 27,105.00
18,973.50
8,131.50
C90.2 EXTRAMEDULLARY PLASMACYTOMA; MALIGNANT PLASMA CELL TUMOUR NOS; PLASMACYTOMA NOS ; SOLITARY MYELOMA 27,105.00
18,973.50
8,131.50
C91.0 ACUTE LYMPHOBLASTIC LEUKEMIA; ACUTE LYMPHOCYTIC LEUKEMIA 27,105.00
18,973.50
8,131.50
C91.1 CHRONIC LYMPHOCYTIC LEUKAEMIA 27,105.00
18,973.50
8,131.50
C91.2 SUBACUTE LYMPHOCYTIC LEUKAEMIA 27,105.00
18,973.50
8,131.50
C91.3 PROLYMPHOCYTIC LEUKAEMIA 27,105.00
18,973.50
8,131.50
C91.4 HAIRY-CELL LEUKAEMIA; LEUKAEMIC RETICULOENDOTHELIOSIS 27,105.00
18,973.50
8,131.50
C91.5 ADULT T-CELL LEUKAEMIA 27,105.00
18,973.50
8,131.50
C91.7 OTHER LYMPHOID LEUKAEMIA 27,105.00
18,973.50
8,131.50
C91.9 LYMPHOID LEUKAEMIA, UNSPECIFIED 27,105.00
18,973.50
8,131.50
C92.0 ACUTE MYELOID LEUKAEMIA 27,105.00
18,973.50
8,131.50
C92.1 CHRONIC MYELOID LEUKAEMIA 27,105.00
18,973.50
8,131.50
C92.2 SUBACUTE MYELOID LEUKAEMIA 27,105.00
18,973.50
8,131.50
C92.3 MYELOID SARCOMA; CHLOROMA; GRANULOCYTIC SARCOMA 27,105.00
18,973.50
8,131.50
C92.4 ACUTE PROMYELOCYTIC LEUKAEMIA 27,105.00
18,973.50
8,131.50
C92.5 ACUTE MYELOMONOCYTIC LEUKAEMIA 27,105.00
18,973.50
8,131.50
C92.7 OTHER MYELOID LEUKAEMIA 27,105.00
18,973.50
8,131.50
C92.9 MYELOID LEUKAEMIA, UNSPECIFIED 27,105.00
18,973.50
8,131.50
C93.0 ACUTE MONOCYTIC LEUKAEMIA 27,105.00
18,973.50
8,131.50
C93.1 CHRONIC MONOCYTIC LEUKAEMIA 27,105.00
18,973.50
8,131.50
C93.9 MONOCYTIC LEUKAEMIA, UNSPECIFIED 27,105.00
18,973.50
8,131.50
C94.0 ACUTE ERYTHRAEMIA AND ERYTHROLEUKAEMIA; ACUTE ERYTHRAEMIC MYELOSIS; DI GUGLIELMO'S DISEASE 27,105.00
18,973.50
8,131.50
C94.2 ACUTE MEGAKARYOBLASTIC LEUKAEMIA; ACUTE MEGAKARYOCYTIC LEUKAEMIA 27,105.00
18,973.50
8,131.50
C94.4 ACUTE PANMYELOSIS 27,105.00
18,973.50
8,131.50
C94.5 ACUTE MYELOFIBROSIS 27,105.00
18,973.50
8,131.50
C95.0 ACUTE LEUKAEMIA OF UNSPECIFIED CELL TYPE; BLAST CELL LEUKAEMIA; STEM CELL LEUKAEMIA 27,105.00
18,973.50
8,131.50
C95.1 CHRONIC LEUKAEMIA OF UNSPECIFIED CELL TYPE 27,105.00
18,973.50
8,131.50
C95.2 SUBACUTE LEUKAEMIA OF UNSPECIFIED CELL TYPE 27,105.00
18,973.50
8,131.50
C95.7 OTHER LEUKAEMIA OF UNSPECIFIED CELL TYPE 27,105.00
18,973.50
8,131.50
C95.9 LEUKAEMIA, UNSPECIFIED 27,105.00
18,973.50
8,131.50
C96.0 LETTERER-SIWE DISEASE; NONLIPID RETICULOENDOTHELIOSIS; NONLIPID RETICULOSIS 27,105.00
18,973.50
8,131.50
C96.1 MALIGNANT HISTIOCYTOSIS; HISTIOCYTIC MEDULLARY RETICULOSIS 27,105.00
18,973.50
8,131.50
C96.2 MALIGNANT MAST CELL TUMOUR; MALIGNANT MASTOCYTOMA; MALIGNANT MASTOCYTOSIS; MAST CELL SARCOMA 27,105.00
18,973.50
8,131.50
C96.7 OTHER SPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID, HAEMATOPOIETIC AND RELATED TISSUE 27,105.00
18,973.50
8,131.50
C96.9 MALIGNANT NEOPLASM OF LYMPHOID, HAEMATOPOIETIC AND RELATED TISSUE, UNSPECIFIED 27,105.00
18,973.50
8,131.50
D10.0 BENIGN NEOPLASM OF LIP; BENIGN NEOPLASM OF FRENULUM OF LIP; BENIGN NEOPLASM OF INNER ASPECT OF LIP; BENIGN NEOPLASM OF MUCOSA OF LIP; VERMILION BORDER OF LIP 18,525.00
12,967.50
5,557.50
D10.1 BENIGN NEOPLASM OF TONGUE;BENIGN NEOPLASM OF LINGUAL TONSIL 18,525.00
12,967.50
5,557.50
D10.3 BENIGN NEOPLASM OF OTHER AND UNSPECIFIED PARTS OF MOUTH; BENIGN NEOPLASM OF MINOR SALIVARY GLAND NOS 18,525.00
12,967.50
5,557.50
D10.6 BENIGN NEOPLASM OF NASOPHARYNX; BENIGN NEOPLASM OF PHARYNGEAL TONSIL; BENIGN NEOPLASM OF POSTERIOR MARGIN OF SEPTUM AND CHOANAE 18,525.00
12,967.50
5,557.50
D10.7 BENIGN NEOPLASM OF HYPOPHARYNX 18,525.00
12,967.50
5,557.50
D10.9 BENIGN NEOPLASM OF PHARYNX, UNSPECIFIED 18,525.00
12,967.50
5,557.50
D11.0 BENIGN NEOPLASM OF PAROTID GLAND 18,525.00
12,967.50
5,557.50
D11.7 BENIGN NEOPLASM OF OTHER MAJOR SALIVARY GLANDS 18,525.00
12,967.50
5,557.50
D11.9 BENIGN NEOPLASM OF MAJOR SALIVARY GLAND, UNSPECIFIED 18,525.00
12,967.50
5,557.50
D12.0
BENIGN NEOPLASM OF CAECUM;BENIGN NEOPLASM OF
ILEOCAECAL VALVE
16,965.00
11,875.50
5,089.50
D12.1 BENIGN NEOPLASM OF APPENDIX 16,965.00
11,875.50
5,089.50
D12.3 BENIGN NEOPLASM OF TRANSVERSE COLON; BENIGN NEOPLASM OF HEPATIC FLEXURE; BENIGN NEOPLASM OF SPLENIC FLEXURE 16,965.00
11,875.50
5,089.50
D12.4 BENIGN NEOPLASM OF DESCENDING COLON 16,965.00
11,875.50
5,089.50
D12.5 BENIGN NEOPLASM OF SIGMOID COLON 16,965.00
11,875.50
5,089.50
Page 14 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate D12.6 BENIGN NEOPLASM OF COLON, UNSPECIFIED; ADENOMATOSIS OF COLON; BENIGN NEOPLASM OF LARGE INTESTINE NOS; HEREDITARY POLYPOSIS OF COLON 16,965.00
11,875.50
5,089.50
D12.7 BENIGN NEOPLASM OF RECTOSIGMOID JUNCTION; ADENOMATOSIS OF COLON; BENIGN NEOPLASM OF LARGE INTESTINE NOS; HEREDITARY POLYPOSIS OF COLON 16,965.00
11,875.50
5,089.50
D12.8 BENIGN NEOPLASM OF RECTUM 16,965.00
11,875.50
5,089.50
D12.9 BENIGN NEOPLASM OF ANUS AND ANAL CANAL 16,965.00
11,875.50
5,089.50
D13.0 BENIGN NEOPLASM OF OESOPHAGUS 16,965.00
11,875.50
5,089.50
D13.1 BENIGN NEOPLASM OF STOMACH 16,965.00
11,875.50
5,089.50
D13.2 BENIGN NEOPLASM OF DUODENUM 16,965.00
11,875.50
5,089.50
D13.3 BENIGN NEOPLASM OF OTHER AND UNSPECIFIED PARTS OF SMALL INTESTINE 16,965.00
11,875.50
5,089.50
D13.4 BENIGN NEOPLASM OF LIVER; BENIGN NEOPLASM OF INTRAHEPATIC BILE DUCTS 16,965.00
11,875.50
5,089.50
D13.5 BENIGN NEOPLASM OF EXTRAHEPATIC BILE DUCTS 16,965.00
11,875.50
5,089.50
D13.6 BENIGN NEOPLASM OF PANCREAS 16,965.00
11,875.50
5,089.50
D13.7 BENIGN NEOPLASM OF ENDOCRINE PANCREAS; BENIGN NEOPLASM OF ISLET CELL TUMOUR; BENIGN NEOPLASM OF ISLETS OF LANGERHANS 16,965.00
11,875.50
5,089.50
D13.9 BENIGN NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE SYSTEM; BENIGN NEOPLASM OF DIGESTIVE SYSTEM NOS; BENIGN NEOPLASM OF INTESTINE NOS; BENIGN NEOPLASM OF SPLEEN 16,965.00
11,875.50
5,089.50
D14.1
BENIGN NEOPLASM OF LARYNX; BENIGN NEOPLASM OF
SUPRAHYOID PORTION OF EPIGLOTTIS
18,525.00
12,967.50
5,557.50
D14.2 BENIGN NEOPLASM OF TRACHEA 18,525.00
12,967.50
5,557.50
D14.3 BENIGN NEOPLASM OF BRONCHUS AND LUNG 19,695.00
13,786.50
5,908.50
D14.4 BENIGN NEOPLASM OF RESPIRATORY SYSTEM, UNSPECIFIED 19,695.00
13,786.50
5,908.50
D15.0 BENIGN NEOPLASM OF THYMUS 19,695.00
13,786.50
5,908.50
D15.1 BENIGN NEOPLASM OF HEART 19,695.00
13,786.50
5,908.50
D15.2 BENIGN NEOPLASM OF MEDIASTINUM 19,695.00
13,786.50
5,908.50
D15.9 BENIGN NEOPLASM OF INTRATHORACIC ORGAN, UNSPECIFIED 19,695.00
13,786.50
5,908.50
D16.0 BENIGN NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB 20,475.00
14,332.50
6,142.50
D16.1 BENIGN NEOPLASM OF SHORT BONES OF UPPER LIMB 20,475.00
14,332.50
6,142.50
D16.2 BENIGN NEOPLASM OFLONG BONES OF LOWER LIMB 20,475.00
14,332.50
6,142.50
D16.3 BENIGN NEOPLASM OF SHORT BONES OF LOWER LIMB 20,475.00
14,332.50
6,142.50
D16.4 BENIGN NEOPLASM OF BONES OF SKULL AND FACE; BENIGN NEOPLASM OF SUPERIOR MAXILLA; BENIGN NEOPLASM OF ORBITAL BONE 20,475.00
14,332.50
6,142.50
D16.5 BENIGN NEOPLASM OF LOWER JAW BONE 20,475.00
14,332.50
6,142.50
D16.6 BENIGN NEOPLASM OF VERTEBRAL COLUMN 20,475.00
14,332.50
6,142.50
D16.7 BENIGN NEOPLASM OF RIBS, STERNUM AND CLAVICLE 20,475.00
14,332.50
6,142.50
D16.8 BENIGN NEOPLASM OF PELVIC BONES, SACRUM AND COCCYX 20,475.00
14,332.50
6,142.50
D16.9 BENIGN NEOPLASM OF BONE AND ARTICULAR CARTILAGE, UNSPECIFIED 20,475.00
14,332.50
6,142.50
D17.4 BENIGN LIPOMATOUS NEOPLASM OF INTRATHORACIC ORGANS 19,695.00
13,786.50
5,908.50
D17.5 BENIGN LIPOMATOUS NEOPLASM OF INTRA-ABDOMINAL ORGANS 16,965.00
11,875.50
5,089.50
D17.6 BENIGN LIPOMATOUS NEOPLASM OF SPERMATIC CORD 16,965.00
11,875.50
5,089.50
D17.7 BENIGN LIPOMATOUS NEOPLASM OF OTHER SITES; BENIGN LIPOMATOUS NEOPLASM OF PERITONEUM; BENIGN LIPOMATOUS NEOPLASM OF RETROPERITONEUM 16,965.00
11,875.50
5,089.50
D18.0 HAEMANGIOMA, ANY SITE; ANGIOMA NOS 17,550.00
12,285.00
5,265.00
D18.1 LYMPHANGIOMA, ANY SITE 17,550.00
12,285.00
5,265.00
D20.0 BENIGN NEOPLASM OF OF SOFT TISSUE OF RETROPERITONEUM 16,965.00
11,875.50
5,089.50
D20.1 BENIGN NEOPLASM OF OF SOFT TISSUE OF PERITONEUM 16,965.00
11,875.50
5,089.50
D21.3 BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF THORAX; BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF AXILLA; BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF DIAPHRAGM; BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF GREAT V 19,695.00
13,786.50
5,908.50
D21.4 BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF ABDOMEN 16,965.00
11,875.50
5,089.50
D25.0 SUBMUCOUS LEIOMYOMA OF UTERUS 18,720.00
13,104.00
5,616.00
D25.1 INTRAMURAL LEIOMYOMA OF UTERUS 18,720.00
13,104.00
5,616.00
D25.2 SUBSEROSAL LEIOMYOMA OF UTERUS 18,720.00
13,104.00
5,616.00
D25.9 LEIOMYOMA OF UTERUS, UNSPECIFIED 18,720.00
13,104.00
5,616.00
D26.0 OTHER BENIGN NEOPLASM OF CERVIX UTERI 18,720.00
13,104.00
5,616.00
D26.1 OTHER BENIGN NEOPLASM OF CORPUS UTERI 18,720.00
13,104.00
5,616.00
D26.7 OTHER BENIGN NEOPLASM OF OTHER PARTS OF UTERUS 18,720.00
13,104.00
5,616.00
D26.9 OTHER BENIGN NEOPLASM OF UTERUS, UNSPECIFIED 18,720.00
13,104.00
5,616.00
D27 BENIGN NEOPLASM OF OVARY 18,720.00
13,104.00
5,616.00
D28.0 BENIGN NEOPLASM OF VULVA 18,720.00
13,104.00
5,616.00
D28.1 BENIGN NEOPLASM OF VAGINA 18,720.00
13,104.00
5,616.00
D28.2 BENIGN NEOPLASM OF UTERINE TUBES AND LIGAMENTS; BENIGN NEOPLASM OF FALLOPIAN TUBES; BENIGN NEOPLASM OF UTERINE BROAD LIGAMENT; BENIGN NEOPLASM OF UTERINE ROUND LIGAMENT 18,720.00
13,104.00
5,616.00
D28.7 BENIGN NEOPLASM OF OTHER SPECIFIED FEMALE GENITAL ORGANS 18,720.00
13,104.00
5,616.00
Page 15 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate D28.9 BENIGN NEOPLASM OF FEMALE GENITAL ORGAN, UNSPECIFIED 18,720.00
13,104.00
5,616.00
D29.0 BENIGN NEOPLASM OF PENIS 15,015.00
10,510.50
4,504.50
D29.1 BENIGN NEOPLASM OF PROSTATE 15,015.00
10,510.50
4,504.50
D29.2 BENIGN NEOPLASM OF TESTIS 15,015.00
10,510.50
4,504.50
D29.4 BENIGN NEOPLASM OF SCROTUM; BENIGN NEOPLASM OF SKIN OF SCROTUM 15,015.00
10,510.50
4,504.50
D30.0 BENIGN NEOPLASM OF KIDNEY 16,185.00
11,329.50
4,855.50
D30.1 BENIGN NEOPLASM OF RENAL PELVIS 16,185.00
11,329.50
4,855.50
D30.3 BENIGN NEOPLASM OF BLADDER; BENIGN NEOPLASM OF URETHRAL ORIFICE OF BLADDER; BENIGN NEOPLASM OF URETERIC ORIFICE OF BLADDER 16,185.00
11,329.50
4,855.50
D30.4 BENIGN NEOPLASM OF URETHRA 16,185.00
11,329.50
4,855.50
D30.9 BENIGN NEOPLASM OF URINARY ORGAN, UNSPECIFIED; BENIGN NEOPLASM OF URINARY SYSTEM NOS 16,185.00
11,329.50
4,855.50
D32.0 BENIGN NEOPLASM OF CEREBRAL MENINGES 28,860.00
20,202.00
8,658.00
D32.1 BENIGN NEOPLASM OF SPINAL MENINGES 28,860.00
20,202.00
8,658.00
D32.9 BENIGN NEOPLASM OF MENINGES, UNSPECIFIED; MENINGIOMA NOS 28,860.00
20,202.00
8,658.00
D33.0 BENIGN NEOPLASM OF BRAIN, SUPRATENTORIAL; BENIGN NEOPLASM OF CEREBRAL VENTRICLE; BENIGN NEOPLASM OF CEREBRUM; BENIGN NEOPLASM OF FRONTAL LOBE; BENIGN NEOPLASM OF OCCIPITAL LOBE; BENIGN NEOPLASM OF PARIETAL LOBE; BENIGN NEOPLASM OF TEMPORAL LOBE 28,860.00
20,202.00
8,658.00
D33.1 BENIGN NEOPLASM OF BRAIN, INFRATENTORIAL; BENIGN NEOPLASM OF BRAIN STEM; BENIGN NEOPLASM OF CEREBELLUM; BENIGN NEOPLASM OF FOURTH VENTRICLE 28,860.00
20,202.00
8,658.00
D33.2 BENIGN NEOPLASM OF BRAIN, UNSPECIFIED 28,860.00
20,202.00
8,658.00
D33.3 BENIGN NEOPLASM OF CRANIAL NERVES; BENIGN NEOPLASM OF OLFACTORY BULB 28,860.00
20,202.00
8,658.00
D33.4 BENIGN NEOPLASM OF SPINAL CORD 28,860.00
20,202.00
8,658.00
D33.7 BENIGN NEOPLASM OF OTHER SPECIFIED PARTS OF CENTRAL NERVOUS SYSTEM 28,860.00
20,202.00
8,658.00
D33.9 BENIGN NEOPLASM OF CENTRAL NERVOUS SYSTEM, UNSPECIFIED; CENTRAL NERVOUS SYSTEM NOS 28,860.00
20,202.00
8,658.00
D34 BENIGN NEOPLASM OF THYROID GLAND 23,400.00
16,380.00
7,020.00
D35.0 BENIGN NEOPLASM OF ADRENAL GLAND 23,400.00
16,380.00
7,020.00
D35.1 BENIGN NEOPLASM OF PARATHYROID GLAND 23,400.00
16,380.00
7,020.00
D35.2 BENIGN NEOPLASM OF PITUITARY GLAND 23,400.00
16,380.00
7,020.00
D35.3 BENIGN NEOPLASM OF CRANIOPHARYNGEAL DUCT 23,400.00
16,380.00
7,020.00
D35.4 BENIGN NEOPLASM OF PINEAL GLAND 23,400.00
16,380.00
7,020.00
D35.9 BENIGN NEOPLASM OF ENDOCRINE GLAND, UNSPECIFIED 23,400.00
16,380.00
7,020.00
D36.1 BENIGN NEOPLASM OF PERIPHERAL NERVES AND AUTONOMIC NERVOUS SYSTEM 28,860.00
20,202.00
8,658.00
D37.0 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF LIP, ORAL CAVITY AND PHARYNX; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF ARYEPIGLOTTIC FOLD NOS; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF HYPOPHARYNGEAL ASPECT OF ARYEPIGLOTTIC FOLD ; NEOPLASM OF UN 23,790.00
16,653.00
7,137.00
D37.1 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF STOMACH 23,790.00
16,653.00
7,137.00
D37.2 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF SMALL INTESTINE 23,790.00
16,653.00
7,137.00
D37.3 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF APPENDIX 23,790.00
16,653.00
7,137.00
D37.4 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF COLON 23,790.00
16,653.00
7,137.00
D37.5 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF RECTUM; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF RECTOSIGMOID JUNCTION 23,790.00
16,653.00
7,137.00
D37.6 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF LIVER, GALLBLADDER AND BILE DUCTS; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF AMPULLA OF VATER 23,790.00
16,653.00
7,137.00
D37.7 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF OTHER DIGESTIVE ORGANS; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF ANAL CANAL; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF ANAL SPHINCTER; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF ANUS NOS; NEOPLASM 23,790.00
16,653.00
7,137.00
D37.9 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF DIGESTIVE ORGAN, UNSPECIFIED 23,790.00
16,653.00
7,137.00
D38.0 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF LARYNX; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF LARYNGEAL ASPECT OF ARYEPIGLOTTIC FOLD; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF SUPRAHYOID PORTION OF EPIGLOTTIS 23,790.00
16,653.00
7,137.00
D38.1 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF TRACHEA, BRONCHUS AND LUNG 23,790.00
16,653.00
7,137.00
D38.2 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF PLEURA 23,790.00
16,653.00
7,137.00
D38.3 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF MEDIASTINUM 23,790.00
16,653.00
7,137.00
D38.4 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF THYMUS 23,790.00
16,653.00
7,137.00
Page 16 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate D38.5 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF OTHER RESPIRATORY ORGANS; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF ACCESSORY SINUSES; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF CARTILAGE OF NOSE; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF MIDDLE 23,790.00
16,653.00
7,137.00
D38.6 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF RESPIRATORY ORGAN, UNSPECIFIED 23,790.00
16,653.00
7,137.00
D39.0 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF UTERUS 23,790.00
16,653.00
7,137.00
D39.1 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF OVARY 23,790.00
16,653.00
7,137.00
D39.2 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF PLACENTA; CHORIOADENOMA DESTRUENS; INVASIVE HYDATIDIFORM MOLE; MALIGNANT HYDATIDIFORM MOLE 23,790.00
16,653.00
7,137.00
D39.7 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF OTHER FEMALE GENITAL ORGANS; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF SKIN OF FEMALE GENITAL ORGANS 23,790.00
16,653.00
7,137.00
D39.9 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF FEMALE GENITAL ORGAN, UNSPECIFIED 23,790.00
16,653.00
7,137.00
D40.0 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF PROSTATE 23,790.00
16,653.00
7,137.00
D40.1 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF TESTIS 23,790.00
16,653.00
7,137.00
D40.7 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF OTHER MALE GENITAL ORGANS; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF SKIN OF MALE GENITAL ORGANS 23,790.00
16,653.00
7,137.00
D40.9 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF MALE GENITAL ORGAN, UNSPECIFIED 23,790.00
16,653.00
7,137.00
D41.0 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF KIDNEY 23,790.00
16,653.00
7,137.00
D41.1 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF RENAL PELVIS 23,790.00
16,653.00
7,137.00
D41.2 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF URETER 23,790.00
16,653.00
7,137.00
D41.3 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF URETHRA 23,790.00
16,653.00
7,137.00
D41.4 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF BLADDER 23,790.00
16,653.00
7,137.00
D41.9 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF URINARY ORGAN, UNSPECIFIED 23,790.00
16,653.00
7,137.00
D42.0 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF CEREBRAL MENINGES 23,790.00
16,653.00
7,137.00
D42.1 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF SPINAL MENINGES 23,790.00
16,653.00
7,137.00
D42.9 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF MENINGES, UNSPECIFIED 23,790.00
16,653.00
7,137.00
D43.0 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF BRAIN, SUPRATENTORIAL; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF CEREBRAL VENTRICLE; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF CEREBRUM; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF FRONTAL LOBE; NEOP 23,790.00
16,653.00
7,137.00
D43.1 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF BRAIN, INFRATENTORIAL; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF BRAIN STEM; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF CEREBELLUM; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF FOURTH VENTRICLE 23,790.00
16,653.00
7,137.00
D43.2 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF BRAIN, UNSPECIFIED 23,790.00
16,653.00
7,137.00
D43.3 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF CRANIAL NERVES 23,790.00
16,653.00
7,137.00
D43.4 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF SPINAL CORD 23,790.00
16,653.00
7,137.00
D43.7 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF OTHER PARTS OF CENTRAL NERVOUS SYSTEM 23,790.00
16,653.00
7,137.00
D43.9 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF CENTRAL NERVOUS SYSTEM, UNSPECIFIED; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF CENTRAL NERVOUS SYSTEM NOS 23,790.00
16,653.00
7,137.00
D44.0 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF THYROID GLAND 23,790.00
16,653.00
7,137.00
D44.1 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF ADRENAL GLAND 23,790.00
16,653.00
7,137.00
D44.2 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF PARATHYROID GLAND 23,790.00
16,653.00
7,137.00
D44.3 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF PITUITARY GLAND 23,790.00
16,653.00
7,137.00
D44.4 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF CRANIOPHARYNGEAL DUCT 23,790.00
16,653.00
7,137.00
D44.5 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF PINEAL GLAND 23,790.00
16,653.00
7,137.00
D44.6 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF CAROTID BODY 23,790.00
16,653.00
7,137.00
D44.7 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF AORTIC BODY AND OTHER PARAGANGLIA 23,790.00
16,653.00
7,137.00
Page 17 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate D44.8 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF PLURIGLANDULAR INVOLVEMENT; MULTIPLE ENDOCRINE ADENOMATOSIS 23,790.00
16,653.00
7,137.00
D44.9 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF ENDOCRINE GLAND, UNSPECIFIED 23,790.00
16,653.00
7,137.00
D45 POLYCYTHAEMIA VERA 23,790.00
16,653.00
7,137.00
D46 MYELODYSPLASTIC SYNDROMES 23,790.00
16,653.00
7,137.00
D46.7 OTHER MYELODYSPLASTIC SYNDROMES 23,790.00
16,653.00
7,137.00
D46.9
MYELODYSPLASTIC SYNDROME, UNSPECIFIED;
MYELODYSPLASTIC SYNDROME NOS; MYELODYSPLASIA NOS;
PRELEUKAEMIA SYNDROME NOS
23,790.00
16,653.00
7,137.00
D47.0
HISTIOCYTIC AND MAST CELL TUMOURS OF UNCERTAIN AND
UNKNOWN BEHAVIOUR; MAST CELL TUMOUR NOS;
MASTOCYTOMA NOS
23,790.00
16,653.00
7,137.00
D47.1 CHRONIC MYELOPROLIFERATIVE DISEASE; MYELOFIBROSIS WITH MYELOID METAPLASIA; MYELOPROLIFERATIVE DISEASE, UNSPECIFIED; MEGAKARYOCYTIC MYELOSCLEROSIS WITH MYELOID METAPLASIA 23,790.00
16,653.00
7,137.00
D47.2 MONOCLONAL GAMMOPATHY 23,790.00
16,653.00
7,137.00
D47.3 ESSENTIAL THROMBOCYTHAEMIA; HAEMORRHAGIC THROMBOCYTHAEMIA; IDIOPATHIC HAEMORRHAGIC THROMBOCYTHAEMIA 23,790.00
16,653.00
7,137.00
D47.7 OTHER SPECIFIED NEOPLASMS OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF LYMPHOID, HAEMATOPOIETIC AND RELATED TISSUE 23,790.00
16,653.00
7,137.00
D47.9 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF LYMPHOID, HAEMATOPOIETIC AND RELATED TISSUE, UNSPECIFIED; LYMPHOPROLIFERATIVE DISEASE NOS 23,790.00
16,653.00
7,137.00
D48.0 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF BONE AND ARTICULAR CARTILAGE 23,790.00
16,653.00
7,137.00
D48.1
NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF
CONNECTIVE AND OTHER SOFT TISSUE; NEOPLASM OF
UNCERTAIN OR UNKNOWN BEHAVIOUR OF CONNECTIVE TISSUE
OF EAR; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF
EYELID
23,790.00
16,653.00
7,137.00
D48.2 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF PERIPHERAL NERVES AND AUTONOMIC NERVOUS SYSTEM 23,790.00
16,653.00
7,137.00
D48.3 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF RETROPERITONEUM 23,790.00
16,653.00
7,137.00
D48.4 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF PERITONEUM 23,790.00
16,653.00
7,137.00
D48.6 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF BREAST; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF CONNECTIVE TISSUE OF BREAST; CYSTOSARCOMA PHYLLODES 23,790.00
16,653.00
7,137.00
D48.7 NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF OTHER SPECIFIED SITES; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF EYE; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF HEART; NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR OF PERIPHERAL NERVES OF ORBIT 23,790.00
16,653.00
7,137.00
D48.9
NEOPLASM OF UNCERTAIN OR UNKNOWN BEHAVIOUR,
UNSPECIFIED; "GROWTH" NOS ; NEOPLASM NOS;
NEW GROWTH NOS; TUMOUR NOS
23,790.00
16,653.00
7,137.00
D50.0 IRON DEFICIENCY ANAEMIA SECONDARY TO BLOOD LOSS (CHRONIC); POSTHAEMORRHAGIC ANAEMIA (CHRONIC) 19,500.00
13,650.00
5,850.00
D50.1
SIDEROPENIC DYSPHAGIA; KELLY-PATERSON SYNDROME;
PLUMMER-VINSON SYNDROME
19,500.00
13,650.00
5,850.00
D50.8 OTHER IRON DEFICIENCY ANAEMIAS 19,500.00
13,650.00
5,850.00
D50.9 IRON DEFICIENCY ANAEMIA, UNSPECIFIED 19,500.00
13,650.00
5,850.00
D51.0 VITAMIN B12 DEFICIENCY ANAEMIA DUE TO INTRINSIC FACTOR DEFICIENCY; ADDISON ANAEMIA; BIERMER ANAEMIA; CONGENITALPERNICIOUS ANAEMIA; CONGENITAL INTRINSIC FACTOR DEFICIENCY 19,500.00
13,650.00
5,850.00
D51.8 OTHER VITAMIN B12 DEFICIENCY ANAEMIAS 19,500.00
13,650.00
5,850.00
D51.9 VITAMIN B12 DEFICIENCY ANAEMIA, UNSPECIFIED 19,500.00
13,650.00
5,850.00
D52.1 DRUG-INDUCED FOLATE DEFICIENCY ANAEMIA 19,500.00
13,650.00
5,850.00
D52.9 FOLATE DEFICIENCY ANAEMIA, UNSPECIFIED; FOLIC ACID DEFICIENCY ANAEMIA NOS 19,500.00
13,650.00
5,850.00
D53.0 PROTEIN DEFICIENCY ANAEMIA; AMINO-ACID DEFICIENCY ANAEMIA; OROTACIDURIC ANAEMIA 19,500.00
13,650.00
5,850.00
D53.1 OTHER MEGALOBLASTIC ANAEMIAS, NOT ELSEWHERE CLASSIFIED; MEGALOBLASTIC ANAEMIA NOS 19,500.00
13,650.00
5,850.00
D53.2 SCORBUTIC ANAEMIA 19,500.00
13,650.00
5,850.00
D53.8 OTHER SPECIFIED NUTRITIONAL ANAEMIAS; ANAEMIA ASSOCIATED WITH DEFICIENCY OF COPPER; ANAEMIA ASSOCIATED WITH DEFICIENCY OF MOLYBDENUM; ANAEMIA ASSOCIATED WITH DEFICIENCY OF ZINC 19,500.00
13,650.00
5,850.00
D53.9 NUTRITIONAL ANAEMIA, UNSPECIFIED; SIMPLE CHRONIC ANAEMIA 19,500.00
13,650.00
5,850.00
D55.0
ANAEMIA DUE TO GLUCOSE-6-PHOSPHATE DEHYDROGENASE
[G6PD] DEFICIENCY; FAVISM;
G6PD DEFICIENCY ANAEMIA
19,500.00
13,650.00
5,850.00
D55.1 ANAEMIA DUE TO OTHER DISORDERS OF GLUTATHIONE METABOLISM; ANAEMIA DUE TO ENZYME DEFICIENCIES, EXCEPT G6PD, RELATED TO THE HEXOSE MONOPHOSPHATE [HMP] SHUNT PATHWAY; ANAEMIA DUE TO HAEMOLYTIC NONSPHEROCYTIC HEREDITARY, TYPE I 19,500.00
13,650.00
5,850.00
Page 18 of 105 of Annex A
Case Rate
Health Facility Fee
Professional Fee
ICD Code
Description
First Case Rate
D55.2
ANAEMIA DUE TO DISORDERS OF GLYCOLYTIC ENZYMES;
HAEMOLYTIC NONSPHEROCYTIC HEREDITARY ANAEMIA, TYPE II;
HEXOKINASE DEFICIENCY ANAEMIA; PYRUVATE KINASE [PK]
DEFICIENCY ANAEMIA; TRIOSE-PHOSPHATE ISOMERASE
DEFICIENCY ANAEMIA
19,500.00
13,650.00
5,850.00
D55.8 OTHER ANAEMIAS DUE TO ENZYME DISORDERS 19,500.00
13,650.00
5,850.00
D55.9 ANAEMIA DUE TO ENZYME DISORDER, UNSPECIFIED 19,500.00
13,650.00
5,850.00
D56.0 ALPHA THALASSAEMIA 10,920.00
7,644.00
3,276.00
D56.1 BETA THALASSAEMIA; COOLEY'S ANAEMIA; SEVERE BETA THALASSAEMIA; THALASSAEMIA INTERMEDIA; THALASSAEMIA MAJOR; 10,920.00
7,644.00
3,276.00
D56.2 DELTA-BETA THALASSAEMIA 10,920.00
7,644.00
3,276.00
D56.3 THALASSAEMIA TRAIT 10,920.00
7,644.00
3,276.00
D56.4 HEREDITARY PERSISTENCE OF FETAL HAEMOGLOBIN [HPFH] 10,920.00
7,644.00
3,276.00
D56.8 OTHER THALASSAEMIAS 10,920.00
7,644.00
3,276.00
D56.9 MEDITERRANEAN ANAEMIA; MEDITERRANEAN ANAEMIA WITH OTHER HAEMOGLOBINOPATHY; THALASSAEMIA MINOR WITH OTHER HAEMOGLOBINOPATHY; THALASSAEMIA MIXED WITH OTHER HAEMOGLOBINOPATHY; 19,500.00
13,650.00
5,850.00
D57.0 SICKLE-CELL ANAEMIA WITH CRISIS; HB-SS DISEASE WITH CRISIS 19,500.00
13,650.00
5,850.00
D57.1 SICKLE-CELL ANAEMIA WITHOUT CRISIS; SICKLE-CELL ANAEMIA NOS; SICKLE-CELL DISEASE NOS ; SICKLE-CELL DISORDER NOS 19,500.00
13,650.00
5,850.00
D57.3 SICKLE-CELL TRAIT; HB-S TRAIT ; HETEROZYGOUS HAEMOGLOBIN S 19,500.00
13,650.00
5,850.00
D57.8 OTHER SICKLE-CELL DISORDERS 19,500.00
13,650.00
5,850.00
D58.0 HEREDITARY SPHEROCYTOSIS; ACHOLURIC (FAMILIAL) JAUNDICE; CONGENITAL (SPHEROCYTIC) HAEMOLYTIC ICTERUS; MINKOWSKI- CHAUFFARD SYNDROME 19,500.00
13,650.00
5,850.00
D58.1 HEREDITARY ELLIPTOCYTOSIS; CONGENITAL ELLIPTOCYTOSIS; CONGENITAL OVALOCYTOSIS; HEREDITARY OVALOCYTOSIS 19,500.00
13,650.00
5,850.00
D58.2 OTHER HAEMOGLOBINOPATHIES; ABNORMAL HAEMOGLOBIN NOS; CONGENITAL HEINZ BODY ANAEMIA; HB-C DISEASE; HB-C DISEASE; HB-D DISEASE; HB-E DISEASE; HAEMOGLOBINOPATHY NOS; UNSTABLE HAEMOGLOBIN HAEMOLYTIC DISEASE 19,500.00
13,650.00
5,850.00
D58.8 OTHER SPECIFIED HEREDITARY HAEMOLYTIC ANAEMIAS; STOMATOCYTOSIS 19,500.00
13,650.00
5,850.00
D58.9 HEREDITARY HAEMOLYTIC ANAEMIA, UNSPECIFIED; ACQUIRED HAEMOLYTIC ANAEMIA 19,500.00
13,650.00
5,850.00
D59.0 DRUG-INDUCED AUTOIMMUNE HAEMOLYTIC ANAEMIA 19,500.00
13,650.00
5,850.00
D59.1 OTHER AUTOIMMUNE HAEMOLYTIC ANAEMIAS; AUTOIMMUNE HAEMOLYTIC DISEASE, COLD TYPE; (AUTOIMMUNE HAEMOLYTIC DISEASE, WARM TYPE; CHRONIC COLD HAEMAGGLUTININ DISEASE; COLD AGGLUTININ DISEASE; COLD AGGLUTININ HAEMOGLOBINURIA; SECONDARY SYMPTOMATIC HAEMOLYTIC A 19,500.00
13,650.00
5,850.00
D59.2 DRUG-INDUCED NONAUTOIMMUNE HAEMOLYTIC ANAEMIA; DRUG- INDUCED ENZYME DEFICIENCY ANAEMIA 19,500.00
13,650.00
5,850.00
D59.3 HAEMOLYTIC-URAEMIC SYNDROME 39,390.00
27,573.00
11,817.00
D59.4 OTHER NONAUTOIMMUNE HAEMOLYTIC ANAEMIAS; MECHANICAL HAEMOLYTIC ANAEMIA; MICROANGIOPATHIC HAEMOLYTIC ANAEMIA; TOXIC HAEMOLYTIC ANAEMIA 19,500.00
13,650.00
5,850.00
D59.5 PAROXYSMAL NOCTURNAL HAEMOGLOBINURIA [MARCHIAFAVA- MICHELI] 19,500.00
13,650.00
5,850.00
D59.6
HAEMOGLOBINURIA DUE TO HAEMOLYSIS FROM OTHER
EXTERNAL CAUSES; HAEMOGLOBINURIA FROM EXERTION;
HAEMOGLOBINURIA MARCH; HAEMOGLOBINURIA PAROXYSMAL
COLD
19,500.00
13,650.00
5,850.00
D59.8 OTHER ACQUIRED HAEMOLYTIC ANAEMIAS 19,500.00
13,650.00
5,850.00
D59.9 ACQUIRED HAEMOLYTIC ANAEMIA, UNSPECIFIED; CHRONIC IDIOPATHIC HAEMOLYTIC ANAEMIA 19,500.00
13,650.00
5,850.00
D60.0 CHRONIC ACQUIRED PURE RED CELL APLASIA 14,235.00
9,964.50
4,270.50
D60.1 TRANSIENT ACQUIRED PURE RED CELL APLASIA 19,500.00
13,650.00
5,850.00
D60.8 OTHER ACQUIRED PURE RED CELL APLASIAS 14,235.00
9,964.50
4,270.50
D60.9 ACQUIRED PURE RED CELL APLASIA, UNSPECIFIED 14,235.00
9,964.50
4,270.50
D61.0 CONSTITUTIONAL APLASTIC ANAEMIA; CONGENITAL PURE RED CELL APLASIA; PURE RED CELL APLASIA OF INFANTS; PRIMARY PURE RED CELL APLASIA; BLACKFAN-DIAMOND SYNDROME; FAMILIAL HYPOPLASTIC ANAEMIA; FANCONI'S ANAEMIA; PANCYTOPENIA WITH MALFORMATIONS 19,500.00
13,650.00
5,850.00
D61.1 DRUG-INDUCED APLASTIC ANAEMIA 19,500.00
13,650.00
5,850.00
D61.2 APLASTIC ANAEMIA DUE TO OTHER EXTERNAL AGENTS 19,500.00
13,650.00
5,850.00
D61.3 IDIOPATHIC APLASTIC ANAEMIA 19,500.00
13,650.00
5,850.00
D61.8 OTHER SPECIFIED APLASTIC ANAEMIAS 19,500.00
13,650.00
5,850.00
D61.9 APLASTIC ANAEMIA, UNSPECIFIED; HYPOPLASTIC ANAEMIA NOS; MEDULLARY HYPOPLASIA; PANMYELOPHTHISIS 19,500.00
13,650.00
5,850.00
D62 ACUTE POSTHAEMORRHAGIC ANAEMIA 19,500.00
13,650.00
5,850.00
D63.0* ANAEMIA IN NEOPLASTIC DISEASE 19,500.00
13,650.00
5,850.00
D63.8* ANAEMIA IN OTHER CHRONIC DISEASES CLASSIFIED ELSEWHERE 19,500.00
13,650.00
5,850.00
Page 19 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate D64.0 HEREDITARY SIDEROBLASTIC ANAEMIA; SEX-LINKED HYPOCHROMIC SIDEROBLASTIC ANAEMIA 19,500.00
13,650.00
5,850.00
D64.1 SECONDARY SIDEROBLASTIC ANAEMIA DUE TO DISEASE 19,500.00
13,650.00
5,850.00
D64.2 SECONDARY SIDEROBLASTIC ANAEMIA DUE TO DRUGS AND TOXINS 19,500.00
13,650.00
5,850.00
D64.3 OTHER SIDEROBLASTIC ANAEMIAS; SIDEROBLASTIC ANAEMIA NOS; PYRIDOXINE-RESPONSIVE NEC SIDEROBLASTIC ANAEMIA 19,500.00
13,650.00
5,850.00
D64.4 CONGENITAL DYSERYTHROPOIETIC ANAEMIA; CONGENITAL DYSHAEMATOPOIETIC ANAEMIA 7,800.00
5,460.00
2,340.00
D64.8 OTHER SPECIFIED ANAEMIAS; INFANTILE PSEUDOLEUKAEMIA; LEUKOERYTHROBLASTIC ANAEMIA 19,500.00
13,650.00
5,850.00
D64.9 ANAEMIA, UNSPECIFIED 19,500.00
13,650.00
5,850.00
D65 DISSEMINATED INTRAVASCULAR COAGULATION [DEFIBRINATION SYNDROME]; ACQUIRED AFIBRINOGENAEMIA; CONSUMPTION COAGULOPATHY; DIFFUSE OR DISSEMINATED INTRAVASCULAR COAGULATION [DIC] ; ACQUIRED FIBRINOLYTIC HAEMORRHAGE; FIBRINOLYTIC PURPURA; PURPURA FULMINANS; 62,400.00
43,680.00
18,720.00
D66
HEREDITARY FACTOR VIII DEFICIENCY; DEFICIENCY FACTOR VIII
(WITH FUNCTIONAL DEFECT); HAEMOPHILIA NOS; HAEMOPHILIA
A; CLASSICAL HAEMOPHILIA
24,960.00
17,472.00
7,488.00
D67 HEREDITARY FACTOR IX DEFICIENCY; CHRISTMAS DISEASE; FACTOR IX DEFICIENCY (WITH FUNCTIONAL DEFECT); PLASMA THROMBOPLASTIN COMPONENT [PTC] DEFICIENCY; HAEMOPHILIA B 24,960.00
17,472.00
7,488.00
D68.0 VON WILLEBRAND'S DISEASE; ANGIOHAEMOPHILIA; FACTOR VIII DEFICIENCY WITH VASCULAR DEFECT; VASCULAR HAEMOPHILIA 24,960.00
17,472.00
7,488.00
D68.1 HEREDITARY FACTOR XI DEFICIENCY; HAEMOPHILIA C PLASMA THROMOPLASTIN ANTECEDENT [PTA] DEFICIENCY 24,960.00
17,472.00
7,488.00
D68.2 HEREDITARY DEFICIENCY OF OTHER CLOTTING FACTORS; CONGENITAL AFIBRINOGENAEMIA; AC GLOBULIN DEFICIENCY; PROACCELERIN DEFICIENCY; DEFICIENCY OF FACTOR I [FIBRINOGEN]; DEFICIENCY OF FACTOR II [PROTHROMBIN]; DEFICIENCY OF FACTOR V [LABILE]; DEFICIENCY OF FAC 24,960.00
17,472.00
7,488.00
D68.3 HAEMORRHAGIC DISORDER DUE TO CIRCULATING ANTICOAGULANTS; HAEMORRHAGE DURING LONG TERM USE OF ANTICOAGULANTS; HYPERHEPARINAEMIA; INCREASE IN ANTITHROMBIN; INCREASE IN ANTI-VIIIA; INCREASE IN ANTI-IXA; INCREASE IN ANTI-XA; INCREASE IN ANTI-XIA 24,960.00
17,472.00
7,488.00
D68.4 ACQUIRED COAGULATION FACTOR DEFICIENCY; DEFICIENCY OF COAGULATION FACTOR DUE TO LIVER DISEASE; DEFICIENCY OF COAGULATION FACTOR DUE TO VITAMIN K DEFICIENCY 24,960.00
17,472.00
7,488.00
D68.8 OTHER SPECIFIED COAGULATION DEFECTS; PRESENCE OF SYSTEMIC LUPUS ERYTHEMATOSUS [SLE] INHIBITOR 24,960.00
17,472.00
7,488.00
D68.9 COAGULATION DEFECT, UNSPECIFIED 24,960.00
17,472.00
7,488.00
D69.0 ALLERGIC PURPURA; ANAPHYLACTOID PURPURA; HENOCH(- SCHöNLEIN) PURPURA; NONTHROMBOCYTOPENIC PURPURA; HAEMORRHAGIC PURPURA; IDIOPATHIC PURPURA; VASCULAR PURPURA; ALLERGICVASCULITIS 24,960.00
17,472.00
7,488.00
D69.1 QUALITATIVE PLATELET DEFECTS; BERNARD-SOULIER [GIANT PLATELET] SYNDROME; GLANZMANN'S DISEASE; GREY PLATELET SYNDROME; HAEMORRHAGIC THROMBOASTHENIA; HEREDITARY THROMBOASTHENIA; THROMBOCYTOPATHY ; 24,960.00
17,472.00
7,488.00
D69.2 OTHER NONTHROMBOCYTOPENIC PURPURA; PURPURA NOS; SENILE PURPURA; SIMPLEX PURPURA 24,960.00
17,472.00
7,488.00
D69.3 IDIOPATHIC THROMBOCYTOPENIC PURPURA; EVANS' SYNDROME 24,960.00
17,472.00
7,488.00
D69.8 OTHER SPECIFIED HAEMORRHAGIC CONDITIONS; HEREDITARY CAPILLARY FRAGILITY; VASCULAR PSEUDOHAEMOPHILIA 24,960.00
17,472.00
7,488.00
D70
AGRANULOCYTOSIS; AGRANULOCYTIC ANGINA; INFANTILE
GENETIC AGRANULOCYTOSIS; KOSTMANN'S DISEASE;
NEUTROPENIA NOS; CONGENITAL NEUTROPENIA; CYCLIC
NEUTROPENIA; DRUG-INDUCED NEUTROPENIA; PERIODIC
NEUTROPENIA; PRIMARY SPLENIC NEUTROPENIA; TOXIC
NEUTROPENIA;
23,595.00
16,516.50
7,078.50
D71
FUNCTIONAL DISORDERS OF POLYMORPHONUCLEAR
NEUTROPHILS; CELL MEMBRANE RECEPTOR COMPLEX [CR3]
DEFECT; CHRONIC (CHILDHOOD) GRANULOMATOUS DISEASE;
CONGENITAL DYSPHAGOCYTOSIS; PROGRESSIVE SEPTIC
GRANULOMATOSIS; OTHER DISORDERS OF WHITE BLOOD CELLS
23,595.00
16,516.50
7,078.50
D72.0 GENETIC ANOMALIES OF LEUKOCYTES; ALDER GRANULATION ANOMALY OR SYNDROME; ALDER GRANULOCYTE ANOMALY OR SYNDROME; MAY-HEGGLIN GRANULATION ANOMALY OR SYNDROME; MAY-HEGGLIN GRANULOCYTE ANOMALY OR SYNDROME; PELGER-HUëT GRANULOCYTE ANOMALY OR SYNDROME; P 23,595.00
16,516.50
7,078.50
Page 20 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate D72.8 OTHER SPECIFIED DISORDERS OF WHITE BLOOD CELLS; LYMPHOCYTIC LEUKAEMOID REACTION; MONOCYTIC LEUKAEMOID REACTION; MYELOCYTIC LEUKAEMOID REACTION; LEUKOCYTOSIS; SYMPTOMATIC LYMPHOCYTOSIS; LYMPHOPENIA; SYMPTOMATIC MONOCYTOSIS; 23,595.00
16,516.50
7,078.50
D73.2 CHRONIC CONGESTIVE SPLENOMEGALY 23,595.00
16,516.50
7,078.50
D73.3 ABSCESS OF SPLEEN 23,595.00
16,516.50
7,078.50
D73.4 CYST OF SPLEEN 23,595.00
16,516.50
7,078.50
D73.5 INFARCTION OF SPLEEN; NONTRAUMATIC SPLENIC RUPTURE; TORSION OF SPLEEN 23,595.00
16,516.50
7,078.50
D73.8
OTHER DISEASES OF SPLEEN; FIBROSIS OF SPLEEN NOS;
PERISPLENITIS; SPLENITIS NOS
23,595.00
16,516.50
7,078.50
D74.0 CONGENITAL METHAEMOGLOBINAEMIA 7,800.00
5,460.00
2,340.00
D74.9 METHAEMOGLOBINAEMIA, UNSPECIFIED 23,595.00
16,516.50
7,078.50
D75.0
FAMILIAL ERYTHROCYTOSIS; BENIGN POLYCYTHAEMIA; FAMILIAL
POLYCYTHAEMIA
23,595.00
16,516.50
7,078.50
D75.1 SECONDARY POLYCYTHAEMIA; ACQUIRED POLYCYTHAEMIA DUE TO ERYTHROPOIETIN; ACQUIRED POLYCYTHAEMIA DUE TO FALL IN PLASMA VOLUME; ACQUIRED POLYCYTHAEMIA DUE TO HIGH ALTITUDE; ACQUIRED POLYCYTHAEMIA DUE TO STRESS; EMOTIONAL POLYCYTHAEMIA; HYPOXAEMIC POLYCYTHA 23,595.00
16,516.50
7,078.50
D75.2 ESSENTIAL THROMBOCYTOSIS 23,595.00
16,516.50
7,078.50
D75.8 OTHER SPECIFIED DISEASES OF BLOOD AND BLOOD-FORMING ORGANS 23,595.00
16,516.50
7,078.50
D76.0 LANGERHANS' CELL HISTIOCYTOSIS, NOT ELSEWHERE CLASSIFIED 23,595.00
16,516.50
7,078.50
D76.1 HAEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS; EOSINOPHILIC GRANULOMA; HAND-SCHüLLER-CHRISTIAN DISEASE; CHRONIC HISTIOCYTOSIS X 23,595.00
16,516.50
7,078.50
D76.2 HAEMOPHAGOCYTIC SYNDROME, INFECTION-ASSOCIATED 23,595.00
16,516.50
7,078.50
D76.3 OTHER HISTIOCYTOSIS SYNDROMES; RETICULOHISTIOCYTOMA (GIANT-CELL); SINUS HISTIOCYTOSIS WITH MASSIVE LYMPHADENOPATHY; XANTHOGRANULOMA 23,595.00
16,516.50
7,078.50
D80.0 HEREDITARY HYPOGAMMAGLOBULINAEMIA; AUTOSOMAL RECESSIVE AGAMMAGLOBULINAEMIA (SWISS TYPE); X-LINKED AGAMMAGLOBULINAEMIA [BRUTON] (WITH GROWTH HORMONE DEFICIENCY) 22,620.00
15,834.00
6,786.00
D80.2 SELECTIVE DEFICIENCY OF IMMUNOGLOBULIN A [IGA] 22,620.00
15,834.00
6,786.00
D80.7 TRANSIENT HYPOGAMMAGLOBULINAEMIA OF INFANCY 22,620.00
15,834.00
6,786.00
D80.8 OTHER IMMUNODEFICIENCIES WITH PREDOMINANTLY ANTIBODY DEFECTS; KAPPA LIGHT CHAIN DEFICIENCY 22,620.00
15,834.00
6,786.00
D80.9 IMMUNODEFICIENCY WITH PREDOMINANTLY ANTIBODY DEFECTS, UNSPECIFIED 22,620.00
15,834.00
6,786.00
D81.1 SEVERE COMBINED IMMUNODEFICIENCY [SCID] WITH LOW T- AND B-CELL NUMBERS 22,620.00
15,834.00
6,786.00
D81.6 MAJOR HISTOCOMPATIBILITY COMPLEX CLASS I DEFICIENCY; BARE LYMPHOCYTE SYNDROME 22,620.00
15,834.00
6,786.00
D81.9 COMBINED IMMUNODEFICIENCY, UNSPECIFIED; SEVERE COMBINED IMMUNODEFICIENCY DISORDER [SCID] NOS 22,620.00
15,834.00
6,786.00
D82.0 WISKOTT-ALDRICH SYNDROME; IMMUNODEFICIENCY WITH THROMBOCYTOPENIA AND ECZEMA 22,620.00
15,834.00
6,786.00
D82.1 DI GEORGE'S SYNDROME; PHARYNGEAL POUCH SYNDROME; THYMIC ALYMPHOPLASIA; THYMIC APLASIA OR HYPOPLASIA WITH IMMUNODEFICIENCY 22,620.00
15,834.00
6,786.00
D82.3 IMMUNODEFICIENCY FOLLOWING HEREDITARY DEFECTIVE RESPONSE TO EPSTEIN-BARR VIRUS; X-LINKED LYMPHOPROLIFERATIVE DISEASE 22,620.00
15,834.00
6,786.00
D82.4 HYPERIMMUNOGLOBULIN E [IGE] SYNDROME 22,620.00
15,834.00
6,786.00
D82.9 IMMUNODEFICIENCY ASSOCIATED WITH MAJOR DEFECT, UNSPECIFIED 22,620.00
15,834.00
6,786.00
D83.0 COMMON VARIABLE IMMUNODEFICIENCY WITH PREDOMINANT ABNORMALITIES OF B-CELL NUMBERS AND FUNCTION 22,620.00
15,834.00
6,786.00
D83.1 COMMON VARIABLE IMMUNODEFICIENCY WITH PREDOMINANT IMMUNOREGULATORY T-CELL DISORDERS 22,620.00
15,834.00
6,786.00
D83.9 COMMON VARIABLE IMMUNODEFICIENCY, UNSPECIFIED 22,620.00
15,834.00
6,786.00
D84.8 OTHER SPECIFIED IMMUNODEFICIENCIES 22,620.00
15,834.00
6,786.00
D84.9 IMMUNODEFICIENCY, UNSPECIFIED 22,620.00
15,834.00
6,786.00
D86.1 SARCOIDOSIS OF LYMPH NODES 22,620.00
15,834.00
6,786.00
D86.8 SARCOIDOSIS OF OTHER AND COMBINED SITES; UVEOPAROTID FEVER [HEERFORDT] 22,620.00
15,834.00
6,786.00
D86.9 SARCOIDOSIS, UNSPECIFIED 22,620.00
15,834.00
6,786.00
D89.0 POLYCLONAL HYPERGAMMAGLOBULINAEMIA; BENIGN HYPERGAMMAGLOBULINAEMIC PURPURA; POLYCLONAL GAMMOPATHY NOS 22,620.00
15,834.00
6,786.00
D89.1 CRYOGLOBULINAEMIA; ESSENTIAL CRYOGLOBULINAEMIA; IDIOPATHIC CRYOGLOBULINAEMIA; MIXED CRYOGLOBULINAEMIA; PRIMARY CRYOGLOBULINAEMIA; SECONDARY CRYOGLOBULINAEMIA; CRYOGLOBULINAEMIC PURPURA; CRYOGLOBULINAEMIC VASCULITIS 22,620.00
15,834.00
6,786.00
D89.2 HYPERGAMMAGLOBULINAEMIA, UNSPECIFIED 22,620.00
15,834.00
6,786.00
D89.8 OTHER SPECIFIED DISORDERS INVOLVING THE IMMUNE MECHANISM, NOT ELSEWHERE CLASSIFIED 22,620.00
15,834.00
6,786.00
D89.9 DISORDER INVOLVING THE IMMUNE MECHANISM, UNSPECIFIED; IMMUNE DISEASE NOS 22,620.00
15,834.00
6,786.00
Page 21 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate E00.0 CONGENITAL IODINE-DEFICIENCY SYNDROME, NEUROLOGICAL TYPE; ENDEMIC CRETINISM, NEUROLOGICAL TYPE 19,305.00
13,513.50
5,791.50
E01.0 IODINE-DEFICIENCY-RELATED DIFFUSE (ENDEMIC) GOITRE 15,795.00
11,056.50
4,738.50
E01.1 IODINE-DEFICIENCY-RELATED MULTINODULAR (ENDEMIC) GOITRE; IODINE-DEFICIENCY-RELATED NODULAR GOITRE 15,795.00
11,056.50
4,738.50
E01.2 IODINE-DEFICIENCY-RELATED (ENDEMIC) GOITRE, UNSPECIFIED 15,795.00
11,056.50
4,738.50
E01.8 OTHER IODINE-DEFICIENCY-RELATED THYROID DISORDERS AND ALLIED CONDITIONS 15,795.00
11,056.50
4,738.50
E02 SUBCLINICAL IODINE-DEFICIENCY HYPOTHYROIDISM 15,795.00
11,056.50
4,738.50
E03.0 CONGENITAL HYPOTHYROIDISM WITH DIFFUSE GOITRE; NONTOXIC CONGENITAL GOITRE NOS; NONTOXIC ONGENITAL PARENCHYMATOUS GOITRE 19,305.00
13,513.50
5,791.50
E03.1 CONGENITAL HYPOTHYROIDISM WITHOUT GOITRE; APLASIA OF THYROID (WITH MYXOEDEMA); CONGENITAL ATROPHY OF THYROID; CONGENITAL HYPOTHYROIDISM NOS 19,305.00
13,513.50
5,791.50
E03.2 HYPOTHYROIDISM DUE TO MEDICAMENTS AND OTHER EXOGENOUS SUBSTANCES 15,795.00
11,056.50
4,738.50
E03.5 MYXOEDEMA COMA 15,795.00
11,056.50
4,738.50
E03.8 OTHER SPECIFIED HYPOTHYROIDISM 15,795.00
11,056.50
4,738.50
E03.9 HYPOTHYROIDISM, UNSPECIFIED; 15,795.00
11,056.50
4,738.50
E05.0 THYROTOXICOSIS WITH DIFFUSE GOITRE; EXOPHTHALMIC OR TOXIC GOITRE NOS; GRAVES' DISEASE; TOXIC DIFFUSE GOITRE 16,575.00
11,602.50
4,972.50
E05.1 THYROTOXICOSIS WITH TOXIC SINGLE THYROID NODULE; THYROTOXICOSIS WITH TOXIC UNINODULAR GOITRE 16,575.00
11,602.50
4,972.50
E05.2 THYROTOXICOSIS WITH TOXIC MULTINODULAR GOITRE; TOXIC NODULAR GOITRE NOS 16,575.00
11,602.50
4,972.50
E05.3 THYROTOXICOSIS FROM ECTOPIC THYROID TISSUE 16,575.00
11,602.50
4,972.50
E05.4 THYROTOXICOSIS FACTITIA 16,575.00
11,602.50
4,972.50
E05.5 THYROID CRISIS OR STORM 16,575.00
11,602.50
4,972.50
E05.8 OTHER THYROTOXICOSIS; OVERPRODUCTION OF THYROID- STIMULATING HORMONE 16,575.00
11,602.50
4,972.50
E05.9 THYROTOXICOSIS, UNSPECIFIED; HYPERTHYROIDISM NOS; THYROIDITIS 16,575.00
11,602.50
4,972.50
E06.0 ACUTE THYROIDITIS; ABSCESS OF THYROID; PYOGENIC THYROIDITIS; SUPPURATIVE THYROIDITIS 16,575.00
11,602.50
4,972.50
E06.1 SUBACUTE THYROIDITIS; DE QUERVAIN THYROIDITIS; GIANT- CELL THYROIDITIS; GRANULOMATOUS THYROIDITIS; NONSUPPURATIVE THYROIDITIS 16,575.00
11,602.50
4,972.50
E06.2 CHRONIC THYROIDITIS WITH TRANSIENT THYROTOXICOSIS 16,575.00
11,602.50
4,972.50
E06.3 AUTOIMMUNE THYROIDITIS; HASHIMOTO'S THYROIDITIS ; TRANSIENT HASHITOXICOSIS; LYMPHADENOID GOITRE; LYMPHOCYTIC THYROIDITIS; STRUMA LYMPHOMATOSA 16,575.00
11,602.50
4,972.50
E06.5
OTHER CHRONIC THYROIDITIS; CHRONIC THYROIDITIS NOS;
CHRONIC FIBROUS THYROIDITIS; LIGNEOUS THYROIDITIS; RIEDEL
THYROIDITIS
16,575.00
11,602.50
4,972.50
E06.9 THYROIDITIS, UNSPECIFIED 16,575.00
11,602.50
4,972.50
E07.0 HYPERSECRETION OF CALCITONIN; C-CELL HYPERPLASIA OF THYROID; HYPERSECRETION OF THYROCALCITONIN 16,575.00
11,602.50
4,972.50
E07.1 DYSHORMOGENETIC GOITRE; FAMILIAL DYSHORMOGENETIC GOITRE; PENDRED'S SYNDROME 16,575.00
11,602.50
4,972.50
E07.8 OTHER SPECIFIED DISORDERS OF THYROID; ABNORMALITY OF THYROID-BINDING GLOBULIN; HAEMORRHAGE OF THYROID; INFARCTION OF THYROID; SICK-EUTHYROID SYNDROME 16,575.00
11,602.50
4,972.50
E10.0 INSULIN-DEPENDENT DIABETES MELLITUS WITH COMA; BRITTLE DIABETES (MELLITUS) WITH COMA; JUVENILE-ONSET DIABETES (MELLITUS) WITHCOMA ; KETOSIS-PRONE DIABETES (MELLITUS) WITH COMA; TYPE I DIABETES (MELLITUS) WITH COMA; 30,810.00
21,567.00
9,243.00
E10.1 INSULIN-DEPENDENT DIABETES MELLITUS WITH ACIDIDOSIS/ KETOACIDOSIS WITHOUT MENTION OF COMA; DIABETIC ACIDIDOSIS WITHOUT MENTION OF COMA; DIABETIC KETOACIDOSIS WITHOUT MENTION OF COMA; 30,810.00
21,567.00
9,243.00
E10.2+ N08.3* INSULIN-DEPENDENT DIABETES MELLITUS WITH RENAL COMPLICATIONS; GLOMERULAR DISORDERS IN DIABETES MELLITUS 24,570.00
17,199.00
7,371.00
E10.5 INSULIN-DEPENDENT DIABETES MELLITUS WITH DIABETIC GANGRENE/ ULCER 24,570.00
17,199.00
7,371.00
E10.6 INSULIN-DEPENDENT DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATIONS 24,570.00
17,199.00
7,371.00
E10.7 INSULIN-DEPENDENT DIABETES MELLITUS WITH MULTIPLE COMPLICATIONS 24,570.00
17,199.00
7,371.00
E10.8 INSULIN-DEPENDENT DIABETES MELLITUS WITH UNSPECIFIED COMPLICATIONS 24,570.00
17,199.00
7,371.00
E10.9 INSULIN DEPENDENT DIABETES MELLITUS WITHOUT COMPLICATIONS 7,800.00
5,460.00
2,340.00
E11.0
NON-INSULIN-DEPENDENT DIABETES MELLITUS WITH COMA;
NONOBESE DIABETES (MELLITUS) WITH COMA ; OBESE DIABETES
MELLITUS WITH COMA ; ADULT-ONSET DIABETES MELLITUS WITH
COMA ; MATURITY-ONSET DIABETES MELLITUS WITH COMA ;
NONKETOTIC DIABETES MELLITUS WITH COM
30,810.00
21,567.00
9,243.00
Page 22 of 105 of Annex A
Case Rate
Health Facility Fee
Professional Fee
ICD Code
Description
First Case Rate
E11.1
NON-INSULIN-DEPENDENT DIABETES MELLITUS WITH
KETOACIDOSIS WITHOUT MENTION OF COMA; ; NONOBESE
DIABETES (MELLITUS) WITH KETOACIDOSIS WITHOUT MENTION
OF COMA; OBESE DIABETES MELLITUS WITH KETOACIDOSIS
WITHOUT MENTION OF COMA; ADULT-ONSET DIABETES MELLITU
30,810.00
21,567.00
9,243.00
E11.2+ N08.3* NON-INSULIN-DEPENDENT DIABETES MELLITUS WITH RENAL COMPLICATIONS; GLOMERULAR DISORDERS IN DIABETES MELLITUS 24,570.00
17,199.00
7,371.00
E11.5
NON-INSULIN-DEPENDENT DIABETES MELLITUS WITH DIABETIC
GANGRENE/ ULCER; NONOBESE DIABETES (MELLITUS) WITH
DIABETIC GANGRENE/ ULCER; OBESE DIABETES MELLITUS WITH
DIABETIC GANGRENE/ ULCER; ADULT-ONSET DIABETES MELLITUS
WITH DIABETIC GANGRENE/ ULCER; MAT
24,570.00
17,199.00
7,371.00
E11.6 NON-INSULIN-DEPENDENT DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATIONS 24,570.00
17,199.00
7,371.00
E11.7
NON-INSULIN-DEPENDENT DIABETES MELLITUS WITH MULTIPLE
COMPLICATIONS ; NONOBESE DIABETES (MELLITUS) WITH
MULTIPLE COMPLICATIONS ; OBESE DIABETES MELLITUS WITH
MULTIPLE COMPLICATIONS ; ADULT-ONSET DIABETES MELLITUS
WITH MULTIPLE COMPLICATIONS ; MATUR
24,570.00
17,199.00
7,371.00
E11.9 NON-INSULIN-DEPENDENT DIABETES MELLITUS WITHOUT COMPLICATIONS 7,800.00
5,460.00
2,340.00
E12.0
MALNUTRITION-RELATED DIABETES MELLITUS WITH COMA;
INSULIN-DEPENDENT MALNUTRITION-RELATED DIABETES
MELLITUS WITH COMA ; NON-INSULIN-DEPENDENT
MALNUTRITION-RELATED DIABETES MELLITUS WITH COMA
30,810.00
21,567.00
9,243.00
E12.2+ N08.3* MALNUTRITION-RELATED DIABETES; GLOMERULAR DISORDERS IN DIABETES MELLITUS 24,570.00
17,199.00
7,371.00
E12.5 MALNUTRITION-RELATED DIABETES MELLITUS WITH DIABETIC GANGRENE/ ULCER; INSULIN-DEPENDENT MALNUTRITION- RELATED DIABETES MELLITUS WITH DIABETIC GANGRENE/ ULCER; NON-INSULIN-DEPENDENT MALNUTRITION-RELATED DIABETES MELLITUS WITH DIABETIC GANGRENE/ ULCER 24,570.00
17,199.00
7,371.00
E12.6 MALNUTRITION-RELTAED DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATIONS 24,570.00
17,199.00
7,371.00
E12.8
MALNUTRITION-RELATED DIABETES MELLITUS WITH
UNSPECIFIED COMPLICATIONS; INSULIN-DEPENDENT
MALNUTRITION-RELATED DIABETES MELLITUS WITH
UNSPECIFIED COMPLICATIONS; NON-INSULIN-DEPENDENT
MALNUTRITION-RELATED DIABETES MELLITUS WITH
UNSPECIFIED COMPLICATI
24,570.00
17,199.00
7,371.00
E13.0 OTHER SPECIFIED DIABETES MELLITUS WITH COMA 30,810.00
21,567.00
9,243.00
E13.1 OTHER SPECIFIED DIABETES MELLITUS WITH ACIDIDOSIS/ KETOACIDOSIS WITHOUT MENTION OF COMA 30,810.00
21,567.00
9,243.00
E13.2+ N08.3* OTHER SPECIFIED DIABETES MELLITUS; GLOMERULAR DISORDERS IN DIABETES MELLITUS 24,570.00
17,199.00
7,371.00
E13.5 OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC GANGRENE/ ULCER 24,570.00
17,199.00
7,371.00
E13.6 OTHER SPECIFIED DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATIONS 24,570.00
17,199.00
7,371.00
E14.0 UNSPECIFIED DIABETES MELLITUS; DIABETES NOS WITH COMA 30,810.00
21,567.00
9,243.00
E14.1 UNSPECIFIED DIABETES MELLITUS; DIABETES NOS WITH ACIDIDOSIS/ KETOACIDOSIS WITHOUT MENTION OF COMA 30,810.00
21,567.00
9,243.00
E14.2+ N08.3* UNSPECIFIED DIABETES MELLITUS; GLOMERULAR DISORDERS IN DIABETES MELLITUS 24,570.00
17,199.00
7,371.00
E14.5 UNSPECIFIED DIABETES MELLITUS; DIABETES NOS WITH DIABETIC GANGRENE/ ULCER 24,570.00
17,199.00
7,371.00
E14.6 UNSPECIFIED DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATIONS 24,570.00
17,199.00
7,371.00
E14.7
UNSPECIFIED DIABETES MELLITUS; DIABETES NOS WITH
MULTIPLE COMPLICATIONS
24,570.00
17,199.00
7,371.00
E15 NONDIABETIC HYPOGLYCAEMIC COMA; NONDIABETIC HYPOGLYCAEMIC COMA; DRUG-INDUCED INSULIN COMA IN NONDIABETIC; HYPERINSULINISM WITH HYPOGLYCAEMIC COMA; HYPOGLYCAEMIC COMA NOS 15,795.00
11,056.50
4,738.50
E16.0 DRUG-INDUCED HYPOGLYCAEMIA WITHOUT COMA 15,795.00
11,056.50
4,738.50
E16.1 OTHER HYPOGLYCAEMIA; FUNCTIONAL NONHYPERINSULINAEMIC HYPOGLYCAEMIA; HYPERINSULINISM NOS; FUNCTIONAL HYPERINSULINISM; HYPERPLASIA OF PANCREATIC ISLET BETA CELLS NOS; POSTHYPOGLYCAEMIC COMA ENCEPHALOPATHY 15,795.00
11,056.50
4,738.50
E16.2 HYPOGLYCEMIA 7,800.00
5,460.00
2,340.00
E16.3 INCREASED SECRETION OF GLUCAGON; HYPERPLASIA OF PANCREATIC ENDOCRINE CELLS WITH GLUCAGON EXCESS; HYPERPLASIA OF PANCREATIC ENDOCRINE CELLS WITH GLUCAGON EXCESS 15,795.00
11,056.50
4,738.50
E16.4 ABNORMAL SECRETION OF GASTRIN; HYPERGASTRINAEMIA 15,795.00
11,056.50
4,738.50
Page 23 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate E16.8 OTHER SPECIFIED DISORDERS OF PANCREATIC INTERNAL SECRETION; INCREASED SECRETION FROM ENDOCRINE PANCREAS OF GROWTH HORMONE-RELEASING HORMONE; INCREASED SECRETION FROM ENDOCRINE PANCREAS OF PANCREATIC POLYPEPTIDE; INCREASED SECRETION FROM ENDOCRINE PANCREA 15,795.00
11,056.50
4,738.50
E16.9 DISORDER OF PANCREATIC INTERNAL SECRETION, UNSPECIFIED; ISLET-CELL HYPERPLASIA NOS; PANCREATIC ENDOCRINE CELL HYPERPLASIA NOS 15,795.00
11,056.50
4,738.50
E20.0 IDIOPATHIC HYPOPARATHYROIDISM 18,135.00
12,694.50
5,440.50
E20.8 OTHER HYPOPARATHYROIDISM 18,135.00
12,694.50
5,440.50
E20.9 HYPOPARATHYROIDISM, UNSPECIFIED; PARATHYROID TETANY 18,135.00
12,694.50
5,440.50
E21.0 PRIMARY HYPERPARATHYROIDISM; HYPERPLASIA OF PARATHYROID; OSTEITIS FIBROSA CYSTICA GENERALISATA [VON RECKLINGHAUSEN'S DISEASE OF BONE] 18,135.00
12,694.50
5,440.50
E21.4 OTHER SPECIFIED DISORDERS OF PARATHYROID GLAND 18,135.00
12,694.50
5,440.50
E21.5 DISORDER OF PARATHYROID GLAND, UNSPECIFIED 18,135.00
12,694.50
5,440.50
E22.2 SYNDROME OF INAPPROPRIATE SECRETION OF ANTIDIURETIC HORMONE 23,010.00
16,107.00
6,903.00
E23.0 HYPOPITUITARISM; FERTILE EUNUCH SYNDROME; HYPOGONADOTROPIC HYPOGONADISM; IDIOPATHIC GROWTH HORMONE DEFICIENCY; ISOLATED DEFICIENCY OF GONADOTROPIN; ISOLATED DEFICIENCY OF GROWTH HORMONE; ISOLATED DEFICIENCY OF PITUITARY HORMONE; KALLMANN'S SYNDROME; LORAI 23,010.00
16,107.00
6,903.00
E23.2 DIABETES INSIPIDUS 19,695.00
13,786.50
5,908.50
E24.0 PITUITARY-DEPENDENT CUSHING'S DISEASE; OVERPRODUCTION OF PITUITARY ACTH; PITUITARY-DEPENDENT HYPERADRENOCORTICISM 18,525.00
12,967.50
5,557.50
E24.1 NELSON'S SYNDROME 18,525.00
12,967.50
5,557.50
E24.2 DRUG-INDUCED CUSHING'S SYNDROME 18,525.00
12,967.50
5,557.50
E24.3 ECTOPIC ACTH SYNDROME 18,525.00
12,967.50
5,557.50
E24.8 OTHER CUSHING'S SYNDROME 18,525.00
12,967.50
5,557.50
E24.9 CUSHING'S SYNDROME, UNSPECIFIED 18,525.00
12,967.50
5,557.50
E25.0 CONGENITAL ADRENOGENITAL DISORDERS ASSOCIATED WITH ENZYME DEFICIENCY; CONGENITAL ADRENAL HYPERPLASIA; 21- HYDROXYLASE DEFICIENCY; SALT-LOSING CONGENITAL ADRENAL HYPERPLASIA 15,210.00
10,647.00
4,563.00
E25.9 ADRENOGENITAL DISORDER, UNSPECIFIED; ADRENOGENITAL SYNDROME NOS 21,255.00
14,878.50
6,376.50
E26.0
PRIMARY HYPERALDOSTERONISM; CONN'S SYNDROME;
PRIMARY ALDOSTERONISM DUE TO ADRENAL HYPERPLASIA
(BILATERAL)
19,305.00
13,513.50
5,791.50
E26.1 SECONDARY HYPERALDOSTERONISM 19,305.00
13,513.50
5,791.50
E26.8 OTHER HYPERALDOSTERONISM; BARTTER'S SYNDROME 19,305.00
13,513.50
5,791.50
E26.9 HYPERALDOSTERONISM, UNSPECIFIED; OTHER DISORDERS OF ADRENAL GLAND 19,305.00
13,513.50
5,791.50
E27.1 PRIMARY ADRENOCORTICAL INSUFFICIENCY; ADDISON'S DISEASE; AUTOIMMUNE ADRENALITIS 19,305.00
13,513.50
5,791.50
E27.2 ADDISONIAN CRISIS; ADRENAL CRISIS; ADRENOCORTICAL CRISIS 19,305.00
13,513.50
5,791.50
E27.3 DRUG-INDUCED ADRENOCORTICAL INSUFFICIENCY 19,305.00
13,513.50
5,791.50
E27.4 OTHER AND UNSPECIFIED ADRENOCORTICAL INSUFFICIENCY; ADRENAL HAEMORRHAGE; ADRENAL INFARCTION; ADRENOCORTICAL INSUFFICIENCY NOS; HYPOALDOSTERONISM 19,305.00
13,513.50
5,791.50
E27.8 OTHER SPECIFIED DISORDERS OF ADRENAL GLAND; ABNORMALITY OF CORTISOL-BINDING GLOBULIN 19,305.00
13,513.50
5,791.50
E28.8 OTHER OVARIAN DYSFUNCTION 21,255.00
14,878.50
6,376.50
E29.1 TESTICULAR HYPOFUNCTION; DEFECTIVE BIOSYNTHESIS OF TESTICULAR ANDROGEN NOS; 5-A-REDUCTASE DEFICIENCY (WITH MALE PSEUDOHERMAPHRODITISM); TESTICULAR HYPOGONADISM NOS 21,255.00
14,878.50
6,376.50
E29.9 TESTICULAR DYSFUNCTION, UNSPECIFIED 21,255.00
14,878.50
6,376.50
E31.0 AUTOIMMUNE POLYGLANDULAR FAILURE 21,255.00
14,878.50
6,376.50
E31.1 POLYGLANDULAR HYPERFUNCTION 21,255.00
14,878.50
6,376.50
E31.9 POLYGLANDULAR DYSFUNCTION, UNSPECIFIED 21,255.00
14,878.50
6,376.50
E32.0 PERSISTENT HYPERPLASIA OF THYMUS; HYPERTROPHY OF THYMUS 21,255.00
14,878.50
6,376.50
E32.8 OTHER DISEASES OF THYMUS 21,255.00
14,878.50
6,376.50
E32.9 DISEASE OF THYMUS, UNSPECIFIED 21,255.00
14,878.50
6,376.50
E34.0 CARCINOID SYNDROME 21,255.00
14,878.50
6,376.50
E34.8 OTHER SPECIFIED ENDOCRINE DISORDERS; PINEAL GLAND DYSFUNCTION; PROGERIA 21,255.00
14,878.50
6,376.50
E34.9 ENDOCRINE DISORDER, UNSPECIFIED; ENDOCRINE DISTURBANCE NOS; HORMONE DISTURBANCE NOS 21,255.00
14,878.50
6,376.50
E40 KWASHIORKOR 22,815.00
15,970.50
6,844.50
E41 NUTRITIONAL MARASMUS; SEVERE MALNUTRITION WITH MARASMUS 22,815.00
15,970.50
6,844.50
E42 MARASMIC KWASHIORKOR; SEVERE PROTEIN-ENERGY MALNUTRITION, INTERMEDIATE FORM; SEVERE PROTEIN- ENERGY MALNUTRITION WITH SIGNS OF BOTH KWASHIORKOR AND MARASMUS 22,815.00
15,970.50
6,844.50
E43 UNSPECIFIED SEVERE PROTEIN-ENERGY MALNUTRITION 22,815.00
15,970.50
6,844.50
E44.0 MODERATE PROTEIN-ENERGY MALNUTRITION 22,815.00
15,970.50
6,844.50
E44.1 MILD PROTEIN-ENERGY MALNUTRITION 22,815.00
15,970.50
6,844.50
Page 24 of 105 of Annex A
Case Rate
Health Facility Fee
Professional Fee
ICD Code
Description
First Case Rate
E45
RETARDED DEVELOPMENT FOLLOWING PROTEIN-ENERGY
MALNUTRITION; NUTRITIONAL SHORT STATURE; NUTRITIONAL
STUNTING; PHYSICAL RETARDATION DUE TO MALNUTRITION
22,815.00
15,970.50
6,844.50
E46 UNSPECIFIED PROTEIN-ENERGY MALNUTRITION; MALNUTRITION NOS; PROTEIN-ENERGY IMBALANCE NOS 22,815.00
15,970.50
6,844.50
E50.0 VITAMIN A DEFICIENCY WITH CONJUNCTIVAL XEROSIS 17,940.00
12,558.00
5,382.00
E50.1 VITAMIN A DEFICIENCY WITH BITOT'S SPOT AND CONJUNCTIVAL XEROSIS; BITOT'S SPOT IN THE YOUNG CHILD 17,940.00
12,558.00
5,382.00
E50.8 OTHER MANIFESTATIONS OF VITAMIN A DEFICIENCY 17,940.00
12,558.00
5,382.00
E50.9 VITAMIN A DEFICIENCY, UNSPECIFIED; HYPOVITAMINOSIS A NOS 17,940.00
12,558.00
5,382.00
E51.1 DRY BERIBERI 17,940.00
12,558.00
5,382.00
E51.2 WERNICKE'S ENCEPHALOPATHY 17,940.00
12,558.00
5,382.00
E51.8 OTHER MANIFESTATIONS OF THIAMINE DEFICIENCY 17,940.00
12,558.00
5,382.00
E51.9 THIAMINE DEFICIENCY, UNSPECIFIED 17,940.00
12,558.00
5,382.00
E53.1 PYRIDOXINE DEFICIENCY; VITAMIN B6 DEFICIENCY 17,940.00
12,558.00
5,382.00
E53.8 DEFICIENCY OF OTHER SPECIFIED B GROUP VITAMINS; BIOTIN DEFICIENCY; CYANOCOBALAMIN DEFICIENCY; FOLATE DEFICIENCY; FOLIC ACID DEFICIENCY; PANTOTHENIC ACID DEFICIENCY; VITAMIN B12 DEFICIENCY 17,940.00
12,558.00
5,382.00
E53.9 VITAMIN B DEFICIENCY, UNSPECIFIED 17,940.00
12,558.00
5,382.00
E54 ASCORBIC ACID DEFICIENCY; DEFICIENCY OF VITAMIN C; SCURVY 17,940.00
12,558.00
5,382.00
E55.0 RICKETS, ACTIVE; INFANTILE OSTEOMALACIA; JUVENILE OSTEOMALACIA 17,940.00
12,558.00
5,382.00
E55.9 VITAMIN D DEFICIENCY, UNSPECIFIED; AVITAMINOSIS D 17,940.00
12,558.00
5,382.00
E56.0 DEFICIENCY OF VITAMIN E 17,940.00
12,558.00
5,382.00
E56.1 DEFICIENCY OF VITAMIN K 17,940.00
12,558.00
5,382.00
E56.8 DEFICIENCY OF OTHER VITAMINS 17,940.00
12,558.00
5,382.00
E56.9 VITAMIN DEFICIENCY, UNSPECIFIED 17,940.00
12,558.00
5,382.00
E58 DIETARY CALCIUM DEFICIENCY 17,940.00
12,558.00
5,382.00
E60 DIETARY ZINC DEFICIENCY 17,940.00
12,558.00
5,382.00
E61.1 IRON DEFICIENCY 17,940.00
12,558.00
5,382.00
E61.2 MAGNESIUM DEFICIENCY 17,940.00
12,558.00
5,382.00
E61.6 VANADIUM DEFICIENCY 17,940.00
12,558.00
5,382.00
E61.9 DEFICIENCY OF NUTRIENT ELEMENT, UNSPECIFIED 17,940.00
12,558.00
5,382.00
E63.1 IMBALANCE OF CONSTITUENTS OF FOOD INTAKE 17,940.00
12,558.00
5,382.00
E63.8 OTHER SPECIFIED NUTRITIONAL DEFICIENCIES 17,940.00
12,558.00
5,382.00
E63.9 NUTRITIONAL DEFICIENCY, UNSPECIFIED 17,940.00
12,558.00
5,382.00
E64.8 SEQUELAE OF OTHER NUTRITIONAL DEFICIENCIES 17,160.00
12,012.00
5,148.00
E64.9 SEQUELAE OF UNSPECIFIED NUTRITIONAL DEFICIENCY 17,940.00
12,558.00
5,382.00
E66.2 EXTREME OBESITY WITH ALVEOLAR HYPOVENTILATION; PICKWICKIAN SYNDROME 26,520.00
18,564.00
7,956.00
E67.0 HYPERVITAMINOSIS A 17,940.00
12,558.00
5,382.00
E67.1 HYPERCAROTENAEMIA 17,940.00
12,558.00
5,382.00
E67.3 HYPERVITAMINOSIS D 17,940.00
12,558.00
5,382.00
E70.0 CLASSICAL PHENYLKETONURIA 20,670.00
14,469.00
6,201.00
E70.1 OTHER HYPERPHENYLALANINAEMIAS 20,670.00
14,469.00
6,201.00
E70.2 DISORDERS OF TYROSINE METABOLISM; ALKAPTONURIA; HYPERTYROSINAEMIA; OCHRONOSIS; TYROSINAEMIA; TYROSINOSIS 20,670.00
14,469.00
6,201.00
E70.3 ALBINISM; OCULARALBINISM; OCULOCUTANEOUS ALBINISM CHEDIAK(-STEINBRINCK)-HIGASHI SYNDROME; CROSS SYNDROME; HERMANSKY-PUDLAK SYNDROME 20,670.00
14,469.00
6,201.00
E70.8 OTHER DISORDERS OF AROMATIC AMINO-ACID METABOLISM; DISORDERS OF HISTIDINE METABOLISM; DISORDERS OF TRYPTOPHAN METABOLISM 20,670.00
14,469.00
6,201.00
E71.0 MAPLE-SYRUP-URINE DISEASE 20,670.00
14,469.00
6,201.00
E71.1 OTHER DISORDERS OF BRANCHED-CHAIN AMINO-ACID METABOLISM; HYPERLEUCINE-ISOLEUCINAEMIA; HYPERVALINAEMIA; ISOVALERIC ACIDAEMIA; METHYLMALONIC ACIDAEMIA; PROPIONIC ACIDAEMIA 20,670.00
14,469.00
6,201.00
E71.3 DISORDERS OF FATTY-ACID METABOLISM; ADRENOLEUKODYSTROPHY [ADDISON-SCHILDER]; MUSCLE CARNITINE PALMITYLTRANSFERASE DEFICIENCY 20,670.00
14,469.00
6,201.00
E72.0 DISORDERS OF AMINO-ACID TRANSPORT; CYSTINOSIS; CYSTINURIA; FANCONI(-DE TONI)(-DEBRé) SYNDROME; HARTNUP'S DISEASE; LOWE'S SYNDROME 20,670.00
14,469.00
6,201.00
E72.2 DISORDERS OF UREA CYCLE METABOLISM; ARGININAEMIA; ARGININOSUCCINIC ACIDURIA; CITRULLINAEMIA; HYPERAMMONAEMIA 20,670.00
14,469.00
6,201.00
E72.3 DISORDERS OF LYSINE AND HYDROXYLYSINE METABOLISM 20,670.00
14,469.00
6,201.00
E72.5 DISORDERS OF GLYCINE METABOLISM; HYPERHYDROXYPROLINAEMIA; HYPERPROLINAEMIA (TYPE I) , HYPERPROLINAEMIA TYPE II; NON-KETOTIC HYPERGLYCINAEMIA; SARCOSINAEMIA 20,670.00
14,469.00
6,201.00
E73.0 CONGENITAL LACTASE DEFICIENCY 11,310.00
7,917.00
3,393.00
E74.0
GLYCOGEN STORAGE DISEASE; CARDIAC GLYCOGENOSIS;
ANDERSEN DISEASE; CORI DISEASE; FORBES DISEASE; HERS
DISEASE; MCARDLE DISEASE; POMPE DISEASE; TAURI DISEASE;
VON GIERKE DISEASE; LIVER PHOSPHORYLASE DEFICIENCY
11,310.00
7,917.00
3,393.00
E74.1 DISORDERS OF FRUCTOSE METABOLISM; ESSENTIAL FRUCTOSURIA; FRUCTOSE-1,6-DIPHOSPHATASE DEFICIENCY; HEREDITARY FRUCTOSE INTOLERANCE 11,310.00
7,917.00
3,393.00
Page 25 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate E74.2 DISORDERS OF GALACTOSE METABOLISM; GALACTOKINASE DEFICIENCY; GALACTOSAEMIA 11,310.00
7,917.00
3,393.00
E74.3 OTHER DISORDERS OF INTESTINAL CARBOHYDRATE ABSORPTION; GLUCOSE-GALACTOSE MALABSORPTION; SUCRASE DEFICIENCY 11,310.00
7,917.00
3,393.00
E74.8 OTHER SPECIFIED DISORDERS OF CARBOHYDRATE METABOLISM 11,310.00
7,917.00
3,393.00
E75.2 OTHER SPHINGOLIPIDOSIS; FABRY(-ANDERSON) DISEASE; GAUCHER DISEASE; KRABBE DISEASE; NIEMANN-PICK DISEASE; FABER'S SYNDROME; METACHROMATIC LEUKODYSTROPHY; SULFATASE DEFICIENCY 15,795.00
11,056.50
4,738.50
E75.4 NEURONAL CEROID LIPOFUSCINOSIS; BATTEN DISEASE; BIELSCHOWSKY-JANSKY DISEASE; KUFS DISEASE; PIELMEYER- VOGT DISEASE 15,795.00
11,056.50
4,738.50
E75.5 OTHER LIPID STORAGE DISORDERS; CEREBROTENDINOUS CHOLESTEROSIS [VAN BOGAERT-SCHERER-EPSTEIN]; WOLMAN'S DISEASE 15,795.00
11,056.50
4,738.50
E75.6 LIPID STORAGE DISORDER, UNSPECIFIED 15,795.00
11,056.50
4,738.50
E76.0 MUCOPOLYSACCHARIDOSIS, TYPE I; HURLER SYNDROME; HURLER-SCHEIE SYNDROME; SCHEIE SYNDROME 21,255.00
14,878.50
6,376.50
E76.1 MUCOPOLYSACCHARIDOSIS, TYPE II; HUNTER'S SYNDROME 21,255.00
14,878.50
6,376.50
E76.2
OTHER MUCOPOLYSACCHARIDOSES; ß-GLUCURONIDASE
DEFICIENCY; MUCOPOLYSACCHARIDOSIS, TYPE III;
MUCOPOLYSACCHARIDOSIS IV, MUCOPOLYSACCHARIDOSIS VI,
MUCOPOLYSACCHARIDOSIS VII;
MILD MAROTEAUX-LAMY SYNDROME; SEVERE MAROTEAUX-LAMY
SYNDROME; MORQUIO-LIKE SYNDROME;
21,255.00
14,878.50
6,376.50
E76.3 MUCOPOLYSACCHARIDOSIS, UNSPECIFIED 21,255.00
14,878.50
6,376.50
E76.8 OTHER DISORDERS OF GLUCOSAMINOGLYCAN METABOLISM 21,255.00
14,878.50
6,376.50
E77.8 OTHER DISORDERS OF GLYCOPROTEIN METABOLISM 20,670.00
14,469.00
6,201.00
E78.0 PURE HYPERCHOLESTEROLAEMIA; FAMILIAL HYPERCHOLESTEROLAEMIA; FREDRICKSON'S HYPERLIPOPROTEINAEMIA, TYPE IIA; HYPERBETALIPOPROTEINAEMIA; HYPERLIPIDAEMIA, GROUP A; LOW-DENSITY-LIPOPROTEIN-TYPE [LDL] HYPERLIPOPROTEINAEMIA 12,870.00
9,009.00
3,861.00
E78.1 PURE HYPERGLYCERIDAEMIA; ENDOGENOUS HYPERGLYCERIDAEMIA; FREDRICKSON'S HYPERLIPOPROTEINAEMIA, TYPE IV; HYPERLIPIDAEMIA, GROUP B; HYPERPREBETALIPOPROTEINAEMIA'; VERY-LOW-DENSITY- LIPOPROTEIN-TYPE [VLDL] HYPERLIPOPROTEINAEMIA 12,870.00
9,009.00
3,861.00
E78.2 MIXED HYPERLIPIDAEMIA; BROAD- OR FLOATING- BETALIPOPROTEINAEMIA; FREDRICKSON'S HYPERLIPOPROTEINAEMIA, TYPE IIB; FREDRICKSON'S HYPERLIPOPROTEINAEMIA TYPE III; HYPERBETALIPOPROTEINAEMIA WITH PREBETALIPOPROTEINAEMIA; HYPERCHOLESTEROLAEMIA WITH ENDOGENOUS HYPE 12,870.00
9,009.00
3,861.00
E78.3 HYPERCHYLOMICRONAEMIA; FREDRICKSON'S HYPERLIPOPROTEINAEMIA, TYPE I; FREDRICKSON'S HYPERLIPOPROTEINAEMIA, TYPE V; HYPERLIPIDAEMIA, GROUP D; MIXED HYPERGLYCERIDAEMIA 12,870.00
9,009.00
3,861.00
E78.4 OTHER HYPERLIPIDAEMIA; FAMILIAL COMBINED HYPERLIPIDAEMIA 12,870.00
9,009.00
3,861.00
E78.6 LIPOPROTEIN DEFICIENCY; ABETALIPOPROTEINAEMIA; HIGH-DENSITY LIPOPROTEIN DEFICIENCY; HYPOALPHALIPOPROTEINAEMIA; FAMILIAL HYPOBETALIPOPROTEINAEMIA; LECITHIN CHOLESTEROL ACYLTRANSFERASE DEFICIENCY; TANGIER DISEASE 12,870.00
9,009.00
3,861.00
E78.8 OTHER DISORDERS OF LIPOPROTEIN METABOLISM 12,870.00
9,009.00
3,861.00
E79.8 OTHER DISORDERS OF PURINE AND PYRIMIDINE METABOLISM; HEREDITARY XANTHINURIA 13,650.00
9,555.00
4,095.00
E80.0 HEREDITARY ERYTHROPOIETIC PORPHYRIA; CONGENITAL ERYTHROPOIETIC PORPHYRIA; ERYTHROPOIETIC PROTOPORPHYRIA 19,110.00
13,377.00
5,733.00
E80.2 OTHER PORPHYRIA; HEREDITARY COPROPORPHYRIA PORPHYRIA NOS; ACUTE INTERMITTENT (HEPATIC) PORPHYRIA 19,110.00
13,377.00
5,733.00
E80.4 GILBERT'S SYNDROME 19,110.00
13,377.00
5,733.00
E80.5 CRIGLER-NAJJAR SYNDROME 19,110.00
13,377.00
5,733.00
E80.6 OTHER DISORDERS OF BILIRUBIN METABOLISM; DUBIN-JOHNSON SYNDROME; ROTOR'S SYNDROME 19,110.00
13,377.00
5,733.00
E83.0 DISORDERS OF COPPER METABOLISM; MENKES' KINKY HAIR DISEASE; MENKES' STEELY HAIR DISEASE; WILSON'S DISEASE 14,235.00
9,964.50
4,270.50
E83.1 DISORDERS OF IRON METABOLISM; HAEMOCHROMATOSIS 14,235.00
9,964.50
4,270.50
E83.2 DISORDERS OF ZINC METABOLISM; ACRODERMATITIS ENTEROPATHICA 14,235.00
9,964.50
4,270.50
E83.3
DISORDERS OF PHOSPHORUS METABOLISM; ACID PHOSPHATASE
DEFICIENCY; FAMILIAL HYPOPHOSPHATAEMIA;
HYPOPHOSPHATASIA; VITAMIN-D-RESISTANT OSTEOMALACIA;
VITAMIN-D-RESISTANT RICKETS
14,235.00
9,964.50
4,270.50
E83.4 DISORDERS OF MAGNESIUM METABOLISM; HYPERMAGNESAEMIA; HYPOMAGNESAEMIA 14,235.00
9,964.50
4,270.50
Page 26 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate E83.5 DISORDERS OF CALCIUM METABOLISM; FAMILIAL HYPOCALCIURIC HYPERCALCAEMIA; IDIOPATHIC HYPERCALCIURIA 14,235.00
9,964.50
4,270.50
E83.8 OTHER DISORDERS OF MINERAL METABOLISM 14,235.00
9,964.50
4,270.50
E84.0 CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONS 14,235.00
9,964.50
4,270.50
E84.1 CYSTIC FIBROSIS WITH INTESTINAL MANIFESTATIONS 14,235.00
9,964.50
4,270.50
E84.8 CYSTIC FIBROSIS WITH OTHER MANIFESTATIONS; CYSTIC FIBROSIS WITH COMBINED MANIFESTATIONS 14,235.00
9,964.50
4,270.50
E84.9 CYSTIC FIBROSIS, UNSPECIFIED 14,235.00
9,964.50
4,270.50
E85.8 OTHER AMYLOIDOSIS; LOCALIZED AMYLOIDOSIS 21,645.00
15,151.50
6,493.50
E86.1 MODERATE DEHYDRATION 7,800.00
5,460.00
2,340.00
E86.2 SEVERE DEHYDRATION 7,800.00
5,460.00
2,340.00
E87.0 HYPEROSMOLALITY AND HYPERNATRAEMIA; SODIUM [NA] EXCESS; SODIUM [NA] OVERLOAD 16,575.00
11,602.50
4,972.50
E87.1 HYPO-OSMOLALITY AND HYPONATRAEMIA 16,575.00
11,602.50
4,972.50
E87.2 ACIDOSIS; ACIDOSIS NOS; LACTIC ACIDOSIS; METABOLIC ACIDOSIS; RESPIRATORY ACIDOSIS 16,575.00
11,602.50
4,972.50
E87.3 ALKALOSIS; ALKALOSIS NOS; METABOLIC ALKALOSIS; RESPIRATORY ALKALOSIS 16,575.00
11,602.50
4,972.50
E87.4 MIXED DISORDER OF ACID-BASE BALANCE 16,575.00
11,602.50
4,972.50
E87.5 HYPERKALAEMIA; POTASSIUM [K] EXCESS; POTASSIUM [K] OVERLOAD 16,575.00
11,602.50
4,972.50
E87.6 HYPOKALAEMIA; POTASSIUM [K] DEFICIENCY 16,575.00
11,602.50
4,972.50
E87.7 FLUID OVERLOAD 16,575.00
11,602.50
4,972.50
E87.8 OTHER DISORDERS OF ELECTROLYTE AND FLUID BALANCE, NOT ELSEWHERE CLASSIFIED; ELECTROLYTE IMBALANCE NOS; HYPERCHLORAEMIA; HYPOCHLORAEMIA; OTHER METABOLIC DISORDERS 16,575.00
11,602.50
4,972.50
E88.0 DISORDERS OF PLASMA-PROTEIN METABOLISM, NOT ELSEWHERE CLASSIFIED; A-1-ANTITRYPSIN DEFICIENCY; BISALBUMINAEMIA 20,865.00
14,605.50
6,259.50
E88.1 LIPODYSTROPHY, NOT ELSEWHERE CLASSIFIED; LIPODYSTROPHY NOS 20,865.00
14,605.50
6,259.50
E88.8 OTHER SPECIFIED METABOLIC DISORDERS; LAUNOIS-BENSAUDE ADENOLIPOMATOSIS; TRIMETHYLAMINURIA 20,865.00
14,605.50
6,259.50
E88.9 METABOLIC DISORDER, UNSPECIFIED 20,865.00
14,605.50
6,259.50
E89.0 POSTPROCEDURAL HYPOTHYROIDISM; POSTIRRADIATION HYPOTHYROIDISM; POSTSURGICAL HYPOTHYROIDISM 20,085.00
14,059.50
6,025.50
E89.2 POSTPROCEDURAL HYPOPARATHYROIDISM; PARATHYROPRIVAL TETANY 20,085.00
14,059.50
6,025.50
E89.3 POSTPROCEDURAL HYPOPITUITARISM; POSTIRRADIATION HYPOPITUITARISM 20,085.00
14,059.50
6,025.50
E89.4 POSTPROCEDURAL OVARIAN FAILURE 20,085.00
14,059.50
6,025.50
E89.5 POSTPROCEDURAL TESTICULAR HYPOFUNCTION 20,085.00
14,059.50
6,025.50
E89.6 POSTPROCEDURAL ADRENOCORTICAL HYPOFUNCTION; POSTPROCEDURAL ADRENO-MEDULLARY HYPOFUNCTION 20,085.00
14,059.50
6,025.50
E89.8 OTHER POSTPROCEDURAL ENDOCRINE AND METABOLIC DISORDERS 20,085.00
14,059.50
6,025.50
F01.0 VASCULAR DEMENTIA OF ACUTE ONSET 15,990.00
11,193.00
4,797.00
F01.1 MULTI-INFARCT DEMENTIA; PREDOMINANTLY CORTICAL DEMENTIA 15,210.00
10,647.00
4,563.00
F01.8 OTHER VASCULAR DEMENTIA 15,210.00
10,647.00
4,563.00
F01.9 VASCULAR DEMENTIA, UNSPECIFIED 15,210.00
10,647.00
4,563.00
F03 UNSPECIFIED DEMENTIA; PRESENILE DEMENTIA NOS; PRESENILE PSYCHOSIS NOS; SENILE DEMENTIA NOS; SENILE DEMENTIA DEPRESSED OR PARANOID TYPE; SENILE PSYCHOSIS NOS 15,210.00
10,647.00
4,563.00
F04 ORGANIC AMNESIC SYNDROME, NOT INDUCED BY ALCOHOL AND OTHER PSYCHOACTIVE SUBSTANCES; KORSAKOV'S PSYCHOSIS OR SYNDROME, NONALCOHOLIC 15,210.00
10,647.00
4,563.00
F05.0 DELIRIUM NOT SUPERIMPOSED ON DEMENTIA, SO DESCRIBED 15,210.00
10,647.00
4,563.00
F05.8 OTHER DELIRIUM 15,210.00
10,647.00
4,563.00
F05.9 OTHER DELIRIUM 15,210.00
10,647.00
4,563.00
F06.0 ORGANIC HALLUCINOSIS; ORGANIC HALLUCINATORY STATE (NONALCOHOLIC) 15,210.00
10,647.00
4,563.00
F06.2 ORGANIC DELUSIONAL [SCHIZOPHRENIA-LIKE] DISORDER; PARANOID AND PARANOID-HALLUCINATORY ORGANIC STATES; SCHIZOPHRENIA-LIKE PSYCHOSIS IN EPILEPSY 15,210.00
10,647.00
4,563.00
F06.3 ORGANIC MOOD [AFFECTIVE] DISORDERS 15,210.00
10,647.00
4,563.00
F06.4 ORGANIC ANXIETY DISORDER 15,210.00
10,647.00
4,563.00
F06.7 MILD COGNITIVE DISORDER 15,210.00
10,647.00
4,563.00
F06.8 OTHER SPECIFIED MENTAL DISORDERS DUE TO BRAIN DAMAGE AND DYSFUNCTION AND TO PHYSICAL DISEASE; EPILEPTIC PSYCHOSIS NOS 15,210.00
10,647.00
4,563.00
F06.9 UNSPECIFIED MENTAL DISORDER DUE TO BRAIN DAMAGE AND DYSFUNCTION AND TO PHYSICAL DISEASE; ORGANIC BRAIN SYNDROME NOS; ORGANIC MENTAL DISORDER NOS 15,210.00
10,647.00
4,563.00
F07.0
ORGANIC PERSONALITY DISORDER; ORGANIC
PSEUDOPSYCHOPATHIC PERSONALITY;
ORGANIC PSEUDORETARDED PERSONALITY; FRONTAL LOBE
SYNDROME; LIMBIC EPILEPSY PERSONALITYSYNDROME ;
LOBOTOMY SYNDROME; POSTLEUCOTOMY SYNDROME
15,210.00
10,647.00
4,563.00
F07.1 POSTENCEPHALITIC SYNDROME 15,210.00
10,647.00
4,563.00
F07.2 POSTCONCUSSIONAL SYNDROME; POSTCONTUSIONAL SYNDROME (ENCEPHALOPATHY); POST-TRAUMATIC BRAIN SYNDROME, NONPSYCHOTIC 15,210.00
10,647.00
4,563.00
Page 27 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate F07.9 UNSPECIFIED ORGANIC PERSONALITY AND BEHAVIOURAL DISORDER DUE TO BRAIN DISEASE, DAMAGE AND DYSFUNCTION; ORGANIC PSYCHOSYNDROME 15,210.00
10,647.00
4,563.00
F09
UNSPECIFIED ORGANIC OR SYMPTOMATIC MENTAL DISORDER;
ORGANIC PSYCHOSIS NOS; SYMPTOMATIC PSYCHOSIS NOS
15,210.00
10,647.00
4,563.00
F10.0 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOL IN ACUTE INTOXICATION 15,210.00
10,647.00
4,563.00
F10.1 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOL:HARMFUL USE 15,210.00
10,647.00
4,563.00
F10.2 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOL: DEPENDENCY SYNDROME 15,210.00
10,647.00
4,563.00
F10.3 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOL:WITHDRAWAL STATE 15,210.00
10,647.00
4,563.00
F10.4 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOL: WITHDRAWAL STATE WITH DELIRIUM 15,210.00
10,647.00
4,563.00
F10.5 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOL: PSYCHOTIC DISORDER 15,210.00
10,647.00
4,563.00
F10.6 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOL: AMNESIC SYNDROME 15,210.00
10,647.00
4,563.00
F10.7 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOL: RESIDUAL AND LATE-ONSET PSYCHOTIC DISORDER 15,210.00
10,647.00
4,563.00
F10.8 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOL: OTHER MENTAL AND BEHAVIOURAL DISORDERS 15,210.00
10,647.00
4,563.00
F10.9 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOL: UNSPECIFIED MENTAL AND BEHAVIOURAL DISORDER 15,210.00
10,647.00
4,563.00
F11.1 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OPIOIDS: HARMFUL USE 15,210.00
10,647.00
4,563.00
F11.2 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OPIOIDS: DEPENDENCE SYNDROME 15,210.00
10,647.00
4,563.00
F11.5 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OPIOIDS: PSYCHOTIC DISORDER 15,210.00
10,647.00
4,563.00
F11.9 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OPIOIDS: UNSPECIFIED MENTAL AND BEHAVIOURAL DISORDER 15,210.00
10,647.00
4,563.00
F12.0 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF CANNABINOIDS: ACUTE INTOXICATION 15,210.00
10,647.00
4,563.00
F12.5 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF CANNABINOIDS: PSYCHOTIC DISORDER 15,210.00
10,647.00
4,563.00
F13.1 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF SEDATIVES OR HYPNOTICS: HARMFUL USE 15,210.00
10,647.00
4,563.00
F13.2 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF SEDATIVES OR HYPNOTICS: DEPENDENCE SYNDROME 15,210.00
10,647.00
4,563.00
F13.3 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF SEDATIVES OR HYPNOTICS: WITHDRAWAL STATE 15,210.00
10,647.00
4,563.00
F13.4 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF SEDATIVES OR HYPNOTICS: WITHDRAWAL STATE WITH DELIRIUM 15,210.00
10,647.00
4,563.00
F13.5 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF SEDATIVES OR HYPNOTICS: PSYCHOTIC DISORDER 15,210.00
10,647.00
4,563.00
F13.7 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF SEDATIVES OR HYPNOTICS: RESIDUAL AND LATE-ONSET PSYCHOTIC DISORDER 15,210.00
10,647.00
4,563.00
F14.0 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF COCAINE: ACUTE INTOXICATION 15,210.00
10,647.00
4,563.00
F14.2 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF COCAINE: DEPENDENCE SYNDROME 15,210.00
10,647.00
4,563.00
F14.5 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF COCAINE: PSYCHOTIC DISORDER 15,210.00
10,647.00
4,563.00
F14.6 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF COCAINE: AMNESIC SYNDROME 15,210.00
10,647.00
4,563.00
F14.9 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF COCAINE: UNSPECIFIED MENTAL AND BEHAVIOURAL DISORDER 15,210.00
10,647.00
4,563.00
F15.0 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OTHER STIMULANTS, INCLUDING CAFFEINE: ACUTE INTOXICATION 15,210.00
10,647.00
4,563.00
F15.1 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OTHER STIMULANTS, INCLUDING CAFFEINE: HARMFUL USE 15,210.00
10,647.00
4,563.00
F15.2 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OTHER STIMULANTS, INCLUDING CAFFEINE: DEPENDENCE SYNDROME 15,210.00
10,647.00
4,563.00
F15.3 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OTHER STIMULANTS, INCLUDING CAFFEINE: WITHDRAWAL STATE 15,210.00
10,647.00
4,563.00
F15.5 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OTHER STIMULANTS, INCLUDING CAFFEINE: PSYCHOTIC DISORDER 15,210.00
10,647.00
4,563.00
F15.8 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OTHER STIMULANTS, INCLUDING CAFFEINE: OTHER MENTAL AND BEHAVIOURAL DISORDERS 15,210.00
10,647.00
4,563.00
F15.9 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF OTHER STIMULANTS, INCLUDING CAFFEINE: UNSPECIFIED MENTAL AND BEHAVIOURAL DISORDER 15,210.00
10,647.00
4,563.00
F16.0 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF HALLUCINOGENS: ACUTE INTOXICATION 15,210.00
10,647.00
4,563.00
Page 28 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate F16.1 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF HALLUCINOGENS: HARMFUL USE 15,210.00
10,647.00
4,563.00
F16.2 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF HALLUCINOGENS: DEPENDENCE SYNDROME 15,210.00
10,647.00
4,563.00
F16.5 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF HALLUCINOGENS: PSYCHOTIC DISORDER 15,210.00
10,647.00
4,563.00
F17.2 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF TOBACCO: DEPENDENCE SYNDROME 15,210.00
10,647.00
4,563.00
F17.3 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF TOBACCO: WITHDRAWAL STATE 15,210.00
10,647.00
4,563.00
F18.0 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF VOLATILE SOLVENTS: ACUTE INTOXICATION 15,210.00
10,647.00
4,563.00
F18.4 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF VOLATILE SOLVENTS: WITHDRAWAL STATE WITH DELIRIUM 15,210.00
10,647.00
4,563.00
F18.6 MENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF VOLATILE SOLVENTS: AMNESIC SYNDROME 15,210.00
10,647.00
4,563.00
F19.1 MENTAL AND BEHAVIOURAL DISORDERS DUE TO MULTIPLE DRUG USE AND USE OF OTHER PSYCHOACTIVE SUBSTANCES; MISUSE OF DRUGS NOS: HARMFUL USE 15,210.00
10,647.00
4,563.00
F19.2 MENTAL AND BEHAVIOURAL DISORDERS DUE TO MULTIPLE DRUG USE AND USE OF OTHER PSYCHOACTIVE SUBSTANCES; MISUSE OF DRUGS NOS: DEPENDENCE SYNDROME 15,210.00
10,647.00
4,563.00
F19.3 MENTAL AND BEHAVIOURAL DISORDERS DUE TO MULTIPLE DRUG USE AND USE OF OTHER PSYCHOACTIVE SUBSTANCES; MISUSE OF DRUGS NOS: WITHDRAWAL STATE 15,210.00
10,647.00
4,563.00
F19.5 MENTAL AND BEHAVIOURAL DISORDERS DUE TO MULTIPLE DRUG USE AND USE OF OTHER PSYCHOACTIVE SUBSTANCES; MISUSE OF DRUGS NOS: PSYCHOTIC DISORDER 15,210.00
10,647.00
4,563.00
F19.7 MENTAL AND BEHAVIOURAL DISORDERS DUE TO MULTIPLE DRUG USE AND USE OF OTHER PSYCHOACTIVE SUBSTANCES; MISUSE OF DRUGS NOS: RESIDUAL AND LATE-ONSET PSYCHOTIC DISORDER 15,210.00
10,647.00
4,563.00
F19.8 MENTAL AND BEHAVIOURAL DISORDERS DUE TO MULTIPLE DRUG USE AND USE OF OTHER PSYCHOACTIVE SUBSTANCES; MISUSE OF DRUGS NOS: OTHER MENTAL AND BEHAVIOURAL DISORDERS 15,210.00
10,647.00
4,563.00
F19.9 MENTAL AND BEHAVIOURAL DISORDERS DUE TO MULTIPLE DRUG USE AND USE OF OTHER PSYCHOACTIVE SUBSTANCES; MISUSE OF DRUGS NOS: UNSPECIFIED MENTAL AND BEHAVIOURAL DISORDER 15,210.00
10,647.00
4,563.00
F20.0 PARANOID SCHIZOPHRENIA; PARAPHRENIC SCHIZOPHRENIA 15,210.00
10,647.00
4,563.00
F20.1 HEBEPHRENIC SCHIZOPHRENIA; DISORGANIZED SCHIZOPHRENIA; HEBEPHRENIA 15,210.00
10,647.00
4,563.00
F20.2
CATATONIC SCHIZOPHRENIA; CATATONIC STUPOR;
SCHIZOPHRENIC CATALEPSY; SCHIZOPHRENIC CATATONIA;
SCHIZOPHRENIC FLEXIBILITAS CEREA
15,210.00
10,647.00
4,563.00
F20.3 UNDIFFERENTIATED SCHIZOPHRENIA; ATYPICAL SCHIZOPHRENIA 15,210.00
10,647.00
4,563.00
F20.5 RESIDUAL SCHIZOPHRENIA; CHRONIC UNDIFFERENTIATED SCHIZOPHRENIA; RESTZUSTAND (SCHIZOPHRENIC); SCHIZOPHRENIC RESIDUAL STATE 15,210.00
10,647.00
4,563.00
F20.6 SIMPLE SCHIZOPHRENIA 15,210.00
10,647.00
4,563.00
F20.8 OTHER SCHIZOPHRENIA; CENESTHOPATHIC SCHIZOPHRENIA; SCHIZOPHRENIFORM DISORDER NOS; SCHIZOPHRENIFORM PSYCHOSIS NOS 15,210.00
10,647.00
4,563.00
F20.9 SCHIZOPHRENIA, UNSPECIFIED 15,210.00
10,647.00
4,563.00
F21 SCHIZOTYPAL DISORDER; LATENT SCHIZOPHRENIC REACTION; SCHIZOPHRENIA BORDERLINE; SCHIZOPHRENIA LATENT; SCHIZOPHRENIA PREPSYCHOTIC; SCHIZOPHRENIA PRODROMAL; SCHIZOPHRENIA PSEUDONEUROTIC; SCHIZOPHRENIA PSEUDOPSYCHOPATHIC; SCHIZOTYPAL PERSONALITY DISORDER 15,210.00
10,647.00
4,563.00
F22.0 DELUSIONAL DISORDER; PARANOIA; PARANOID PSYCHOSIS; PARANOID STATE; PARAPHRENIA (LATE); SENSITIVER BEZIEHUNGSWAHN 15,210.00
10,647.00
4,563.00
F22.8 OTHER PERSISTENT DELUSIONAL DISORDERS; DELUSIONAL DYSMORPHOPHOBIA; INVOLUTIONAL PARANOID STATE; PARANOIA QUERULANS 15,210.00
10,647.00
4,563.00
F23.0 ACUTE POLYMORPHIC PSYCHOTIC DISORDER WITHOUT SYMPTOMS OF SCHIZOPHRENIA; BOUFFéE DéLIRANTE WITHOUT SYMPTOMS OF SCHIZOPHRENIA OR UNSPECIFIED; CYCLOID PSYCHOSIS WITHOUT SYMPTOMS OF SCHIZOPHRENIA OR UNSPECIFIED 15,210.00
10,647.00
4,563.00
F23.1 ACUTE POLYMORPHIC PSYCHOTIC DISORDER WITH SYMPTOMS OF SCHIZOPHRENIA; BOUFFéE DéLIRANTE WITH SYMPTOMS OF SCHIZOPHRENIA; CYCLOID PSYCHOSIS WITH SYMPTOMS OF SCHIZOPHRENIA 15,210.00
10,647.00
4,563.00
F23.2 ACUTE SCHIZOPHRENIA-LIKE PSYCHOTIC DISORDER;ACUTE (UNDIFFERENTIATED) SCHIZOPHRENIA;BRIEF SCHIZOPHRENIFORM DISORDER; BRIEF SCHIZOPHRENIFORM PSYCHOSIS; ONEIROPHRENIA; SCHIZOPHRENIC REACTION 15,210.00
10,647.00
4,563.00
F23.3 OTHER ACUTE PREDOMINANTLY DELUSIONAL PSYCHOTIC DISORDERS; PARANOID REACTION; PSYCHOGENIC PARANOID PSYCHOSIS 15,210.00
10,647.00
4,563.00
Page 29 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate F23.8 OTHER ACUTE AND TRANSIENT PSYCHOTIC DISORDERS 15,210.00
10,647.00
4,563.00
F23.9 ACUTE AND TRANSIENT PSYCHOTIC DISORDER, UNSPECIFIED; BRIEF REACTIVE PSYCHOSIS NOS; REACTIVE PSYCHOSIS 15,210.00
10,647.00
4,563.00
F24 INDUCED DELUSIONAL DISORDER; FOLIE à DEUX; INDUCED PARANOID DISORDER; INDUCED PSYCHOTIC DISORDER 15,210.00
10,647.00
4,563.00
F25.0 SCHIZOAFFECTIVE DISORDER, MANIC TYPE; SCHIZOAFFECTIVE PSYCHOSIS, MANIC TYPE; SCHIZOPHRENIFORM PSYCHOSIS, MANIC TYPE 15,210.00
10,647.00
4,563.00
F25.1 SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TYPE; SCHIZOAFFECTIVE PSYCHOSIS, DEPRESSIVE TYPE; SCHIZOPHRENIFORM PSYCHOSIS, DEPRESSIVE TYPE 15,210.00
10,647.00
4,563.00
F25.2 SCHIZOAFFECTIVE DISORDER, MIXED TYPE; CYCLIC SCHIZOPHRENIA; MIXED SCHIZOPHRENIC AND AFFECTIVE PSYCHOSIS 15,210.00
10,647.00
4,563.00
F25.8 OTHER SCHIZOAFFECTIVE DISORDERS 15,210.00
10,647.00
4,563.00
F25.9 SCHIZOAFFECTIVE DISORDER, UNSPECIFIED; SCHIZOAFFECTIVE PSYCHOSIS NOS 15,210.00
10,647.00
4,563.00
F28 OTHER NONORGANIC PSYCHOTIC DISORDERS; CHRONIC HALLUCINATORY PSYCHOSIS 15,210.00
10,647.00
4,563.00
F29 UNSPECIFIED NONORGANIC PSYCHOSIS; PSYCHOSIS NOS 15,210.00
10,647.00
4,563.00
F30.0 HYPOMANIA 15,210.00
10,647.00
4,563.00
F30.1 MANIA WITHOUT PSYCHOTIC SYMPTOMS 15,210.00
10,647.00
4,563.00
F30.2 MANIA WITH PSYCHOTIC SYMPTOMS; MANIA WITH MOOD- CONGRUENT PSYCHOTIC SYMPTOMS; MANIA WITH MOOD- INCONGRUENT PSYCHOTIC SYMPTOMS; MANIC STUPOR 15,210.00
10,647.00
4,563.00
F30.9 MANIC EPISODE, UNSPECIFIED; MANIA NOS 15,210.00
10,647.00
4,563.00
F31.0 BIPOLAR AFFECTIVE DISORDER, CURRENT EPISODE HYPOMANIC 15,210.00
10,647.00
4,563.00
F31.1 BIPOLAR AFFECTIVE DISORDER, CURRENT EPISODE MANIC WITHOUT PSYCHOTIC SYMPTOMS 15,210.00
10,647.00
4,563.00
F31.2 BIPOLAR AFFECTIVE DISORDER, CURRENT EPISODE MANIC WITH PSYCHOTIC SYMPTOMS 15,210.00
10,647.00
4,563.00
F31.3 BIPOLAR AFFECTIVE DISORDER, CURRENT EPISODE MILD OR MODERATE DEPRESSION 15,210.00
10,647.00
4,563.00
F31.5 BIPOLAR AFFECTIVE DISORDER, CURRENT EPISODE SEVERE DEPRESSION WITH PSYCHOTIC SYMPTOMS 15,210.00
10,647.00
4,563.00
F31.6 BIPOLAR AFFECTIVE DISORDER, CURRENT EPISODE MIXED 15,210.00
10,647.00
4,563.00
F31.7 BIPOLAR AFFECTIVE DISORDER, CURRENTLY IN REMISSION 15,210.00
10,647.00
4,563.00
F31.8 OTHER BIPOLAR AFFECTIVE DISORDERS; BIPOLAR II DISORDER; RECURRENT MANIC EPISODES NOS 15,210.00
10,647.00
4,563.00
F31.9 BIPOLAR AFFECTIVE DISORDER, UNSPECIFIED 15,210.00
10,647.00
4,563.00
F32.0 MILD DEPRESSIVE EPISODE 15,210.00
10,647.00
4,563.00
F32.1 MODERATE DEPRESSIVE EPISODE 15,210.00
10,647.00
4,563.00
F32.2 SEVERE DEPRESSIVE EPISODE WITHOUT PSYCHOTIC SYMPTOMS; [AGITATED DEPRESSION, MAJOR DEPRESSION, VITAL DEPRESSION] SINGLE EPISODE WITHOUT PSYCHOTIC SYMPTOMS 15,210.00
10,647.00
4,563.00
F32.3 SEVERE DEPRESSIVE EPISODE WITH PSYCHOTIC SYMPTOMS; SINGLE EPISODES OF MAJOR DEPRESSION WITH PSYCHOTIC SYMPTOMS; SINGLE EPISODES OF PSYCHOGENIC DEPRESSIVE PSYCHOSIS; SINGLE EPISODES OF PSYCHOTIC DEPRESSION; SINGLE EPISODES OF REACTIVE DEPRESSIVE PSYCHOSIS 15,210.00
10,647.00
4,563.00
F32.8 OTHER DEPRESSIVE EPISODES; ATYPICAL DEPRESSION; SINGLE EPISODES OF "MASKED" DEPRESSION NOS 15,210.00
10,647.00
4,563.00
F32.9 DEPRESSIVE EPISODE, UNSPECIFIED; DEPRESSION NOS; DEPRESSIVE DISORDER NOS 15,210.00
10,647.00
4,563.00
F33.2 RECURRENT DEPRESSIVE DISORDER, CURRENT EPISODE SEVERE WITHOUT PSYCHOTIC SYMPTOMS; ENDOGENOUS DEPRESSION WITHOUT PSYCHOTIC SYMPTOMS; MAJOR DEPRESSION, RECURRENT WITHOUT PSYCHOTIC SYMPTOMS; MANIC- DEPRESSIVE PSYCHOSIS, DEPRESSED TYPE WITHOUT PSYCHOTIC SYMPTO 15,210.00
10,647.00
4,563.00
F33.3 RECURRENT DEPRESSIVE DISORDER, CURRENT EPISODE SEVERE WITH PSYCHOTIC SYMPTOMS INCLUDING ENDOGENOUS DEPRESSION WITH PSYCHOTIC SYMPTOMS; MANIC-DEPRESSIVE PSYCHOSIS, DEPRESSED TYPE WITH PSYCHOTIC SYMPTOMS; RECURRENT SEVERE EPISODES OF MAJOR DEPRESSION WITH 15,210.00
10,647.00
4,563.00
F33.8 OTHER RECURRENT DEPRESSIVE DISORDERS 15,210.00
10,647.00
4,563.00
F33.9 RECURRENT DEPRESSIVE DISORDER, UNSPECIFIED; MONOPOLAR DEPRESSION NOS 15,210.00
10,647.00
4,563.00
F34.0 CYCLOTHYMIA; AFFECTIVE PERSONALITY DISORDER; CYCLOID PERSONALITY; CYCLOTHYMIC PERSONALITY 15,210.00
10,647.00
4,563.00
F34.1 DYSTHYMIA; DEPRESSIVE NEUROSIS; DEPRESSIVE PERSONALITY DISORDER; NEUROTIC DEPRESSION; PERSISTENT ANXIETY DEPRESSION 15,210.00
10,647.00
4,563.00
F42.1 PREDOMINANTLY COMPULSIVE ACTS [OBSESSIONAL RITUALS] 15,210.00
10,647.00
4,563.00
F42.2 MIXED OBSESSIONAL THOUGHTS AND ACTS 15,210.00
10,647.00
4,563.00
F42.8 OTHER OBSESSIVE-COMPULSIVE DISORDERS 15,210.00
10,647.00
4,563.00
F42.9 OBSESSIVE-COMPULSIVE DISORDER, UNSPECIFIED 15,210.00
10,647.00
4,563.00
F43.0 ACUTE STRESS REACTION INCLUDING ACUTE CRISIS REACTION; ACUTE REACTION TO STRESS; COMBAT FATIGUE; CRISIS STATE; PSYCHIC SHOCK 15,210.00
10,647.00
4,563.00
F43.1 POST-TRAUMATIC STRESS DISORDER; TRAUMATIC NEUROSIS 15,210.00
10,647.00
4,563.00
Page 30 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate F43.2 ADJUSTMENT DISORDERS; CULTURE SHOCK; GRIEF REACTION; HOSPITALISM IN CHILDREN 15,210.00
10,647.00
4,563.00
F43.8 OTHER REACTIONS TO SEVERE STRESS 15,210.00
10,647.00
4,563.00
F44.0 DISSOCIATIVE AMNESIA 15,210.00
10,647.00
4,563.00
F44.4 DISSOCIATIVE MOTOR DISORDERS; PSYCHOGENIC APHONIA; PSYCHOGENIC DYSPHONIA 15,210.00
10,647.00
4,563.00
F44.8 OTHER DISSOCIATIVE [CONVERSION] DISORDERS; GANSER'S SYNDROME; MULTIPLE PERSONALITY; PSYCHOGENIC CONFUSION; PSYCHOGENIC TWILIGHT STATE 15,210.00
10,647.00
4,563.00
F44.9 DISSOCIATIVE [CONVERSION] DISORDER, UNSPECIFIED 15,210.00
10,647.00
4,563.00
F45.0 SOMATIZATION DISORDER; BRIQUET’S DISORDER; MULTIPLE PSYCHOSOMATIC DISORDER 15,210.00
10,647.00
4,563.00
F45.1 UNDIFFERENTIATED SOMATOFORM DISORDER; UNDIFFERENTIATED PSYCHOSOMATIC DISORDER 15,210.00
10,647.00
4,563.00
F45.2 HYPOCHONDRIACAL DISORDER; BODY DYSMORPHIC DISORDER; DYSMORPHOPHOBIA (NONDELUSIONAL); HYPOCHONDRIACAL NEUROSIS; HYPOCHONDRIASIS; NOSOPHOBIA 15,210.00
10,647.00
4,563.00
F45.3
SOMATOFORM AUTONOMIC DYSFUNCTION; CARDIAC NEUROSIS;
DA COSTA'S SYNDROME; GASTRIC NEUROSIS ;
NEUROCIRCULATORY ASTHENIA
PSYCHOGENIC FORMS OF AEROPHAGY; PSYCHOGENIC FORMS OF
COUGH, PSYCHOGENIC FORMS OF DIARRHEA; PSYCHOGENIC
FORMS OF DYSPEPSIA; PSYCHOGENIC
15,210.00
10,647.00
4,563.00
F45.4 PERSISTENT SOMATOFORM PAIN DISORDER; PSYCHALGIA; PSYCHOGENIC BACKACHE; PSYCHOGENIC HEADACHE; SOMATOFORM PAIN DISORDER 15,210.00
10,647.00
4,563.00
F45.8 OTHER SOMATOFORM DISORDERS; PSYCHOGENIC DYSMENORRHOEA; PSYCHOGENIC DYSPHAGIA, INCLUDING "GLOBUS HYSTERICUS"; PSYCHOGENIC PRURITUS; PSYCHOGENIC TORTICOLLIS; TEETH-GRINDING 15,210.00
10,647.00
4,563.00
F45.9 SOMATOFORM DISORDER, UNSPECIFIED; PSYCHOSOMATIC DISORDER NOS 15,210.00
10,647.00
4,563.00
F48.8 OTHER SPECIFIED NEUROTIC DISORDERS; DHAT SYNDROME; OCCUPATIONAL NEUROSIS, INCLUDING WRITER'S CRAMP; PSYCHASTHENIA; PSYCHASTHENIC NEUROSIS; PSYCHOGENIC SYNCOPE 15,210.00
10,647.00
4,563.00
F48.9 NEUROTIC DISORDER, UNSPECIFIED; NEUROSIS NOS 15,210.00
10,647.00
4,563.00
F50.2 BULIMIA NERVOSA; BULIMIA NOS; HYPEROREXIA NERVOSA 15,210.00
10,647.00
4,563.00
F53.0 MILD MENTAL AND BEHAVIOURAL DISORDERS ASSOCIATED WITH THE PUERPERIUM, NOT ELSEWHERE CLASSIFIED; DEPRESSION POSTNATAL NOS; DEPRESSION POSTPARTUM NOS 15,210.00
10,647.00
4,563.00
F53.1 SEVERE MENTAL AND BEHAVIOURAL DISORDERS ASSOCIATED WITH THE PUERPERIUM, NOT ELSEWHERE CLASSIFIED; PUERPERAL PSYCHOSIS NOS 15,210.00
10,647.00
4,563.00
F53.9 PUERPERAL MENTAL DISORDER, UNSPECIFIED 15,210.00
10,647.00
4,563.00
F55 ABUSE OF NON-DEPENDENCE-PRODUCING SUBSTANCES; ABUSE OF ANTACIDS; ABUSE OF HERBAL OR FOLK REMEDIES; ABUSE OF STEROIDS OR HORMONES; ABUSE OF VITAMINS; LAXATIVE HABIT 15,210.00
10,647.00
4,563.00
F59 UNSPECIFIED BEHAVIOURAL SYNDROMES ASSOCIATED WITH PHYSIOLOGICAL DISTURBANCES AND PHYSICAL FACTORS; PSYCHOGENIC PHYSIOLOGICAL DYSFUNCTION NOS 15,210.00
10,647.00
4,563.00
F70.0 MILD MENTAL RETARDATION; FEEBLE-MINDEDNESS; MILD MENTAL SUBNORMALITY WITH THE STATEMENT OF NO, OR MINIMAL, IMPAIRMENT OF BEHAVIOUR 15,210.00
10,647.00
4,563.00
F72.9 SEVERE MENTAL RETARDATION; SEVERE MENTAL SUBNORMALITY WITHOUT MENTION OF IMPAIRMENT OF BEHAVIOUR 15,210.00
10,647.00
4,563.00
F78.1 OTHER MENTAL RETARDATION WITH SIGNIFICANT IMPAIRMENT OF BEHAVIOUR REQUIRING ATTENTION OR TREATMENT 15,210.00
10,647.00
4,563.00
F78.8 OTHER MENTAL RETARDATION WITH OTHER IMPAIRMENTS OF BEHAVIOUR 15,210.00
10,647.00
4,563.00
F78.9 OTHER MENTAL RETARDATION WITHOUT MENTION OF IMPAIRMENT OF BEHAVIOUR 15,210.00
10,647.00
4,563.00
F79.8 UNSPECIFIED MENTAL RETARDATION; MENTAL DEFICIENCY NOS; MENTAL SUBNORMALITY NOS WITH OTHER IMPAIRMENTS OF BEHAVIOUR 15,210.00
10,647.00
4,563.00
F80.3 ACQUIRED APHASIA WITH EPILEPSY [LANDAU-KLEFFNER] 15,210.00
10,647.00
4,563.00
F82 SPECIFIC DEVELOPMENTAL DISORDER OF MOTOR FUNCTION; CLUMSY CHILD SYNDROME; DEVELOPMENTAL COORDINATION DISORDER; DEVELOPMENTAL DYSPRAXIA 15,210.00
10,647.00
4,563.00
F84.0 CHILDHOOD AUTISM; AUTISTIC DISORDER; INFANTILE AUTISM; INFANTILE PSYCHOSIS; KANNER'S SYNDROME 15,210.00
10,647.00
4,563.00
F84.2 RETT'S SYNDROME 15,210.00
10,647.00
4,563.00
F84.3 OTHER CHILDHOOD DISINTEGRATIVE DISORDER; DEMENTIA INFANTILIS; DISINTEGRATIVE PSYCHOSIS; HELLER'S SYNDROME; SYMBIOTIC PSYCHOSIS 15,210.00
10,647.00
4,563.00
F84.5 ASPERGER'S SYNDROME; AUTISTIC PSYCHOPATHY; SCHIZOID DISORDER OF CHILDHOOD 15,210.00
10,647.00
4,563.00
F84.9 PERVASIVE DEVELOPMENTAL DISORDER, UNSPECIFIED 15,210.00
10,647.00
4,563.00
F89 UNSPECIFIED DISORDER OF PSYCHOLOGICAL DEVELOPMENT; DEVELOPMENTAL DISORDER NOS 15,210.00
10,647.00
4,563.00
F90.8 OTHER HYPERKINETIC DISORDERS 15,210.00
10,647.00
4,563.00
F92.0 DEPRESSIVE CONDUCT DISORDER 15,210.00
10,647.00
4,563.00
Page 31 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate F98.1 NONORGANIC ENCOPRESIS; FUNCTIONAL ENCOPRESIS; INCONTINENCE OF FAECES OF NONORGANIC ORIGIN; PSYCHOGENIC ENCOPRESIS 15,210.00
10,647.00
4,563.00
F99 MENTAL DISORDER, NOT OTHERWISE SPECIFIED; MENTAL ILLNESS NOS 15,210.00
10,647.00
4,563.00
G00.0 HAEMOPHILUS MENINGITIS; MENINGITIS DUE TO HAEMOPHILUS INFLUENZAE 50,115.00
35,080.50
15,034.50
G00.1 PNEUMOCOCCAL MENINGITIS 50,115.00
35,080.50
15,034.50
G00.2 STREPTOCOCCAL MENINGITIS 50,115.00
35,080.50
15,034.50
G00.3 STAPHYLOCOCCAL MENINGITIS 50,115.00
35,080.50
15,034.50
G00.8 OTHER BACTERIAL MENINGITIS; MENINGITIS DUE TO ESCHERICHIA COLI; MENINGITIS DUE TO FRIEDLäNDER BACILLUS; MENINGITIS DUE TO KLEBSIELLA 50,115.00
35,080.50
15,034.50
G00.9 BACTERIAL MENINGITIS, UNSPECIFIED; MENINGITIS PURULENT NOS; MENINGITIS PYOGENIC NOS; MENINGITIS SUPPURATIVE NOS 50,115.00
35,080.50
15,034.50
G03.0 NONPYOGENIC MENINGITIS; NONBACTERIAL MENINGITIS 50,115.00
35,080.50
15,034.50
G03.1 CHRONIC MENINGITIS 50,115.00
35,080.50
15,034.50
G03.8 MENINGITIS DUE TO OTHER SPECIFIED CAUSES 50,115.00
35,080.50
15,034.50
G03.9 MENINGITIS, UNSPECIFIED; ARACHNOIDITIS (SPINAL) NOS 50,115.00
35,080.50
15,034.50
G04.0 ACUTE DISSEMINATED ENCEPHALITIS; POSTIMMUNIZATION [ENCEPHALITIS; POSTIMMUNIZATION ENCEPHALOMYELITIS 42,120.00
29,484.00
12,636.00
G04.1 TROPICAL SPASTIC PARAPLEGIA 42,120.00
29,484.00
12,636.00
G04.2 BACTERIAL MENINGOENCEPHALITIS AND MENINGOMYELITIS, NOT ELSEWHERE CLASSIFIED 42,120.00
29,484.00
12,636.00
G04.8 OTHER ENCEPHALITIS, MYELITIS AND ENCEPHALOMYELITIS; POSTINFECTIOUS ENCEPHALITIS AND ENCEPHALOMYELITIS NOS 42,120.00
29,484.00
12,636.00
G04.9 ENCEPHALITIS, MYELITIS AND ENCEPHALOMYELITIS, UNSPECIFIED; VENTRICULITIS (CEREBRAL) NOS 42,120.00
29,484.00
12,636.00
G05.8* ENCEPHALITIS, MYELITIS AND ENCEPHALOMYELITIS IN OTHER DISEASES CLASSIFIED ELSEWHERE 42,120.00
29,484.00
12,636.00
G06.0
INTRACRANIAL ABSCESS AND GRANULOMA; ABSCESS
(EMBOLIC)(OF) BRAIN [ANY PART]; ABSCESS (EMBOLIC)(OF)
CEREBELLAR; ABSCESS (EMBOLIC)(OF) CEREBRAL; ABSCESS
(EMBOLIC)(OF) OTOGENIC; IINTRACRANIAL ABSCESS OR
GRANULOMA, EPIDURAL; INTRACRANIAL ABSCESS OR GRANULOM
54,405.00
38,083.50
16,321.50
G06.1
INTRASPINAL ABSCESS AND GRANULOMA; ABSCESS (EMBOLIC) OF
SPINAL CORD [ANY PART]; INTRASPINAL ABSCESS OR
GRANULOMA EPIDURAL; INTRASPINAL ABSCESS OR GRANULOMA
EXTRADURAL; INTRASPINAL ABSCESS OR GRANULOMA
SUBDURAL
54,405.00
38,083.50
16,321.50
G06.2 ENCEPHALITIS, MYELITIS AND ENCEPHALOMYELITIS IN EXTRADURAL AND SUBDURAL ABSCESS, UNSPECIFIED 54,405.00
38,083.50
16,321.50
G07* INTRACRANIAL AND INTRASPINAL ABSCESS AND GRANULOMA IN DISEASES CLASSIFIED ELSEWHERE 42,120.00
29,484.00
12,636.00
G08 INTRACRANIAL AND INTRASPINAL PHLEBITIS AND THROMBOPHLEBITIS; SEPTIC [EMBOLISM, ENDOPHLEBITIS, PHLEBITIS, THROMBOPHLEBITIS, THROMBOSIS] OF INTRACRANIAL OR INTRASPINAL VENOUS SINUSES AND VEINS 42,120.00
29,484.00
12,636.00
G09 SEQUELAE OF INFLAMMATORY DISEASES OF CENTRAL NERVOUS SYSTEM 15,600.00
10,920.00
4,680.00
G10 HUNTINGTON'S DISEASE; HUNTINGTON'S CHOREA 20,280.00
14,196.00
6,084.00
G11.0 CONGENITAL NONPROGRESSIVE ATAXIA 20,280.00
14,196.00
6,084.00
G11.1 EARLY-ONSET CEREBELLAR ATAXIA INCLUDING EARLY-ONSET CEREBELLAR ATAXIA WITH ESSENTIAL TREMOR; EARLY-ONSET CEREBELLAR ATAXIA WITH MYOCLONUS [HUNT'S ATAXIA]; EARLY- ONSET CEREBELLAR ATAXIA WITH RETAINED TENDON REFLEXES; FRIEDREICH'S ATAXIA (AUTOSOMAL RECESSIV 20,280.00
14,196.00
6,084.00
G11.3 CEREBELLAR ATAXIA WITH DEFECTIVE DNA REPAIR; ATAXIA TELANGIECTASIA [LOUIS-BAR] 20,280.00
14,196.00
6,084.00
G11.9 HEREDITARY ATAXIA, UNSPECIFIED; HEREDITARY CEREBELLAR ATAXIA NOS; HEREDITARY CEREBELLAR DEGENERATION; HEREDITARY CEREBELLAR DISEASE; HEREDITARY CEREBELLAR SYNDROME 20,280.00
14,196.00
6,084.00
G12.0 INFANTILE SPINAL MUSCULAR ATROPHY, TYPE I [WERDNIG- HOFFMAN] 20,280.00
14,196.00
6,084.00
G12.1 OTHER INHERITED SPINAL MUSCULAR ATROPHY; PROGRESSIVE BULBAR PALSY OF CHILDHOOD [FAZIO-LONDE]; SPINAL MUSCULAR ATROPHY ADULT FORM SPINAL MUSCULAR ATROPHY CHILDHOOD FORM, TYPE II; SPINAL MUSCULAR ATROPHY DISTAL; SPINAL MUSCULAR ATROPHY JUVENILE FORM, TYPE 20,280.00
14,196.00
6,084.00
G12.2 MOTOR NEURON DISEASE; FAMILIAL MOTOR NEURON DISEASE; AMYOTROPHICLATERAL SCLEROSIS; PRIMARY LATERAL SCLEROSIS ; PROGRESSIVE BULBAR PALSY; PROGRESSIVE SPINAL MUSCULAR ATROPHY 20,280.00
14,196.00
6,084.00
G12.9 SPINAL MUSCULAR ATROPHY, UNSPECIFIED 20,280.00
14,196.00
6,084.00
G20 PARKINSON'S DISEASE; HEMIPARKINSONISM; PARALYSIS AGITANS; PARKINSONISM OR PARKINSON'S DISEASE NOS; IDIOPATHIC PARKINSONISM OR PARKINSON'S DISEASE; PRIMARY PARKINSONISM OR PARKINSON'S DISEASE 20,280.00
14,196.00
6,084.00
G21.0 MALIGNANT NEUROLEPTIC SYNDROME 16,185.00
11,329.50
4,855.50
G21.1 OTHER DRUG-INDUCED SECONDARY PARKINSONISM 16,185.00
11,329.50
4,855.50
G21.8 OTHER SECONDARY PARKINSONISM 16,185.00
11,329.50
4,855.50
Page 32 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate G21.9 SECONDARY PARKINSONISM, UNSPECIFIED 16,185.00
11,329.50
4,855.50
G23.0 HALLERVORDEN-SPATZ DISEASE; PIGMENTARY PALLIDAL DEGENERATION 16,185.00
11,329.50
4,855.50
G23.1 PROGRESSIVE SUPRANUCLEAR OPHTHALMOPLEGIA [STEELE- RICHARDSON-OLSZEWSKI] 16,185.00
11,329.50
4,855.50
G23.8 OTHER SPECIFIED DEGENERATIVE DISEASES OF BASAL GANGLIA; CALCIFICATION OF BASAL GANGLIA 16,185.00
11,329.50
4,855.50
G23.9 DEGENERATIVE DISEASE OF BASAL GANGLIA, UNSPECIFIED 16,185.00
11,329.50
4,855.50
G24.0 CARCINOMATOUS NEUROMYOPATHY IN DRUG-INDUCED DYSTONIA 16,185.00
11,329.50
4,855.50
G24.1 IDIOPATHIC FAMILIAL DYSTONIA; IDIOPATHIC DYSTONIA NOS 16,185.00
11,329.50
4,855.50
G24.3 SPASMODIC TORTICOLLIS 16,185.00
11,329.50
4,855.50
G24.4 IDIOPATHIC OROFACIAL DYSTONIA; OROFACIAL DYSKINESIA 16,185.00
11,329.50
4,855.50
G24.8 OTHER DYSTONIA 16,185.00
11,329.50
4,855.50
G24.9 DYSTONIA, UNSPECIFIED; DYSKINESIA NOS 16,185.00
11,329.50
4,855.50
G25.3 MYOCLONUS; DRUG-INDUCED MYOCLONUS 16,185.00
11,329.50
4,855.50
G25.5 OTHER CHOREA; CHOREA NOS 16,185.00
11,329.50
4,855.50
G25.8 OTHER SPECIFIED EXTRAPYRAMIDAL AND MOVEMENT DISORDERS; RESTLESS LEGS SYNDROME; STIFF-MAN SYNDROME 16,185.00
11,329.50
4,855.50
G25.9 EXTRAPYRAMIDAL AND MOVEMENT DISORDER, UNSPECIFIED 16,185.00
11,329.50
4,855.50
G30.0 ALZHEIMER'S DISEASE WITH EARLY ONSET 19,500.00
13,650.00
5,850.00
G30.1 ALZHEIMER'S DISEASE WITH LATE ONSET 19,500.00
13,650.00
5,850.00
G30.8 OTHER ALZHEIMER'S DISEASE 19,500.00
13,650.00
5,850.00
G30.9+F00.9* DEMENTIA IN ALZHEIMER'S DISEASE, UNSPECIFIED 19,500.00
13,650.00
5,850.00
G31.0 CIRCUMSCRIBED BRAIN ATROPHY; PICK'S DISEASE; PROGRESSIVE ISOLATED APHASIA 19,500.00
13,650.00
5,850.00
G31.1 SENILE DEGENERATION OF BRAIN, NOT ELSEWHERE CLASSIFIED 19,500.00
13,650.00
5,850.00
G31.2 DEGENERATION OF NERVOUS SYSTEM DUE TO ALCOHOL; ALCOHOLIC CEREBELLAR ATAXIA; ALCOHOLIC CEREBELLAR DEGENERATION; ALCOHOLIC CEREBRAL DEGENERATION; ALCOHOLIC ENCEPHALOPATHY; DYSFUNCTION OF AUTONOMIC NERVOUS SYSTEM DUE TO ALCOHOL 19,500.00
13,650.00
5,850.00
G31.8 OTHER SPECIFIED DEGENERATIVE DISEASES OF NERVOUS SYSTEM; GREY-MATTER DEGENERATION [ALPERS]; LEWY BODY (IES) DEMENTIA; LEWY BODY (IES) DISEASE; SUBACUTE NECROTIZING ENCEPHALOPATHY [LEIGH] 19,500.00
13,650.00
5,850.00
G32.8* OTHER SPECIFIED DEGENERATIVE DISORDERS OF NERVOUS SYSTEM IN DISEASES CLASSIFIED ELSEWHERE 19,500.00
13,650.00
5,850.00
G35
MULTIPLE SCLEROSIS; MULTIPLE SCLEROSIS NOS; MULTIPLE
SCLEROSIS OF BRAIN STEM; MULTIPLE SCLEROSIS OF CORD;
MULTIPLE SCLEROSIS, DISSEMINATED; MULTIPLE SCLEROSIS,
GENERALIZED
22,620.00
15,834.00
6,786.00
G36.0 NEUROMYELITIS OPTICA [DEVIC]; DEMYELINATION IN OPTIC NEURITIS 22,620.00
15,834.00
6,786.00
G36.1 ACUTE AND SUBACUTE HAEMORRHAGIC LEUKOENCEPHALITIS [HURST] 22,620.00
15,834.00
6,786.00
G36.8 OTHER SPECIFIED ACUTE DISSEMINATED DEMYELINATION 22,620.00
15,834.00
6,786.00
G36.9 ACUTE DISSEMINATED DEMYELINATION, UNSPECIFIED 22,620.00
15,834.00
6,786.00
G37.0 DIFFUSE SCLEROSIS; PERIAXIAL ENCEPHALITIS; SCHILDER'S DISEASE 22,620.00
15,834.00
6,786.00
G37.1 CENTRAL DEMYELINATION OF CORPUS CALLOSUM 22,620.00
15,834.00
6,786.00
G37.2 CENTRAL PONTINE MYELINOLYSIS 22,620.00
15,834.00
6,786.00
G37.3 ACUTE TRANSVERSE MYELITIS IN DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM; ACUTE TRANSVERSE MYELITIS NOS 22,620.00
15,834.00
6,786.00
G37.4 SUBACUTE NECROTIZING MYELITIS 22,620.00
15,834.00
6,786.00
G37.8 OTHER SPECIFIED DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM 22,620.00
15,834.00
6,786.00
G37.9 DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM, UNSPECIFIED 22,620.00
15,834.00
6,786.00
G40.0 LOCALIZATION-RELATED FOCAL IDIOPATHIC EPILEPSY AND EPILEPTIC SYNDROMES WITH SEIZURES OF LOCALIZED ONSET; LOCALIZATION-RELATED PARTIAL IDIOPATHIC EPILEPSY AND EPILEPTIC SYNDROMES WITH SEIZURES OF LOCALIZED ONSET; BENIGN CHILDHOOD EPILEPSY WITH CENTROTEMPOR 15,210.00
10,647.00
4,563.00
G40.1 LOCALIZATION-RELATED FOCAL SYMPTOMATIC EPILEPSY AND EPILEPTIC SYNDROMES WITH SIMPLE PARTIAL SEIZURES; LOCALIZATION-RELATED PARTIAL SYMPTOMATIC EPILEPSY AND EPILEPTIC SYNDROMES WITH SIMPLE PARTIAL SEIZURES; ATTACKS WITHOUT ALTERATION OF CONSCIOUSNESS ; SIM 15,210.00
10,647.00
4,563.00
G40.2
LOCALIZATION-RELATED FOCAL SYMPTOMATIC EPILEPSY AND
EPILEPTIC SYNDROMES WITH COMPLEX PARTIAL SEIZURES;
LOCALIZATION-RELATED PARTIAL SYMPTOMATIC EPILEPSY AND
EPILEPTIC SYNDROMES WITH COMPLEX PARTIAL SEIZURES;
ATTACKS WITH ALTERATION OF CONSCIOUSNESS, OFTE
15,210.00
10,647.00
4,563.00
Page 33 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate G40.3 GENERALIZED IDIOPATHIC EPILEPSY AND EPILEPTIC SYNDROMES; BENIGN MYOCLONIC EPILEPSY IN INFANCY; BENIGN FAMILIAL NEONATAL CONVULSIONS; CHILDHOOD ABSENCE EPILEPSY [PYKNOLEPSY]; EPILEPSY WITH GRAND MAL SEIZURES ON AWAKENING; JUVENILE ABSENCE EPILEPSY; JUVENI 15,210.00
10,647.00
4,563.00
G40.4 OTHER GENERALIZED EPILEPSY AND EPILEPTIC SYNDROMES; EPILEPSY WITH MYOCLONIC ABSENCES; EPILEPSY WITH MYOCLONIC-ASTATIC SEIZURES; INFANTILE SPASMS; LENNOX- GASTAUT SYNDROME; SALAAM ATTACKS; SYMPTOMATIC EARLY MYOCLONIC; ENCEPHALOPATHY; WEST'S SYNDROME 15,210.00
10,647.00
4,563.00
G40.5 SPECIAL EPILEPTIC SYNDROMES; EPILEPSIA PARTIALIS CONTINUA [KOZHEVNIKOF]; EPILEPTIC SEIZURES RELATED TO ALCOHOL; EPILEPTIC SEIZURES RELATED TO DRUGS; EPILEPTIC SEIZURES RELATED TO HORMONAL CHANGES; EPILEPTIC SEIZURES RELATED TO SLEEP DEPRIVATION; EPILEPTIC 15,210.00
10,647.00
4,563.00
G40.6 GRAND MAL SEIZURES, UNSPECIFIED (WITH OR WITHOUT PETIT MAL) 15,210.00
10,647.00
4,563.00
G40.7 PETIT MAL, UNSPECIFIED, WITHOUT GRAND MAL SEIZURES 15,210.00
10,647.00
4,563.00
G40.8 OTHER EPILEPSY; EPILEPSIES AND EPILEPTIC SYNDROMES UNDETERMINED AS TO WHETHER THEY ARE FOCAL OR GENERALIZED 15,210.00
10,647.00
4,563.00
G40.9 EPILEPSY, UNSPECIFIED; EPILEPTIC CONVULSIONS NOS; EPILEPTIC FITS NOS; EPILEPTIC SEIZURES NOS 15,210.00
10,647.00
4,563.00
G41.0 GRAND MAL STATUS EPILEPTICUS; TONIC-CLONIC STATUS EPILEPTICUS 30,420.00
21,294.00
9,126.00
G41.1 PETIT MAL STATUS EPILEPTICUS; EPILEPTIC ABSENCE STATUS 30,420.00
21,294.00
9,126.00
G41.2 COMPLEX PARTIAL STATUS EPILEPTICUS 30,420.00
21,294.00
9,126.00
G41.8 OTHER STATUS EPILEPTICUS 30,420.00
21,294.00
9,126.00
G41.9 STATUS EPILEPTICUS, UNSPECIFIED 30,420.00
21,294.00
9,126.00
G43.0 MIGRAINE WITHOUT AURA [COMMON MIGRAINE] 10,725.00
7,507.50
3,217.50
G43.1 MIGRAINE WITH AURA [CLASSICAL MIGRAINE]; MIGRAINE AURA WITHOUT HEADACHE; MIGRAINE, BASILAR; MIGRAINE EQUIVALENTS; FAMILIAL HEMIPLEGIC MIGRAINE; MIGRAINE WITH ACUTE-ONSET AURA; MIGRAINE WITH PROLONGED AURA; MIGRAINE WITH TYPICAL AURA 10,725.00
7,507.50
3,217.50
G43.2 STATUS MIGRAINOSUS 10,725.00
7,507.50
3,217.50
G43.3 COMPLICATED MIGRAINE 10,725.00
7,507.50
3,217.50
G43.8 OTHER MIGRAINE; OPHTHALMOPLEGIC MIGRAINE; RETINAL MIGRAINE 10,725.00
7,507.50
3,217.50
G43.9 MIGRAINE, UNSPECIFIED 10,725.00
7,507.50
3,217.50
G44.0 CLUSTER HEADACHE SYNDROME; CHRONIC PAROXYSMAL HEMICRANIA; CHRONIC CLUSTER HEADACHE; EPISODIC CLUSTER HEADACHE 10,725.00
7,507.50
3,217.50
G44.1 VASCULAR HEADACHE, NOT ELSEWHERE CLASSIFIED; VASCULAR HEADACHE NOS 10,725.00
7,507.50
3,217.50
G44.2 TENSION-TYPE HEADACHE; CHRONIC TENSION-TYPE HEADACHE; EPISODIC TENSION HEADACHE; TENSION HEADACHE NOS 10,725.00
7,507.50
3,217.50
G44.3 CHRONIC POST-TRAUMATIC HEADACHE 10,725.00
7,507.50
3,217.50
G44.4 DRUG-INDUCED HEADACHE, NOT ELSEWHERE CLASSIFIED 10,725.00
7,507.50
3,217.50
G44.8 OTHER SPECIFIED HEADACHE SYNDROMES 10,725.00
7,507.50
3,217.50
G45.0 VERTEBRO-BASILAR ARTERY SYNDROME 14,235.00
9,964.50
4,270.50
G45.1 HEMISPHERIC CAROTID ARTERY SYNDROME 14,235.00
9,964.50
4,270.50
G45.2 MULTIPLE AND BILATERAL PRECEREBRAL ARTERY SYNDROMES 14,235.00
9,964.50
4,270.50
G45.3 AMAUROSIS FUGAX 14,235.00
9,964.50
4,270.50
G45.4 TRANSIENT GLOBAL AMNESIA 14,235.00
9,964.50
4,270.50
G45.8 OTHER TRANSIENT CEREBRAL ISCHAEMIC ATTACKS AND RELATED SYNDROMES 14,235.00
9,964.50
4,270.50
G45.9 TRANSIENT CEREBRAL ISCHAEMIC ATTACK, UNSPECIFIED; SPASM OF CEREBRAL ARTERY; TRANSIENT CEREBRAL ISCHAEMIA NOS 14,235.00
9,964.50
4,270.50
G47.3 SLEEP APNOEA; SLEEP APNOEA, CENTRAL; SLEEP APNOEA, OBSTRUCTIVE 21,060.00
14,742.00
6,318.00
G50.0 TRIGEMINAL NEURALGIA; SYNDROME OF PAROXYSMAL FACIAL PAIN; TIC DOULOUREUX 14,430.00
10,101.00
4,329.00
G50.8 OTHER DISORDERS OF TRIGEMINAL NERVE 14,430.00
10,101.00
4,329.00
G51.0 BELL'S PALSY; FACIAL PALSY 14,430.00
10,101.00
4,329.00
G51.1 GENICULATE GANGLIONITIS 14,430.00
10,101.00
4,329.00
G51.3 CLONIC HEMIFACIAL SPASM 14,430.00
10,101.00
4,329.00
G51.4 FACIAL MYOKYMIA 14,430.00
10,101.00
4,329.00
G51.8 OTHER DISORDERS OF FACIAL NERVE 14,430.00
10,101.00
4,329.00
G51.9 DISORDER OF FACIAL NERVE, UNSPECIFIED 14,430.00
10,101.00
4,329.00
G52.0 DISORDERS OF OLFACTORY NERVE; DISORDER OF 1ST CRANIAL NERVE 14,430.00
10,101.00
4,329.00
G52.1 DISORDERS OF GLOSSOPHARYNGEAL NERVE; DISORDER OF 9TH CRANIAL NERVE; GLOSSOPHARYNGEAL NEURALGIA 14,430.00
10,101.00
4,329.00
G52.2 DISORDERS OF VAGUS NERVE; DISORDER OF PNEUMOGASTRIC [10TH] NERVE 14,430.00
10,101.00
4,329.00
G52.7 DISORDERS OF MULTIPLE CRANIAL NERVES; POLYNEURITIS CRANIALIS 14,430.00
10,101.00
4,329.00
G52.8 DISORDERS OF OTHER SPECIFIED CRANIAL NERVES 14,430.00
10,101.00
4,329.00
G54.0 BRACHIAL PLEXUS DISORDERS; THORACIC OUTLET SYNDROME 15,405.00
10,783.50
4,621.50
Page 34 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate G54.1 LUMBOSACRAL PLEXUS DISORDERS 15,405.00
10,783.50
4,621.50
G54.2 CERVICAL ROOT DISORDERS, NOT ELSEWHERE CLASSIFIED 15,405.00
10,783.50
4,621.50
G54.3 THORACIC ROOT DISORDERS, NOT ELSEWHERE CLASSIFIED 15,405.00
10,783.50
4,621.50
G54.4 LUMBOSACRAL ROOT DISORDERS, NOT ELSEWHERE CLASSIFIED 15,405.00
10,783.50
4,621.50
G54.5 NEURALGIC AMYOTROPHY; PARSONAGE-ALDREN-TURNER SYNDROME; SHOULDER-GIRDLE NEURITIS 15,405.00
10,783.50
4,621.50
G54.8 OTHER NERVE ROOT AND PLEXUS DISORDERS 15,405.00
10,783.50
4,621.50
G54.9 NERVE ROOT AND PLEXUS DISORDER, UNSPECIFIED 15,405.00
10,783.50
4,621.50
G55.8* NERVE ROOT AND PLEXUS COMPRESSIONS IN OTHER DISEASES CLASSIFIED ELSEWHERE 15,405.00
10,783.50
4,621.50
G60.0 HEREDITARY MOTOR AND SENSORY NEUROPATHY; DISEASE CHARCOT-MARIE-TOOTH; DISEASE DéJERINE-SOTTAS; HEREDITARY MOTOR AND SENSORY NEUROPATHY, TYPES I-IV; HYPERTROPHIC NEUROPATHY OF INFANCY; PERONEAL MUSCULAR ATROPHY AXONAL TYPE; PERONEAL MUSCULAR ATROPHY HYPERT 20,670.00
14,469.00
6,201.00
G60.1 REFSUM'S DISEASE 20,670.00
14,469.00
6,201.00
G60.2 NEUROPATHY IN ASSOCIATION WITH HEREDITARY ATAXIA 20,670.00
14,469.00
6,201.00
G60.3 IDIOPATHIC PROGRESSIVE NEUROPATHY 20,670.00
14,469.00
6,201.00
G60.8 OTHER HEREDITARY AND IDIOPATHIC NEUROPATHIES; MORVAN'S DISEASE; NELATON'S SYNDROME; SENSORY NEUROPATHY DOMINANTLY INHERITED; SENSORY NEUROPATHY RECESSIVELY INHERITED 20,670.00
14,469.00
6,201.00
G60.9 HEREDITARY AND IDIOPATHIC NEUROPATHY, UNSPECIFIED 20,670.00
14,469.00
6,201.00
G61.0 GUILLAIN-BARRé SYNDROME; ACUTE POST- INFECTIVE POLYNEURITIS; ACUTE INFECTIVE POLYNEURITIS 20,670.00
14,469.00
6,201.00
G61.8 OTHER INFLAMMATORY POLYNEUROPATHIES 20,670.00
14,469.00
6,201.00
G61.9 INFLAMMATORY POLYNEUROPATHY, UNSPECIFIED 20,670.00
14,469.00
6,201.00
G62.0 DRUG-INDUCED POLYNEUROPATHY 20,670.00
14,469.00
6,201.00
G62.1 ALCOHOLIC POLYNEUROPATHY 20,670.00
14,469.00
6,201.00
G62.2 POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS 20,670.00
14,469.00
6,201.00
G62.8 OTHER SPECIFIED POLYNEUROPATHIES; RADIATION-INDUCED POLYNEUROPATHY 20,670.00
14,469.00
6,201.00
G62.9 POLYNEUROPATHY, UNSPECIFIED; NEUROPATHY NOS 20,670.00
14,469.00
6,201.00
G63.8* POLYNEUROPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE 20,670.00
14,469.00
6,201.00
G64 OTHER DISORDERS OF PERIPHERAL NERVOUS SYSTEM; DISORDER OF PERIPHERAL NERVOUS SYSTEM NOS 20,670.00
14,469.00
6,201.00
G70.0 MYASTHENIA GRAVIS 15,405.00
10,783.50
4,621.50
G70.2 CONGENITAL AND DEVELOPMENTAL MYASTHENIA 15,405.00
10,783.50
4,621.50
G70.8 OTHER SPECIFIED MYONEURAL DISORDERS 15,405.00
10,783.50
4,621.50
G70.9 MYONEURAL DISORDER, UNSPECIFIED 15,405.00
10,783.50
4,621.50
G71.0 MUSCULAR DYSTROPHY; MUSCULAR DYSTROPHY AUTOSOMAL RECESSIVE, CHILDHOOD TYPE, RESEMBLING DUCHENNE OR BECKER; MUSCULAR DYSTROPHY BENIGN [BECKER]; MUSCULAR DYSTROPHY BENIGN; CAPULOPERONEAL WITH EARLY CONTRACTURES [EMERY-DREIFUSS]; MUSCULAR DYSTROPHY DISTAL; 15,405.00
10,783.50
4,621.50
G71.1 MYOTONIC DISORDERS; DYSTROPHIA MYOTONICA [STEINERT]; MYOTONIA, CHONDRODYSTROPHIC; MYOTONIA, DRUG-INDUCED; MYOTONIA, SYMPTOMATIC; MYOTONIA, CONGENITA NOS; MYOTONIA, CONGENITA DOMINANT [THOMSEN]; MYOTONIA, CONGENITAL RECESSIVE [BECKER]; NEUROMYOTONIA [ISAAC 15,405.00
10,783.50
4,621.50
G71.2 CONGENITAL MYOPATHIES; CONGENITAL MUSCULAR DYSTROPHY NOS; CONGENITAL MUSCULAR DYSTROPHY WITH SPECIFIC MORPHOLOGICAL ABNORMALITIES OF THE MUSCLE FIBRE; CENTRAL COREDISEASE ; MINICORE DISEASE ; MULTICOREDISEASE ; FIBRE-TYPE DISPROPORTION; MYOPATHY MYOTUBULA 15,405.00
10,783.50
4,621.50
G71.9 PRIMARY DISORDER OF MUSCLE, UNSPECIFIED; HEREDITARY MYOPATHY NOS 15,405.00
10,783.50
4,621.50
G72.0 DRUG-INDUCED MYOPATHY 15,405.00
10,783.50
4,621.50
G72.1 ALCOHOLIC MYOPATHY 15,405.00
10,783.50
4,621.50
G72.2 MYOPATHY DUE TO OTHER TOXIC AGENTS 15,405.00
10,783.50
4,621.50
G72.3
PERIODIC PARALYSIS; PERIODIC PARALYSIS (FAMILIAL)
HYPERKALAEMIC; PERIODIC PARALYSIS (FAMILIAL)
HYPOKALAEMIC; PERIODIC PARALYSIS (FAMILIAL) MYOTONIC;
PERIODIC PARALYSIS (FAMILIAL) NORMOKALAEMIC
15,405.00
10,783.50
4,621.50
G72.4 INFLAMMATORY MYOPATHY, NOT ELSEWHERE CLASSIFIED 15,405.00
10,783.50
4,621.50
G72.8 OTHER SPECIFIED MYOPATHIES 15,405.00
10,783.50
4,621.50
G72.9 MYOPATHY, UNSPECIFIED 15,405.00
10,783.50
4,621.50
G80.0 SPASTIC CEREBRAL PALSY; CONGENITAL SPASTIC PARALYSIS (CEREBRAL); SPASTIC TETRAPLEGIC CEREBRAL PALSY 18,525.00
12,967.50
5,557.50
G80.1 SPASTIC DIPLEGIA; SPASTIC CEREBRAL PALSY NOS 18,525.00
12,967.50
5,557.50
G80.2 INFANTILE HEMIPLEGIA 18,525.00
12,967.50
5,557.50
G80.3 DYSKINETIC CEREBRAL PALSY; ATHETOID CEREBRAL PALSY; DYSTONIC CEREBRAL PALSY 18,525.00
12,967.50
5,557.50
G80.4 ATAXIC CEREBRAL PALSY 18,525.00
12,967.50
5,557.50
G80.8 OTHER INFANTILE CEREBRAL PALSY; MIXED CEREBRAL PALSY SYNDROMES 18,525.00
12,967.50
5,557.50
G80.9 INFANTILE CEREBRAL PALSY, UNSPECIFIED; CEREBRAL PALSY NOS 18,525.00
12,967.50
5,557.50
Page 35 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate G83.4 CAUDA EQUINA SYNDROME; NEUROGENIC BLADDER DUE TO CAUDA EQUINA SYNDROME EXCLUDES: CORD BLADDER NOS (G95.8) 17,160.00
12,012.00
5,148.00
G90.0 IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY; CAROTID SINUS SYNCOPE 30,810.00
21,567.00
9,243.00
G90.1 FAMILIAL DYSAUTONOMIA [RILEY-DAY] 30,810.00
21,567.00
9,243.00
G90.2 HORNER'S SYNDROME; BERNARD(-HORNER) SYNDROME 30,810.00
21,567.00
9,243.00
G90.4 AUTONOMIC DYSREFLEXIA 30,810.00
21,567.00
9,243.00
G90.9 DISORDER OF AUTONOMIC NERVOUS SYSTEM, UNSPECIFIED; ACQUIRED HYDROCEPHALUS 30,810.00
21,567.00
9,243.00
G91.0 COMMUNICATING HYDROCEPHALUS 33,735.00
23,614.50
10,120.50
G91.1 OBSTRUCTIVE HYDROCEPHALUS 33,735.00
23,614.50
10,120.50
G91.2 NORMAL-PRESSURE HYDROCEPHALUS 33,735.00
23,614.50
10,120.50
G91.3 POST-TRAUMATIC HYDROCEPHALUS, UNSPECIFIED 33,735.00
23,614.50
10,120.50
G91.8 OTHER HYDROCEPHALUS 33,735.00
23,614.50
10,120.50
G91.9 HYDROCEPHALUS, UNSPECIFIED 33,735.00
23,614.50
10,120.50
G92 TOXIC ENCEPHALOPATHY 43,290.00
30,303.00
12,987.00
G93.0 CEREBRAL CYSTS; ARACHNOID CYST; PORENCEPHALIC CYST, ACQUIRED 30,810.00
21,567.00
9,243.00
G93.1 ANOXIC BRAIN DAMAGE, NOT ELSEWHERE CLASSIFIED 43,290.00
30,303.00
12,987.00
G93.2 BENIGN INTRACRANIAL HYPERTENSION 30,810.00
21,567.00
9,243.00
G93.3 POSTVIRAL FATIGUE SYNDROME; BENIGN MYALGIC ENCEPHALOMYELITIS 30,810.00
21,567.00
9,243.00
G93.4 ENCEPHALOPATHY, UNSPECIFIED 30,810.00
21,567.00
9,243.00
G93.5 COMPRESSION OF BRAIN; [COMPRESSION, HERNIATION] OF BRAIN (STEM) 43,680.00
30,576.00
13,104.00
G93.7 REYE'S SYNDROME 30,810.00
21,567.00
9,243.00
G93.8 OTHER SPECIFIED DISORDERS OF BRAIN 30,810.00
21,567.00
9,243.00
G93.9 DISORDER OF BRAIN, UNSPECIFIED 30,810.00
21,567.00
9,243.00
G94.8* OTHER SPECIFIED DISORDERS OF BRAIN IN DISEASES CLASSIFIED ELSEWHERE 30,810.00
21,567.00
9,243.00
G95.0 SYRINGOMYELIA AND SYRINGOBULBIA 30,810.00
21,567.00
9,243.00
G95.1 VASCULAR MYELOPATHIES; ACUTE INFARCTION OF SPINAL CORD (EMBOLIC)(NONEMBOLIC); ARTERIAL THROMBOSIS OF SPINAL CORD; HAEMATOMYELIA; NONPYOGENIC INTRASPINAL PHLEBITIS AND THROMBOPHLEBITIS; OEDEMA OF SPINAL CORD; SUBACUTE NECROTIC MYELOPATHY 30,810.00
21,567.00
9,243.00
G95.2 CORD COMPRESSION, UNSPECIFIED 30,810.00
21,567.00
9,243.00
G95.8 OTHER SPECIFIED DISEASES OF SPINAL CORD; CORD BLADDER NOS; ELOPATHY DRUG-INDUCED; MYELOPATHY RADIATION- INDUCED 30,810.00
21,567.00
9,243.00
G95.9 DISEASE OF SPINAL CORD, UNSPECIFIED; MYELOPATHY NOS 30,810.00
21,567.00
9,243.00
G96.0 CEREBROSPINAL FLUID LEAK 30,810.00
21,567.00
9,243.00
G96.1 DISORDERS OF MENINGES, NOT ELSEWHERE CLASSIFIED; CEREBRAL MENINGEAL ADHESIONS; SPINAL MENINGEAL ADHESIONS 30,810.00
21,567.00
9,243.00
G96.8 OTHER SPECIFIED DISORDERS OF CENTRAL NERVOUS SYSTEM 30,810.00
21,567.00
9,243.00
G96.9 DISORDER OF CENTRAL NERVOUS SYSTEM, UNSPECIFIED 30,810.00
21,567.00
9,243.00
G97.1 OTHER REACTION TO SPINAL AND LUMBAR PUNCTURE 20,085.00
14,059.50
6,025.50
G97.8 OTHER POSTPROCEDURAL DISORDERS OF NERVOUS SYSTEM 20,085.00
14,059.50
6,025.50
G98 OTHER DISORDERS OF NERVOUS SYSTEM, NOT ELSEWHERE CLASSIFIED; NERVOUS SYSTEM DISORDER NOS 30,810.00
21,567.00
9,243.00
H05.0 ACUTE INFLAMMATION OF ORBIT; ABSCESS OF ORBIT;CELLULITIS OF ORBIT; OSTEOMYELITIS OF ORBIT; PERIOSTITIS OF ORBIT, TENONITIS OF ORBIT 18,525.00
12,967.50
5,557.50
H05.2 EXOPHTHALMIC CONDITIONS; DISPLACEMENT OF GLOBE (LATERAL) NOS; HAEMORRHAGE OF ORBIT; OEDEMA OF ORBIT 18,525.00
12,967.50
5,557.50
H30.1 DISSEMINATED CHORIORETINAL INFLAMMATION; DISSEMINATED CHORIORETINITIS; DISSEMINATED CHOROIDITIS; DISSEMINATED RETINITIS; DISSEMINATED RETINOCHOROIDITIS 8,970.00
6,279.00
2,691.00
H30.8 OTHER CHORIORETINAL INFLAMMATIONS; HARADA'S DISEASE 8,970.00
6,279.00
2,691.00
H31.3 CHOROIDAL HAEMORRHAGE AND RUPTURE; CHOROIDAL HAEMORRHAGE NOS; CHOROIDAL HAEMORRHAGE EXPULSIVE 8,970.00
6,279.00
2,691.00
H34.1 CENTRAL RETINAL ARTERY OCCLUSION 15,015.00
10,510.50
4,504.50
H34.2 OTHER RETINAL ARTERY OCCLUSIONS; HOLLENHORST'S PLAQUE; RETINAL ARTERY OCCLUSION; RETINAL ARTERY BRANCH OCCLUSION ; RETINAL ARTERY PARTIAL OCCLUSION; RETINAL MICROEMBOLISM 15,015.00
10,510.50
4,504.50
H34.8 OTHER RETINAL VASCULAR OCCLUSIONS; RETINAL CENTRAL VEIN OCCLUSION ; RETINAL VEIN OCCLUSION INCIPIENT; RETINAL VEIN OCCLUSION PARTIAL; RETINAL VEIN OCCLUSION TRIBUTARY 15,015.00
10,510.50
4,504.50
H34.9 RETINAL VASCULAR OCCLUSION, UNSPECIFIED 15,015.00
10,510.50
4,504.50
H40.0 GLAUCOMA SUSPECT; OCULAR HYPERTENSION 12,675.00
8,872.50
3,802.50
H40.1 PRIMARY OPEN-ANGLE GLAUCOMA; PRIMARY CAPSULAR WITH PSEUDOEXFOLIATION OF LENS GLAUCOMA; RESIDUAL STAGE CAPSULAR WITH PSEUDOEXFOLIATION OF LENS; PRIMARY CHRONIC SIMPLE GLAUCOMA; RESIDUAL STAGE CHRONIC SIMPLE GLAUCOMA; PRIMARY LOW-TENSION GLAUCOMA; RESIDUAL 12,675.00
8,872.50
3,802.50
Page 36 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate H40.2 PRIMARY ANGLE-CLOSURE GLAUCOMA; PRIMARY ACUTE ANGLE- CLOSURE GLAUCOMA ; ACUTE RESIDUAL STAGE ANGLE-CLOSURE GLAUCOMA ; PRIMARY CHRONIC ANGLE-CLOSURE GLAUCOMA ; RESIDUAL STAGE CHRONIC ANGLE-CLOSURE GLAUCOMA; PRIMARY INTERMITTENT ANGLE-CLOURE GLAUCOMA; RESIDU 12,675.00
8,872.50
3,802.50
H40.3 GLAUCOMA SECONDARY TO EYE TRAUMA 12,675.00
8,872.50
3,802.50
H40.4 GLAUCOMA SECONDARY TO EYE INFLAMMATION 12,675.00
8,872.50
3,802.50
H40.5 GLAUCOMA SECONDARY TO OTHER EYE DISORDERS 12,675.00
8,872.50
3,802.50
H40.8 OTHER GLAUCOMA 12,675.00
8,872.50
3,802.50
H40.9 GLAUCOMA, UNSPECIFIED 12,675.00
8,872.50
3,802.50
H43.0 VITREOUS PROLAPSE 20,280.00
14,196.00
6,084.00
H43.1 VITREOUS HAEMORRHAGE 20,280.00
14,196.00
6,084.00
H44.0 PURULENT ENDOPHTHALMITIS; PANOPHTHALMITIS; VITREOUS ABSCESS 20,280.00
14,196.00
6,084.00
H44.1 OTHER ENDOPHTHALMITIS; PARASITIC ENDOPHTHALMITIS NOS; SYMPATHETIC UVEITIS 20,280.00
14,196.00
6,084.00
H44.5 DEGENERATED CONDITIONS OF GLOBE; ABSOLUTE GLAUCOMA; ATROPHY OF GLOBE; PHTHISIS BULBI 20,280.00
14,196.00
6,084.00
H46 OPTIC NEURITIS; OPTIC NEUROPATHY, EXCEPT ISCHAEMIC; OPTIC PAPILLITIS; RETROBULBAR NEURITIS NOS 14,430.00
10,101.00
4,329.00
H47.0 DISORDERS OF OPTIC NERVE, NOT ELSEWHERE CLASSIFIED; COMPRESSION OF OPTIC NERVE; HAEMORRHAGE IN OPTIC NERVE SHEATH; ISCHAEMIC OPTIC NEUROPATHY 14,430.00
10,101.00
4,329.00
H59.0 VITREOUS SYNDROME FOLLOWING CATARACT SURGERY 20,085.00
14,059.50
6,025.50
H59.8 OTHER POSTPROCEDURAL DISORDERS OF EYE AND ADNEXA; CHORIORETINAL SCARS AFTER SURGERY FOR DETACHMENT 20,085.00
14,059.50
6,025.50
H59.9 POSTPROCEDURAL DISORDER OF EYE AND ADNEXA, UNSPECIFIED 20,085.00
14,059.50
6,025.50
H60.1 CELLULITIS OF EXTERNAL EAR; CELLULITIS OF AURICLE; CELLULITIS OF EXTERNAL AUDITORY CANAL 17,550.00
12,285.00
5,265.00
H60.2 MALIGNANT OTITIS EXTERNA 17,550.00
12,285.00
5,265.00
H60.3 OTHER INFECTIVE OTITIS EXTERNA; DIFFUSE OTITIS EXTERNA ; HAEMORRHAGIC OTITIS EXTERNA ; SWIMMER'S EAR 17,550.00
12,285.00
5,265.00
H60.4 CHOLESTEATOMA OF EXTERNAL EAR; KERATOSIS OBTURANS OF EXTERNAL EAR (CANAL) 17,550.00
12,285.00
5,265.00
H65.0 ACUTE SEROUS OTITIS MEDIA; ACUTE AND SUBACUTE SECRETORY OTITIS MEDIA 15,210.00
10,647.00
4,563.00
H65.1 OTHER ACUTE NONSUPPURATIVE OTITIS MEDIA; ACUTE OTITIS MEDIA; S UBACUTE OTITIS MEDIA; ACUTE MUCOID ALLERGIC OTITIS MEDIA; SUBACUTE MUCOID ALLERGIC OTITIS MEDIA; ACUTE ALLERGIC SANGUINOUS OTITIS MEDIA; SUBACUTE SANGUINOUS ALLERGIC OTITIS MEDIA; ACUTE A 15,210.00
10,647.00
4,563.00
H65.2 CHRONIC SEROUS OTITIS MEDIA; CHRONIC TUBOTYMPANAL CATARRH 15,210.00
10,647.00
4,563.00
H65.3 CHRONIC MUCOID OTITIS MEDIA; GLUE EAR; OTITIS MEDIA, CHRONIC MUCINOUS; OTITIS MEDIA, CHRONIC SECRETORY; OTITIS MEDIA, CHRONIC TRANSUDATIVE 15,210.00
10,647.00
4,563.00
H65.4 OTHER CHRONIC NONSUPPURATIVE OTITIS MEDIA; OTITIS MEDIA, CHRONIC ALLERGIC; OTITIS MEDIA, CHRONIC EXUDATIVE; OTITIS MEDIA, CHRONIC NONSUPPURATIVE NOS; OTITIS MEDIA, CHRONIC SEROMUCINOUS; OTITIS MEDIA, CHRONIC WITH EFFUSION (NONPURULENT) 15,210.00
10,647.00
4,563.00
H65.9 NONSUPPURATIVE OTITIS MEDIA, UNSPECIFIED; ALLERGIC OTITIS MEDIA ; CATARRHAL OTITIS MEDIA; EXUDATIVE OTITIS MEDIA ; MUCOID OTITIS MEDIA ; SECRETORY OTITIS MEDIA ; SEROMUCINOUS OTITIS MEDIA; SEROUS OTITIS MEDIA; TRANSUDATIVE OTITIS MEDIA; OTITIS MEDIA WITH 15,210.00
10,647.00
4,563.00
H66.0 ACUTE SUPPURATIVE OTITIS MEDIA 15,210.00
10,647.00
4,563.00
H66.1 CHRONIC TUBOTYMPANIC SUPPURATIVE OTITIS MEDIA; BENIGN CHRONIC SUPPURATIVE OTITIS MEDIA; CHRONIC TUBOTYMPANIC DISEASE 15,210.00
10,647.00
4,563.00
H66.2 CHRONIC ATTICOANTRAL SUPPURATIVE OTITIS MEDIA; CHRONIC ATTICOANTRAL DISEASE 15,210.00
10,647.00
4,563.00
H66.3 OTHER CHRONIC SUPPURATIVE OTITIS MEDIA; CHRONIC SUPPURATIVE OTITIS MEDIA NOS 15,210.00
10,647.00
4,563.00
H66.4 SUPPURATIVE OTITIS MEDIA, UNSPECIFIED; PURULENT OTITIS MEDIA NOS 15,210.00
10,647.00
4,563.00
H66.9 OTITIS MEDIA, UNSPECIFIED; OTITIS MEDIA NOS; ACUTE OTITIS MEDIA NOS; CHRONIC OTITIS MEDIA NOS 15,210.00
10,647.00
4,563.00
H68.1 OBSTRUCTION OF EUSTACHIAN TUBE; COMPRESSION OF EUSTACHIAN TUBE; STENOSIS OF EUSTACHIAN TUBE; STRICTURE OF EUSTACHIAN TUBE 20,280.00
14,196.00
6,084.00
H69.9 EUSTACHIAN TUBE DISORDER, UNSPECIFIED 20,280.00
14,196.00
6,084.00
H70.0 ACUTE MASTOIDITIS; ABSCESS OF MASTOID; EMPYEMA OF MASTOID 20,280.00
14,196.00
6,084.00
H70.1 CHRONIC MASTOIDITIS; CARIES OF MASTOID; FISTULA OF MASTOID 20,280.00
14,196.00
6,084.00
H70.2 PETROSITIS; ACUTE INFLAMMATION OF PETROUS BONE; CHRONIC INFLAMMATION OF PETROUS BONE 20,280.00
14,196.00
6,084.00
H70.8 OTHER MASTOIDITIS AND RELATED CONDITIONS 20,280.00
14,196.00
6,084.00
H70.9 MASTOIDITIS, UNSPECIFIED 20,280.00
14,196.00
6,084.00
Page 37 of 105 of Annex A
Case Rate
Health Facility Fee
Professional Fee
ICD Code
Description
First Case Rate
H71
CHOLESTEATOMA OF MIDDLE EAR; CHOLESTEATOMA TYMPANI;
PERFORATION OF TYMPANIC MEMBRANE; PERSISTENT POST-
TRAUMATIC PERFORATION OF EAR DRUM; POSTINFLAMMATORY
PERFORATION OF EAR DRUM
20,280.00
14,196.00
6,084.00
H73.0 ACUTE MYRINGITIS; ACUTE TYMPANITIS; BULLOUS MYRINGITIS 20,280.00
14,196.00
6,084.00
H73.1 CHRONIC MYRINGITIS; CHRONIC TYMPANITIS 20,280.00
14,196.00
6,084.00
H73.8 OTHER SPECIFIED DISORDERS OF TYMPANIC MEMBRANE 20,280.00
14,196.00
6,084.00
H73.9 DISORDER OF TYMPANIC MEMBRANE, UNSPECIFIED 20,280.00
14,196.00
6,084.00
H74.8 OTHER SPECIFIED DISORDERS OF MIDDLE EAR AND MASTOID 20,280.00
14,196.00
6,084.00
H74.9 DISORDER OF MIDDLE EAR AND MASTOID, UNSPECIFIED 20,280.00
14,196.00
6,084.00
H81.0 MéNIèRE'S DISEASE; LABYRINTHINE HYDROPS; MéNIèRE'S SYNDROME OR VERTIGO 11,115.00
7,780.50
3,334.50
H81.1 BENIGN PAROXYSMAL VERTIGO 11,115.00
7,780.50
3,334.50
H81.2 VESTIBULAR NEURONITIS 11,115.00
7,780.50
3,334.50
H81.3 OTHER PERIPHERAL VERTIGO; LERMOYEZ' SYNDROME; AURAL VERTIGO ; OTOGENIC VERTIGO; PERIPHERAL NOS VERTIGO 11,115.00
7,780.50
3,334.50
H81.4 VERTIGO OF CENTRAL ORIGIN; CENTRAL POSITIONAL NYSTAGMUS 11,115.00
7,780.50
3,334.50
H81.8 OTHER DISORDERS OF VESTIBULAR FUNCTION 11,115.00
7,780.50
3,334.50
H81.9 DISORDER OF VESTIBULAR FUNCTION, UNSPECIFIED; VERTIGINOUS SYNDROME NOS 11,115.00
7,780.50
3,334.50
H83.0 LABYRINTHITIS 12,090.00
8,463.00
3,627.00
H83.1 LABYRINTHINE FISTULA 11,115.00
7,780.50
3,334.50
H83.2 LABYRINTHINE DYSFUNCTION; HYPERSENSITIVITY OF LABYRINTH; HYPOFUNCTION OF LABYRINTH; LOSS OF FUNCTION OF LABYRINTH 11,115.00
7,780.50
3,334.50
H83.8 OTHER SPECIFIED DISEASES OF INNER EAR 12,090.00
8,463.00
3,627.00
H95.8 OTHER POSTPROCEDURAL DISORDERS OF EAR AND MASTOID PROCESS 20,085.00
14,059.50
6,025.50
I00 RHEUMATIC FEVER WITHOUT MENTION OF HEART INVOLVEMENT; ARTHRITIS, RHEUMATIC, ACUTE OR SUBACUTE INVOLVEMENT 19,695.00
13,786.50
5,908.50
I00+ J17.8* PNEUMONIA IN RHEUMATIC FEVER 29,250.00
20,475.00
8,775.00
I01.0 ACUTE RHEUMATIC PERICARDITIS; ACUTE RHEUMATIC PERICARDITIS 19,695.00
13,786.50
5,908.50
I01.1 ACUTE RHEUMATIC ENDOCARDITIS; ACUTE RHEUMATIC VALVULITIS 19,695.00
13,786.50
5,908.50
I01.2 ACUTE RHEUMATIC MYOCARDITIS; 19,695.00
13,786.50
5,908.50
I01.8 OTHER ACUTE RHEUMATIC HEART DISEASE; ACUTE RHEUMATIC PANCARDITIS 19,695.00
13,786.50
5,908.50
I01.9 ACUTE RHEUMATIC HEART DISEASE UNSPECIFIED; ACUTE RHEUMATIC CARDITIS; ACTIVE RHEUMATIC HEART DISEASE; ACUTE RHEUMATIC HEART DISEASE 19,695.00
13,786.50
5,908.50
I02.0 RHEUMATIC CHOREA WITH HEART INVOLVEMENT; CHOREA NOS WITH HEART INVOLVEMENT 19,695.00
13,786.50
5,908.50
I02.9 RHEUMATIC CHOREA WITHOUT HEART INVOLVEMENT; RHEUMATIC CHOREA NOS 19,695.00
13,786.50
5,908.50
I05.0 MITRAL STENOSIS; RHEUMATIC MITRAL VALVE OBSTRUCTION 24,960.00
17,472.00
7,488.00
I05.1 RHEUMATIC MITRAL INSUFFICIENCY; RHEUMATIC MITRAL INCOMPETENCE; RHEUMATIC MITRAL REGURGITATION 24,960.00
17,472.00
7,488.00
I05.2 MITRAL STENOSIS WITH INSUFFICIENCY; MITRAL STENOSIS WITH INCOMPETENCE OR REGURGITATION 24,960.00
17,472.00
7,488.00
I05.8 OTHER MITRAL VALVE DISEASES; MITRAL VALVE FAILURE 24,960.00
17,472.00
7,488.00
I05.9 MITRAL VALVE DISEASE UNSPECIFIED; CHRONIC MITRAL VALVE DISORDER NOS 24,960.00
17,472.00
7,488.00
I06.0 RHEUMATIC AORTIC STENOSIS; RHEUMATIC AORTIC VALVE OBSTRUCTION 24,960.00
17,472.00
7,488.00
I06.1 RHEUMATIC AORTIC INSUFFICIENCY; RHEUMATIC AORTIC INCOMPETENCE; RHEUMATIC AORTIC REGURGITATION 24,960.00
17,472.00
7,488.00
I06.2 RHEUMATIC AORTIC STENOSIS WITH INSUFFICIENCY; RHEUMATIC AORTIC STENOSIS WITH INCOMPETENCE OR REGURGITATION 24,960.00
17,472.00
7,488.00
I06.8 OTHER RHEUMATIC AORTIC VALVE DISEASES 24,960.00
17,472.00
7,488.00
I06.9 RHEUMATIC AORTIC VALVE DISEASE UNSPECIFIED; RHEUMATIC AORTIC VALVE DISEASE NOS 24,960.00
17,472.00
7,488.00
I07.0 TRICUSPID STENOSIS; RHEUMATIC TRICUSPID VALVE STENOSIS 24,960.00
17,472.00
7,488.00
I07.1 TRICUSPID INSUFFICIENCY; RHEUMATIC TRICUSPID VALVE INSUFFICIENCY 24,960.00
17,472.00
7,488.00
I07.9 TRICUSPID VALVE DISEASE UNSPECIFIED; TRICUSPID VALVE DISORDER NOS 24,960.00
17,472.00
7,488.00
I08.0 DISORDERS OF BOTH MITRAL AND AORTIC VALVES; INVOLVEMENT OF BOTH MITRAL AND AORTIC VALVES WHETHER SPECIFIED AS RHEUMATIC OR OF UNSPECIFIED ORIGIN 24,960.00
17,472.00
7,488.00
I08.1 DISORDERS OF BOTH MITRAL AND TRICUSPID VALVES 24,960.00
17,472.00
7,488.00
I08.2 DISORDERS OF BOTH AORTIC AND TRICUSPID VALVES 24,960.00
17,472.00
7,488.00
I08.3 COMBINED DISORDERS OF MITRAL AORTIC AND TRICUSPID VALVES 24,960.00
17,472.00
7,488.00
I08.8 OTHER MULTIPLE VALVE DISEASES 24,960.00
17,472.00
7,488.00
I08.9 MULTIPLE VALVE DISEASE, UNSPECIFIED 24,960.00
17,472.00
7,488.00
I09.0 RHEUMATIC MYOCARDITIS 24,960.00
17,472.00
7,488.00
I09.1 RHEUMATIC DISEASES OF ENDOCARDIUM, VALVE UNSPECIFIED; CHRONIC RHEUMATIC ENDOCARDITIS; CHRONIC RHEUMATIC VALVULITIS 24,960.00
17,472.00
7,488.00
Page 38 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate I09.2 CHRONIC RHEUMATIC PERICARDITIS; RHEUMATIC ADHERENT PERICARDIUM; CHRONIC RHEUMATIC MEDIASTINOPERICARDITIS; CHRONIC RHEUMATIC MYOPERICARDITIS 24,960.00
17,472.00
7,488.00
I09.8 OTHER SPECIFIED RHEUMATIC HEART DISEASES; RHEUMATIC DISEASE OF PULMONARY VALVE 24,960.00
17,472.00
7,488.00
I09.9 RHEUMATIC HEART DISEASE, UNSPECIFIED; RHEUMATIC CARDITIS; RHEUMATIC HEART FAILURE 30,615.00
21,430.50
9,184.50
I10.1 HYPERTENSION, STAGE II 17,550.00
12,285.00
5,265.00
I10.9 ESSENTIAL HYPERTENSION; MALIGNANT HYPERTENSION 17,550.00
12,285.00
5,265.00
I11.0 HYPERTENSIVE HEART DISEASE WITH (CONGESTIVE) HEART FAILURE; HYPERTENSIVE HEART FAILURE 17,550.00
12,285.00
5,265.00
I11.9 HYPERTENSIVE HEART DISEASE WITHOUT (CONGESTIVE) HEART FAILURE; HYPERTENSIVE HEART DISEASE NOS 17,550.00
12,285.00
5,265.00
I12.0 HYPERTENSIVE RENAL DISEASE WITH RENAL FAILURE; HYPERTENSIVE RENAL FAILURE 17,550.00
12,285.00
5,265.00
I12.9 HYPERTENSIVE RENAL DISEASE WITHOUT RENAL FAILURE; HYPERTENSIVE RENAL DISEASE NOS 17,550.00
12,285.00
5,265.00
I13.0 HYPERTENSIVE HEART AND RENAL DISEASE WITH (CONGESTIVE) HEART FAILURE 17,550.00
12,285.00
5,265.00
I13.1 HYPERTENSIVE HEART AND RENAL DISEASE WITH RENAL FAILURE 17,550.00
12,285.00
5,265.00
I13.2 HYPERTENSIVE HEART AND RENAL DISEASE WITH BOTH (CONGESTIVE) HEART FAILURE AND RENAL FAILURE 17,550.00
12,285.00
5,265.00
I13.9 HYPERTENSIVE HEART AND RENAL DISEASE, UNSPECIFIED 17,550.00
12,285.00
5,265.00
I15.0 RENOVASCULAR HYPERTENSION 17,550.00
12,285.00
5,265.00
I15.1 HYPERTENSION SECONDARY TO OTHER RENAL DISORDERS 17,550.00
12,285.00
5,265.00
I15.2 HYPERTENSION SECONDARY TO ENDOCRINE DISORDERS 17,550.00
12,285.00
5,265.00
I15.8 OTHER SECONDARY HYPERTENSION 17,550.00
12,285.00
5,265.00
I15.9 SECONDARY HYPERTENSION, UNSPECIFIED 17,550.00
12,285.00
5,265.00
I20.0 UNSTABLE ANGINA; ANGINA CRESCENDO; ANGINA DE NOVO EFFORT; ANGINA WORSENING EFFORT; INTERMEDIATE CORONARY SYNDROME; PREINFARCTION SYNDROME 23,400.00
16,380.00
7,020.00
I20.1
ANGINA PECTORIS WITH DOCUMENTED SPASM; ANGIOSPASTIC
ANGINA ; PRINZMETAL ANGINA ; SPASM-INDUCED ANGINA ;
VARIANT ANGINA
23,400.00
16,380.00
7,020.00
I20.8 OTHER FORMS OF ANGINA PECTORIS; ANGINA OF EFFORT; STENOCARDIA 23,400.00
16,380.00
7,020.00
I20.9 ANGINA PECTORIS, UNSPECIFIED; ANGINA NOS; CARDIAC ANGINA ; ANGINAL SYNDROME; ISCHAEMIC CHEST PAIN 23,400.00
16,380.00
7,020.00
I23.0 HAEMOPERICARDIUM AS CURRENT COMPLICATION FOLLOWING ACUTE MYOCARDIAL INFARCTION 36,855.00
25,798.50
11,056.50
I23.1 ATRIAL SEPTAL DEFECT AS CURRENT COMPLICATION FOLLOWING ACUTE MYOCARDIAL INFARCTION 36,855.00
25,798.50
11,056.50
I23.2 VENTRICULAR SEPTAL DEFECT AS CURRENT COMPLICATION FOLLOWING ACUTE MYOCARDIAL INFARCTION 36,855.00
25,798.50
11,056.50
I23.3 RUPTURE OF CARDIAC WALL WITHOUT HAEMOPERICARDIUM AS CURRENT COMPLICATION FOLLOWING ACUTE MYOCARDIAL INFARCTION 36,855.00
25,798.50
11,056.50
I23.4 RUPTURE OF CHORDAE TENDINEAE AS CURRENT COMPLICATION FOLLOWING ACUTE MYOCARDIAL INFARCTION 36,855.00
25,798.50
11,056.50
I23.5 RUPTURE OF PAPILLARY MUSCLE AS CURRENT COMPLICATION FOLLOWING ACUTE MYOCARDIAL INFARCTION 36,855.00
25,798.50
11,056.50
I23.8 OTHER CURRENT COMPLICATIONS FOLLOWING ACUTE MYOCARDIAL INFARCTION 36,855.00
25,798.50
11,056.50
I24.0 CORONARY THROMBOSIS NOT RESULTING IN MYOCARDIAL INFARCTION; CORONARY ARTERY EMBOLISM NOT RESULTING IN MYOCARDIAL INFACTION; CORONARY VEIN EMBOLISM NOT RESULTING IN MYOCARDIAL INFARCTION; CORONARY ARTERY OCCLUSION NOT RESULTING IN MYOCARDIAL INFARCTION; CO 23,400.00
16,380.00
7,020.00
I24.1 DRESSLER'S SYNDROME; POSTMYOCARDIAL INFARCTION SYNDROME 36,855.00
25,798.50
11,056.50
I24.8 OTHER FORMS OF ACUTE ISCHAEMIC HEART DISEASE; CORONARY FAILURE; CORONARY INSUFFICIENCY 23,400.00
16,380.00
7,020.00
I25.0 ATHEROSCLEROTIC CARDIOVASCULARDISEASE, SO DESCRIBED 7,800.00
5,460.00
2,340.00
I25.1 ATHEROSCLEROTIC HEAR TDISEASE; CORONARY ARTERY ATHEROMA; CORONARY ARTERY ATHEROSCLEROSIS; CORONARY ARTERY DISEASE; CORONARY ARTERY SCLEROSIS 7,800.00
5,460.00
2,340.00
I25.3 ANEURYSM OF HEART; MURAL ANEURYSM; VENTICULAR ANEURYSM 7,800.00
5,460.00
2,340.00
I25.4 CORONARY ARTERY ANEURYSM; CORONARY ARTERIOVENOUS FISTULA, ACQUIRED 7,800.00
5,460.00
2,340.00
I25.5 ISCHAEMIC CARDIOMYOPATHY 23,400.00
16,380.00
7,020.00
I25.6 SILENT MYOCARDIAL ISCHAEMIA 23,400.00
16,380.00
7,020.00
I25.8 OTHER FORMS OF CHRONIC ISCHAEMIC HEART DISEASE 23,400.00
16,380.00
7,020.00
I25.9 CHRONIC ISCHAEMIC HEART DISEASE, UNSPECIFIED; CHRONIC ISCHAEMIC HEART DISEASE NOS 23,400.00
16,380.00
7,020.00
I26.0 PULMONARY EMBOLISM WITH MENTION OF ACUTE COR PULMONALE; ACUTE COR PULMONALE NOS 47,385.00
33,169.50
14,215.50
I26.9 PULMONARY EMBOLISM WITHOUT MENTION OF ACUTE COR PULMONALE; PULMONARY EMBOLISM NOS 47,385.00
33,169.50
14,215.50
I27.0 PRIMARY PULMONARY HYPERTENSION 27,495.00
19,246.50
8,248.50
Page 39 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate I27.1 KYPHOSCOLIOTIC HEART DISEASE 27,495.00
19,246.50
8,248.50
I27.2 OTHER SECONDARY PULMONARY HYPERTENSION; PULMONARY ARTERY HYPERTENSION 27,495.00
19,246.50
8,248.50
I27.8 OTHER SPECIFIED PULMONARY HEART DISEASES 27,495.00
19,246.50
8,248.50
I27.9 PULMONARY HEART DISEASE, UNSPECIFIED; CHRONIC CARDIOPULMONARY DISEASE; CHRONIC COR PULMONALE NOS 27,495.00
19,246.50
8,248.50
I28.8 OTHER SPECIFIED DISEASES OF PULMONARY VESSELS; RUPTURE OF PULMONARY VESSEL; STENOSIS OF PULMONARY VESSEL; STRICTURE OF PULMONARY VESSEL 25,545.00
17,881.50
7,663.50
I30.0 ACUTE NONSPECIFIC IDIOPATHIC PERICARDITIS 28,080.00
19,656.00
8,424.00
I30.1 INFECTIVE PERICARDITIS; PNEUMOCOCCAL PERICARDITIS; PURULENT PERICARDITIS; STAPHYLOCOCCAL PERICARDITIS; STREPTOCOCCAL PERICARDITIS; VIRAL PERICARDITIS; PYOPERICARDITIS 28,080.00
19,656.00
8,424.00
I30.8 OTHER FORMS OF ACUTE PERICARDITIS 28,080.00
19,656.00
8,424.00
I30.9 ACUTE PERICARDITIS, UNSPECIFIED 28,080.00
19,656.00
8,424.00
I31.0 CHRONIC ADHESIVE PERICARDITIS; ACCRETIO CORDIS; ADHERENT PERICARDIUM; ADHESIVE MEDIASTINOPERICARDITIS 28,080.00
19,656.00
8,424.00
I31.1 CHRONIC CONSTRICTIVE PERICARDITIS; CONCRETIO CORDIS; PERICARDIAL CALCIFICATION 28,080.00
19,656.00
8,424.00
I33.0 ACUTE AND SUBACUTE INFECTIVE ENDOCARDITIS; ACUTE BACTERIAL ENDOCARDITIS; SUBACUTE BACTERIAL ENDOCARDITIS; ACUTE INFECTIVE ENDOCARDITIS NOS; SUBACUTE INFECTIVE ENDOCARDITIS NOS; ACUTE LENTA ENDOCARDITIS; SUBACUTE LENTA ENDOCARDITIS; ACUTE MALIGNANT ENDOCAR 28,080.00
19,656.00
8,424.00
I33.9 ACUTE ENDOCARDITIS, UNSPECIFIED; ENDOCARDITIS, ACUTE OR SUBACUTE; MYOENDOCARDITIS, ACUTE OR SUBACUTE; PERIENDOCARDITIS, ACUTE OR SUBACUTE 28,080.00
19,656.00
8,424.00
I34.0 MITRAL (VALVE) INSUFFICIENCY; INCOMPETENCE MITRAL VALVE NOS OR OF SPECIFIED CAUSE, EXCEPT RHEUMATIC; REGURGITATION MITRAL VALVE NOS OR OF SPECIFIED CAUSE, EXCEPT RHEUMATIC 16,380.00
11,466.00
4,914.00
I34.1 MITRAL (VALVE) PROLAPSE; FLOPPY MITRAL VALVE SYNDROME 16,380.00
11,466.00
4,914.00
I34.2 NONRHEUMATIC MITRAL (VALVE) STENOSIS 16,380.00
11,466.00
4,914.00
I34.8 OTHER NONRHEUMATIC MITRAL HEART VALVE DISORDERS 16,380.00
11,466.00
4,914.00
I34.9 NONRHEUMATIC MITRAL VALVE DISORDER, UNSPECIFIED 16,380.00
11,466.00
4,914.00
I35.0 AORTIC (VALVE) STENOSIS 16,380.00
11,466.00
4,914.00
I35.1 AORTIC (VALVE) INSUFFICIENCY; INCOMPETENCE AORTIC VALVE NOS OR OF SPECIFIED CAUSE, EXCEPT RHEUMATIC; AORTIC VALVE REGURGITATION NOS OR OF SPECIFIED CAUSE, EXCEPT RHEUMATIC 16,380.00
11,466.00
4,914.00
I35.2 AORTIC (VALVE) STENOSIS WITH INSUFFICIENCY 16,380.00
11,466.00
4,914.00
I35.8 OTHER AORTIC HEART VALVE DISORDERS 16,380.00
11,466.00
4,914.00
I35.9 AORTIC VALVE DISORDER, UNSPECIFIED 16,380.00
11,466.00
4,914.00
I36.0 NONRHEUMATIC TRICUSPID (VALVE) STENOSIS 16,380.00
11,466.00
4,914.00
I36.1 NONRHEUMATIC TRICUSPID (VALVE) INSUFFICIENCY; INCOMPETENCE TRICUSPID VALVE OF SPECIFIED CAUSE, EXCEPT RHEUMATIC; TRICUSPID VALVE REGURGITATION OF SPECIFIED CAUSE, EXCEPT RHEUMATIC 16,380.00
11,466.00
4,914.00
I36.8 OTHER NONRHEUMATIC TRICUSPID VALVE DISORDERS 16,380.00
11,466.00
4,914.00
I36.9 NONRHEUMATIC TRICUSPID VALVE DISORDER, UNSPECIFIED 16,380.00
11,466.00
4,914.00
I37.0 PULMONARY VALVE STENOSIS 16,380.00
11,466.00
4,914.00
I37.1 PULMONARY VALVE INSUFFICIENCY; INCOMPETENCE PULMONARY VALVE NOS OR SPECIFIED CAUSE, EXCEPT RHEUMATIC; PULMONARY VALVE REGURGITATION NOS OR OF SPECIFIED CAUSE, EXCEPT RHEUMATIC 16,380.00
11,466.00
4,914.00
I37.8 OTHER PULMONARY HEART VALVE DISORDERS 16,380.00
11,466.00
4,914.00
I37.9 PULMONARY VALVE DISORDER, UNSPECIFIED 16,380.00
11,466.00
4,914.00
I38 ENDOCARDITIS, VALVE UNSPECIFIED; CHRONIC ENDOCARDITIS NOS; VALVULAR INCOMPETENCE OF UNSPECIFIED VALVE NOS OR OF SPECIFIED CAUSE, EXCEPT RHEUMATIC OR CONGENITAL; VALVULAR INSUFFICIENCY OF UNSPECIFIED VALVE NOS OR OF SPECIFIED CAUSE, EXCEPT RHEUMATIC OR CON 28,080.00
19,656.00
8,424.00
I40.0 INFECTIVE MYOCARDITIS; SEPTIC MYOCARDITIS 28,080.00
19,656.00
8,424.00
I40.1 ISOLATED MYOCARDITIS 28,080.00
19,656.00
8,424.00
I40.8 OTHER ACUTE MYOCARDITIS 28,080.00
19,656.00
8,424.00
I40.9 ACUTE MYOCARDITIS, UNSPECIFIED 28,080.00
19,656.00
8,424.00
I42.0 DILATED CARDIOMYOPATHY; CONGESTIVE CARDIOMYOPATHY 26,130.00
18,291.00
7,839.00
I42.1 OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY; HYPERTROPHIC SUBAORTIC STENOSIS 26,130.00
18,291.00
7,839.00
I42.2 OTHER HYPERTROPHIC CARDIOMYOPATHY; NONOBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY 26,130.00
18,291.00
7,839.00
I42.3 ENDOMYOCARDIAL (EOSINOPHILIC) DISEASE; ENDOMYOCARDIAL (TROPICAL) FIBROSIS; LöFFLER'S ENDOCARDITIS 26,130.00
18,291.00
7,839.00
I42.4 ENDOCARDIAL FIBROELASTOSIS; CONGENITAL CARDIOMYOPATHY 26,130.00
18,291.00
7,839.00
I42.5 OTHER RESTRICTIVE CARDIOMYOPATHY 26,130.00
18,291.00
7,839.00
I42.6 ALCOHOLIC CARDIOMYOPATHY 26,130.00
18,291.00
7,839.00
I42.7 CARDIO MYOPATHY DUE TO DRUGS AND OTHER EXTERNAL AGENTS 26,130.00
18,291.00
7,839.00
I42.8 OTHER CARDIOMYOPATHIES 26,130.00
18,291.00
7,839.00
Page 40 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate I42.9 CARDIO MYOPATHY, UNSPECIFIED; PRIMARY CARDIOMYOPATHY NOS; SECONDARY CARDIOMYOPATHY NOS 26,130.00
18,291.00
7,839.00
I44.2 ATRIOVENTRICULAR BLOCK, COMPLETE; COMPLETE HEART BLOCK NOS; THIRD-DEGREE BLOCK 23,985.00
16,789.50
7,195.50
I44.3 OTHER AND UNSPECIFIED ATRIOVENTRICULAR BLOCK; ATRIOVENTRICULAR BLOCK NOS 23,985.00
16,789.50
7,195.50
I44.4 LEFT ANTERIOR FASCICULAR BLOCK 23,985.00
16,789.50
7,195.50
I45.5 OTHER SPECIFIED HEART BLOCKL; SINOATRIAL NOS; SINOAURICULAR BLOCK 23,985.00
16,789.50
7,195.50
I45.6 PRE-EXCITATION SYNDROME; ANOMALOUS ATRIOVENTICULAR EXCITATION; ATRIOVENTRICULAR CONDUCTION, ACCELERATED; ATRIOVENTICULAR CONDUCTION, ACCESORY; ATRIOVENTICULAR CONDUCTION PRE-EXCITATION; LOWN-GANONG-LEVINE SYNDROME; WOLFF-PARKINSON-WHITE SYNDROME 23,985.00
16,789.50
7,195.50
I45.8 OTHER SPECIFIED HEART CONDUCTION DISORDERSS; ATRIOVENTICULAR [AV] DISSOCIATION; INTERFERENCE DISSOCIATION 23,985.00
16,789.50
7,195.50
I45.9 HEART CONDUCTION DISORDERS, UNSPECIFIED; HEART BLOCK NOS; STOKES-ADAMS SYNDROME 23,985.00
16,789.50
7,195.50
I47.0 RE-ENTRY VENTRICULAR ARRHYTHMIA 23,790.00
16,653.00
7,137.00
I47.1 SUPRAVENTRICULAR TACHYCARDIA; ATRIAL PAROXYSMAL TACHYCARDIA; ATRIOVENTRICULAR [AV] PAROXYSMAL TACHYCARDIA; JUNCTIONAL PAROXYSMAL TACHYCARDIA; NODAL PAROXYSMAL TACHYCARDIA 23,790.00
16,653.00
7,137.00
I47.2 VENTRICULAR TACHYCARDIA 23,790.00
16,653.00
7,137.00
I47.9 PAROXYSMAL TACHYCARDIA, UNSPECIFIED; BOUVERET (- HOFFMANN) SYNDROME 23,790.00
16,653.00
7,137.00
I48 ATRIAL FIBRILLATION AND FLUTTER 23,790.00
16,653.00
7,137.00
I49.0 VENTRICULAR FIBRILLATION AND FLUTTER 23,790.00
16,653.00
7,137.00
I49.1 ATRIAL PREMATURE DEPOLARIZATION; ATRIAL PREMATURE BEATS 23,790.00
16,653.00
7,137.00
I49.2 JUNCTIONAL PREMATURE DEPOLARIZATION 23,790.00
16,653.00
7,137.00
I49.3 VENTRICULAR PREMATURE DEPOLARIZATION 23,790.00
16,653.00
7,137.00
I49.4 OTHER AND UNSPECIFIED PREMATURE DEPOLARIZATION; ECTOPIC BEATS; EXTRASYSTOLES; EXTRASYSTOLIC ARRHYTHMIAS; PREMATURE BEATS NOS; PREMATURE CONTRACTIONS 23,790.00
16,653.00
7,137.00
I49.5 SICK SINUS SYNDROME; TACHYCARDIA-BRADYCARDIA SYNDROME 23,790.00
16,653.00
7,137.00
I49.8 OTHER SPECIFIED CARDIAC ARRHYTHMIAS; CORONARY SINUS RHYTHM DISORDER; ECTOPIC RHYTHM DISORDER; NODAL RHYTHM DISORDER 23,790.00
16,653.00
7,137.00
I49.9 CARDIAC ARRHYTHMIA, UNSPECIFIED; CARDIAC ARRHYTHMIA NOS 23,790.00
16,653.00
7,137.00
I50.0 CONGESTIVE HEART FAILURE; CONGESTIVE HEART DISEASE; RIGHT VENTICULAR FAILURE (SECONDARY TO LEFT HEART FAILURE) 30,615.00
21,430.50
9,184.50
I50.00 ADVANCED CONGESTIVE HEART FAILURE; GRAVE CONGESTIVE HEART FAILURE; SEVERE CONGESTIVE HEART FAILURE 30,615.00
21,430.50
9,184.50
I50.1 LEFT VENTRICULAR FAILURE; ACUTE OEDEMA OF LUNG WITH MENTION OF HEART DISEASE NOS OR HEART FAILURE; ACUTE PULMONARY OEDEMA WITH MENTION OF HEART DISEASE NOS OR HEART FAILURE; CARDIAC ASTHMA WITH MENTION OF HEART DISEASE NOS OR HEART FAILURE; LEFT HEART FAI 30,615.00
21,430.50
9,184.50
I50.9 HEART FAILURE, UNSPECIFIED; CARDIAC, HEART OR MYOCARDIAL FAILURE NOS 30,615.00
21,430.50
9,184.50
I51.0 CARDIAC SEPTAL DEFECT, ACQUIRED; ACQUIRED ATRIAL SEPTAL DEFECT OLD; ACQUIRED AURICULAR SEPTAL DEFECT OLD ; ACQUIRED VENTRICULAR SEPTAL DEFECT OLD 28,080.00
19,656.00
8,424.00
I51.1 RUPTURE OF CHORDAE TENDINEAE, NOT ELSEWHERE CLASSIFIED 28,080.00
19,656.00
8,424.00
I51.2 RUPTURE OF PAPILLARY MUSCLE, NOT ELSEWHERE CLASSIFIED 28,080.00
19,656.00
8,424.00
I51.3
INTRA CARDIAC THROMBOSIS, NOTEL SEWHERE CLASSIFIED; OLD
APICAL THROMBOSIS; OLD ATRIAL THROMBOSIS; OLD
AURICULAR THROMBOSIS; OLD VENTICULAR THROMBOSIS
28,080.00
19,656.00
8,424.00
I51.4 MYOCARDITIS, UNSPECIFIED; MYOCARDIAL FIBROSIS; MYOCARDITIS NOS; CHRONIC INTERSTITIAL MYOCARDITIS 28,080.00
19,656.00
8,424.00
I51.5 MYOCARDIAL DEGENERATION; FATTY DEGENERATION OF HEART OR MYOCARDIUM FATTY; SENILE DEGENERATION OF HEART OR MYOCARDIUM; MYOCARDIAL DISEASE 28,080.00
19,656.00
8,424.00
I51.8 OTHER ILL-DEFINED HEART DISEASES; ACUTE CARDITIS; CHRONIC CARDITIS; ACUTE PANCARDITIS; CHRONIC PANCARDITIS 28,080.00
19,656.00
8,424.00
I65.2 OCCLUSION AND STENOSIS OF CAROTID ARTERY 29,640.00
20,748.00
8,892.00
I67.0 DISSECTION OF CEREBRAL ARTERIES, NONRUPTURED 29,640.00
20,748.00
8,892.00
I67.1 CEREBRAL ANEURYSM, NONRUPTURED; CEREBRAL ANEURYSM NOS; CEREBRAL ARTERIOVENOUS FISTULA, ACQUIRED 29,640.00
20,748.00
8,892.00
I67.2 CEREBRAL ATHEROSCLEROSIS; ATHEROMA OF CEREBRAL ARTERIES 29,640.00
20,748.00
8,892.00
I67.3 PROGRESSIVE VASCULAR LEUKOENCEPHALOPATHY; BINSWANGER'S DISEASE 29,640.00
20,748.00
8,892.00
Page 41 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate I67.4 HYPERTENSIVE ENCEPHALOPATHY 43,290.00
30,303.00
12,987.00
I67.5 MOYAMOYA DISEASE 29,640.00
20,748.00
8,892.00
I67.6 NONPYOGENIC THROMBOSIS OF INTRACRANIAL VENOUS SYSTEM; NONPYOGENIC THROMBOSIS OF CEREBRAL VEIN; NONPYOGENIC THROMBOSIS OF INTRACRANNIAL VENOUS SINUS 29,640.00
20,748.00
8,892.00
I67.7 CEREBRAL ARTERITIS, NOT ELSEWHERE CLASSIFIED 29,640.00
20,748.00
8,892.00
I67.8 OTHER SPECIFIED CEREBROVASCULAR DISEASES; ACUTE CEREBROVASCULAR INSUFFICIENCY NOS; CHRONIC CEREBRAL ISCHAEMIA 29,640.00
20,748.00
8,892.00
I67.9+G46.7* OTHER LACUNAR SYNDROME IN UNSPECIFIED CEREBROVASCULAR DISEASE 29,640.00
20,748.00
8,892.00
I67.9+G46.8* OTHER VASCULAR SYNDROME IN UNSPECIFIED CEREBROVASCULAR DISEASE 29,640.00
20,748.00
8,892.00
I69.0 SEQUELAE OF SUBARACHNOID HAEMORRHAGE 20,085.00
14,059.50
6,025.50
I69.1 SEQUELAE OF INTRACEREBRAL HAEMORRHAGE 20,085.00
14,059.50
6,025.50
I69.2 SEQUELAE OF OTHER NONTRAUMATIC INTRACRANIAL HAEMORRHAGE 20,085.00
14,059.50
6,025.50
I69.3 SEQUELAE OF CEREBRAL INFARCTION 20,085.00
14,059.50
6,025.50
I69.4 SEQUELAE OF STROKE, NOT SPECIFIED AS HAEMORRHAGE OR INFARCTION 20,085.00
14,059.50
6,025.50
I69.8 SEQUELAE OF OTHER AND UNSPECIFIED CEREBROVASCULAR DISEASES 20,085.00
14,059.50
6,025.50
I71.0 DISSECTION OF AORTA [ANYPART]; DISSECTING ANEURYSM OF AORTA (RUPTURED) [ANY PART] 25,545.00
17,881.50
7,663.50
I71.9 AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT MENTION OF RUPTURE; ANEURYSM OF AORTA; DILATATION OF AORTA; HYALINE NECROSIS OF AORTA 25,545.00
17,881.50
7,663.50
I74.0 EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA; AORTIC BIFURCATION SYNDROME; LERICHE'S SYNDROME 25,545.00
17,881.50
7,663.50
I74.1 EMBOLISM AND THROMBOSIS OF OTHER AND UNSPECIFIED PARTS OF AORTA 25,545.00
17,881.50
7,663.50
I74.2 EMBOLISM AND THROMBOSIS OF ARTERIES OF UPPER EXTREMITIES 25,545.00
17,881.50
7,663.50
I74.3 EMBOLISM AND THROMBOSIS OF ARTERIES OF LOWER EXTREMITIES 25,545.00
17,881.50
7,663.50
I74.4 EMBOLISM AND THROMBOSIS OF ARTERIES OF EXTREMITIES, UNSPECIFIED; PERIPHERAL ARTERIAL EMBOLISM 25,545.00
17,881.50
7,663.50
I74.5 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY 25,545.00
17,881.50
7,663.50
I74.8 EMBOLISM AND THROMBOSIS OF OTHER ARTERIES 25,545.00
17,881.50
7,663.50
I74.9 EMBOLISM AND THROMBOSIS OF UNSPECIFIED ARTERY 25,545.00
17,881.50
7,663.50
I77.4 COELIAC ARTERY COMPRESSION SYNDROME 25,545.00
17,881.50
7,663.50
I77.6 ARTERITIS, UNSPECIFIED; AORTITIS NOS; ENDARTERITIS NOS 25,545.00
17,881.50
7,663.50
I77.8 OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES 25,545.00
17,881.50
7,663.50
I80.0 PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITIES 24,180.00
16,926.00
7,254.00
I80.1 PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN 24,180.00
16,926.00
7,254.00
I80.2 PHLEBITIS AND THROMBOPHLEBITIS OF OTHER DEEP VESSELS OF LOWER EXTREMITIES; DEEP VEIN THROMBOSIS NOS 24,180.00
16,926.00
7,254.00
I80.3 PHLEBITIS AND THROMBOPHLEBITIS OF LOWER EXTREMITIES, UNSPECIFIED; EMBOLISM OR THROMBOSIS OF LOWER EXTERMITY NOS 24,180.00
16,926.00
7,254.00
I80.8 PHLEBITIS AND THROMBOPHLEBITIS OF OTHER SITES 24,180.00
16,926.00
7,254.00
I80.9 PHLEBITIS AND THROMBOPHLEBITIS OF UNSPECIFIED SITE 24,180.00
16,926.00
7,254.00
I81 PORTAL VEIN THROMBOSIS; PORTAL (VEIN) OBSTRUCTION 24,180.00
16,926.00
7,254.00
I82.0 BUDD-CHIARI SYNDROME 24,180.00
16,926.00
7,254.00
I82.1 THROMBOPHLEBITIS MIGRANS 24,180.00
16,926.00
7,254.00
I82.2 EMBOLISM AND THROMBOSIS OF VENA CAVA 24,180.00
16,926.00
7,254.00
I82.3 EMBOLISM AND THROMBOSIS OF RENAL VEIN 24,180.00
16,926.00
7,254.00
I82.8 EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS 24,180.00
16,926.00
7,254.00
I82.9 EMBOLISM AND THROMBOSIS OF UNSPECIFIED VEIN 24,180.00
16,926.00
7,254.00
I85.0 OESOPHAGEAL VARICES WITH BLEEDING 25,545.00
17,881.50
7,663.50
I87.1 COMPRESSION OF VEIN; STRICTURE OF VEIN; INFERIOR VENA CAVA SYNDROME; SUPERIOR VENA CAVA SYNDROME 25,545.00
17,881.50
7,663.50
I88.0 NONSPECIFIC MESENTERIC LYMPHADENITIS; ACUTE MESENTERIC LYMPHADENITIS; CHRONIC MESENTERIC LYMPHADENITIS 13,260.00
9,282.00
3,978.00
I89.1 LYMPHANGITIS; LYMPHANGITIS NOS; CHRONIC LYMPHANGITIS; SUBACUTE LYMPHANGITIS 17,355.00
12,148.50
5,206.50
I89.8 OTHER SPECIFIED NONINFECTIVE DISORDERS OF LYMPHATIC VESSELS AND LYMPH NODES; CHYLOCELE (NONFILARIAL); LIPOMELANOTIC RETICULOSIS 17,355.00
12,148.50
5,206.50
I89.9 NONINFECTIVE DISORDER OF LYMPHATIC VESSELS AND LYMPH NODES, UNSPECIFIED; DISEASE OF LYMPHATIC VESSELS NOS 17,355.00
12,148.50
5,206.50
I97.0 POSTCARDIOTOMY SYNDROME 20,085.00
14,059.50
6,025.50
I97.2 POSTMASTECTOMY LYMPHOEDEMA SYNDROME; ELEPHANTIASIS DUE TO MASTECTOMY; OBLITERATION OF LYMPHATIC VESSELS DUE TO MASTECTOMY 20,085.00
14,059.50
6,025.50
J03.0 STREPTOCOCCAL TONSILLITIS 7,800.00
5,460.00
2,340.00
J03.8 ACUTE TONSILLITIS DUE TO OTHER SPECIFIED ORGANISMS 7,800.00
5,460.00
2,340.00
Page 42 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate J03.9 ACUTE TONSILLITIS, UNSPECIFIED; ACUTE TONSILLITIS NOS; ACUTE FOLLICULAR TONSILLITIS; ACUTE GANGRENOUS TONSILLITIS; ACUTE INFECTIVE TONSILLITIS; ACUTE ULCERATIVE TONSILLITIS 7,800.00
5,460.00
2,340.00
J05.0 ACUTE OBSTRUCTIVE LARYNGITIS [CROUP]; OBSTRUCTIVE LARYNGITIS NOS 15,990.00
11,193.00
4,797.00
J05.1 ACUTE EPIGLOTTITIS; EPIGLOTTITIS NOS 18,915.00
13,240.50
5,674.50
J06.0 ACUTE LARYNGOPHARYNGITIS 7,800.00
5,460.00
2,340.00
J06.8 OTHER ACUTE UPPER RESPIRATORY INFECTIONS OF MULTIPLE SITES 7,800.00
5,460.00
2,340.00
J06.9 ACUTE UPPER RESPIRATORY INFECTION, UNSPECIFIED; ACUTE UPPER RESPIRATORY DISEASE; UPPER RESPIRATORY INFECTION NOS 7,800.00
5,460.00
2,340.00
J09 INFLUENZA A H5N1 (AVIAN INFLUENZA) 12,870.00
9,009.00
3,861.00
J10.0 INFLUENZA WITH PNEUMONIA, INFLUENZA VIRUS IDENTIFIED; INFLUENZAL (BRONCHO) PNEUMONIA, INFLUENZA VIRUS INDENTIFIED 12,870.00
9,009.00
3,861.00
J10.1 INFLUENZA WITH OTHER RESPIRATORY MANIFESTATIONS, INFLUENZA VIRUS IDENTIFIED; INFLUENZA, INFLUENZA VIRUS IDENTIFIED; ACUTE UPPER RESPIRATORY INFLUENZAL INFECTION, INFLUENZA VIRUS IDENTIFIED; INFLUENZAL LARYNGITIS, INFLUENZA VIRUS IDENTIFIED; INFLUENZAL PHA 12,870.00
9,009.00
3,861.00
J10.8 INFLUENZA WITH OTHER MANIFESTATIONS, INFLUENZA VIRUS IDENTIFIED; ENCEPHALOPATHY DUE TO INFLUENZA, INFLUENZA VIRUS IDENTIFIED; INFLUENZAL GASTROENTERITIS, INFLUENZA VIRUS IDENTIFIED; ACUTE INFLUENZAL MYOCARDITIS, INFLUENZA VIRUS IDENTIFIED 12,870.00
9,009.00
3,861.00
J11.0 INFLUENZA WITH PNEUMONIA, VIRUS NOT IDENTIFIED; INFLUENZAL (BRONCHO) PNEUMONIA, UNSPECIFIED OR SPECIFIC VIRUS NOT IDENTIFIED 12,870.00
9,009.00
3,861.00
J11.1 INFLUENZA WITH OTHER RESPIRATORY MANIFESTATIONS, VIRUS NOT IDENTIFIED; INFLUENZA NOS; INFLUENZAL ACUTE UPPER RESPIRATORY INFECTION, UNSPECIFIED OR SPECIFIC VIRUS NOT IDENTIFIED; INFLUENZAL LARYNGITIS, UNSPECIFIED OR SPECIFIC VIRUS NOT IDENTIFIED; INFLUEN 12,870.00
9,009.00
3,861.00
J11.8 INFLUENZA WITH OTHER MANIFESTATIONS, VIRUS NOT IDENTIFIED; ENCEPHALOPATHY DUE TO INFLUENZA, UNSPECIFIED OR SPECIFIC VIRUS NOT IDENTIFIED; INFLUENZAL GASTROENTIRITIS, UNSPECIFIED OR SPECIFIC VIRUS NOT IDENTIFIED; ACUTE INFLUENZAL MYOCARDITIS, UNSPECIFIED O 12,870.00
9,009.00
3,861.00
J11.8+ I41.1* ACUTE INFLUENZAL MYOCARDITIS, VIRUS NOT IDENTIFIED 12,870.00
9,009.00
3,861.00
J12.02 ADENOVIRAL PNEUMONIA, MODERATE RISK 29,250.00
20,475.00
8,775.00
J12.12 RESPIRATORY SYNCYTIAL VIRUS PNEUMONIA, MODERATE RISK 29,250.00
20,475.00
8,775.00
J12.22 PARAINFLUENZA VIRUS PNEUMONIA, MODERATE RISK 29,250.00
20,475.00
8,775.00
J12.32 HUMAN METAPNEUMOVIRUS PNEUMONIA, MODERATE RISK 29,250.00
20,475.00
8,775.00
J12.92 VIRAL PNEUMONIA, MODERATE RISK 29,250.00
20,475.00
8,775.00
J13.2 PNEUMONIA [BRONCHOPNEUMONIA] DUE TO STREPTOCOCCUS PNEUMONIAE, MODERATE RISK 29,250.00
20,475.00
8,775.00
J14.2 PNEUMONIA [BRONCHOPNEUMONIA]DUE TO HAEMOPHILUS INFLUENZAE, MODERATE RISK 29,250.00
20,475.00
8,775.00
J15.02 PNEUMONIA DUE TO KLEBSIELLA PNEUMONIAE, MODERATE RISK 29,250.00
20,475.00
8,775.00
J15.12 PNEUMONIA DUE TO PSEUDOMONAS, MODERATE RISK 29,250.00
20,475.00
8,775.00
J15.22 PNEUMONIA DUE TO STAPHYLOCOCCUS, MODERATE RISK 29,250.00
20,475.00
8,775.00
J15.32 PNEUMONIA DUE TO STREPTOCOCCUS, GROUP B, MODERATE RISK 29,250.00
20,475.00
8,775.00
J15.42 PNEUMONIA DUE TO OTHER STREPTOCOCCI, MODERATE RISK 29,250.00
20,475.00
8,775.00
J15.52 PNEUMONIA DUE TO ESCHERICHIA COLI, MODERATE RISK 29,250.00
20,475.00
8,775.00
J15.62 PNEUMONIA DUE TO OTHER AEROBIC GRAM-NEGATIVE BACTERIA; PNEUMONIA DUE TO SERRATIA MARCESCENS, MODERATE RISK 29,250.00
20,475.00
8,775.00
J15.72 PNEUMONIA DUE TO MYCOPLASMA PNEUMONIAE, MODERATE RISK 29,250.00
20,475.00
8,775.00
J15.92 BACTERIAL PNEUMONIA [BRONCHOPNEUMONIA], MODERATE RISK 29,250.00
20,475.00
8,775.00
J16.02 CHLAMYDIAL PNEUMONIA, MODERATE RISK 29,250.00
20,475.00
8,775.00
J18.02 BRONCHOPNEUMONIA, MODERATE RISK 29,250.00
20,475.00
8,775.00
J18.12 LOBAR PNEUMONIA, MODERATE RISK 29,250.00
20,475.00
8,775.00
J18.22 HYPOSTATIC PNEUMONIA, MODERATE RISK 29,250.00
20,475.00
8,775.00
J18.92 COMMUNITY-ACQUIRED PNEUMONIA III (THIS CLASSIFICATION UTILIZED THE AMERICAN THORACIC SOCIETY RECOMMENDATION. THIS IS EQUIVALENT TO CAP, MODERATE RISK IN THE PHILIPPINE CLINICAL PRACTICE GUIDELINES ON THE DIAGNOSIS, EMPIRIC MANAGEMENT, AND PREVENTION OF C 29,250.00
20,475.00
8,775.00
J20.0 ACUTE BRONCHITIS DUE TO MYCOPLASMA PNEUMONIAE 7,800.00
5,460.00
2,340.00
J20.1 ACUTE BRONCHITIS DUE TO HAEMOPHILUS INFLUENZAE 7,800.00
5,460.00
2,340.00
J20.2 ACUTE BRONCHITIS DUE TO STREPTOCOCCUS 7,800.00
5,460.00
2,340.00
J20.3 ACUTE BRONCHITIS DUE TO COXSACKIEVIRUS 7,800.00
5,460.00
2,340.00
J20.4 ACUTE BRONCHITIS DUE TO PARAINFLUENZA VIRUS 7,800.00
5,460.00
2,340.00
Page 43 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate J20.5 ACUTE BRONCHITIS DUE TO RESPIRATORY SYNCYTIAL VIRUS 7,800.00
5,460.00
2,340.00
J20.6 ACUTE BRONCHITIS DUE TO RHINOVIRUS 7,800.00
5,460.00
2,340.00
J20.7 ACUTE BRONCHITIS DUE TO ECHOVIRUS 7,800.00
5,460.00
2,340.00
J20.8 ACUTE BRONCHITIS DUE TO OTHER SPECIFIED ORGANISMS 7,800.00
5,460.00
2,340.00
J20.9 ACUTE BRONCHITIS, UNSPECIFIED 7,800.00
5,460.00
2,340.00
J22 UNSPECIFIED ACUTE LOWER RESPIRATORY INFECTION 7,800.00
5,460.00
2,340.00
J36 PERITONSILLAR ABSCESS; ABSCESS OF TONSIL; PERITONSILLAR CELLULITIS; QUINSY 19,500.00
13,650.00
5,850.00
J38.7 OTHER DISEASES OF LARYNX; ABSCESS OF LARYNX; CELLULITIS OF LARYNX; DISEASE NOS OF LARYNX; NECROSIS OF LARYNX; PACHYDERMA OF LARYNX; PERICHONDRITIS OF LARYNX; ULCER OF LARYNX 19,500.00
13,650.00
5,850.00
J39.0 RETROPHARYNGEAL AND PARAPHARYNGEAL ABSCESS; PERIPHARYNGEAL ABSCESS 19,500.00
13,650.00
5,850.00
J39.1 OTHER ABSCESS OF PHARYNX; CELLULITIS OF PHARYNX; NASOPHARYNGEAL ABSCESS 19,500.00
13,650.00
5,850.00
J39.2 OTHER DISEASES OF PHARYNX; CYST OF PHARYNX OR NASOPHARYNX; OEDEMA OF PHARYNX OR NASOPHARYNX 19,500.00
13,650.00
5,850.00
J40 BRONCHITIS, NOT SPECIFIED AS ACUTE OR CHRONIC 7,800.00
5,460.00
2,340.00
J43.0 MACLEOD'S SYNDROME; UNILATERAL EMPHYSEMA; UNILATERAL TRANSPARENCY OF LUNG 22,230.00
15,561.00
6,669.00
J43.1 PANLOBULAR EMPHYSEMA; PANACINAR EMPHYSEMA 22,230.00
15,561.00
6,669.00
J43.2 CENTRILOBULAR EMPHYSEMA 22,230.00
15,561.00
6,669.00
J43.8 OTHER EMPHYSEMA 22,230.00
15,561.00
6,669.00
J43.9 EMPHYSEMA, UNSPECIFIED; LUNG EMPHYSEMA NOS; PULMONARY EMPHYSEMA NOS; BULLOUS LUNG EMPHYSEMA; BULLOUS PULMONARY EMPHYSEMA; VESICULAR LUNG EMPHYSEMA; VESUCULAR PULMONARY EMPHYSEMA; EMPHYSEMATOUS BLEB 22,230.00
15,561.00
6,669.00
J44.0 CHRONIC OBSTRUCTIVE/ ASTHMATIC/ EMPHYSEMATOUS PULMONARY DISEASE WITH ACUTE LOWER RESPIRATORY INFECTION 23,790.00
16,653.00
7,137.00
J44.1 CHRONIC OBSTRUCTIVE/ ASTHMATIC/ EMPHYSEMATOUS PULMONARY DISEASE WITH ACUTE EXACERBATION, UNSPECIFIED 23,790.00
16,653.00
7,137.00
J44.8 CHRONIC ASTHMATIC (OBSTRUCTIVE) BRONCHITIS NOS; CHRONIC EMPHYSEMATOUS BRONCHITIS NOS; CHRONIC OBSTRUCTIVE BRONCHITIS NOS 23,790.00
16,653.00
7,137.00
J44.9 CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED; CHRONIC OBSTRUCTIVE AIRWAY DISEASE NOS; CHRONIC OBSTRUCTIVE LUNG DISEASE NOS 23,790.00
16,653.00
7,137.00
J60 COALWORKER'S PNEUMOCONIOSIS; ANTHRACOSILICOSIS; ANTHRACOSIS; COALWORKER'S LUNG 28,665.00
20,065.50
8,599.50
J61 PNEUMOCONIOSIS DUE TO ASBESTOS AND OTHER MINERAL FIBRES; ASBESTOSIS 28,665.00
20,065.50
8,599.50
J62.0 PNEUMOCONIOSIS DUE TO TALC DUST 28,665.00
20,065.50
8,599.50
J62.8 PNEUMOCONIOSIS DUE TO OTHER DUST CONTAINING SILICA; SILICOSIS NOS 28,665.00
20,065.50
8,599.50
J63.0 ALUMINOSIS (OF LUNG) 28,665.00
20,065.50
8,599.50
J63.3 GRAPHITE FIBROSIS (OF LUNG) 28,665.00
20,065.50
8,599.50
J63.4 SIDEROSIS 28,665.00
20,065.50
8,599.50
J63.8 PNEUMOCONIOSIS DUE TO OTHER SPECIFIED INORGANIC DUSTS 28,665.00
20,065.50
8,599.50
J64 UNSPECIFIED PNEUMOCONIOSIS 28,665.00
20,065.50
8,599.50
J65 PNEUMOCONIOSIS ASSOCIATED WITH TUBERCULOSIS 28,665.00
20,065.50
8,599.50
J66.2 CANNABINOSIS 28,665.00
20,065.50
8,599.50
J66.8 AIRWAY DISEASE DUE TO OTHER SPECIFIC ORGANIC DUSTS 28,665.00
20,065.50
8,599.50
J67.0 FARMER'S LUNG; HARVESTER'S LUNG; HAYMAKER'S LUNG; MOULDY HAY DISEASE 28,665.00
20,065.50
8,599.50
J67.1 BAGASSOSIS; BAGASSE DISEASE; BAGASSE PNEUMONITIS 28,665.00
20,065.50
8,599.50
J67.5 MUSHROOM-WORKER'S LUNG 28,665.00
20,065.50
8,599.50
J67.7 AIR-CONDITIONER AND HUMIDIFIER LUNG; ALLERGIC ALVEOLITIS DUE TO FUNGI, THERMOPHILIC ACTINOMYCETEES AND OTHER ORGANISMS GROWING IN VENTILATION (AIR-CONDITIONING) SYSTEMS 28,665.00
20,065.50
8,599.50
J67.8 HYPERSENSITIVITY PNEUMONITIS DUE TO OTHER ORGANIC DUSTS; CHEESE-WASHER'S LUNG; COFFEE-WORKER'S LUNG; FISHMEAL-WORKER'S LUNG; FURRIER'S LUNG; SEQUOIOSIS 28,665.00
20,065.50
8,599.50
J67.9 HYPERSENSITIVITY PNEUMONITIS DUE TO UNSPECIFIED ORGANIC DUST; EXTRINSIC ALLERGIC ALVEOLITIS NOS; HYPERSENSITIVITY PNEUMONITIS NOS 28,665.00
20,065.50
8,599.50
J68.0 BRONCHITIS AND PNEUMONITIS DUE TO CHEMICALS, GASES, FUMES AND VAPOURS; ACUTE CHEMICAL BRONCHITIS 28,665.00
20,065.50
8,599.50
J68.1 ACUTE PULMONARY OEDEMA DUE TO CHEMICALS, GASES, FUMES AND VAPOURS; ACUTE CHEMICAL PULMONARY OEDEMA 28,665.00
20,065.50
8,599.50
J68.2 UPPER RESPIRATORY INFLAMMATION DUE TO CHEMICALS, GASES, FUMES AND VAPOURS, NOT ELSEWHERE CLASSIFIED 28,665.00
20,065.50
8,599.50
J68.3 OTHER ACUTE AND SUBACUTE RESPIRATORY CONDITIONS DUE TO CHEMICALS, GASES, FUMES AND VAPOURS; REACTIVE AIRWAYS DYSFUNCTION SYNDROME; HYPERACTIVE AIRWAY DISEASE 28,665.00
20,065.50
8,599.50
Page 44 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate J68.4 CHRONIC RESPIRATORY CONDITIONS DUE TO CHEMICALS, GASES, FUMES AND VAPOURS; DIFFUSE EMPHYSEMA DUE TO INHALATION OF CHEMICALS, GASES, FUMES AND VAPOURS; CHRONIC EMPHYSEMA DUE TO INHALATION OF CHEMICALS, GASES, FUMES AND VAPOURS; CHRONIC OBLITERATIVE BRONCHI 28,665.00
20,065.50
8,599.50
J68.8 OTHER RESPIRATORY CONDITIONS DUE TO CHEMICALS, GASES, FUMES AND VAPOURS 28,665.00
20,065.50
8,599.50
J68.9 UNSPECIFIED RESPIRATORY CONDITION DUE TO CHEMICALS, GASES, FUMES AND VAPOURS 28,665.00
20,065.50
8,599.50
J69.0 PNEUMONITIS DUE TO FOOD AND VOMIT; ASPIRATION PNEUMONIA DUE TO NOS; ASPIRATION PNEUMONIA DUE TO REGURGITATED FOOD; ASPIRATION PNEUMONIA DUE TO GASTRIC SECRETIONS; ASPIRATION PNEUMONIA DUE TO MILK; ASPIRATION PNEUMONIA DUE TO VOMIT 28,665.00
20,065.50
8,599.50
J69.1 PNEUMONITIS DUE TO OILS AND ESSENCES; LIPID PNEUMONIA 28,665.00
20,065.50
8,599.50
J69.8 PNEUMONITIS DUE TO OTHER SOLIDS AND LIQUIDS; PNEUMONITIS DUE TO ASPIRATION OF BLOOD 28,665.00
20,065.50
8,599.50
J70.0 ACUTE PULMONARY MANIFESTATIONS DUE TO RADIATION; RADIATION PNEUMONITIS 28,665.00
20,065.50
8,599.50
J70.2 ACUTE DRUG-INDUCED INTERSTITIAL LUNG DISORDERS 28,665.00
20,065.50
8,599.50
J70.4 DRUG-INDUCED INTERSTITIAL LUNG DISORDERS, UNSPECIFIED 28,665.00
20,065.50
8,599.50
J70.8 RESPIRATORY CONDITIONS DUE TO OTHER SPECIFIED EXTERNAL AGENTS 28,665.00
20,065.50
8,599.50
J70.9 RESPIRATORY CONDITIONS DUE TO UNSPECIFIED EXTERNAL AGENT 28,665.00
20,065.50
8,599.50
J80 ADULT RESPIRATORY DISTRESS SYNDROME; ADULT HYALINE MEMBRANE DISEASE 62,400.00
43,680.00
18,720.00
J81 PULMONARY OEDEMA; ACUTE OEDEMA OF LUNG; PASSIVE PULMONARY CONGESTION; LUNG DROPSY 27,300.00
19,110.00
8,190.00
J82 PULMONARY EOSINOPHILIA, NOT ELSEWHERE CLASSIFIED; EOSINOPHILIC ASTHMA; LOFFLER'S PNEUMONIA; TROPICAL PULMONARY EOSINOPHILIA NOS 27,300.00
19,110.00
8,190.00
J84.0 ALVEOLAR AND PARIETOALVEOLAR CONDITIONS; ALVEOLAR PROTEINOSIS; PULMONARY ALVEOLAR MICROLITHIASIS 27,300.00
19,110.00
8,190.00
J84.1 OTHER INTERSTITIAL PULMONARY DISEASES WITH FIBROSIS; DIFFUSE PULMONARY FIBROSIS; CRYPTOGENIC FIBROSING ALVEOLITIS; HAMMAN-RICH SYNDROME; IDIOPATHIC PULMONARY FIBROSIS 27,300.00
19,110.00
8,190.00
J84.8 OTHER SPECIFIED INTERSTITIAL PULMONARY DISEASES 27,300.00
19,110.00
8,190.00
J84.9 INTERSTITIAL PULMONARY DISEASE, UNSPECIFIED; INTERSTITIAL PNEUMONIA NOS 27,300.00
19,110.00
8,190.00
J85.0 GANGRENE AND NECROSIS OF LUNG 25,740.00
18,018.00
7,722.00
J85.1 ABSCESS OF LUNG WITH PNEUMONIA 19,500.00
13,650.00
5,850.00
J85.2 ABSCESS OF LUNG WITHOUT PNEUMONIA; ABSCESS OF LUNG NOS 19,500.00
13,650.00
5,850.00
J85.3 ABSCESS OF MEDIASTINUM 19,500.00
13,650.00
5,850.00
J86.0 PYOTHORAX WITH FISTULA 19,500.00
13,650.00
5,850.00
J86.9 PYOTHORAX WITHOUT FISTULA; ABSCESS OF PLEURA; ABSCESS OF THORAX; EMPYEMA; PYOPNEUMOTHORAX 19,500.00
13,650.00
5,850.00
J90 PLEURAL EFFUSION, NOT ELSEWHERE CLASSIFIED; PLEURISY WITH EFFUSION 27,690.00
19,383.00
8,307.00
J91* PLEURAL EFFUSION IN CONDITIONS CLASSIFIED ELSEWHERE 27,690.00
19,383.00
8,307.00
J92.9 PLEURAL PLAQUE WITHOUT ASBESTOS; PLEURAL PLAQUE NOS; PLEURAL THICKENING 26,325.00
18,427.50
7,897.50
J93.0 SPONTANEOUS TENSION PNEUMOTHORAX 29,835.00
20,884.50
8,950.50
J93.1 OTHER SPONTANEOUS PNEUMOTHORAX 29,835.00
20,884.50
8,950.50
J93.8 OTHER PNEUMOTHORAX 29,835.00
20,884.50
8,950.50
J93.9 PNEUMOTHORAX, UNSPECIFIED 29,835.00
20,884.50
8,950.50
J94.0 CHYLOUS EFFUSION; CHYLIFORM EFFUSION 26,325.00
18,427.50
7,897.50
J94.1 FIBROTHORAX 26,325.00
18,427.50
7,897.50
J94.8 OTHER SPECIFIED PLEURAL CONDITIONS; HYDROTHORAX 26,325.00
18,427.50
7,897.50
J94.9 PLEURAL CONDITION, UNSPECIFIED 26,325.00
18,427.50
7,897.50
J95.0 TRACHEOSTOMY MALFUNCTION; HAEMORRHAGE FROM TRACHEOSTOMY STOMA; OBSTRUCTION OF TRACHEOSTOMY AIRWAY; SEPSIS OF TRACHEOSTOMY STOMA; TRACHEO- OESOPHAGEAL FISTULA FOLLOWING TRACHEOSTOMY 20,085.00
14,059.50
6,025.50
J95.1 ACUTE PULMONARY INSUFFICIENCY FOLLOWING THORACIC SURGERY 20,085.00
14,059.50
6,025.50
J95.2 ACUTE PULMONARY INSUFFICIENCY FOLLOWING NONTHORACIC SURGERY 20,085.00
14,059.50
6,025.50
J95.4 MENDELSON'S SYNDROME 20,085.00
14,059.50
6,025.50
J95.5 POSTPROCEDURAL SUBGLOTTIC STENOSIS 20,085.00
14,059.50
6,025.50
J95.8 OTHER POSTPROCEDURAL RESPIRATORY DISORDERS 20,085.00
14,059.50
6,025.50
J95.9 POSTPROCEDURAL RESPIRATORY DISORDER, UNSPECIFIED 20,085.00
14,059.50
6,025.50
J96.0 ACUTE RESPIRATORY FAILURE 62,400.00
43,680.00
18,720.00
J96.1 CHRONIC RESPIRATORY FAILURE 62,400.00
43,680.00
18,720.00
J96.9 RESPIRATORY FAILURE, UNSPECIFIED 62,400.00
43,680.00
18,720.00
J98.0 DISEASES OF BRONCHUS, NOT ELSEWHERE CLASSIFIED; BRONCHOLITHIASIS; CALCIFICATION OF BRONCHUS; STENOSIS OF BRONCHUS; ULCER OF BRONCHUS; TRACHEOBRONCHIAL COLLAPSE; TRACHEOBRONCHIAL DYSKINESIA 19,890.00
13,923.00
5,967.00
Page 45 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate J98.1 PULMONARY COLLAPSE; ATELECTASIS; COLLAPSE OF LUNG; BROCK'S SYNDROME 26,910.00
18,837.00
8,073.00
J98.2 INTERSTITIAL EMPHYSEMA; MEDIASTINAL EMPHYSEMA 22,230.00
15,561.00
6,669.00
J98.3 COMPENSATORY EMPHYSEMA 22,230.00
15,561.00
6,669.00
J98.4 OTHER DISORDERS OF LUNG; CALCIFICATION OF LUNG; ACQUIRED CYSTIC LUNG DISEASE; LUNG DISEASE NOS; PULMOLITHIASIS 19,890.00
13,923.00
5,967.00
J98.5 DISEASES OF MEDIASTINUM, NOT ELSEWHERE CLASSIFIED; FIBROSIS OF MEDIASTINUM; HERNIA OF MEDIASTINUM; RETRACTION OF MEDIASTINUM; MEDIASTINITIS OF MEDIASTINUM 19,890.00
13,923.00
5,967.00
J98.6 DISORDERS OF DIAPHRAGM; DIAPHRAGMATITIS; PARALYSIS OF DIAPHRAGM; RELAXATION OF DIAPHRAGM 19,890.00
13,923.00
5,967.00
J98.8 OTHER SPECIFIED RESPIRATORY DISORDERS 19,890.00
13,923.00
5,967.00
J98.9 RESPIRATORY DISORDER, UNSPECIFIED; CHRONIC RESPIRATORY DISEASE NOS 19,890.00
13,923.00
5,967.00
K04.0 PULPITIS; PULPAL ABSCESS; PULPAL POLYP; ACUTE PULPITIS; HYPERPLASTIC CHRONIC PULPITIS; ULCERATIVE CHRONIC PULPITIS; SUPPARATIVE PULPITIS 7,800.00
5,460.00
2,340.00
K04.1 NECROSIS OF PULP; PULPAL GANGRENE 7,800.00
5,460.00
2,340.00
K04.2 PULP DEGENERATION; DENTICLES; PULPAL CALCIFICATIONS; PULPAL STONES 7,800.00
5,460.00
2,340.00
K04.3 ABNORMAL HARD TISSUE FORMATION IN PULP; SECONDARY OR IRREGULAR DENTINE 7,800.00
5,460.00
2,340.00
K04.4 ACUTE APICAL PERIODONTITIS OF PULPAL ORIGIN; ACUTE APICAL PERIODONTITIS NOS 7,800.00
5,460.00
2,340.00
K04.5 CHRONIC APICAL PERIODONTITIS; APICAL OR PERIAPICAL GRANULOMA; APICAL PERIODONTITIS NOS 7,800.00
5,460.00
2,340.00
K04.6 PERIAPICAL ABSCESS WITH SINUS; DENTAL ABSCESS WITH SINUS; DENTOALVEOLAR ABSCESS WITH SINUS 7,800.00
5,460.00
2,340.00
K04.7 PERIAPICAL ABSCESS WITHOUT SINUS; DENTAL ABSCESS NOS; DENTOALVEOLAR ABSCESS NOS; PERIAPICAL ABSCESS NOS 7,800.00
5,460.00
2,340.00
K04.8 RADICULAR CYST; PERIODONTAL APICAL CYST; PERIAPICAL CYST; RESIDUAL RADICULAR CYST 7,800.00
5,460.00
2,340.00
K04.9 OTHER AND UNSPECIFIED DISEASES OF PULP AND PERIAPICAL TISSUES 7,800.00
5,460.00
2,340.00
K09.0 DEVELOPMENTAL ODONTOGENIC CYSTS; DENTIGEROUS CYST; ERUPTION CYST; FOLLICULAR CYST; GINGIVAL CYST; LATERAL PERIODONTAL CYST; PRIMORDIAL CYST; KERATOCYST 16,185.00
11,329.50
4,855.50
K09.1 DEVELOPMENTAL (NONODONTOGENIC) CYSTS OF ORAL REGION; CYST OF GLOBULOMAXILLARY; CYST OF INCISIVE CANAL; CYST OF MEDIAN PALATAL; CYST OF NASOPALATINE; CYST OF PALATINE PAPILLA 16,185.00
11,329.50
4,855.50
K09.2 OTHER CYSTS OF JAW; CYST OF JAW NOS; ANEURYSMAL CYST OF JAW; HAEMORRHAGIC CYST OF JAW; TRAUMATIC CYST OF JAW 16,185.00
11,329.50
4,855.50
K09.8 OTHER CYSTS OF ORAL REGION, NOT ELSEWHERE CLASSIFIED; DERMOID CYST OF MOUTH; EPIDERMOID CYST OF MOUTH; LYMPHOEPITHELIAL CYST OF MOUTH; EPSTEIN'S PEARL; NASOALVEOLAR CYST; NASOLABIAL CYST 16,185.00
11,329.50
4,855.50
K09.9 CYST OF ORAL REGION, UNSPECIFIED 16,185.00
11,329.50
4,855.50
K10.0 DEVELOPMENTAL DISORDERS OF JAWS; LATENT BONE CYST OF JAW; STAFNE'S CYST; TORUS MANDIBULARIS; TORUS PALATINUS 16,185.00
11,329.50
4,855.50
K10.1 GIANT CELL GRANULOMA, CENTRAL; GIANT CELL GRANULOMA NOS 16,185.00
11,329.50
4,855.50
K10.2 INFLAMMATORY CONDITIONS OF JAWS; ACUTE OSTEITIS OF JAW; CHRONIC OSTEITIS OF JAW; SUPPARATIVE OSTEITIS OF JAW; ACUTE NEONATAL OSTEOMYELITIS OF JAW; CHRONIC NEONATAL OSTEOMYELITIS OF JAW; SUPPARATIVE NEONATAL OSTEOMYELITIS OF JAW; ACUTE OSTEORADIONECROSIS O 16,185.00
11,329.50
4,855.50
K10.3 ALVEOLITIS OF JAWS; ALVEOLAR OSTEITIS; DRY SOCKET 16,185.00
11,329.50
4,855.50
K10.8 OTHER SPECIFIED DISEASES OF JAWS; CHERUBISM OF JAW; EXOSTOSIS OF JAW; FIBROUS DYSPLASIA OF JAW; UNILATERAL CONDYLAR HYPERPLASIA; UNILATERAL CONDYLAR HYPOPLASIA 16,185.00
11,329.50
4,855.50
K11.2 SIALOADENITIS 16,185.00
11,329.50
4,855.50
K11.3 ABSCESS OF SALIVARY GLAND 16,185.00
11,329.50
4,855.50
K11.4 FISTULA OF SALIVARY GLAND 16,185.00
11,329.50
4,855.50
K11.5 SIALOLITHIASIS; CALCULUS OF SALIVARY GLAND OR DUCT; STONE OF SALIVARY GLAND OR DUCT 16,185.00
11,329.50
4,855.50
K11.6 MUCOCELE OF SALIVARY GLAND; MUCOUS EXTRAVASATION CYST OF SALIVARY GLAND; MUCOUS RETENTION CYST OF SALIVARY GLAND; RANULA 16,185.00
11,329.50
4,855.50
K11.8 OTHER DISEASES OF SALIVARY GLANDS; BENIGN LYMPHOEPITHELIAL LESION OF SALIVARY GLAND; MIKULICZ' DISEASE; NECROTIZING SIALOMETAPLASIA; SIALECTASIA; STENOSIS OF SALIVARY DUCT; STRICTURE OF SALIVARY DUCT 16,185.00
11,329.50
4,855.50
K11.9 DISEASE OF SALIVARY GLAND, UNSPECIFIED; SIALOADENOPATHY NOS 16,185.00
11,329.50
4,855.50
K12.2 CELLULITIS AND ABSCESS OF MOUTH; CELLULITIS OF FLOOR OF MOUTH; SUBMANDIBULAR ABSCESS 16,185.00
11,329.50
4,855.50
Page 46 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate K13.4 GRANULOMA AND GRANULOMA-LIKE LESIONS OF ORAL MUCOSA; EOSINOPHILIC GRANULOMA OF ORAL MUCOSA; GRANULOMA PYOGENICUM OF ORAL MUCOSA; VERRUCOUS XANTHOMA OF ORAL MUCOSA 16,185.00
11,329.50
4,855.50
K13.7 OTHER AND UNSPECIFIED LESIONS OF ORAL MUCOSA; FOCAL ORAL MUCINOSIS 16,185.00
11,329.50
4,855.50
K20 OESOPHAGITIS; ABSCESS OF OESOPHAGUS; OESOPHAGITIS NOS; CHEMICAL OESOPHAGITIS; PEPTIC OESOPHAGITIS 16,185.00
11,329.50
4,855.50
K21.0 GASTRO-OESOPHAGEAL REFLUX DISEASE WITH OESOPHAGITIS; REFLUX OESOPHAGITIS 11,895.00
8,326.50
3,568.50
K21.9 GASTRO-OESOPHAGEAL REFLUX DISEASE WITHOUT OESOPHAGITIS; OESOPHAGEAL REFLUX NOS 11,895.00
8,326.50
3,568.50
K22.0 ACHALASIA OF CARDIA; ACHALASIA NOS; CARDIOSPASM 16,185.00
11,329.50
4,855.50
K22.1 ULCER OF OESOPHAGUS; EROSION OF OESOPHAGUS; ULCER OF OESOPHAGUS NOS; ULCER OF OESOPHAGUS DUE TO INGESTION OF CHEMICALS; ULCER OF OESOPHAGUS DUE TO INGESTION OF DRUGS AND MEDICAMENTS; FUNGAL ULCER OF OESOPHAGUS; PEPTIC ULCER OF OESOPHAGUS 16,185.00
11,329.50
4,855.50
K22.2 OESOPHAGEAL OBSTRUCTION; COMPRESSION OF OESOPHAGUS; CONSTRICTION OF OESOPHAGUS; STENOSIS OF OESOPHAGUS; STRICTURE OF OESOPHAGUS; 16,185.00
11,329.50
4,855.50
K22.3 PERFORATION OF OESOPHAGUS; RUPTURE OF OESOPHAGUS 16,185.00
11,329.50
4,855.50
K22.4 DYSKINESIA OF OESOPHAGUS; CORKSREW OESOPHAGUS; DIFFUSE OESOPHAGEAL SPASM; SPASM OF OESOPHAGUS 16,185.00
11,329.50
4,855.50
K22.6 GASTRO-OESOPHAGEAL LACERATION-HAEMORRHAGE SYNDROME; MALLORY-WEISS SYNDROME 16,185.00
11,329.50
4,855.50
K22.7 BARRETT'S ESOPHAGUS; BARRET'S DISEASE; BARETT'S SYNDROME 16,185.00
11,329.50
4,855.50
K22.8 OTHER SPECIFIED DISEASES OF OESOPHAGUS; HAEMORRHAGE OF OESOPHAGUS NOS 16,185.00
11,329.50
4,855.50
K22.9 DISEASE OF OESOPHAGUS, UNSPECIFIED 16,185.00
11,329.50
4,855.50
K25.0 GASTRIC ULCER, ACUTE / ACUTE EROSION OF STOMACH/ PYLORUS PEPTIC ULCER / STOMACH PEPTIC ULCER WITH HEMORRHAGE 24,960.00
17,472.00
7,488.00
K25.1 GASTRIC ULCER, ACUTE/ ACUTE EROSION OF STOMACH/ PYLORUS PEPTIC ULCER / STOMACH PEPTIC ULCER WITH PERFORATION 24,960.00
17,472.00
7,488.00
K25.2 GASTRIC ULCER, ACUTE / ACUTE EROSION OF STOMACH/ PYLORUS PEPTIC ULCER / STOMACH PEPTIC ULCER WITH BOTH HAEMORRHAGE AND PERFORATION 24,960.00
17,472.00
7,488.00
K25.3 GASTRIC ULCER, ACUTE / ACUTE EROSION OF STOMACH/ PYLORUS PEPTIC ULCER / STOMACH PEPTIC ULCER WITHOUT HAEMORRHAGE OR PERFORATION 11,895.00
8,326.50
3,568.50
K25.4 GASTRIC/ PEPTIC/ PYLORIC ULCER/ EROSION, CHRONIC OR UNSPECIFIED WITH HAEMORRHAGE 24,960.00
17,472.00
7,488.00
K25.5 GASTRIC/ PEPTIC/ PYLORIC ULCER/ EROSION, CHRONIC OR UNSPECIFIED WITH PERFORATION 24,960.00
17,472.00
7,488.00
K25.6 GASTRIC/ PEPTIC/ PYLORIC ULCER/ EROSION, CHRONIC OR UNSPECIFIED WITH BOTH HAEMORRHAGE AND PERFORATION 24,960.00
17,472.00
7,488.00
K25.7 GASTRIC/ PEPTIC/ PYLORIC ULCER/ EROSION, CHRONIC WITHOUT HAEMORRHAGE OR PERFORATION 11,895.00
8,326.50
3,568.50
K25.9 GASTRIC/ PEPTIC/ PYLORIC ULCER/ EROSION, UNSPECIFIED AS ACUTE OR CHRONIC, WITHOUT HAEMORRHAGE OR PERFORATION 11,895.00
8,326.50
3,568.50
K26.0 DUODENAL ULCER, ACUTE / ACUTE EROSION OF DUODENUM/ DUODENAL PEPTIC ULCER/ POSTPYLORIC PEPTIC ULCER WITH HAEMORRHAGE 24,960.00
17,472.00
7,488.00
K26.1 DUODENAL ULCER, ACUTE / ACUTE EROSION OF DUODENUM/ DUODENAL PEPTIC ULCER/ POSTPYLORIC PEPTIC ULCER WITH PERFORATION 24,960.00
17,472.00
7,488.00
K26.3 DUODENAL ULCER, ACUTE / ACUTE EROSION OF DUODENUM/ DUODENAL PEPTIC ULCER/ POSTPYLORIC PEPTIC ULCER WITHOUT HAEMORRHAGE OR PERFORATION 11,895.00
8,326.50
3,568.50
K26.4 CHRONIC DUODENAL/ POSTPYLORIC ULCER/ EROSION, OR UNSPECIFIED WITH HAEMORRHAGE 24,960.00
17,472.00
7,488.00
K26.5 CHRONIC DUODENAL/ POSTPYLORIC ULCER/ EROSION, OR UNSPECIFIED WITH PERFORATION 24,960.00
17,472.00
7,488.00
K26.6 CHRONIC DUODENAL/ POSTPYLORIC ULCER/ EROSION, OR UNSPECIFIED WITH BOTH HAEMORRHAGE AND PERFORATION 24,960.00
17,472.00
7,488.00
K26.7 CHRONIC DUODENAL/ POSTPYLORIC ULCER/ EROSION, WITHOUT HAEMORRHAGE OR PERFORATION 11,895.00
8,326.50
3,568.50
K26.9 DUODENAL/ POSTPYLORIC ULCER/ EROSION, UNSPECIFIED AS ACUTE OR CHRONIC, WITHOUT HAEMORRHAGE OR PERFORATION 11,895.00
8,326.50
3,568.50
K27.0 ACUTE PEPTIC ULCER/ GASTRODUODENAL ULCER NOS, SITE UNSPECIFIED, WITH HAEMORRHAGE 24,960.00
17,472.00
7,488.00
K27.1 ACUTE PEPTIC ULCER / GASTRODUODENAL ULCER, SITE UNSPECIFIED, WITH PERFORATION 24,960.00
17,472.00
7,488.00
K27.2
ACUTE PEPTIC/ GASTRODUODENAL ULCER, SITE UNSPECIFIED,
WITH BOTH HAEMORRHAGE AND PERFORATION
24,960.00
17,472.00
7,488.00
K27.3 ACUTE PEPTIC/ GASTRODUODENAL ULCER, SITE UNSPECIFIED, WITHOUT HAEMORRHAGE OR PERFORATION 11,895.00
8,326.50
3,568.50
K27.4 CHRONIC OR UNSPECIFIED PEPTIC/ GASTRODUODENAL ULCER, SITE UNSPECIFIED, WITH HAEMORRHAGE 24,960.00
17,472.00
7,488.00
Page 47 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate K27.5 CHRONIC OR UNSPECIFIED PEPTIC/ GASTRODUODENAL ULCER, SITE UNSPECIFIED WITH PERFORATION 24,960.00
17,472.00
7,488.00
K27.6 CHRONIC OR UNSPECIFIED PEPTIC/ GASTRODUODENAL ULCER, SITE UNSPECIFIED, WITH BOTH HAEMORRHAGE AND PERFORATION 24,960.00
17,472.00
7,488.00
K27.7
CHRONIC PEPTIC/ GASTRODUODENAL ULCER, SITE UNSPECIFIED,
WITHOUT HAEMORRHAGE OR PERFORATION
11,895.00
8,326.50
3,568.50
K27.9 PEPTIC/ GASTRODUODENAL ULCER, UNSPECIFIED AS ACUTE OR CHRONIC, WITHOUT HAEMORRHAGE OR PERFORATION 11,895.00
8,326.50
3,568.50
K28.0 ACUTE GASTROJEJUNAL ULCER/ ANASTOMOTIC PEPTIC ULCER OR EROSION/ GASTROCOLIC PEPTIC ULCER OR EROSION/ GASTROINTESTINAL PEPTIC ULCER OR EROSION/ GASTROJEJUNAL PEPTIC ULCER OR EROSION/ JEJUNAL PEPTIC ULCER OR EROSION/ MARGINAL PEPTIC ULCER OR EROSION/ STOMAL 24,960.00
17,472.00
7,488.00
K28.1 ACUTE GASTROJEJUNAL ULCER/ ANASTOMOTIC PEPTIC ULCER OR EROSION/ GASTROCOLIC PEPTIC ULCER OR EROSION/ GASTROINTESTINAL PEPTIC ULCER OR EROSION/ GASTROJEJUNAL PEPTIC ULCER OR EROSION/ JEJUNAL PEPTIC ULCER OR EROSION/ MARGINAL PEPTIC ULCER OR EROSION/ STOMAL 24,960.00
17,472.00
7,488.00
K28.2 ACUTE GASTROJEJUNAL ULCER/ ANASTOMOTIC PEPTIC ULCER OR EROSION/ GASTROCOLIC PEPTIC ULCER OR EROSION/ GASTROINTESTINAL PEPTIC ULCER OR EROSION/ GASTROJEJUNAL PEPTIC ULCER OR EROSION/ JEJUNAL PEPTIC ULCER OR EROSION/ MARGINAL PEPTIC ULCER OR EROSION/ STOMAL 24,960.00
17,472.00
7,488.00
K28.3 ACUTE GASTROJEJUNAL ULCER/ ANASTOMOTIC PEPTIC ULCER OR EROSION/ GASTROCOLIC PEPTIC ULCER OR EROSION/ GASTROINTESTINAL PEPTIC ULCER OR EROSION/ GASTROJEJUNAL PEPTIC ULCER OR EROSION/ JEJUNAL PEPTIC ULCER OR EROSION/ MARGINAL PEPTIC ULCER OR EROSION/ STOMAL 24,960.00
17,472.00
7,488.00
K28.4 CHRONIC OR UNSPECIFIED GASTROJEJUNAL ULCER/ ANASTOMOTIC PEPTIC ULCER OR EROSION/ GASTROCOLIC PEPTIC ULCER OR EROSION/ GASTROINTESTINAL PEPTIC ULCER OR EROSION/ GASTROJEJUNAL PEPTIC ULCER OR EROSION/ JEJUNAL PEPTIC ULCER OR EROSION/ MARGINAL PEPTIC ULCER O 24,960.00
17,472.00
7,488.00
K28.5 CHRONIC OR UNSPECIFIED GASTROJEJUNAL ULCER/ ANASTOMOTIC PEPTIC ULCER OR EROSION/ GASTROCOLIC PEPTIC ULCER OR EROSION/ GASTROINTESTINAL PEPTIC ULCER OR EROSION/ GASTROJEJUNAL PEPTIC ULCER OR EROSION/ JEJUNAL PEPTIC ULCER OR EROSION/ MARGINAL PEPTIC ULCER O 24,960.00
17,472.00
7,488.00
K28.6 CHRONIC OR UNSPECIFIED GASTROJEJUNAL ULCER/ ANASTOMOTIC PEPTIC ULCER OR EROSION/ GASTROCOLIC PEPTIC ULCER OR EROSION/ GASTROINTESTINAL PEPTIC ULCER OR EROSION/ GASTROJEJUNAL PEPTIC ULCER OR EROSION/ JEJUNAL PEPTIC ULCER OR EROSION/ MARGINAL PEPTIC ULCER O 24,960.00
17,472.00
7,488.00
K28.7 CHRONIC GASTROJEJUNAL ULCER/ ANASTOMOTIC PEPTIC ULCER OR EROSION/ GASTROCOLIC PEPTIC ULCER OR EROSION/ GASTROINTESTINAL PEPTIC ULCER OR EROSION/ GASTROJEJUNAL PEPTIC ULCER OR EROSION/ JEJUNAL PEPTIC ULCER OR EROSION/ MARGINAL PEPTIC ULCER OR EROSION/ STOM 11,895.00
8,326.50
3,568.50
K28.9 UNSPECIFIED AS ACUTE OR CHRONIC GASTROJEJUNAL ULCER/ ANASTOMOTIC PEPTIC ULCER OR EROSION/ GASTROCOLIC PEPTIC ULCER OR EROSION/ GASTROINTESTINAL PEPTIC ULCER OR EROSION/ GASTROJEJUNAL PEPTIC ULCER OR EROSION/ JEJUNAL PEPTIC ULCER OR EROSION/ MARGINAL PEPTI 11,895.00
8,326.50
3,568.50
K29.0 ACUTE HAEMORRHAGIC GASTRITIS; ACUTE EROSIVE GASTRITIS WITH HAEMORRHAGE 24,960.00
17,472.00
7,488.00
K29.1 OTHER ACUTE GASTRITIS 11,895.00
8,326.50
3,568.50
K29.2 ALCOHOLIC GASTRITIS 11,895.00
8,326.50
3,568.50
K29.3 CHRONIC SUPERFICIAL GASTRITIS 11,895.00
8,326.50
3,568.50
K29.4 CHRONIC ATROPHIC GASTRITIS; GASTRIC ATROPHY 11,895.00
8,326.50
3,568.50
K29.5 CHRONIC GASTRITIS, UNSPECIFIED; CHRONIC ANTRAL GASTRITIS; CHRONIC FUNDAL GASTRITIS 11,895.00
8,326.50
3,568.50
K29.6 OTHER GASTRITIS; GIANT HYPERTROPHIC GASTRITIS; GRANULOMATOUS GASTRITIS; MENETRIER'S DISEASE 11,895.00
8,326.50
3,568.50
K29.7 GASTRITIS, UNSPECIFIED 11,895.00
8,326.50
3,568.50
K29.8 DUODENITIS 11,895.00
8,326.50
3,568.50
K29.9 GASTRODUODENITIS, UNSPECIFIED 11,895.00
8,326.50
3,568.50
K30 DYSPEPSIA 7,800.00
5,460.00
2,340.00
K31.0 ACUTE DILATATION OF STOMACH; ACUTE DISTENSION OF STOMACH 7,800.00
5,460.00
2,340.00
K31.1 ADULT HYPERTROPHIC PYLORIC STENOSIS; PYLORIC STENOSIS NOS 12,870.00
9,009.00
3,861.00
K31.2 HOURGLASS STRICTURE AND STENOSIS OF STOMACH 12,870.00
9,009.00
3,861.00
K31.3 PYLOROSPASM, NOT ELSEWHERE CLASSIFIED 12,870.00
9,009.00
3,861.00
K31.4 GASTRIC DIVERTICULUM 12,870.00
9,009.00
3,861.00
K31.5 OBSTRUCTION OF DUODENUM; CONSTRICTION OF DUODENUM; STENOSIS OF DUODENUM; STRICTURE OF DUODENUM; CHRONIC DUODENAL ILEUS 12,870.00
9,009.00
3,861.00
Page 48 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate K31.6 FISTULA OF STOMACH AND DUODENUM; GASTROCOLIC FISTULA; GASTROJEJUNOCOLIC FISTULA 12,870.00
9,009.00
3,861.00
K31.7 POLYP OF STOMACH AND DUODENUM 12,870.00
9,009.00
3,861.00
K31.8 OTHER SPECIFIED DISEASES OF STOMACH AND DUODENUM; ACHLORHYDRIA; GASTROPTOSIS; HOURGLASS CONTRACTION OF STOMACH 12,870.00
9,009.00
3,861.00
K31.9 DISEASE OF STOMACH AND DUODENUM, UNSPECIFIED 7,800.00
5,460.00
2,340.00
K50.0 CROHN'S DISEASE OF SMALL INTESTINE; CROHN'S DISEASE [REGIONAL ENTERITIS] OF DUODENUM; CROHN'S DISEASE [REGIONAL ENTERITIS] OF ILEUM; CROHN'S DISEASE [REGIONAL ENTERITIS] OF JEJUNUM; REGIONAL ILEITIS; TERMINAL ILEITIS 17,745.00
12,421.50
5,323.50
K50.1 CROHN'S DISEASE OF LARGE INTESTINE; GRANULOMATOUS COLITIS; REGIONAL COLITIS; CROHN'S DISEASE [REGIONAL ENTERITIS] OF COLON; CROHN'S DISEASE [REGIONAL ENTERITIS] OF LARGE BOWEL; CROHN'S DISEASE [REGIONAL ENTERITIS] OF RECTUM 17,745.00
12,421.50
5,323.50
K50.8 OTHER CROHN'S DISEASE; CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE 17,745.00
12,421.50
5,323.50
K50.9 CROHN'S DISEASE [REGIONAL ENTERITIS], UNSPECIFIED; CROHN'S DISEASE NOS; REGIONAL ENTERITIS NOS; GRANULOMATOUS ENTERITIS NOS 17,745.00
12,421.50
5,323.50
K51.0 ULCERATIVE (CHRONIC) ENTEROCOLITIS 17,745.00
12,421.50
5,323.50
K51.1 ULCERATIVE (CHRONIC) ILEOCOLITIS 17,745.00
12,421.50
5,323.50
K51.2 ULCERATIVE (CHRONIC) PROCTITIS 17,745.00
12,421.50
5,323.50
K51.3 ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS 17,745.00
12,421.50
5,323.50
K51.5 MUCOSAL PROCTOCOLITIS 17,745.00
12,421.50
5,323.50
K51.8 OTHER ULCERATIVE COLITIS 17,745.00
12,421.50
5,323.50
K51.9 ULCERATIVE COLITIS, UNSPECIFIED; ULCERATIVE ENTERITIS NOS 17,745.00
12,421.50
5,323.50
K52.0 GASTROENTERITIS AND COLITIS DUE TO RADIATION 11,700.00
8,190.00
3,510.00
K52.1 TOXIC GASTROENTERITIS AND COLITIS 11,700.00
8,190.00
3,510.00
K52.2 ALLERGIC AND DIETETIC GASTROENTERITIS AND COLITIS; FOOD HYPERSENSITIVITY GASTROENTERITIS OR COLITIS 11,700.00
8,190.00
3,510.00
K52.8 OTHER SPECIFIED NONINFECTIVE GASTROENTERITIS AND COLITIS; EOSINOPHILIC GASTRITIS OR GASTROENTERITIS 11,700.00
8,190.00
3,510.00
K52.9 NONINFECTIVE GASTROENTERITIS AND COLITIS, UNSPECIFIED; DIARRHOEA SPECIFIED AS NONINFECTIVE, OR NOS IN COUNTRIES WHERE THE CONDITIONS CAN BE PRESUMED TO BE OF NONINFECTIOUS ORIGIN; ENTERITIS SPECIFIED AS NONINFECTIVE, OR NOS IN COUNTRIES WHERE THE CONDITIO 11,700.00
8,190.00
3,510.00
K55.0 ACUTE VASCULAR DISORDERS OF INTESTINE; ACUTE FULMINANT ISCHAEMIC COLITIS; ACUTE INTESTINAL INFARCTION; ACUTE SMALL INTESTINE ISCHAEMIA; MESENTRIC ARTERY EMBOLISM; MESENTRIC VEIN EMBOLISM; MESENTRIC ARTERY INFARCTION; MESENTRIC VEIN INFARCTION; MESENTRIC A 18,525.00
12,967.50
5,557.50
K55.1 CHRONIC VASCULAR DISORDERS OF INTESTINE; CHRONIC ISCHAEMIC COLITIS; CHRONIC ISCHAEMIC ENTERITIS; CHRONIC ISCHAEMIC ENTEROCOLITIS; ISCHAEMIC STRICTURE OF INTESTINE; MESENTRIC ATHEROSCLEROSIS; MESENTRIC VASCULAR INSUFFICIENCY 18,525.00
12,967.50
5,557.50
K55.2 ANGIODYSPLASIA OF COLON 18,525.00
12,967.50
5,557.50
K55.9 VASCULAR DISORDER OF INTESTINE, UNSPECIFIED; ISCHAEMIC COLITIS NOS; ISCHAEMIC ENTERITIS NOS; ISCHAEMIC ENTEROCOLITIS NOS 18,525.00
12,967.50
5,557.50
K56.0 PARALYTIC ILEUS; PARALYSIS OF BOWEL; PARALYSIS OF COLON; PARALYSIS OF INTESTINE 19,695.00
13,786.50
5,908.50
K56.1 INTUSSUSCEPTION; INTUSSUSCEPTION OR INVAGINATION OF BOWEL; INTUSSUSCEPTION OR INVAGINATION OF COLON; INTUSSUSCEPTION OR INVAGINATION OF INTESTINE; INTUSSUSCEPTION OR INVAGINATION OF RECTUM 19,695.00
13,786.50
5,908.50
K56.2 VOLVULUS; STRANGULATION OF COLON OR INTESTINE; TORSION OF COLON OR INTESTINE; TWIST OF COLON OR INTESTINE 19,695.00
13,786.50
5,908.50
K56.3 GALLSTONE ILEUS; OBSTRUCTION OF INTESTINE BY GALLSTONE 19,695.00
13,786.50
5,908.50
K56.4 OTHER IMPACTION OF INTESTINE; ENTEROLITH; IMPACTION OF COLON; IMFACTION OF FAECAL 19,695.00
13,786.50
5,908.50
K56.5 INTESTINAL ADHESIONS [BANDS] WITH OBSTRUCTION; PERITONEAL ADHESIONS [BANDS] WITH INTESTINAL OBSTRUCTION 19,695.00
13,786.50
5,908.50
K56.6 OTHER AND UNSPECIFIED INTESTINAL OBSTRUCTION; ENTEROTENOSIS; OBSTRUCTIVE ILEUS NOS; OCCLUSION OF COLON OR INTESTINE; STENOSIS OF COLON OR INTESTINE; STRICTURE OF COLON OR INTESTINE 19,695.00
13,786.50
5,908.50
K56.7 ILEUS, UNSPECIFIED 19,695.00
13,786.50
5,908.50
K57.0 DIVERTICULAR DISEASE OF SMALL INTESTINE WITH PERFORATION AND ABSCESS; DIVERTICULAR DISEASE OF SMALL INTESTINE WITH PERITONITIS 18,525.00
12,967.50
5,557.50
K57.1 DIVERTICULAR DISEASE OF SMALL INTESTINE WITHOUT PERFORATION OR ABSCESS; DIVERTICULAR DISEASE OF SMALL INTESTINE NOS 18,525.00
12,967.50
5,557.50
Page 49 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate K57.2 DIVERTICULAR DISEASE OF LARGE INTESTINE WITH PERFORATION AND ABSCESS; DIVERTICULAR DISEASE/ DIVERTICULITIS/ DIVERTICULOSIS/ DIVERTICULUM OF COLON WITH PERITONITIS 18,525.00
12,967.50
5,557.50
K57.3 DIVERTICULAR DISEASE OF LARGE INTESTINE WITHOUT PERFORATION OR ABSCESS; DIVERTICULAR DISEASE OF COLON NOS 18,525.00
12,967.50
5,557.50
K57.4 DIVERTICULAR DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH PERFORATION AND ABSCESS; DIVERTICULAR DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH PERITONITIS 18,525.00
12,967.50
5,557.50
K57.5 DIVERTICULAR DISEASE OF BOTH SMALL AND LARGE INTESTINE WITHOUT PERFORATION OR ABSCESS; DIVERTICULAR DISEASE OF BOTH SMALL AND LARGE INTESTINE NOS 18,525.00
12,967.50
5,557.50
K57.8 DIVERTICULAR DISEASE OF INTESTINE, PART UNSPECIFIED, WITH PERFORATION AND ABSCESS; DIVERTICULAR DISEASE OF INTESTINE NOS WITH PERITONITIS 18,525.00
12,967.50
5,557.50
K57.9 DIVERTICULAR DISEASE OF INTESTINE, PART UNSPECIFIED, WITHOUT PERFORATION OR ABSCESS; DIVERTICULAR DISEASE OF INTESTINE NOS 18,525.00
12,967.50
5,557.50
K58.0 IRRITABLE BOWEL SYNDROME WITH DIARRHOEA 11,700.00
8,190.00
3,510.00
K59.0 CONSTIPATION 7,800.00
5,460.00
2,340.00
K59.3 MEGACOLON, NOT ELSEWHERE CLASSIFIED; DILATATION OF COLON; TOXIC MEGACOLON 18,525.00
12,967.50
5,557.50
K59.8 OTHER SPECIFIED FUNCTIONAL INTESTINAL DISORDERS; ATONY OF COLON 18,525.00
12,967.50
5,557.50
K59.9 FUNCTIONAL INTESTINAL DISORDER, UNSPECIFIED 18,525.00
12,967.50
5,557.50
K63.0 ABSCESS OF INTESTINE 18,525.00
12,967.50
5,557.50
K63.1 NONTRAUMATIC PERFORATION OF INTESTINE 18,525.00
12,967.50
5,557.50
K63.2 FISTULA OF INTESTINE 18,525.00
12,967.50
5,557.50
K63.3 ULCER OF INTESTINE; PRIMARY ULCER OF SMALL INTESTINE 18,525.00
12,967.50
5,557.50
K63.4 ENTEROPTOSIS 18,525.00
12,967.50
5,557.50
K63.5 POLYP OF COLON 18,525.00
12,967.50
5,557.50
K63.8 OTHER SPECIFIED DISEASES OF INTESTINE 18,525.00
12,967.50
5,557.50
K63.9 DISEASE OF INTESTINE, UNSPECIFIED 18,525.00
12,967.50
5,557.50
K65.0 ACUTE PERITONITIS; ABDOMINOPELVIC ABSCESS; MESENTERIC ABSCESS; ABSCESS OF OMENTUM; ABSCESS OF PERITONEUM; RETROCAECAL ABSCESS; RETROPERITONEAL ABSCESS; SUBDIAPHRAGMATIC ABSCESS; SUBHEPATIC ABSCESS; SUBPHRENIC ABSCESS; ACUTE GENERALIZED PERITONITIS; ACUTE 28,665.00
20,065.50
8,599.50
K65.8 OTHER PERITONITIS; CHRONIC PROLIFERATIVE PERITONITIS; MESENTRIC FAT NECROSIS; MESENTRIC SAPONIFICATION; PERITONITIS DUE TO BILE; PERITONITIS DUE TO URINE 28,665.00
20,065.50
8,599.50
K65.9 PERITONITIS, UNSPECIFIED 28,665.00
20,065.50
8,599.50
K66.0
PERITONEAL ADHESIONS; ADHESIONS OF ABDOMINAL WALL;
ADHESIONS OF DIAPHRAGM; ADHESIONS OF INTESTINE;
ADHESIONS OF MALE PELVIS; MESENTERICADHESIONS;
ADHESIONS OF OMENTUM; ADHESIONS OF STOMACH; ADHESIVE
BANDS
21,060.00
14,742.00
6,318.00
K66.8 OTHER SPECIFIED DISORDERS OF PERITONEUM 21,060.00
14,742.00
6,318.00
K66.9 DISORDER OF PERITONEUM, UNSPECIFIED 21,060.00
14,742.00
6,318.00
K70.0 ALCOHOLIC FATTY LIVER 23,010.00
16,107.00
6,903.00
K70.1 ALCOHOLIC HEPATITIS 23,010.00
16,107.00
6,903.00
K70.2 ALCOHOLIC FIBROSIS AND SCLEROSIS OF LIVER 23,010.00
16,107.00
6,903.00
K70.3 ALCOHOLIC CIRRHOSIS OF LIVER; ALCOHOLIC CIRRHOSIS NOS; LAENNEC'S CIRRHOSIS 23,010.00
16,107.00
6,903.00
K70.4 ALCOHOLIC HEPATIC FAILURE; ALCOHOLIC HEPATIC FAILURE NOS; ACUTE ALCOHOLIC HEPATIC FAILURE; CHRONIC ALCOHOLIC HEPATIC FAILURE; SUBACUTE ALCOHOLIC HEPATIC FAILURE; ALCOHOLIC HEPATIC FAILURE WITH OR WITHOUT HEPATIC COMA 40,170.00
28,119.00
12,051.00
K70.9 ALCOHOLIC LIVER DISEASE, UNSPECIFIED 23,010.00
16,107.00
6,903.00
K71.0 TOXIC LIVER DISEASE WITH CHOLESTASIS; CHOLESTATIS WITH HEPATOCYTE INJURY; PURE CHOLESTASIS 23,010.00
16,107.00
6,903.00
K71.1 TOXIC LIVER DISEASE WITH HEPATIC NECROSIS; ACUTE HEPATIC FAILURE DUE TO DRUGS; CHRONIC HEPATIC FAILURE DUE TO DRUGS 23,010.00
16,107.00
6,903.00
K71.2 TOXIC LIVER DISEASE WITH ACUTE HEPATITIS 23,010.00
16,107.00
6,903.00
K71.3 TOXIC LIVER DISEASE WITH CHRONIC PERSISTENT HEPATITIS 23,010.00
16,107.00
6,903.00
K71.4 TOXIC LIVER DISEASE WITH CHRONIC LOBULAR HEPATITIS 29,445.00
20,611.50
8,833.50
K71.5 TOXIC LIVER DISEASE WITH CHRONIC ACTIVE HEPATITIS; TOXIC LIVER DISEASE WITH LUPOID HEPATITIS 23,010.00
16,107.00
6,903.00
K71.6 TOXIC LIVER DISEASE WITH HEPATITIS, NOT ELSEWHERE CLASSIFIED 23,010.00
16,107.00
6,903.00
K71.7 TOXIC LIVER DISEASE WITH FIBROSIS AND CIRRHOSIS OF LIVER 29,445.00
20,611.50
8,833.50
K71.8 TOXIC LIVER DISEASE WITH OTHER DISORDERS OF LIVER; TOXIC LIVER DISEASE WITH FOCAL NODULAR HYPERPLASIA; TOXIC LIVER DISEASE WITH HEPATIC GRANULOMAS; TOXIC LIVER DISEASE WITH PELIOSIS HEPATIS; TOXIC LIVER DISEASE WITH VENO-OCCLUSIVE DISEASE OF LIVER 23,010.00
16,107.00
6,903.00
K71.9 TOXIC LIVER DISEASE, UNSPECIFIED 23,010.00
16,107.00
6,903.00
Page 50 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate K72.0 ACUTE AND SUBACUTE HEPATIC FAILURE 40,170.00
28,119.00
12,051.00
K72.1 CHRONIC HEPATIC FAILURE 40,170.00
28,119.00
12,051.00
K72.9 HEPATIC FAILURE 40,170.00
28,119.00
12,051.00
K73.0 CHRONIC PERSISTENT HEPATITIS, NOT ELSEWHERE CLASSIFIED 23,010.00
16,107.00
6,903.00
K73.2 CHRONIC ACTIVE HEPATITIS, NOT ELSEWHERE CLASSIFIED; LUPOID HEPATITIS NEC 23,010.00
16,107.00
6,903.00
K73.8 OTHER CHRONIC HEPATITIS, NOT ELSEWHERE CLASSIFIED 23,010.00
16,107.00
6,903.00
K73.9 CHRONIC HEPATITIS, UNSPECIFIED 23,010.00
16,107.00
6,903.00
K74.0 HEPATIC FIBROSIS 29,445.00
20,611.50
8,833.50
K74.1 HEPATIC SCLEROSIS 23,010.00
16,107.00
6,903.00
K74.2 HEPATIC FIBROSIS WITH HEPATIC SCLEROSIS 29,445.00
20,611.50
8,833.50
K74.3 PRIMARY BILIARY CIRRHOSIS; CHRONIC NONSUPPARATIVE DESTRUCTIVE CHOLANGITIS 25,740.00
18,018.00
7,722.00
K74.4 SECONDARY BILIARY CIRRHOSIS 19,110.00
13,377.00
5,733.00
K74.5 BILIARY CIRRHOSIS, UNSPECIFIED 19,110.00
13,377.00
5,733.00
K74.6 OTHER AND UNSPECIFIED CIRRHOSIS OF LIVER; CIRRHOSIS OF LIVER NOS; CRYPTOGENIC CIRRHOSIS OF LIVER; MACRONODULAR CIRRHOSIS OF LIVER; MICRONODULAR CIRRHOSIS OF LIVER; MIXED TYPE CIRRHOSIS OF LIVER; PORTAL CIRRHOSIS OF LIVER; POSTNECROTIC CIRRHOSIS OF LIVER; 29,445.00
20,611.50
8,833.50
K74.6+I98.2* OESOPHAGEAL VARICES IN OTHER AND UNSPECIFIED CIRRHOSIS OF LIVER 23,010.00
16,107.00
6,903.00
K75.0 ABSCESS OF LIVER; HEPATIC ABSCESS NOS; CHOLANGITIC HEPATIC ABSCESS; HAEMATOGENIC HEPATIC ABSCESS; LYMPHOGENIC HEPATIC ABSCESS; PYLEPHLEBITIC HEPATIC ABSCESS 23,010.00
16,107.00
6,903.00
K75.1 PHLEBITIS OF PORTAL VEIN; PYLEPHLEBITIS 23,010.00
16,107.00
6,903.00
K75.2 NONSPECIFIC REACTIVE HEPATITIS 23,010.00
16,107.00
6,903.00
K75.3 GRANULOMATOUS HEPATITIS, NOT ELSEWHERE CLASSIFIED 23,010.00
16,107.00
6,903.00
K75.4 AUTOIMMUNE HEPATITIS 23,010.00
16,107.00
6,903.00
K75.8 OTHER SPECIFIED INFLAMMATORY LIVER DISEASES 23,010.00
16,107.00
6,903.00
K75.9 INFLAMMATORY LIVER DISEASE, UNSPECIFIED; HEPATITIS NOS 23,010.00
16,107.00
6,903.00
K76.0 FATTY (CHANGE OF) LIVER, NOT ELSEWHERE CLASSIFIED 23,010.00
16,107.00
6,903.00
K76.1 CHRONIC PASSIVE CONGESTION OF LIVER; CARDIAC CIRRHOSIS (SO-CALLED) OF LIVER; CARDIAC SCLEROSIS OF LIVER 29,445.00
20,611.50
8,833.50
K76.2 CENTRAL HAEMORRHAGIC NECROSIS OF LIVER 29,445.00
20,611.50
8,833.50
K76.3 INFARCTION OF LIVER 29,445.00
20,611.50
8,833.50
K76.4 PELIOSIS HEPATIS; HEPATIC ANGIOMATOSIS 29,445.00
20,611.50
8,833.50
K76.6 PORTAL HYPERTENSION 29,445.00
20,611.50
8,833.50
K76.7 HEPATORENAL SYNDROME 29,445.00
20,611.50
8,833.50
K76.8 OTHER SPECIFIED DISEASES OF LIVER; FOCAL NODULAR HYPERPLASIA OF LIVER; HEPATOPTOSIS 23,010.00
16,107.00
6,903.00
K76.9 LIVER DISEASE, UNSPECIFIED 23,010.00
16,107.00
6,903.00
K80.0 CALCULUS OF GALLBLADDER WITH ACUTE CHOLECYSTITIS; ANY CONDITION LISTED IN K80.2 WITH ACUTE CHOLECYSTITIS 22,035.00
15,424.50
6,610.50
K80.1 CALCULUS OF GALLBLADDER WITH OTHER CHOLECYSTITIS; ANY CONDITION LISTED IN K80.2 WITH CHRONIC CHOLECYSTITIS; CHOLECYSTITIS WITH CHOLELITHIASIS NOS 22,035.00
15,424.50
6,610.50
K80.2 CALCULUS OF GALLBLADDER WITHOUT CHOLECYSTITIS; CHOLECYSTOLITHIASIS UNSPECIFIED OR WITHOUT CHOLECYSTITIS; CHOLELITHIASIS UNSPECIFIED OR WITHOUT CHOLECYSTITIS; RECURRENT COLIC OF GALLBLADDER UNSPECIFIED OR WITHOUT CHOLECYSTITIS; IMPACTED GALLSTONE OF CYSTIC 19,110.00
13,377.00
5,733.00
K80.3 CALCULUS OF BILE DUCT WITH CHOLANGITIS; ANY CONDITION LISTED IN K80.5 WITH CHOLANGITIS 25,740.00
18,018.00
7,722.00
K80.4 CALCULUS OF BILE DUCT WITH CHOLECYSTITIS; ANY CONDITION LISTED IN K80.5 WITH CHOLECYSTITIS (WITH CHOLANGITIS) 22,035.00
15,424.50
6,610.50
K80.5 CALCULUS OF BILE DUCT WITHOUT CHOLANGITIS OR CHOLECYSTITIS; CHOLEDOCHOLITHIASIS UNSPECIFIED OR WITHOUT CHOLANGITIS OR CHOLECYSTITIS; IMPACTED GALLSTONE OF BILE DUCT NOS UNSPECIFIED OR WITHOUT CHOLANGITIS OR CHOLECYSTITIS; IMPACTED GALLSTONE OF COMMON DUCT 19,110.00
13,377.00
5,733.00
K80.8 OTHER CHOLELITHIASIS 19,110.00
13,377.00
5,733.00
K81.0 ACUTE CHOLECYSTITIS; ABSCESS OF GALLBLADDER WITHOUT CALCULUS; ANGIOCHOLECYSTITIS WITHOUT CALCULUS; ACUTE EMPHYSEMATOUS CHOLECYSTITIS WITHOUT CALCULUS; GANGRENOUS CHOLECYSTITIS WITHOUT CALCULUS; SUPPARATIVE CHOLECYSTITIS WITHOUT CALCULUS; EMPYEMA OF GALLBL 22,035.00
15,424.50
6,610.50
K81.1 CHRONIC CHOLECYSTITIS 22,035.00
15,424.50
6,610.50
K81.8 OTHER CHOLECYSTITIS 22,035.00
15,424.50
6,610.50
K82.0 OBSTRUCTION OF GALLBLADDER; OCCLUSION OF CYSTIC DUCT OF GALLBLADDER WITHOUT CALCULUS; STENOSIS OF CYSTIC DUCT OR GALLBLADDER WITHOUT CALCULUS; STRICTURE OF CYSTIC DUCT OR GALLBLADDER WITHOUT CALCULUS 19,110.00
13,377.00
5,733.00
K82.1 HYDROPS OF GALLBLADDER; MUCOCELE OF GALLBLADDER 19,110.00
13,377.00
5,733.00
K82.2 PERFORATION OF GALLBLADDER; RUPTURE OF CYSTIC DUCT OR GALLBLADDER 19,110.00
13,377.00
5,733.00
Page 51 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate K82.3 FISTULA OF GALLBLADDER; CHOLECYSTOCOLIC FISTULA; CHOLECYSTODUODENAL FISTULA 19,110.00
13,377.00
5,733.00
K82.4 CHOLESTEROLOSIS OF GALLBLADDER; STRAWBERRY GALLBLADDER 19,110.00
13,377.00
5,733.00
K82.8 OTHER SPECIFIED DISEASES OF GALLBLADDER; ADHESIONS OF CYSTIC DUCT OR GALLBLADDER; ATROPHY OF CYSTIC DUCT OR GALLBLADDER; CYST OF CYSTIC DUCT OR GALLBLADDER; DYSKINESIA OF CYSTIC DUCT OR GALLBLADDER; HYPERTROPHY OF CYSTIC DUCT OR GALLBLADDER; NONFUNCTIONIN 19,110.00
13,377.00
5,733.00
K83.0 CHOLANGITIS; CHOLANGITIS NOS; ASCENDING CHOLANGITIS; PRIMARY CHOLANGITIS; RECURRENT CHOLANGITIS; SCLEROSING CHOLANGITIS; SECONDARY CHOLANGITIS; STENOSING CHOLANGITIS; SUPPURATIVE CHOLANGITIS 19,110.00
13,377.00
5,733.00
K83.1 OBSTRUCTION OF BILE DUCT; OCCLUSION OF BILE DUCT WITHOUT CALCULUS; STENOSIS OF BILE DUCT WITHOUT CALCULUS; STRICTURE OF BILE DUCT WITHOUT CALCULUS 19,110.00
13,377.00
5,733.00
K83.3 FISTULA OF BILE DUCT; CHOLEDOCHODUODENAL FISTULA 19,110.00
13,377.00
5,733.00
K83.4 SPASM OF SPHINCTER OF ODDI 19,110.00
13,377.00
5,733.00
K83.5 BILIARY CYST 19,110.00
13,377.00
5,733.00
K83.8 OTHER SPECIFIED DISEASES OF BILIARY TRACT; ADHESIONS OF BILE DUCT; ATROPHY OF BILE DUCT; HYPERTROPHY OF BILE DUCT; ULCER OF BILE DUCT 19,110.00
13,377.00
5,733.00
K85 ACUTE PANCREATITIS; ABSCESS OF PANCREAS; ACUTE NECROSIS OF PANCREAS; INFECTIVE NECROSIS OF PANCREAS; PANCREATITIS NOS; ACUTE RECURRENT PANCREATITIS; HAEMORRHAGIC PANCREATITIS; SUBACUTE PANCREATITIS; SUPPARATIVE PANCREATITIS 24,570.00
17,199.00
7,371.00
K85.0 IDIOPATHIC ACUTE PANCREATITIS 24,570.00
17,199.00
7,371.00
K85.1 BILIARY ACUTE PANCREATITIS; GALLSTONE PANCREATITIS 24,570.00
17,199.00
7,371.00
K85.2 ALCOHOL-INDUCED ACUTE PANCREATITIS 24,570.00
17,199.00
7,371.00
K85.8 OTHER ACUTE PANCREATITIS 24,570.00
17,199.00
7,371.00
K85.9 ACUTE PANCREATITIS, UNSPECIFIED; OTHER DISEASES OF PANCREAS 24,570.00
17,199.00
7,371.00
K86.0 ALCOHOL-INDUCED CHRONIC PANCREATITIS 24,570.00
17,199.00
7,371.00
K86.1 OTHER CHRONIC PANCREATITIS; CHRONIC PANCREATITIS NOS; INFECTIOUS CHRONIC PANCREATITIS; RECURRENT CHRONIC PANCREATITIS; RELAPSING CHRONIC PANCREATITIS 24,570.00
17,199.00
7,371.00
K86.2 CYST OF PANCREAS 24,570.00
17,199.00
7,371.00
K86.3 PSEUDOCYST OF PANCREAS 24,570.00
17,199.00
7,371.00
K86.8 OTHER SPECIFIED DISEASES OF PANCREAS; ATROPHY OF PANCREAS; CALCULUS OF PANCREAS; CIRRHOSIS OF PANCREAS; FIBROSIS OF PANCREAS; PANCREATIC INFANTILISM; PANCREATIC NECROSIS NOS; ASEPTIC PANCREATIC NECROSIS; FAT NECROSIS OF PANCREAS 24,570.00
17,199.00
7,371.00
K90.0 COELIAC DISEASE; GLUTEN-SENSITIVE ENTEROPATHY; IDIOPATHIC STEATORRHOEA; NONTROPICAL SPRUE 7,995.00
5,596.50
2,398.50
K90.1 TROPICAL SPRUE; SPRUE NOS; TROPICAL STEATORRHOEA 7,995.00
5,596.50
2,398.50
K90.2 BLIND LOOP SYNDROME, NOT ELSEWHERE CLASSIFIED; BLIND LOOP SYNDROME NOS 7,995.00
5,596.50
2,398.50
K90.3 PANCREATIC STEATORRHOEA 7,995.00
5,596.50
2,398.50
K90.4 MALABSORPTION DUE TO INTOLERANCE, NOT ELSEWHERE CLASSIFIED; MALABSORPTION DUE TO INTOLERANCE TO CARBOHYDRATE; MALABSORPTION DUE TO INTOLERANCE TO FAT; MALABSORPTION DUE TO INTOLERANCE TO PROTEIN; MALABSORPTION DUE TO INTOLERANCE TO STARCH 7,995.00
5,596.50
2,398.50
K90.8 OTHER INTESTINAL MALABSORPTION 7,995.00
5,596.50
2,398.50
K90.9 INTESTINAL MALABSORPTION, UNSPECIFIED 7,995.00
5,596.50
2,398.50
K91.0 VOMITING FOLLOWING GASTROINTESTINAL SURGERY 20,085.00
14,059.50
6,025.50
K91.1 POSTGASTRIC SURGERY SYNDROMES; DUMPING SYNDROME; POSTGASTRECTOMY SYNDROME; POSTVAGOTOMY SYNDROME 20,085.00
14,059.50
6,025.50
K91.2 POSTSURGICAL MALABSORPTION, NOT ELSEWHERE CLASSIFIED; POSTSURGICAL BLIND LOOP SYNDROME 20,085.00
14,059.50
6,025.50
K91.3 POSTOPERATIVE INTESTINAL OBSTRUCTION 20,085.00
14,059.50
6,025.50
K91.4 COLOSTOMY AND ENTEROSTOMY MALFUNCTION 20,085.00
14,059.50
6,025.50
K91.5 POSTCHOLECYSTECTOMY SYNDROME 20,085.00
14,059.50
6,025.50
K91.8 OTHER POSTPROCEDURAL DISORDERS OF DIGESTIVE SYSTEM, NOT ELSEWHERE CLASSIFIED 20,085.00
14,059.50
6,025.50
K91.9 POSTPROCEDURAL DISORDER OF DIGESTIVE SYSTEM, UNSPECIFIED 20,085.00
14,059.50
6,025.50
L00 STAPHYLOCOCCAL SCALDED SKIN SYNDROME; PEMPHIGUS NEONATORUM; RITTER'S DISEASE 19,890.00
13,923.00
5,967.00
L02.0 CUTANEOUS ABSCESS, FURUNCLE AND CARBUNCLE OF FACE 7,800.00
5,460.00
2,340.00
L02.1 CUTANEOUS ABSCESS, FURUNCLE AND CARBUNCLE OF NECK 7,800.00
5,460.00
2,340.00
L02.2 CUTANEOUS ABSCESS, FURUNCLE AND CARBUNCLE OF TRUNK; CUTANEOUS ABSCESS, FURUNCLE AND CARBUNCLE OF ABDOMINAL WALL; CUTANEOUS ABSCESS, FURUNCLE AND CARBUNCLE OF BACK [ANY PART, EXCEPT BUTTOCK]; CUTANEOUS ABSCESS, FURUNCLE AND CARBUNCLE OF CHEST WALL; CUTANEO 7,800.00
5,460.00
2,340.00
L02.3 CUTANEOUS ABSCESS, FURUNCLE AND CARBUNCLE OF BUTTOCK; CUTANEOUS ABSCESS, FURUNCLE AND CARBUNCLE OF GLUTEAL REGION 7,800.00
5,460.00
2,340.00
Page 52 of 105 of Annex A
Case Rate
Health Facility Fee
Professional Fee
ICD Code
Description
First Case Rate
L02.4
CUTANEOUS ABSCESS, FURUNCLE AND CARBUNCLE OF LIMB,
AXILLA, HIP & SHOULDER
7,800.00
5,460.00
2,340.00
L02.8 CUTANEOUS ABSCESS, FURUNCLE AND CARBUNCLE OF OTHER SITES: HEAD [ANY PART, EXCEPT FACE]; SCALP 7,800.00
5,460.00
2,340.00
L02.9 CUTANEOUS ABSCESS, FURUNCLE AND CARBUNCLE, UNSPECIFIED; FURUNCULOSIS NOS 7,800.00
5,460.00
2,340.00
L03.0 CELLULITIS OF FINGER AND TOE; INFECTION OF NAIL; ONYCHIA; PARONYCHIA; PERIONYCHIA 18,720.00
13,104.00
5,616.00
L03.1 CELLULITIS OF OTHER PARTS OF LIMB, AXILLA; CELLULITIS OF HIP;CELLULITIS OF SHOULDER 18,720.00
13,104.00
5,616.00
L03.2 CELLULITIS OF FACE 18,720.00
13,104.00
5,616.00
L03.3 CELLULITIS OF TRUNK;CELLULITIS OF ABDOMINAL WALL;CELLULITIS OF BACK [ANY PART]; CELLULITIS OF CHEST WALL;CELLULITIS OF GROIN;CELLULITIS OF PERINEUM;CELLULITIS OF UMBILICUS 18,720.00
13,104.00
5,616.00
L03.8 CELLULITIS OF OTHER SITES; CELLULITIS OF HEAD [ANY PART, EXCEPT FACE];CELLULITIS OF SCALP 18,720.00
13,104.00
5,616.00
L03.9 CELLULITIS, UNSPECIFIED 18,720.00
13,104.00
5,616.00
L10.0 PEMPHIGUS VULGARIS 23,400.00
16,380.00
7,020.00
L10.1 PEMPHIGUS VEGETANS 23,400.00
16,380.00
7,020.00
L10.2 PEMPHIGUS FOLIACEUS 23,400.00
16,380.00
7,020.00
L10.4 PEMPHIGUS ERYTHEMATOSUS; SENEAR-USHER SYNDROME 23,400.00
16,380.00
7,020.00
L10.8 OTHER PEMPHIGUS 23,400.00
16,380.00
7,020.00
L10.9 PEMPHIGUS, UNSPECIFIED 23,400.00
16,380.00
7,020.00
L11.0 ACQUIRED KERATOSIS FOLLICULARIS 23,400.00
16,380.00
7,020.00
L11.1 TRANSIENT ACANTHOLYTIC DERMATOSIS [GROVER] 23,400.00
16,380.00
7,020.00
L11.9 ACANTHOLYTIC DISORDER, UNSPECIFIED 23,400.00
16,380.00
7,020.00
L12.0 BULLOUS PEMPHIGOID 23,400.00
16,380.00
7,020.00
L12.1 CICATRICIAL PEMPHIGOID; BENIGN MUCOUS MEMBRANE PEMPHIGOID 23,400.00
16,380.00
7,020.00
L12.2 CHRONIC BULLOUS DISEASE OF CHILDHOOD; JUVENILE DERMATITIS HERPETIFORMIS 23,400.00
16,380.00
7,020.00
L12.3 ACQUIRED EPIDERMOLYSIS BULLOSA 23,400.00
16,380.00
7,020.00
L12.8 OTHER PEMPHIGOID 23,400.00
16,380.00
7,020.00
L13.0 DERMATITIS HERPETIFORMIS; DUHRING'S DISEASE 23,400.00
16,380.00
7,020.00
L13.1 SUBCORNEAL PUSTULAR DERMATITIS; SNEDDON-WILKINSON DISEASE 23,400.00
16,380.00
7,020.00
L13.9 BULLOUS DISORDER, UNSPECIFIED 23,400.00
16,380.00
7,020.00
L51.1 BULLOUS ERYTHEMA MULTIFORME; STEVENS-JOHNSON SYNDROME 23,985.00
16,789.50
7,195.50
L51.2 TOXIC EPIDERMAL NECROLYSIS [LYELL] 31,005.00
21,703.50
9,301.50
L72.0 EPIDERMAL CYST 7,800.00
5,460.00
2,340.00
L72.1 TRICHILEMMAL CYST; PILAR CYST; SEBACEOUS CYST 7,800.00
5,460.00
2,340.00
L72.2 STEATOCYSTOMA MULTIPLEX 7,800.00
5,460.00
2,340.00
L72.8 OTHER FOLLICULAR CYSTS OF SKIN AND SUBCUTANEOUS TISSUE 7,800.00
5,460.00
2,340.00
L72.9 FOLLICULAR CYST OF SKIN AND SUBCUTANEOUS TISSUE, UNSPECIFIED 7,800.00
5,460.00
2,340.00
L88 PYODERMA GANGRENOSUM; DERMATITIS GANGRENOSA; PHAGEDENIC PYODERMA 25,740.00
18,018.00
7,722.00
L93.0 DISCOID LUPUS ERYTHEMATOSUS; LUPUS ERYTHEMATOSUS 23,205.00
16,243.50
6,961.50
L93.1 SUBACUTE CUTANEOUS LUPUS ERYTHEMATOSUS 23,205.00
16,243.50
6,961.50
L93.2 LUPUS ERYMATOSUS PROFUNDUS; LUPUS PANNICULITIS 23,205.00
16,243.50
6,961.50
L98.3 EOSINOPHILIC CELLULITIS [WELLS] 18,720.00
13,104.00
5,616.00
M00.16 PNEUMOCOCCAL ARTHRITIS AND POLYARTHRITIS, LOWER LEG 18,915.00
13,240.50
5,674.50
M00.19 PNEUMOCOCCAL ARTHRITIS AND POLYARTHRITIS, SITE UNSPECIFIED 18,915.00
13,240.50
5,674.50
M00.29 OTHER STREPTOCOCCAL ARTHRITIS AND POLYARTHRITIS, SITE UNSPECIFIED 18,915.00
13,240.50
5,674.50
M00.82 ARTHRITIS AND POLYARTHRITIS DUE TO OTHER SPECIFIED BACTERIAL AGENTS UPPER ARM 18,915.00
13,240.50
5,674.50
M00.90 PYOGENIC ARTHRITIS, UNSPECIFIED; INFECTIVE ARTHRITIS NOS MULTIPLE SITES 18,915.00
13,240.50
5,674.50
M00.91 PYOGENIC ARTHRITIS, UNSPECIFIED; INFECTIVE ARTHRITIS NOS SHOULDER REGION 18,915.00
13,240.50
5,674.50
M00.93 PYOGENIC ARTHRITIS, UNSPECIFIED; INFECTIVE ARTHRITIS NOS FOREARM 18,915.00
13,240.50
5,674.50
M00.94 PYOGENIC ARTHRITIS, UNSPECIFIED; INFECTIVE ARTHRITIS NOS HAND 18,915.00
13,240.50
5,674.50
M00.95 PYOGENIC ARTHRITIS, UNSPECIFIED; INFECTIVE ARTHRITIS NOS PELVIC REGION AND THIGH 18,915.00
13,240.50
5,674.50
M00.96 PYOGENIC ARTHRITIS, UNSPECIFIED; INFECTIVE ARTHRITIS NOS LOWER LEG 18,915.00
13,240.50
5,674.50
M00.97 PYOGENIC ARTHRITIS, UNSPECIFIED; INFECTIVE ARTHRITIS NOS ANKLE AND FOOT 18,915.00
13,240.50
5,674.50
M00.98 PYOGENIC ARTHRITIS, UNSPECIFIED; INFECTIVE ARTHRITIS NOS OTHER SITES 18,915.00
13,240.50
5,674.50
Page 53 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate M00.99 PYOGENIC ARTHRITIS, UNSPECIFIED; INFECTIVE ARTHRITIS NOS SITE UNSPECIFIED 18,915.00
13,240.50
5,674.50
M02.39 REITER'S DISEASE, SITE UNSPECIFIED 18,915.00
13,240.50
5,674.50
M02.99 REACTIVE ARTHROPATHY, UNSPECIFIED, SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M05.99 SEROPOSITIVE RHEUMATOID ARTHRITIS, UNSPECIFIED, SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M06.01 SERONEGATIVE RHEUMATOID ARTHRITIS, SHOULDER REGION 13,650.00
9,555.00
4,095.00
M06.09 SERONEGATIVE RHEUMATOID ARTHRITIS, SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M06.19 ADULT-ONSET STILL'S DISEASE, SITE UNSPECIFIED 18,915.00
13,240.50
5,674.50
M06.36 RHEUMATOID NODULE, LOWER LEG 13,650.00
9,555.00
4,095.00
M06.45 INFLAMMATORY POLYARTHROPATHY, PELVIC REGION AND THIGH 13,650.00
9,555.00
4,095.00
M06.49 INFLAMMATORY POLYARTHROPATHY, SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M06.81 OTHER SPECIFIED RHEUMATOID ARTHRITIS, SHOULDER REGION 13,650.00
9,555.00
4,095.00
M06.86 OTHER SPECIFIED RHEUMATOID ARTHRITIS, LOWER LEG 13,650.00
9,555.00
4,095.00
M06.87 OTHER SPECIFIED RHEUMATOID ARTHRITIS, ANKLE AND FOOT 13,650.00
9,555.00
4,095.00
M06.89 OTHER SPECIFIED RHEUMATOID ARTHRITIS, SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M06.90 RHEUMATOID ARTHRITIS, UNSPECIFIED, MULTIPLE SITES 13,650.00
9,555.00
4,095.00
M06.91 RHEUMATOID ARTHRITIS, UNSPECIFIED, SHOULDER REGION 13,650.00
9,555.00
4,095.00
M06.93 RHEUMATOID ARTHRITIS, UNSPECIFIED, FOREARM 13,650.00
9,555.00
4,095.00
M06.94 RHEUMATOID ARTHRITIS, UNSPECIFIED, HAND 13,650.00
9,555.00
4,095.00
M06.95 RHEUMATOID ARTHRITIS, UNSPECIFIED, PELVIC REGION AND THIGH 13,650.00
9,555.00
4,095.00
M06.96 RHEUMATOID ARTHRITIS, UNSPECIFIED, LOWER LEG 13,650.00
9,555.00
4,095.00
M06.97 RHEUMATOID ARTHRITIS, UNSPECIFIED, ANKLE AND FOOT 13,650.00
9,555.00
4,095.00
M06.98 RHEUMATOID ARTHRITIS, UNSPECIFIED, OTHER SITES 13,650.00
9,555.00
4,095.00
M06.99 RHEUMATOID ARTHRITIS, UNSPECIFIED, SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M08.06 JUVENILE RHEUMATOID ARTHRITIS; JUVENILE RHEUMATOID ARTHRITIS WITH OR WITHOUT RHEUMATOID FACTOR LOWER LEG 13,650.00
9,555.00
4,095.00
M08.07 JUVENILE RHEUMATOID ARTHRITIS; JUVENILE RHEUMATOID ARTHRITIS WITH OR WITHOUT RHEUMATOID FACTOR ANKLE AND FOOT 13,650.00
9,555.00
4,095.00
M08.09 JUVENILE RHEUMATOID ARTHRITIS; JUVENILE RHEUMATOID ARTHRITIS WITH OR WITHOUT RHEUMATOID FACTOR SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M08.19 JUVENILE ANKYLOSING SPONDYLITIS SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M08.29 JUVENILE ARTHRITIS WITH SYSTEMIC ONSET; STILL'S DISEASE NOS SITE UNSPECIFIED 18,915.00
13,240.50
5,674.50
M08.86 OTHER JUVENILE ARTHRITIS LOWER LEG 13,650.00
9,555.00
4,095.00
M08.89 OTHER JUVENILE ARTHRITIS SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M08.91 JUVENILE ARTHRITIS, UNSPECIFIED SHOULDER REGION 13,650.00
9,555.00
4,095.00
M08.96 JUVENILE ARTHRITIS, UNSPECIFIED LOWER LEG 13,650.00
9,555.00
4,095.00
M08.99 JUVENILE ARTHRITIS, UNSPECIFIED SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M10.00 IDIOPATHIC GOUT; GOUTY BURSITIS; PRIMARY GOUT MULTIPLE SITES 13,650.00
9,555.00
4,095.00
M10.01 URATE TOPHUS OF HEART SHOULDER REGION 13,650.00
9,555.00
4,095.00
M10.02 URATE TOPHUS OF HEART UPPER ARM 13,650.00
9,555.00
4,095.00
M10.03 IDIOPATHIC GOUT; GOUTY BURSITIS; PRIMARY GOUT FOREARM 13,650.00
9,555.00
4,095.00
M10.04 URATE TOPHUS OF HEART HAND 13,650.00
9,555.00
4,095.00
M10.05 URATE TOPHUS OF HEART PELVIC REGION AND THIGH 13,650.00
9,555.00
4,095.00
M10.06 IDIOPATHIC GOUT; GOUTY BURSITIS; PRIMARY GOUT LOWER LEG 13,650.00
9,555.00
4,095.00
M10.07 URATE TOPHUS OF HEART ANKLE AND FOOT 13,650.00
9,555.00
4,095.00
M10.08 URATE TOPHUS OF HEART OTHER SITES 13,650.00
9,555.00
4,095.00
M10.09 URATE TOPHUS OF HEART SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M10.10 LEAD-INDUCED GOUT MULTIPLE SITES 13,650.00
9,555.00
4,095.00
M10.29 DRUG-INDUCED GOUT SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M10.30 GOUT DUE TO IMPAIRMENT OF RENAL FUNCTION MULTIPLE SITES 13,650.00
9,555.00
4,095.00
M10.36 GOUT DUE TO IMPAIRMENT OF RENAL FUNCTION LOWER LEG 13,650.00
9,555.00
4,095.00
M10.39 GOUT DUE TO IMPAIRMENT OF RENAL FUNCTION SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M10.40 OTHER SECONDARY GOUT MULTIPLE SITES 13,650.00
9,555.00
4,095.00
M10.49 OTHER SECONDARY GOUT SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M10.90 GOUT, UNSPECIFIED MULTIPLE SITES 13,650.00
9,555.00
4,095.00
M10.91 GOUT, UNSPECIFIED SHOULDER REGION 13,650.00
9,555.00
4,095.00
M10.92 GOUT, UNSPECIFIED UPPER ARM 13,650.00
9,555.00
4,095.00
M10.93 GOUT, UNSPECIFIED FOREARM 13,650.00
9,555.00
4,095.00
M10.94 GOUT, UNSPECIFIED HAND 13,650.00
9,555.00
4,095.00
M10.96 GOUT, UNSPECIFIED LOWER LEG 13,650.00
9,555.00
4,095.00
M10.97 GOUT, UNSPECIFIED ANKLE AND FOOT 13,650.00
9,555.00
4,095.00
M10.98 GOUT, UNSPECIFIED OTHER SITES 13,650.00
9,555.00
4,095.00
M10.99 GOUT, UNSPECIFIED SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M11.89 OTHER SPECIFIED CRYSTAL ARTHROPATHIES SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M11.90 CRYSTAL ARTHROPATHY, UNSPECIFIED MULTIPLE SITES 13,650.00
9,555.00
4,095.00
M11.99 CRYSTAL ARTHROPATHY, UNSPECIFIED SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
Page 54 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate M12.26 VILLONODULAR SYNOVITIS (PIGMENTED) LOWER LEG 13,650.00
9,555.00
4,095.00
M12.39 PALINDROMIC RHEUMATISM SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M12.50 TRAUMATIC ARTHROPATHY MULTIPLE SITES 13,650.00
9,555.00
4,095.00
M12.52 TRAUMATIC ARTHROPATHY UPPER ARM 13,650.00
9,555.00
4,095.00
M12.53 TRAUMATIC ARTHROPATHY FOREARM 13,650.00
9,555.00
4,095.00
M12.54 TRAUMATIC ARTHROPATHY HAND 13,650.00
9,555.00
4,095.00
M12.55 TRAUMATIC ARTHROPATHY PELVIC REGION AND THIGH 13,650.00
9,555.00
4,095.00
M12.56 TRAUMATIC ARTHROPATHY LOWER LEG 13,650.00
9,555.00
4,095.00
M12.57 TRAUMATIC ARTHROPATHY ANKLE AND FOOT 13,650.00
9,555.00
4,095.00
M12.58 TRAUMATIC ARTHROPATHY OTHER SITES 13,650.00
9,555.00
4,095.00
M12.59 TRAUMATIC ARTHROPATHY SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M12.86 OTHER SPECIFIC ARTHROPATHIES, NOT ELSEWHERE CLASSIFIED; TRANSIENT ARTHROPATHY LOWER LEG 13,650.00
9,555.00
4,095.00
M12.89 OTHER SPECIFIC ARTHROPATHIES, NOT ELSEWHERE CLASSIFIED; TRANSIENT ARTHROPATHY SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M13.00 POLYARTHRITIS, UNSPECIFIED MULTIPLE SITES 13,650.00
9,555.00
4,095.00
M13.01 POLYARTHRITIS, UNSPECIFIED SHOULDER REGION 13,650.00
9,555.00
4,095.00
M13.02 POLYARTHRITIS, UNSPECIFIED UPPER ARM 13,650.00
9,555.00
4,095.00
M13.06 POLYARTHRITIS, UNSPECIFIED LOWER LEG 13,650.00
9,555.00
4,095.00
M13.09 POLYARTHRITIS, UNSPECIFIED SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M13.13 MONOARTHRITIS, NOT ELSEWHERE CLASSIFIED FOREARM 13,650.00
9,555.00
4,095.00
M13.16 MONOARTHRITIS, NOT ELSEWHERE CLASSIFIED LOWER LEG 13,650.00
9,555.00
4,095.00
M13.17 MONOARTHRITIS, NOT ELSEWHERE CLASSIFIED ANKLE AND FOOT 13,650.00
9,555.00
4,095.00
M13.18 MONOARTHRITIS, NOT ELSEWHERE CLASSIFIED OTHER SITES 13,650.00
9,555.00
4,095.00
M13.80 OTHER SPECIFIED ARTHRITIS; ALLERGIC ARTHRITIS MULTIPLE SITES 13,650.00
9,555.00
4,095.00
M13.81 OTHER SPECIFIED ARTHRITIS; ALLERGIC ARTHRITIS SHOULDER REGION 13,650.00
9,555.00
4,095.00
M13.85 OTHER SPECIFIED ARTHRITIS; ALLERGIC ARTHRITIS PELVIC REGION AND THIGH 13,650.00
9,555.00
4,095.00
M13.86 OTHER SPECIFIED ARTHRITIS; ALLERGIC ARTHRITIS LOWER LEG 13,650.00
9,555.00
4,095.00
M13.87 OTHER SPECIFIED ARTHRITIS; ALLERGIC ARTHRITIS ANKLE AND FOOT 13,650.00
9,555.00
4,095.00
M13.88 OTHER SPECIFIED ARTHRITIS; ALLERGIC ARTHRITIS OTHER SITES 13,650.00
9,555.00
4,095.00
M13.89 OTHER SPECIFIED ARTHRITIS; ALLERGIC ARTHRITIS SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M13.90 ARTHRITIS, UNSPECIFIED; ARTHROPATHY NOS MULTIPLE SITES 13,650.00
9,555.00
4,095.00
M13.91 ARTHRITIS, UNSPECIFIED; ARTHROPATHY NOS SHOULDER REGION 13,650.00
9,555.00
4,095.00
M13.92 ARTHRITIS, UNSPECIFIED; ARTHROPATHY NOS UPPER ARM 13,650.00
9,555.00
4,095.00
M13.93 ARTHRITIS, UNSPECIFIED; ARTHROPATHY NOS FOREARM 13,650.00
9,555.00
4,095.00
M13.94 ARTHRITIS, UNSPECIFIED; ARTHROPATHY NOS HAND 13,650.00
9,555.00
4,095.00
M13.95 ARTHRITIS, UNSPECIFIED; ARTHROPATHY NOS PELVIC REGION AND THIGH 13,650.00
9,555.00
4,095.00
M13.96 ARTHRITIS, UNSPECIFIED; ARTHROPATHY NOS LOWER LEG 13,650.00
9,555.00
4,095.00
M13.97 ARTHRITIS, UNSPECIFIED; ARTHROPATHY NOS ANKLE AND FOOT 13,650.00
9,555.00
4,095.00
M13.98 ARTHRITIS, UNSPECIFIED; ARTHROPATHY NOS OTHER SITES 13,650.00
9,555.00
4,095.00
M13.99 ARTHRITIS, UNSPECIFIED; ARTHROPATHY NOS SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M15.0 PRIMARY GENERALIZED (OSTEO)ARTHROSIS 13,650.00
9,555.00
4,095.00
M15.2 BOUCHARD'S NODES (WITH ARTHROPATHY) 13,650.00
9,555.00
4,095.00
M15.3 SECONDARY MULTIPLE ARTHROSIS; POST-TRAUMATIC POLYARTHROSIS 13,650.00
9,555.00
4,095.00
M15.4 EROSIVE (OSTEO)ARTHROSIS 13,650.00
9,555.00
4,095.00
M15.8 OTHER POLYARTHROSIS 13,650.00
9,555.00
4,095.00
M15.9 POLYARTHROSIS, UNSPECIFIED; GENERALIZED OSTEOARTHRITIS NOS 13,650.00
9,555.00
4,095.00
M16.0 PRIMARY COXARTHROSIS, BILATERAL 13,650.00
9,555.00
4,095.00
M16.1 OTHER PRIMARY COXARTHROSIS; PRIMARY COXARTHROSIS NOS; PRIMARY COXARTHROSIS UNILATERAL 13,650.00
9,555.00
4,095.00
M16.2 COXARTHROSIS RESULTING FROM DYSPLASIA, BILATERAL 13,650.00
9,555.00
4,095.00
M16.3 OTHER DYSPLASTIC COXARTHROSIS; DYSPLASTIC COXARTHROSIS NOS; DYSPLASTIC COXARTHROSIS UNILATERAL 13,650.00
9,555.00
4,095.00
M16.9 COXARTHROSIS, UNSPECIFIED 13,650.00
9,555.00
4,095.00
M17.0 PRIMARY GONARTHROSIS, BILATERAL 13,650.00
9,555.00
4,095.00
M17.1 OTHER PRIMARY GONARTHROSIS; PRIMARY GONARTHROSIS NOS; PRIMARY GONARTHROSIS UNILATERAL 13,650.00
9,555.00
4,095.00
M17.2 POST-TRAUMATIC GONARTHROSIS, BILATERAL 13,650.00
9,555.00
4,095.00
M17.3 OTHER POST-TRAUMATIC GONARTHROSIS; POST-TRAUMATIC GONARTHROSIS NOS; POST-TRAUMATIC GONARTHROSIS UNILATERAL 13,650.00
9,555.00
4,095.00
M17.5 OTHER SECONDARY GONARTHROSIS; SECONDARY GONARTHROSIS NOS; SECONDARY GONARTHROSIS UNILATERAL 13,650.00
9,555.00
4,095.00
M17.9 GONARTHROSIS, UNSPECIFIED 13,650.00
9,555.00
4,095.00
M18.0 PRIMARY ARTHROSIS OF FIRST CARPOMETACARPAL JOINTS, BILATERAL 13,650.00
9,555.00
4,095.00
Page 55 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate M18.9 ARTHROSIS OF FIRST CARPOMETACARPAL JOINT, UNSPECIFIED 13,650.00
9,555.00
4,095.00
M19.00 PRIMARY ARTHROSIS OF OTHER JOINTS; PRIMARY ARTHROSIS NOSMULTIPLE SITES 13,650.00
9,555.00
4,095.00
M19.02 PRIMARY ARTHROSIS OF OTHER JOINTS; PRIMARY ARTHROSIS NOSUPPER ARM 13,650.00
9,555.00
4,095.00
M19.05 PRIMARY ARTHROSIS OF OTHER JOINTS; PRIMARY ARTHROSIS NOSPELVIC REGION AND THIGH 13,650.00
9,555.00
4,095.00
M19.06 PRIMARY ARTHROSIS OF OTHER JOINTS; PRIMARY ARTHROSIS NOSLOWER LEG 13,650.00
9,555.00
4,095.00
M19.08 PRIMARY ARTHROSIS OF OTHER JOINTS; PRIMARY ARTHROSIS NOSOTHER SITES 13,650.00
9,555.00
4,095.00
M19.09 PRIMARY ARTHROSIS OF OTHER JOINTS; PRIMARY ARTHROSIS NOSSITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M19.10 POST-TRAUMATIC ARTHROSIS OF OTHER JOINTS; POST- TRAUMATIC ARTHROSIS NOS MULTIPLE SITES 13,650.00
9,555.00
4,095.00
M19.11 POST-TRAUMATIC ARTHROSIS OF OTHER JOINTS; POST- TRAUMATIC ARTHROSIS NOS SHOULDER REGION 13,650.00
9,555.00
4,095.00
M19.12 POST-TRAUMATIC ARTHROSIS OF OTHER JOINTS; POST- TRAUMATIC ARTHROSIS NOS UPPER ARM 13,650.00
9,555.00
4,095.00
M19.19 POST-TRAUMATIC ARTHROSIS OF OTHER JOINTS; POST- TRAUMATIC ARTHROSIS NOS SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M19.21 OTHER SECONDARY ARTHROSIS; SECONDARY ARTHROSIS NOS SHOULDER REGION 13,650.00
9,555.00
4,095.00
M19.29 OTHER SECONDARY ARTHROSIS; SECONDARY ARTHROSIS NOS SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M19.81 OTHER SPECIFIED ARTHROSIS SHOULDER REGION 13,650.00
9,555.00
4,095.00
M19.86 OTHER SPECIFIED ARTHROSIS LOWER LEG 13,650.00
9,555.00
4,095.00
M19.87 OTHER SPECIFIED ARTHROSIS ANKLE AND FOOT 13,650.00
9,555.00
4,095.00
M19.88 OTHER SPECIFIED ARTHROSIS OTHER SITES 13,650.00
9,555.00
4,095.00
M19.89 OTHER SPECIFIED ARTHROSIS SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M19.90 ARTHROSIS, UNSPECIFIED MULTIPLE SITES 13,650.00
9,555.00
4,095.00
M19.91 ARTHROSIS, UNSPECIFIED SHOULDER REGION 13,650.00
9,555.00
4,095.00
M19.92 ARTHROSIS, UNSPECIFIED UPPER ARM 13,650.00
9,555.00
4,095.00
M19.93 ARTHROSIS, UNSPECIFIED FOREARM 13,650.00
9,555.00
4,095.00
M19.94 ARTHROSIS, UNSPECIFIED HAND 13,650.00
9,555.00
4,095.00
M19.95 ARTHROSIS, UNSPECIFIED PELVIC REGION AND THIGH 13,650.00
9,555.00
4,095.00
M19.96 ARTHROSIS, UNSPECIFIED LOWER LEG 13,650.00
9,555.00
4,095.00
M19.97 ARTHROSIS, UNSPECIFIED ANKLE AND FOOT 13,650.00
9,555.00
4,095.00
M19.98 ARTHROSIS, UNSPECIFIED OTHER SITES 13,650.00
9,555.00
4,095.00
M19.99 ARTHROSIS, UNSPECIFIED SITE UNSPECIFIED 13,650.00
9,555.00
4,095.00
M23.20 DERANGEMENT OF MENISCUS DUE TO OLD TEAR OR INJURY; OLD BUCKET-HANDLE TEAR MULTIPLE SITES 17,940.00
12,558.00
5,382.00
M23.21 DERANGEMENT OF MENISCUS DUE TO OLD TEAR OR INJURY; OLD BUCKET-HANDLE TEAR ANTERIOR CRUCIATE LIGAMENT OR ANTERIOR HORN OF MEDIAL MENISCUS 17,940.00
12,558.00
5,382.00
M23.22 DERANGEMENT OF MENISCUS DUE TO OLD TEAR OR INJURY; OLD BUCKET-HANDLE TEAR POSTERIOR CRUCIATE LIGAMENT OR POSTERIOR HORN OF MEDIAL MENISCUS 17,940.00
12,558.00
5,382.00
M23.25 DERANGEMENT OF MENISCUS DUE TO OLD TEAR OR INJURY; OLD BUCKET-HANDLE TEAR POSTERIOR HORN OF LATERAL MENISCUS 17,940.00
12,558.00
5,382.00
M23.46 LOOSE BODY IN KNEEOTHER AND UNSPECIFIED LATERAL MENISCUS 17,940.00
12,558.00
5,382.00
M23.5 CHRONIC INSTABILITY OF KNEE 17,940.00
12,558.00
5,382.00
M23.80 OTHER INTERNAL DERANGEMENTS OF KNEE; LAXITY OF LIGAMENT OF KNEE; SNAPPING KNEE MULTIPLE SITES 17,940.00
12,558.00
5,382.00
M23.9 INTERNAL DERANGEMENT OF KNEE 17,940.00
12,558.00
5,382.00
M23.91 INTERNAL DERANGEMENT OF KNEE, UNSPECIFIED ANTERIOR CRUCIATE LIGAMENT OR ANTERIOR HORN OF MEDIAL MENISCUS 17,940.00
12,558.00
5,382.00
M24.08 LOOSE BODY IN JOINT OTHER SITES 17,940.00
12,558.00
5,382.00
M24.1 OTHER ARTICULAR CARTILAGE DISORDERS 17,940.00
12,558.00
5,382.00
M24.2 DISORDER OF LIGAMENT; INSTABILITY SECONDARY TO OLD LIGAMENT INJURY; LIGAMENTOUS LAXITY NOS 17,940.00
12,558.00
5,382.00
M24.4 RECURRENT DISLOCATION AND SUBLUXATION OF JOINT 17,940.00
12,558.00
5,382.00
M24.41 RECURRENT DISLOCATION AND SUBLUXATION OF JOINT SHOULDER REGION 17,940.00
12,558.00
5,382.00
M24.50 CONTRACTURE OF JOINT MULTIPLE SITES 17,940.00
12,558.00
5,382.00
M24.54 CONTRACTURE OF JOINT HAND 17,940.00
12,558.00
5,382.00
M24.56 CONTRACTURE OF JOINT LOWER LEG 17,940.00
12,558.00
5,382.00
M24.6 ANKYLOSIS OF JOINT 17,940.00
12,558.00
5,382.00
M24.65 ANKYLOSIS OF JOINT PELVIC REGION AND THIGH 17,940.00
12,558.00
5,382.00
M24.66 ANKYLOSIS OF JOINT LOWER LEG 17,940.00
12,558.00
5,382.00
M24.69 ANKYLOSIS OF JOINT SITE UNSPECIFIED 17,940.00
12,558.00
5,382.00
M24.7 PROTRUSIO ACETABULI 17,940.00
12,558.00
5,382.00
M24.88 OTHER SPECIFIC JOINT DERANGEMENTS, NOT ELSEWHERE CLASSIFIED; IRRITABLE HIP OTHER SITES 17,940.00
12,558.00
5,382.00
M25.00 HAEMARTHROSIS MULTIPLE SITES 15,210.00
10,647.00
4,563.00
M25.01 HAEMARTHROSIS SHOULDER REGION 15,210.00
10,647.00
4,563.00
M25.05 HAEMARTHROSIS PELVIC REGION AND THIGH 15,210.00
10,647.00
4,563.00
M25.06 HAEMARTHROSIS LOWER LEG 15,210.00
10,647.00
4,563.00
M25.07 HAEMARTHROSIS ANKLE AND FOOT 15,210.00
10,647.00
4,563.00
M25.08 HAEMARTHROSIS OTHER SITES 15,210.00
10,647.00
4,563.00
M25.09 HAEMARTHROSIS SITE UNSPECIFIED 15,210.00
10,647.00
4,563.00
M25.38 OTHER INSTABILITY OF JOINT OTHER SITES 15,210.00
10,647.00
4,563.00
M25.40 EFFUSION OF JOINT MULTIPLE SITES 15,210.00
10,647.00
4,563.00
M25.41 EFFUSION OF JOINT SHOULDER REGION 15,210.00
10,647.00
4,563.00
M25.46 EFFUSION OF JOINT LOWER LEG 15,210.00
10,647.00
4,563.00
Page 56 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate M25.47 EFFUSION OF JOINT ANKLE AND FOOT 15,210.00
10,647.00
4,563.00
M30.0 POLYARTERITIS NODOSA 26,910.00
18,837.00
8,073.00
M30.1 POLYARTERITIS WITH LUNG INVOLVEMENT [CHURG-STRAUSS]; ALLERGIC GRANULOMATOUS ANGIITIS 26,910.00
18,837.00
8,073.00
M30.2 JUVENILE POLYARTERITIS 26,910.00
18,837.00
8,073.00
M30.3 MUCOCUTANEOUS LYMPH NODE SYNDROME [KAWASAKI] 26,910.00
18,837.00
8,073.00
M30.8 OTHER CONDITIONS RELATED TO POLYARTERITIS NODOSA; POLYANGIITIS OVERLAP SYNDROME 26,910.00
18,837.00
8,073.00
M31.0 HYPERSENSITIVITY ANGIITIS; GOODPASTURE'S SYNDROME 26,910.00
18,837.00
8,073.00
M31.1 THROMBOTIC MICROANGIOPATHY; THROMBOTIC THROMBOCYTOPENIC PURPURA 26,910.00
18,837.00
8,073.00
M31.3 WEGENER'S GRANULOMATOSIS; NECROTIZING RESPIRATORY GRANULOMATOSIS 26,910.00
18,837.00
8,073.00
M31.4 AORTIC ARCH SYNDROME [TAKAYASU] 26,910.00
18,837.00
8,073.00
M31.6 OTHER GIANT CELL ARTERITIS 26,910.00
18,837.00
8,073.00
M31.8 OTHER SPECIFIED NECROTIZING VASCULOPATHIES; HYPOCOMPLEMENTAEMIC VASCULITIS 26,910.00
18,837.00
8,073.00
M31.9 NECROTIZING VASCULOPATHY, UNSPECIFIED 26,910.00
18,837.00
8,073.00
M32.0 DRUG-INDUCED SYSTEMIC LUPUS ERYTHEMATOSUS 23,205.00
16,243.50
6,961.50
M32.8 OTHER FORMS OF SYSTEMIC LUPUS ERYTHEMATOSUS 23,205.00
16,243.50
6,961.50
M32.9 SYSTEMIC LUPUS ERYTHEMATOSUS, UNSPECIFIED 23,205.00
16,243.50
6,961.50
M33.0 JUVENILE DERMATOMYOSITIS 26,910.00
18,837.00
8,073.00
M33.1 OTHER DERMATOMYOSITIS 26,910.00
18,837.00
8,073.00
M33.2 POLYMYOSITIS 26,910.00
18,837.00
8,073.00
M33.9 DERMATOPOLYMYOSITIS, UNSPECIFIED 26,910.00
18,837.00
8,073.00
M34.0 PROGRESSIVE SYSTEMIC SCLEROSIS 26,910.00
18,837.00
8,073.00
M34.1 CR(E)ST SYNDROME; COMBINATION OF CALCINOSIS, RAYNAUD'S PHENOMENON, (O)ESOPHAGEAL DYSFUNCTION, SCLERODACTYLY, TELANGIECTASIA 26,910.00
18,837.00
8,073.00
M34.2 SYSTEMIC SCLEROSIS INDUCED BY DRUGS AND CHEMICALS 26,910.00
18,837.00
8,073.00
M34.9 SYSTEMIC SCLEROSIS, UNSPECIFIED 26,910.00
18,837.00
8,073.00
M35.0 SICCA SYNDROME [SJÖGREN] 26,910.00
18,837.00
8,073.00
M35.1 OTHER OVERLAP SYNDROMES; MIXED CONNECTIVE TISSUE DISEASE 26,910.00
18,837.00
8,073.00
M35.2 BEHçET'S DISEASE 26,910.00
18,837.00
8,073.00
M35.3 POLYMYALGIA RHEUMATICA 26,910.00
18,837.00
8,073.00
M35.4 DIFFUSE (EOSINOPHILIC) FASCIITIS 26,910.00
18,837.00
8,073.00
M35.8 OTHER SPECIFIED SYSTEMIC INVOLVEMENT OF CONNECTIVE TISSUE 26,910.00
18,837.00
8,073.00
M35.9 SYSTEMIC INVOLVEMENT OF CONNECTIVE TISSUE, UNSPECIFIED; SYSTEMIC AUTOIMMUNE DISEASE NOS; COLLAGEN (VASCULAR) DISEASE NOS 26,910.00
18,837.00
8,073.00
M42.1 ADULT OSTEOCHONDROSIS OF SPINE 14,820.00
10,374.00
4,446.00
M43.0 SPONDYLOLYSIS 16,185.00
11,329.50
4,855.50
M43.02 SPONDYLOLYSIS CERVICAL REGION 14,820.00
10,374.00
4,446.00
M43.03 SPONDYLOLYSIS CERVICOTHORACIC REGION 14,820.00
10,374.00
4,446.00
M43.04 SPONDYLOLYSIS THORACIC REGION 14,820.00
10,374.00
4,446.00
M43.06 SPONDYLOLYSIS LUMBAR REGION 14,820.00
10,374.00
4,446.00
M43.07 SPONDYLOLYSIS LUMBOSACRAL REGION 14,820.00
10,374.00
4,446.00
M43.09 SPONDYLOLYSIS SITE UNSPECIFIED 14,820.00
10,374.00
4,446.00
M43.1 SPONDYLOLISTHESIS 16,185.00
11,329.50
4,855.50
M43.10 SPONDYLOLISTHESIS MULTIPLE SITES IN SPINE 14,820.00
10,374.00
4,446.00
M43.12 SPONDYLOLISTHESIS CERVICAL REGION 14,820.00
10,374.00
4,446.00
M43.15 SPONDYLOLISTHESIS THORACOLUMBAR REGION 14,820.00
10,374.00
4,446.00
M43.16 SPONDYLOLISTHESIS LUMBAR REGION 14,820.00
10,374.00
4,446.00
M43.17 SPONDYLOLISTHESIS LUMBOSACRAL REGION 14,820.00
10,374.00
4,446.00
M43.18 SPONDYLOLISTHESIS SACRAL AND SACROCOCCYGEAL REGION 14,820.00
10,374.00
4,446.00
M43.19 SPONDYLOLISTHESIS SITE UNSPECIFIED 14,820.00
10,374.00
4,446.00
M43.2 OTHER FUSION OF SPINE; ANKYLOSIS OF SPINAL JOINT 16,185.00
11,329.50
4,855.50
M43.22 OTHER FUSION OF SPINE; ANKYLOSIS OF SPINAL JOINT CERVICAL REGION 14,820.00
10,374.00
4,446.00
M43.26 OTHER FUSION OF SPINE; ANKYLOSIS OF SPINAL JOINT LUMBAR REGION 14,820.00
10,374.00
4,446.00
M43.27 OTHER FUSION OF SPINE; ANKYLOSIS OF SPINAL JOINT LUMBOSACRAL REGION 14,820.00
10,374.00
4,446.00
M43.29 OTHER FUSION OF SPINE; ANKYLOSIS OF SPINAL JOINT SITE UNSPECIFIED 14,820.00
10,374.00
4,446.00
M43.42 OTHER RECURRENT ATLANTOAXIAL SUBLUXATION CERVICAL REGION 14,820.00
10,374.00
4,446.00
M43.49 OTHER RECURRENT ATLANTOAXIAL SUBLUXATION SITE UNSPECIFIED 14,820.00
10,374.00
4,446.00
M43.5 OTHER RECURRENT VERTEBRAL SUBLUXATION 16,185.00
11,329.50
4,855.50
M43.6 TORTICOLLIS 16,185.00
11,329.50
4,855.50
M43.60 TORTICOLLIS MULTIPLE SITES IN SPINE 14,820.00
10,374.00
4,446.00
M43.62 TORTICOLLIS CERVICAL REGION 14,820.00
10,374.00
4,446.00
M43.64 TORTICOLLIS THORACIC REGION 14,820.00
10,374.00
4,446.00
M43.66 TORTICOLLIS LUMBAR REGION 14,820.00
10,374.00
4,446.00
M43.68 TORTICOLLIS SACRAL AND SACROCOCCYGEAL REGION 14,820.00
10,374.00
4,446.00
M43.69 TORTICOLLIS SITE UNSPECIFIED 14,820.00
10,374.00
4,446.00
M43.8 OTHER SPECIFIED DEFORMING DORSOPATHIES 14,820.00
10,374.00
4,446.00
M43.82 OTHER SPECIFIED DEFORMING DORSOPATHIES CERVICAL REGION 14,820.00
10,374.00
4,446.00
M43.85 OTHER SPECIFIED DEFORMING DORSOPATHIES THORACOLUMBAR REGION 14,820.00
10,374.00
4,446.00
M43.86 OTHER SPECIFIED DEFORMING DORSOPATHIES LUMBAR REGION 14,820.00
10,374.00
4,446.00
M43.87 OTHER SPECIFIED DEFORMING DORSOPATHIES LUMBOSACRAL REGION 14,820.00
10,374.00
4,446.00
Page 57 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate M43.88 OTHER SPECIFIED DEFORMING DORSOPATHIES SACRAL AND SACROCOCCYGEAL REGION 14,820.00
10,374.00
4,446.00
M43.89 OTHER SPECIFIED DEFORMING DORSOPATHIES SITE UNSPECIFIED 14,820.00
10,374.00
4,446.00
M43.9 DEFORMING DORSOPATHY, UNSPECIFIED; CURVATURE OF SPINE NOS 14,820.00
10,374.00
4,446.00
M43.94 DEFORMING DORSOPATHY, UNSPECIFIED; CURVATURE OF SPINE NOS THORACIC REGION 14,820.00
10,374.00
4,446.00
M43.95 DEFORMING DORSOPATHY, UNSPECIFIED; CURVATURE OF SPINE NOS THORACOLUMBAR REGION 14,820.00
10,374.00
4,446.00
M43.96 DEFORMING DORSOPATHY, UNSPECIFIED; CURVATURE OF SPINE NOS LUMBAR REGION 14,820.00
10,374.00
4,446.00
M43.97 DEFORMING DORSOPATHY, UNSPECIFIED; CURVATURE OF SPINE NOS LUMBOSACRAL REGION 14,820.00
10,374.00
4,446.00
M43.99 DEFORMING DORSOPATHY, UNSPECIFIED; CURVATURE OF SPINE NOS SITE UNSPECIFIED 14,820.00
10,374.00
4,446.00
M45 ANKYLOSING SPONDYLITIS; RHEUMATOID ARTHRITIS OF SPINE 16,185.00
11,329.50
4,855.50
M46.0 SPINAL ENTHESOPATHY; DISORDER OF LIGAMENTOUS OR MUSCULAR ATTACHMENTS OF SPINE 16,185.00
11,329.50
4,855.50
M46.1 SACROILIITIS, NOT ELSEWHERE CLASSIFIED 16,185.00
11,329.50
4,855.50
M46.16 SACROILIITIS, NOT ELSEWHERE CLASSIFIED LUMBAR REGION 16,185.00
11,329.50
4,855.50
M46.19 SACROILIITIS, NOT ELSEWHERE CLASSIFIED SITE UNSPECIFIED 16,185.00
11,329.50
4,855.50
M46.2 OSTEOMYELITIS OF VERTEBRA 16,185.00
11,329.50
4,855.50
M46.28 OSTEOMYELITIS OF VERTEBRA SACRAL AND SACROCOCCYGEAL REGION 16,185.00
11,329.50
4,855.50
M46.29 OSTEOMYELITIS OF VERTEBRA SITE UNSPECIFIED 16,185.00
11,329.50
4,855.50
M46.3 INFECTION OF INTERVERTEBRAL DISC (PYOGENIC) 16,185.00
11,329.50
4,855.50
M46.36 INFECTION OF INTERVERTEBRAL DISC (PYOGENIC) LUMBAR REGION 16,185.00
11,329.50
4,855.50
M46.4 DISCITIS, UNSPECIFIED 16,185.00
11,329.50
4,855.50
M46.46 DISCITIS, UNSPECIFIED LUMBAR REGION 16,185.00
11,329.50
4,855.50
M46.47 DISCITIS, UNSPECIFIED LUMBOSACRAL REGION 16,185.00
11,329.50
4,855.50
M46.49 DISCITIS, UNSPECIFIED SITE UNSPECIFIED 16,185.00
11,329.50
4,855.50
M46.5 OTHER INFECTIVE SPONDYLOPATHIES 16,185.00
11,329.50
4,855.50
M46.8 OTHER SPECIFIED INFLAMMATORY SPONDYLOPATHIES 16,185.00
11,329.50
4,855.50
M46.87
OTHER SPECIFIED INFLAMMATORY SPONDYLOPATHIES
LUMBOSACRAL REGION
16,185.00
11,329.50
4,855.50
M46.9 INFLAMMATORY SPONDYLOPATHY, UNSPECIFIED 16,185.00
11,329.50
4,855.50
M46.92 INFLAMMATORY SPONDYLOPATHY, UNSPECIFIED CERVICAL REGION 16,185.00
11,329.50
4,855.50
M46.97 INFLAMMATORY SPONDYLOPATHY, UNSPECIFIED LUMBOSACRAL REGION 16,185.00
11,329.50
4,855.50
M46.98 INFLAMMATORY SPONDYLOPATHY, UNSPECIFIED SACRAL AND SACROCOCCYGEAL REGION 16,185.00
11,329.50
4,855.50
M46.99 INFLAMMATORY SPONDYLOPATHY, UNSPECIFIED SITE UNSPECIFIED 16,185.00
11,329.50
4,855.50
M47.1 OTHER SPONDYLOSIS WITH MYELOPATHY 16,185.00
11,329.50
4,855.50
M47.1+G99.2* MYELOPATHY IN OTHER SPONDYLOSIS WITH MYELOPATHY 16,185.00
11,329.50
4,855.50
M47.2 OTHER SPONDYLOSIS WITH RADICULOPATHY 16,185.00
11,329.50
4,855.50
M47.20 OTHER SPONDYLOSIS WITH RADICULOPATHY MULTIPLE SITES IN SPINE 16,185.00
11,329.50
4,855.50
M47.22 OTHER SPONDYLOSIS WITH RADICULOPATHY CERVICAL REGION 16,185.00
11,329.50
4,855.50
M47.26 OTHER SPONDYLOSIS WITH RADICULOPATHY LUMBAR REGION 16,185.00
11,329.50
4,855.50
M47.27 OTHER SPONDYLOSIS WITH RADICULOPATHY LUMBOSACRAL REGION 16,185.00
11,329.50
4,855.50
M47.29 OTHER SPONDYLOSIS WITH RADICULOPATHY SITE UNSPECIFIED 16,185.00
11,329.50
4,855.50
M47.8 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; THORACIC SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY 16,185.00
11,329.50
4,855.50
M47.80 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; THORACIC SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY MULTIPLE SITES IN SPINE 16,185.00
11,329.50
4,855.50
M47.81 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; THORACIC SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY OCCIPITO-ATLANTO- AXIAL REGION 16,185.00
11,329.50
4,855.50
M47.82 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; THORACIC SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY CERVICAL REGION 16,185.00
11,329.50
4,855.50
M47.83 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; THORACIC SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY CERVICOTHORACIC REGION 16,185.00
11,329.50
4,855.50
Page 58 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate M47.84 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; THORACIC SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY THORACIC REGION 16,185.00
11,329.50
4,855.50
M47.85 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; THORACIC SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY THORACOLUMBAR REGION 16,185.00
11,329.50
4,855.50
M47.86 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; THORACIC SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY LUMBAR REGION 16,185.00
11,329.50
4,855.50
M47.87 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; THORACIC SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY LUMBOSACRAL REGION 16,185.00
11,329.50
4,855.50
M47.88 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; THORACIC SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY SACRAL AND SACROCOCCYGEAL REGION 16,185.00
11,329.50
4,855.50
M47.89 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY; THORACIC SPONDYLOSIS WITHOUT MYELOPATHY OR RADICULOPATHY SITE UNSPECIFIED 16,185.00
11,329.50
4,855.50
M47.9 SPONDYLOSIS, UNSPECIFIED 16,185.00
11,329.50
4,855.50
M47.90 SPONDYLOSIS, UNSPECIFIED MULTIPLE SITES IN SPINE 16,185.00
11,329.50
4,855.50
M47.92 SPONDYLOSIS, UNSPECIFIED CERVICAL REGION 16,185.00
11,329.50
4,855.50
M47.94 SPONDYLOSIS, UNSPECIFIED THORACIC REGION 16,185.00
11,329.50
4,855.50
M47.95 SPONDYLOSIS, UNSPECIFIED THORACOLUMBAR REGION 16,185.00
11,329.50
4,855.50
M47.96 SPONDYLOSIS, UNSPECIFIED LUMBAR REGION 16,185.00
11,329.50
4,855.50
M47.97 SPONDYLOSIS, UNSPECIFIED LUMBOSACRAL REGION 16,185.00
11,329.50
4,855.50
M47.99 SPONDYLOSIS, UNSPECIFIED SITE UNSPECIFIED 16,185.00
11,329.50
4,855.50
M48.0 SPINAL STENOSIS; CAUDAL STENOSIS 16,185.00
11,329.50
4,855.50
M48.00 SPINAL STENOSIS; CAUDAL STENOSIS MULTIPLE SITES IN SPINE 16,185.00
11,329.50
4,855.50
M48.02 SPINAL STENOSIS; CAUDAL STENOSIS CERVICAL REGION 16,185.00
11,329.50
4,855.50
M48.03 SPINAL STENOSIS; CAUDAL STENOSIS CERVICOTHORACIC REGION 16,185.00
11,329.50
4,855.50
M48.04 SPINAL STENOSIS; CAUDAL STENOSIS THORACIC REGION 16,185.00
11,329.50
4,855.50
M48.05 SPINAL STENOSIS; CAUDAL STENOSIS THORACOLUMBAR REGION 16,185.00
11,329.50
4,855.50
M48.06 SPINAL STENOSIS; CAUDAL STENOSIS LUMBAR REGION 16,185.00
11,329.50
4,855.50
M48.07 SPINAL STENOSIS; CAUDAL STENOSIS LUMBOSACRAL REGION 16,185.00
11,329.50
4,855.50
M48.08 SPINAL STENOSIS; CAUDAL STENOSIS SACRAL AND SACROCOCCYGEAL REGION 16,185.00
11,329.50
4,855.50
M48.09 SPINAL STENOSIS; CAUDAL STENOSIS SITE UNSPECIFIED 16,185.00
11,329.50
4,855.50
M48.1 ANKYLOSING HYPEROSTOSIS [FORESTIER]; DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS [DISH] 16,185.00
11,329.50
4,855.50
M48.16 ANKYLOSING HYPEROSTOSIS [FORESTIER]; DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS [DISH] LUMBAR REGION 16,185.00
11,329.50
4,855.50
M48.2 KISSING SPINE 16,185.00
11,329.50
4,855.50
M48.3 TRAUMATIC SPONDYLOPATHY 16,185.00
11,329.50
4,855.50
M48.32 TRAUMATIC SPONDYLOPATHY CERVICAL REGION 16,185.00
11,329.50
4,855.50
M48.4 FATIGUE FRACTURE OF VERTEBRA; STRESS FRACTURE OF VERTEBRA 16,185.00
11,329.50
4,855.50
M48.5 COLLAPSED VERTEBRA NOS; WEDGING OF VERTEBRA NOS 16,185.00
11,329.50
4,855.50
M48.54 COLLAPSED VERTEBRA NOS; WEDGING OF VERTEBRA NOS THORACIC REGION 16,185.00
11,329.50
4,855.50
M48.56 COLLAPSED VERTEBRA NOS; WEDGING OF VERTEBRA NOS LUMBAR REGION 16,185.00
11,329.50
4,855.50
M48.57 COLLAPSED VERTEBRA NOS; WEDGING OF VERTEBRA NOS LUMBOSACRAL REGION 16,185.00
11,329.50
4,855.50
M48.8 OSSIFICATION OF POSTERIOR LONGITUDINAL LIGAMENT 16,185.00
11,329.50
4,855.50
M48.80 OSSIFICATION OF POSTERIOR LONGITUDINAL LIGAMENT MULTIPLE SITES IN SPINE 16,185.00
11,329.50
4,855.50
M48.85 OSSIFICATION OF POSTERIOR LONGITUDINAL LIGAMENT THORACOLUMBAR REGION 16,185.00
11,329.50
4,855.50
M48.86 OSSIFICATION OF POSTERIOR LONGITUDINAL LIGAMENT LUMBAR REGION 16,185.00
11,329.50
4,855.50
M48.89 OSSIFICATION OF POSTERIOR LONGITUDINAL LIGAMENT SITE UNSPECIFIED 16,185.00
11,329.50
4,855.50
M48.9 SPONDYLOPATHY, UNSPECIFIED 16,185.00
11,329.50
4,855.50
M48.92 SPONDYLOPATHY, UNSPECIFIED CERVICAL REGION 16,185.00
11,329.50
4,855.50
M48.95 SPONDYLOPATHY, UNSPECIFIED THORACOLUMBAR REGION 16,185.00
11,329.50
4,855.50
M48.96 SPONDYLOPATHY, UNSPECIFIED LUMBAR REGION 16,185.00
11,329.50
4,855.50
M48.98 SPONDYLOPATHY, UNSPECIFIED SACRAL AND SACROCOCCYGEAL REGION 16,185.00
11,329.50
4,855.50
M48.99 SPONDYLOPATHY, UNSPECIFIED SITE UNSPECIFIED 16,185.00
11,329.50
4,855.50
M49.0* POTT'S CURVATURE 16,185.00
11,329.50
4,855.50
Page 59 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate M49.8* SPONDYLOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE 16,185.00
11,329.50
4,855.50
M50.1 CERVICAL DISC DISORDER WITH RADICULOPATHY 15,210.00
10,647.00
4,563.00
M50.2 OTHER CERVICAL DISC DISPLACEMENT 15,210.00
10,647.00
4,563.00
M50.3 OTHER CERVICAL DISC DEGENERATION 15,210.00
10,647.00
4,563.00
M50.8 OTHER CERVICAL VERTEBRAL DISC DISORDERS 15,210.00
10,647.00
4,563.00
M51.1 LUMBAR AND OTHER INTERVERTEBRAL DISC DISORDERS WITH RADICULOPATHY; SCIATICA DUE TO INTERVERTEBRAL DISC DISORDER 15,210.00
10,647.00
4,563.00
M51.2 OTHER SPECIFIED INTERVERTEBRAL DISC DISPLACEMENT LUMBAGO DUE TO DISPLACEMENT OF INTERVERTEBRAL DISC 15,210.00
10,647.00
4,563.00
M51.3 OTHER SPECIFIED INTERVERTEBRAL DISC DEGENERATIONS 15,210.00
10,647.00
4,563.00
M51.4 SCHMORL'S NODE 15,210.00
10,647.00
4,563.00
M51.8 OTHER SPECIFIED INTERVERTEBRAL VERTEBRAL DISC DISORDERS 15,210.00
10,647.00
4,563.00
M53.0 CERVICOCRANIAL SYNDROME; POSTERIOR CERVICAL SYMPATHETIC SYNDROME 14,820.00
10,374.00
4,446.00
M53.1 CERVICOBRACHIAL SYNDROME 14,820.00
10,374.00
4,446.00
M53.12 CERVICOBRACHIAL SYNDROME CERVICAL REGION 14,820.00
10,374.00
4,446.00
M53.19 CERVICOBRACHIAL SYNDROME SITE UNSPECIFIED 14,820.00
10,374.00
4,446.00
M53.2 SPINAL INSTABILITIES 14,820.00
10,374.00
4,446.00
M53.22 SPINAL INSTABILITIES CERVICAL REGION 14,820.00
10,374.00
4,446.00
M53.24 SPINAL INSTABILITIES THORACIC REGION 14,820.00
10,374.00
4,446.00
M53.26 SPINAL INSTABILITIES LUMBAR REGION 14,820.00
10,374.00
4,446.00
M53.27 SPINAL INSTABILITIES LUMBOSACRAL REGION 14,820.00
10,374.00
4,446.00
M53.28 SPINAL INSTABILITIES SACRAL AND SACROCOCCYGEAL REGION 14,820.00
10,374.00
4,446.00
M53.29 SPINAL INSTABILITIES SITE UNSPECIFIED 14,820.00
10,374.00
4,446.00
M53.3 COCCYGODYNIA 14,820.00
10,374.00
4,446.00
M53.38 COCCYGODYNIA SACRAL AND SACROCOCCYGEAL REGION 14,820.00
10,374.00
4,446.00
M53.8 OTHER SPECIFIED DORSOPATHIES 14,820.00
10,374.00
4,446.00
M53.86 OTHER SPECIFIED DORSOPATHIES LUMBAR REGION 14,820.00
10,374.00
4,446.00
M53.87 OTHER SPECIFIED DORSOPATHIES LUMBOSACRAL REGION 14,820.00
10,374.00
4,446.00
M53.89 OTHER SPECIFIED DORSOPATHIES SITE UNSPECIFIED 14,820.00
10,374.00
4,446.00
M53.9 DORSOPATHY, UNSPECIFIED 14,820.00
10,374.00
4,446.00
M53.92 DORSOPATHY, UNSPECIFIED CERVICAL REGION 14,820.00
10,374.00
4,446.00
M53.95 DORSOPATHY, UNSPECIFIED THORACOLUMBAR REGION 14,820.00
10,374.00
4,446.00
M54 DORSALGIA 14,820.00
10,374.00
4,446.00
M54.01 PANNICULITIS AFFECTING REGIONS OF NECK AND BACK OCCIPITO- ATLANTO-AXIAL REGION 12,480.00
8,736.00
3,744.00
M54.06 PANNICULITIS AFFECTING REGIONS OF NECK AND BACK LUMBAR REGION 12,480.00
8,736.00
3,744.00
M54.08 PANNICULITIS AFFECTING REGIONS OF NECK AND BACK SACRAL AND SACROCOCCYGEAL REGION 12,480.00
8,736.00
3,744.00
M54.10
RADICULOPATHY; BRACHIAL NEURITIS OR RADICULITIS NOS;
LUMBAR NEURITIS OR RADICULITIS NOS; LUMBOSACRAL;
THORACIC NEURITIS OR RADICULITIS NOS ; RADICULITIS NOS
MULTIPLE SITES IN SPINE
12,480.00
8,736.00
3,744.00
M54.11
RADICULOPATHY; BRACHIAL NEURITIS OR RADICULITIS NOS;
LUMBAR NEURITIS OR RADICULITIS NOS; LUMBOSACRAL;
THORACIC NEURITIS OR RADICULITIS NOS ; RADICULITIS NOS
OCCIPITO-ATLANTO-AXIAL REGION
12,480.00
8,736.00
3,744.00
M54.12
RADICULOPATHY; BRACHIAL NEURITIS OR RADICULITIS NOS;
LUMBAR NEURITIS OR RADICULITIS NOS; LUMBOSACRAL;
THORACIC NEURITIS OR RADICULITIS NOS ; RADICULITIS NOS
CERVICAL REGION
12,480.00
8,736.00
3,744.00
M54.14
RADICULOPATHY; BRACHIAL NEURITIS OR RADICULITIS NOS;
LUMBAR NEURITIS OR RADICULITIS NOS; LUMBOSACRAL;
THORACIC NEURITIS OR RADICULITIS NOS ; RADICULITIS NOS
THORACIC REGION
12,480.00
8,736.00
3,744.00
M54.15
RADICULOPATHY; BRACHIAL NEURITIS OR RADICULITIS NOS;
LUMBAR NEURITIS OR RADICULITIS NOS; LUMBOSACRAL;
THORACIC NEURITIS OR RADICULITIS NOS ; RADICULITIS NOS
THORACOLUMBAR REGION
12,480.00
8,736.00
3,744.00
M54.16
RADICULOPATHY; BRACHIAL NEURITIS OR RADICULITIS NOS;
LUMBAR NEURITIS OR RADICULITIS NOS; LUMBOSACRAL;
THORACIC NEURITIS OR RADICULITIS NOS ; RADICULITIS NOS
LUMBAR REGION
12,480.00
8,736.00
3,744.00
M54.17
RADICULOPATHY; BRACHIAL NEURITIS OR RADICULITIS NOS;
LUMBAR NEURITIS OR RADICULITIS NOS; LUMBOSACRAL;
THORACIC NEURITIS OR RADICULITIS NOS ; RADICULITIS NOS
LUMBOSACRAL REGION
12,480.00
8,736.00
3,744.00
M54.18
RADICULOPATHY; BRACHIAL NEURITIS OR RADICULITIS NOS;
LUMBAR NEURITIS OR RADICULITIS NOS; LUMBOSACRAL;
THORACIC NEURITIS OR RADICULITIS NOS ; RADICULITIS NOS
SACRAL AND SACROCOCCYGEAL REGION
12,480.00
8,736.00
3,744.00
Page 60 of 105 of Annex A
Case Rate
Health Facility Fee
Professional Fee
ICD Code
Description
First Case Rate
M54.19
RADICULOPATHY; BRACHIAL NEURITIS OR RADICULITIS NOS;
LUMBAR NEURITIS OR RADICULITIS NOS; LUMBOSACRAL;
THORACIC NEURITIS OR RADICULITIS NOS ; RADICULITIS NOS
SITE UNSPECIFIED
12,480.00
8,736.00
3,744.00
M54.2 CERVICALGIA 12,480.00
8,736.00
3,744.00
M54.20 CERVICALGIA MULTIPLE SITES IN SPINE 12,480.00
8,736.00
3,744.00
M54.22 CERVICALGIA CERVICAL REGION 12,480.00
8,736.00
3,744.00
M54.26 CERVICALGIA LUMBAR REGION 12,480.00
8,736.00
3,744.00
M54.3 SCIATICA 12,480.00
8,736.00
3,744.00
M54.30 SCIATICA MULTIPLE SITES IN SPINE 12,480.00
8,736.00
3,744.00
M54.31 SCIATICA OCCIPITO-ATLANTO-AXIAL REGION 12,480.00
8,736.00
3,744.00
M54.35 SCIATICA THORACOLUMBAR REGION 12,480.00
8,736.00
3,744.00
M54.36 SCIATICA LUMBAR REGION 12,480.00
8,736.00
3,744.00
M54.37 SCIATICA LUMBOSACRAL REGION 12,480.00
8,736.00
3,744.00
M54.38 SCIATICA SACRAL AND SACROCOCCYGEAL REGION 12,480.00
8,736.00
3,744.00
M54.39 SCIATICA SITE UNSPECIFIED 12,480.00
8,736.00
3,744.00
M54.4 LUMBAGO WITH SCIATICA 12,480.00
8,736.00
3,744.00
M54.41 LUMBAGO WITH SCIATICA OCCIPITO-ATLANTO-AXIAL REGION 12,480.00
8,736.00
3,744.00
M54.44 LUMBAGO WITH SCIATICA THORACIC REGION 12,480.00
8,736.00
3,744.00
M54.46 LUMBAGO WITH SCIATICA LUMBAR REGION 12,480.00
8,736.00
3,744.00
M54.48 LUMBAGO WITH SCIATICA SACRAL AND SACROCOCCYGEAL REGION 12,480.00
8,736.00
3,744.00
M54.49 LUMBAGO WITH SCIATICA SITE UNSPECIFIED 12,480.00
8,736.00
3,744.00
M54.5 LOW BACK PAIN; LOIN PAIN; LOW BACK STRAIN; LUMBAGO NOS 12,480.00
8,736.00
3,744.00
M54.50 LOW BACK PAIN; LOIN PAIN; LOW BACK STRAIN; LUMBAGO NOS MULTIPLE SITES IN SPINE 12,480.00
8,736.00
3,744.00
M54.51 LOW BACK PAIN; LOIN PAIN; LOW BACK STRAIN; LUMBAGO NOS OCCIPITO-ATLANTO-AXIAL REGION 12,480.00
8,736.00
3,744.00
M54.52 LOW BACK PAIN; LOIN PAIN; LOW BACK STRAIN; LUMBAGO NOS CERVICAL REGION 12,480.00
8,736.00
3,744.00
M54.84 OTHER DORSALGIA THORACIC REGION 12,480.00
8,736.00
3,744.00
M54.88 OTHER DORSALGIA SACRAL AND SACROCOCCYGEAL REGION 12,480.00
8,736.00
3,744.00
M54.91 DORSALGIA, UNSPECIFIED; BACKACHE NOS OCCIPITO-ATLANTO- AXIAL REGION 12,480.00
8,736.00
3,744.00
M54.93 DORSALGIA, UNSPECIFIED; BACKACHE NOS CERVICOTHORACIC REGION 12,480.00
8,736.00
3,744.00
M54.96 DORSALGIA, UNSPECIFIED; BACKACHE NOS LUMBAR REGION 12,480.00
8,736.00
3,744.00
M54.97 DORSALGIA, UNSPECIFIED; BACKACHE NOS LUMBOSACRAL REGION 12,480.00
8,736.00
3,744.00
M54.98 DORSALGIA, UNSPECIFIED; BACKACHE NOS SACRAL AND SACROCOCCYGEAL REGION 12,480.00
8,736.00
3,744.00
M54.99 DORSALGIA, UNSPECIFIED; BACKACHE NOS SITE UNSPECIFIED 12,480.00
8,736.00
3,744.00
M60.0 INFECTIVE MYOSITIS; TROPICAL PYOMYOSITIS 12,675.00
8,872.50
3,802.50
M60.00 INFECTIVE MYOSITIS; TROPICAL PYOMYOSITIS MULTIPLE SITE 12,675.00
8,872.50
3,802.50
M60.01 INFECTIVE MYOSITIS; TROPICAL PYOMYOSITIS SHOULDER REGION 12,675.00
8,872.50
3,802.50
M60.02 INFECTIVE MYOSITIS; TROPICAL PYOMYOSITIS UPPER ARM 12,675.00
8,872.50
3,802.50
M60.05 INFECTIVE MYOSITIS; TROPICAL PYOMYOSITIS PELVIC REGION AND THIGH 12,675.00
8,872.50
3,802.50
M60.06 INFECTIVE MYOSITIS; TROPICAL PYOMYOSITIS LOWER LEG 12,675.00
8,872.50
3,802.50
M60.07 INFECTIVE MYOSITIS; TROPICAL PYOMYOSITIS ANKLE AND FOOT 12,675.00
8,872.50
3,802.50
M60.08 INFECTIVE MYOSITIS; TROPICAL PYOMYOSITIS OTHER 12,675.00
8,872.50
3,802.50
M60.09 INFECTIVE MYOSITIS; TROPICAL PYOMYOSITIS SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M60.1 INTERSTITIAL MYOSITIS 12,675.00
8,872.50
3,802.50
M60.11 INTERSTITIAL MYOSITIS SHOULDER REGION 12,675.00
8,872.50
3,802.50
M60.2 FOREIGN BODY GRANULOMA OF SOFT TISSUE, NOT ELSEWHERE CLASSIFIED 12,675.00
8,872.50
3,802.50
M60.21 FOREIGN BODY GRANULOMA OF SOFT TISSUE, NOT ELSEWHERE CLASSIFIED SHOULDER REGION 12,675.00
8,872.50
3,802.50
M60.23 FOREIGN BODY GRANULOMA OF SOFT TISSUE, NOT ELSEWHERE CLASSIFIED FOREARM 12,675.00
8,872.50
3,802.50
M60.27 FOREIGN BODY GRANULOMA OF SOFT TISSUE, NOT ELSEWHERE CLASSIFIED ANKLE AND FOOT 12,675.00
8,872.50
3,802.50
M60.8 OTHER MYOSITIS 12,675.00
8,872.50
3,802.50
M60.80 OTHER MYOSITIS MULTIPLE SITE 12,675.00
8,872.50
3,802.50
M60.81 OTHER MYOSITIS SHOULDER REGION 12,675.00
8,872.50
3,802.50
M60.88 OTHER MYOSITIS OTHER 12,675.00
8,872.50
3,802.50
M60.89 OTHER MYOSITIS SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M60.9 MYOSITIS, UNSPECIFIED 12,675.00
8,872.50
3,802.50
M60.90 MYOSITIS, UNSPECIFIED MULTIPLE SITE 12,675.00
8,872.50
3,802.50
M60.91 MYOSITIS, UNSPECIFIED SHOULDER REGION 12,675.00
8,872.50
3,802.50
M60.92 MYOSITIS, UNSPECIFIED UPPER ARM 12,675.00
8,872.50
3,802.50
M60.95 MYOSITIS, UNSPECIFIED PELVIC REGION AND THIGH 12,675.00
8,872.50
3,802.50
M60.96 MYOSITIS, UNSPECIFIED LOWER LEG 12,675.00
8,872.50
3,802.50
M60.98 MYOSITIS, UNSPECIFIED OTHER 12,675.00
8,872.50
3,802.50
M60.99 MYOSITIS, UNSPECIFIED SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
Page 61 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate M61.3 CALCIFICATION AND OSSIFICATION OF MUSCLES ASSOCIATED WITH BURNS; MYOSITIS OSSIFICANS ASSOCIATED WITH BURNS 12,675.00
8,872.50
3,802.50
M61.55 OTHER OSSIFICATION OF MUSCLE PELVIC REGION AND THIGH 12,675.00
8,872.50
3,802.50
M61.59 OTHER OSSIFICATION OF MUSCLE SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M61.9 CALCIFICATION AND OSSIFICATION OF MUSCLE, UNSPECIFIED 12,675.00
8,872.50
3,802.50
M62.0 DIASTASIS OF MUSCLE 12,675.00
8,872.50
3,802.50
M62.05 DIASTASIS OF MUSCLE PELVIC REGION AND THIGH 12,675.00
8,872.50
3,802.50
M62.08 DIASTASIS OF MUSCLE OTHER 12,675.00
8,872.50
3,802.50
M62.1 OTHER RUPTURE OF MUSCLE (NONTRAUMATIC) 12,675.00
8,872.50
3,802.50
M62.48 CONTRACTURE OF MUSCLE OTHER 12,675.00
8,872.50
3,802.50
M62.49 CONTRACTURE OF MUSCLE SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M62.56 MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED; DISUSE ATROPHY NEC LOWER LEG 12,675.00
8,872.50
3,802.50
M62.59 MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED; DISUSE ATROPHY NEC SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M62.60 MUSCLE STRAIN MULTIPLE SITE 12,675.00
8,872.50
3,802.50
M62.61 MUSCLE STRAIN SHOULDER REGION 12,675.00
8,872.50
3,802.50
M62.62 MUSCLE STRAIN UPPER ARM 12,675.00
8,872.50
3,802.50
M62.63 MUSCLE STRAIN FOREARM 12,675.00
8,872.50
3,802.50
M62.65 MUSCLE STRAIN PELVIC REGION AND THIGH 12,675.00
8,872.50
3,802.50
M62.66 MUSCLE STRAIN LOWER LEG 12,675.00
8,872.50
3,802.50
M62.67 MUSCLE STRAIN ANKLE AND FOOT 12,675.00
8,872.50
3,802.50
M62.68 MUSCLE STRAIN OTHER 12,675.00
8,872.50
3,802.50
M62.69 MUSCLE STRAIN SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M62.8 MUSCLE (SHEATH) HERNIA 12,675.00
8,872.50
3,802.50
M62.80 MUSCLE (SHEATH) HERNIA MULTIPLE SITE 12,675.00
8,872.50
3,802.50
M62.85 MUSCLE (SHEATH) HERNIA PELVIC REGION AND THIGH 12,675.00
8,872.50
3,802.50
M62.86 MUSCLE (SHEATH) HERNIA LOWER LEG 12,675.00
8,872.50
3,802.50
M62.88 MUSCLE (SHEATH) HERNIA OTHER 12,675.00
8,872.50
3,802.50
M62.89 MUSCLE (SHEATH) HERNIA SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M62.9 DISORDER OF MUSCLE, UNSPECIFIED 12,675.00
8,872.50
3,802.50
M62.90 DISORDER OF MUSCLE, UNSPECIFIED MULTIPLE SITE 12,675.00
8,872.50
3,802.50
M62.91 DISORDER OF MUSCLE, UNSPECIFIED SHOULDER REGION 12,675.00
8,872.50
3,802.50
M62.95 DISORDER OF MUSCLE, UNSPECIFIED PELVIC REGION AND THIGH 12,675.00
8,872.50
3,802.50
M62.96 DISORDER OF MUSCLE, UNSPECIFIED LOWER LEG 12,675.00
8,872.50
3,802.50
M62.97 DISORDER OF MUSCLE, UNSPECIFIED ANKLE AND FOOT 12,675.00
8,872.50
3,802.50
M62.98 DISORDER OF MUSCLE, UNSPECIFIED OTHER 12,675.00
8,872.50
3,802.50
M62.99 DISORDER OF MUSCLE, UNSPECIFIED SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M65.0 ABSCESS OF TENDON SHEATH 12,675.00
8,872.50
3,802.50
M65.1 OTHER INFECTIVE TENOSYNOVITIS 12,675.00
8,872.50
3,802.50
M65.13 OTHER INFECTIVE (TENO)SYNOVITIS FOREARM 12,675.00
8,872.50
3,802.50
M65.2 CALCIFIC TENDINITIS 12,675.00
8,872.50
3,802.50
M65.20 CALCIFIC TENDINITIS MULTIPLE SITE 12,675.00
8,872.50
3,802.50
M65.22 CALCIFIC TENDINITIS UPPER ARM 12,675.00
8,872.50
3,802.50
M65.25 CALCIFIC TENDINITIS PELVIC REGION AND THIGH 12,675.00
8,872.50
3,802.50
M65.29 CALCIFIC TENDINITIS SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M65.3 TRIGGER FINGER;NODULAR TENDINOUS DISEASE 12,675.00
8,872.50
3,802.50
M65.4 RADIAL STYLOID TENOSYNOVITIS [DE QUERVAIN] 12,675.00
8,872.50
3,802.50
M65.8 OTHER SYNOVITIS AND TENOSYNOVITIS 12,675.00
8,872.50
3,802.50
M65.80 OTHER SYNOVITIS AND TENOSYNOVITIS MULTIPLE SITE 12,675.00
8,872.50
3,802.50
M65.84 OTHER SYNOVITIS AND TENOSYNOVITIS HAND 12,675.00
8,872.50
3,802.50
M65.86 OTHER SYNOVITIS AND TENOSYNOVITIS LOWER LEG 12,675.00
8,872.50
3,802.50
M65.87 OTHER SYNOVITIS AND TENOSYNOVITIS ANKLE AND FOOT 12,675.00
8,872.50
3,802.50
M65.89 OTHER SYNOVITIS AND TENOSYNOVITIS SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M65.9 SYNOVITIS AND TENOSYNOVITIS, UNSPECIFIED 12,675.00
8,872.50
3,802.50
M65.90 SYNOVITIS AND TENOSYNOVITIS, UNSPECIFIED MULTIPLE SITE 12,675.00
8,872.50
3,802.50
M65.91 SYNOVITIS AND TENOSYNOVITIS, UNSPECIFIED SHOULDER REGION 12,675.00
8,872.50
3,802.50
M65.92 SYNOVITIS AND TENOSYNOVITIS, UNSPECIFIED UPPER ARM 12,675.00
8,872.50
3,802.50
M65.93 SYNOVITIS AND TENOSYNOVITIS, UNSPECIFIED FOREARM 12,675.00
8,872.50
3,802.50
M65.94 SYNOVITIS AND TENOSYNOVITIS, UNSPECIFIED HAND 12,675.00
8,872.50
3,802.50
M65.95 SYNOVITIS AND TENOSYNOVITIS, UNSPECIFIED PELVIC REGION AND THIGH 12,675.00
8,872.50
3,802.50
M65.96 SYNOVITIS AND TENOSYNOVITIS, UNSPECIFIED LOWER LEG 12,675.00
8,872.50
3,802.50
M65.97 SYNOVITIS AND TENOSYNOVITIS, UNSPECIFIED ANKLE AND FOOT 12,675.00
8,872.50
3,802.50
M65.99 SYNOVITIS AND TENOSYNOVITIS, UNSPECIFIED SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M66.0 RUPTURE OF POPLITEAL CYST 12,675.00
8,872.50
3,802.50
M66.4 SPONTANEOUS RUPTURE OF OTHER TENDONS 12,675.00
8,872.50
3,802.50
M66.5 SPONTANEOUS RUPTURE OF UNSPECIFIED TENDON; RUPTURE AT MUSCULOTENDINOUS JUNCTION, NONTRAUMATIC 12,675.00
8,872.50
3,802.50
M67.0 SHORT ACHILLES TENDON (ACQUIRED) 12,675.00
8,872.50
3,802.50
M67.1 OTHER CONTRACTURE OF TENDON (SHEATH) 12,675.00
8,872.50
3,802.50
M67.2 SYNOVIAL HYPERTROPHY, NOT ELSEWHERE CLASSIFIED 12,675.00
8,872.50
3,802.50
M67.3 TRANSIENT SYNOVITIS; TOXIC SYNOVITIS 12,675.00
8,872.50
3,802.50
M67.4 GANGLION; GANGLION OF JOINT OR TENDON (SHEATH) 12,675.00
8,872.50
3,802.50
M67.8 OTHER SPECIFIED DISORDERS OF SYNOVIUM AND TENDON 12,675.00
8,872.50
3,802.50
M67.9 DISORDER OF SYNOVIUM AND TENDON, UNSPECIFIED 12,675.00
8,872.50
3,802.50
M70.0 CHRONIC CREPITANT SYNOVITIS OF HAND AND WRIST 12,675.00
8,872.50
3,802.50
Page 62 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate M70.1 BURSITIS OF HAND 12,675.00
8,872.50
3,802.50
M70.2 OLECRANON BURSITIS 12,675.00
8,872.50
3,802.50
M70.3 OTHER BURSITIS OF ELBOW 12,675.00
8,872.50
3,802.50
M70.4 PREPATELLAR BURSITIS 12,675.00
8,872.50
3,802.50
M70.5 OTHER BURSITIS OF KNEE 12,675.00
8,872.50
3,802.50
M70.6
TROCHANTERIC BURSITIS; TROCHANTERIC TENDINITIS
SHOULDER REGION
12,675.00
8,872.50
3,802.50
M70.7 OTHER BURSITIS OF HIP; ISCHIAL BURSITIS 12,675.00
8,872.50
3,802.50
M70.8 OTHER SOFT TISSUE DISORDERS RELATED TO USE, OVERUSE AND PRESSURE 12,675.00
8,872.50
3,802.50
M70.9 UNSPECIFIED SOFT TISSUE DISORDER RELATED TO USE, OVERUSE AND PRESSURE 12,675.00
8,872.50
3,802.50
M71.1 OTHER INFECTIVE BURSITIS 12,675.00
8,872.50
3,802.50
M71.2 SYNOVIAL CYST OF POPLITEAL SPACE [BAKER] 12,675.00
8,872.50
3,802.50
M71.3 OTHER BURSAL CYST; SYNOVIAL CYST NOS 12,675.00
8,872.50
3,802.50
M71.31 OTHER BURSAL CYST; SYNOVIAL CYST NOS SHOULDER REGION 12,675.00
8,872.50
3,802.50
M71.5 OTHER BURSITIS, NOT ELSEWHERE CLASSIFIED 12,675.00
8,872.50
3,802.50
M71.51 OTHER BURSITIS, NOT ELSEWHERE CLASSIFIED SHOULDER REGION 12,675.00
8,872.50
3,802.50
M71.8 OTHER SPECIFIED BURSOPATHIES 12,675.00
8,872.50
3,802.50
M71.9 BURSOPATHY, UNSPECIFIED 12,675.00
8,872.50
3,802.50
M71.91 BURSOPATHY, UNSPECIFIED SHOULDER REGION 12,675.00
8,872.50
3,802.50
M71.99 BURSOPATHY, UNSPECIFIED SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M72.0 PALMAR FASCIAL FIBROMATOSIS [DUPUYTREN] 12,675.00
8,872.50
3,802.50
M72.2 PLANTAR FASCIAL FIBROMATOSIS; PLANTAR FASCIITIS 12,675.00
8,872.50
3,802.50
M72.5 FASCIITIS, NOT ELSEWHERE CLASSIFIED, 12,675.00
8,872.50
3,802.50
M72.88 OTHER FIBROBLASTIC DISORDERS; ABSCESS OF FASCIA OTHER 12,675.00
8,872.50
3,802.50
M72.9 FIBROBLASTIC DISORDER, UNSPECIFIED; FASCIITIS NOS; FIBROMATOSIS NOS 12,675.00
8,872.50
3,802.50
M72.98 FIBROBLASTIC DISORDER, UNSPECIFIED; FASCIITIS NOS; FIBROMATOSIS NOS OTHER 12,675.00
8,872.50
3,802.50
M72.99 FIBROBLASTIC DISORDER, UNSPECIFIED; FASCIITIS NOS; FIBROMATOSIS NOS SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M75.0 ADHESIVE CAPSULITIS OF SHOULDER; FROZEN SHOULDER; PERIARTHRITIS OF SHOULDER 12,675.00
8,872.50
3,802.50
M75.1 ROTATOR CUFF SYNDROME; ROTATOR CUFF OR SUPRASPINATUS TEAR OR RUPTURE COMPLETE)(INCOMPLETE), NOT SPECIFIED AS TRAUMATIC; SUPRASPINATUS SYNDROME 12,675.00
8,872.50
3,802.50
M75.2 BICIPITAL TENDINITIS 12,675.00
8,872.50
3,802.50
M75.3 CALCIFIC TENDINITIS OF SHOULDER; CALCIFIED BURSA OF SHOULDER 12,675.00
8,872.50
3,802.50
M75.4 IMPINGEMENT SYNDROME OF SHOULDER 12,675.00
8,872.50
3,802.50
M75.5 BURSITIS OF SHOULDER 12,675.00
8,872.50
3,802.50
M75.8 OTHER SHOULDER LESIONS 12,675.00
8,872.50
3,802.50
M75.9 SHOULDER LESION, UNSPECIFIED 12,675.00
8,872.50
3,802.50
M76 ENTHESOPATHIES OF LOWER LIMB, EXCLUDING FOOT 12,675.00
8,872.50
3,802.50
M76.0 GLUTEAL TENDINITIS 12,675.00
8,872.50
3,802.50
M76.1 PSOAS TENDINITIS 12,675.00
8,872.50
3,802.50
M76.3 ILIOTIBIAL BAND SYNDROME 12,675.00
8,872.50
3,802.50
M76.4 TIBIAL COLLATERAL BURSITIS [PELLEGRINI-STIEDA] 12,675.00
8,872.50
3,802.50
M76.5 PATELLAR TENDINITIS 12,675.00
8,872.50
3,802.50
M76.6 ACHILLES TENDINITIS; ACHILLES BURSITIS 12,675.00
8,872.50
3,802.50
M76.7 PERONEAL TENDINITIS 12,675.00
8,872.50
3,802.50
M76.8 OTHER ENTHESOPATHIES OF LOWER LIMB, EXCLUDING FOOT; ANTERIOR TIBIAL SYNDROME; POSTERIOR TIBIAL TENDINITIS 12,675.00
8,872.50
3,802.50
M76.9 ENTHESOPATHY OF LOWER LIMB, UNSPECIFIED 12,675.00
8,872.50
3,802.50
M77.0 MEDIAL EPICONDYLITIS 12,675.00
8,872.50
3,802.50
M77.1 LATERAL EPICONDYLITIS; TENNIS ELBOW 12,675.00
8,872.50
3,802.50
M77.3 CALCANEAL SPUR 12,675.00
8,872.50
3,802.50
M77.5 OTHER ENTHESOPATHY OF FOOT 12,675.00
8,872.50
3,802.50
M77.8 OTHER ENTHESOPATHIES, NOT ELSEWHERE CLASSIFIED 12,675.00
8,872.50
3,802.50
M77.9 ENTHESOPATHY, UNSPECIFIED; BONE SPUR NOS; CAPSULITIS NOS; PERIARTHRITIS NOS; TENDINITIS NOS 12,675.00
8,872.50
3,802.50
M79.00 RHEUMATISM, UNSPECIFIED MULTIPLE SITE 11,505.00
8,053.50
3,451.50
M79.01 RHEUMATISM, UNSPECIFIED SHOULDER REGION 11,505.00
8,053.50
3,451.50
M79.02 RHEUMATISM, UNSPECIFIED UPPER ARM 11,505.00
8,053.50
3,451.50
M79.05 RHEUMATISM, UNSPECIFIED PELVIC REGION AND THIGH 11,505.00
8,053.50
3,451.50
M79.07 RHEUMATISM, UNSPECIFIED ANKLE AND FOOT 11,505.00
8,053.50
3,451.50
M79.08 RHEUMATISM, UNSPECIFIED OTHER 11,505.00
8,053.50
3,451.50
M79.09 RHEUMATISM, UNSPECIFIED SITE UNSPECIFIED 11,505.00
8,053.50
3,451.50
M79.10 MYALGIA MULTIPLE SITE 11,505.00
8,053.50
3,451.50
M79.11 MYALGIA SHOULDER REGION 11,505.00
8,053.50
3,451.50
M79.12 MYALGIA UPPER ARM 11,505.00
8,053.50
3,451.50
M79.15 MYALGIA PELVIC REGION AND THIGH 11,505.00
8,053.50
3,451.50
M79.16 MYALGIA LOWER LEG 11,505.00
8,053.50
3,451.50
M79.18 MYALGIA OTHER 11,505.00
8,053.50
3,451.50
M79.19 MYALGIA SITE UNSPECIFIED 11,505.00
8,053.50
3,451.50
M79.20 NEURALGIA AND NEURITIS, UNSPECIFIED MULTIPLE SITE 11,505.00
8,053.50
3,451.50
M79.21 NEURALGIA AND NEURITIS, UNSPECIFIED SHOULDER REGION 11,505.00
8,053.50
3,451.50
M79.22 NEURALGIA AND NEURITIS, UNSPECIFIED UPPER ARM 11,505.00
8,053.50
3,451.50
M79.25 NEURALGIA AND NEURITIS, UNSPECIFIED PELVIC REGION AND THIGH 11,505.00
8,053.50
3,451.50
M79.28 NEURALGIA AND NEURITIS, UNSPECIFIED OTHER 11,505.00
8,053.50
3,451.50
Page 63 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate M79.29 NEURALGIA AND NEURITIS, UNSPECIFIED SITE UNSPECIFIED 11,505.00
8,053.50
3,451.50
M79.39 PANNICULITIS, UNSPECIFIED SITE UNSPECIFIED 11,505.00
8,053.50
3,451.50
M79.80 OTHER SPECIFIED SOFT TISSUE DISORDERS MULTIPLE SITE 12,675.00
8,872.50
3,802.50
M79.81 OTHER SPECIFIED SOFT TISSUE DISORDERS SHOULDER REGION 12,675.00
8,872.50
3,802.50
M79.82 OTHER SPECIFIED SOFT TISSUE DISORDERS UPPER ARM 12,675.00
8,872.50
3,802.50
M79.84 OTHER SPECIFIED SOFT TISSUE DISORDERS HAND 12,675.00
8,872.50
3,802.50
M79.85 OTHER SPECIFIED SOFT TISSUE DISORDERS PELVIC REGION AND THIGH 12,675.00
8,872.50
3,802.50
M79.86 OTHER SPECIFIED SOFT TISSUE DISORDERS LOWER LEG 12,675.00
8,872.50
3,802.50
M79.87 OTHER SPECIFIED SOFT TISSUE DISORDERS ANKLE AND FOOT 12,675.00
8,872.50
3,802.50
M79.88 OTHER SPECIFIED SOFT TISSUE DISORDERS OTHER 12,675.00
8,872.50
3,802.50
M79.89 OTHER SPECIFIED SOFT TISSUE DISORDERS SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M79.91 SOFT TISSUE DISORDER, UNSPECIFIED SHOULDER REGION 12,675.00
8,872.50
3,802.50
M79.95 SOFT TISSUE DISORDER, UNSPECIFIED PELVIC REGION AND THIGH 12,675.00
8,872.50
3,802.50
M79.98 SOFT TISSUE DISORDER, UNSPECIFIED OTHER 12,675.00
8,872.50
3,802.50
M79.99 SOFT TISSUE DISORDER, UNSPECIFIED SITE UNSPECIFIED 12,675.00
8,872.50
3,802.50
M80.0 POSTMENOPAUSAL OSTEOPOROSIS WITH PATHOLOGICAL FRACTURE 15,405.00
10,783.50
4,621.50
M80.1 POSTOOPHORECTOMY OSTEOPOROSIS WITH PATHOLOGICAL FRACTURE 15,405.00
10,783.50
4,621.50
M80.3 POSTSURGICAL MALABSORPTION OSTEOPOROSIS WITH PATHOLOGICAL FRACTURE 15,405.00
10,783.50
4,621.50
M81.0 POSTMENOPAUSAL OSTEOPOROSIS 15,405.00
10,783.50
4,621.50
M81.08 POSTMENOPAUSAL OSTEOPOROSIS OTHER 15,405.00
10,783.50
4,621.50
M81.1 POSTOOPHORECTOMY OSTEOPOROSIS 15,405.00
10,783.50
4,621.50
M81.4 DRUG-INDUCED OSTEOPOROSIS 15,405.00
10,783.50
4,621.50
M81.40 DRUG-INDUCED OSTEOPOROSIS MULTIPLE SITE 15,405.00
10,783.50
4,621.50
M81.55 IDIOPATHIC OSTEOPOROSIS PELVIC REGION AND THIGH 15,405.00
10,783.50
4,621.50
M81.58 IDIOPATHIC OSTEOPOROSIS OTHER 15,405.00
10,783.50
4,621.50
M81.6 LOCALIZED OSTEOPOROSIS [LEQUESNE] 15,405.00
10,783.50
4,621.50
M81.8 OTHER OSTEOPOROSIS; SENILE OSTEOPOROSIS 15,405.00
10,783.50
4,621.50
M81.88 OTHER OSTEOPOROSIS; SENILE OSTEOPOROSIS OTHER 15,405.00
10,783.50
4,621.50
M81.89 OTHER OSTEOPOROSIS; SENILE OSTEOPOROSIS SITE UNSPECIFIED 15,405.00
10,783.50
4,621.50
M81.9 OSTEOPOROSIS, UNSPECIFIED 15,405.00
10,783.50
4,621.50
M81.95 OSTEOPOROSIS, UNSPECIFIED PELVIC REGION AND THIGH 15,405.00
10,783.50
4,621.50
M81.98 OSTEOPOROSIS, UNSPECIFIED OTHER 15,405.00
10,783.50
4,621.50
M83.2 ADULT OSTEOMALACIA DUE TO MALABSORPTION; POSTSURGICAL MALABSORPTION OSTEOMALACIA IN ADULTS 15,405.00
10,783.50
4,621.50
M83.4 ALUMINIUM BONE DISEASE 15,405.00
10,783.50
4,621.50
M83.8 OTHER ADULT OSTEOMALACIA 15,405.00
10,783.50
4,621.50
M83.87 OTHER ADULT OSTEOMALACIA ANKLE AND FOOT 15,405.00
10,783.50
4,621.50
M83.89 OTHER ADULT OSTEOMALACIA SITE UNSPECIFIED 15,405.00
10,783.50
4,621.50
M83.9 ADULT OSTEOMALACIA, UNSPECIFIED 15,405.00
10,783.50
4,621.50
M83.99 ADULT OSTEOMALACIA, UNSPECIFIED SITE UNSPECIFIED 15,405.00
10,783.50
4,621.50
M85.0 FIBROUS DYSPLASIA (MONOSTOTIC) 15,405.00
10,783.50
4,621.50
M85.1 SKELETAL FLUOROSIS MULTIPLE SITE 15,405.00
10,783.50
4,621.50
M85.2 HYPEROSTOSIS OF SKULL 15,405.00
10,783.50
4,621.50
M85.5 ANEURYSMAL BONE CYST 15,405.00
10,783.50
4,621.50
M85.55 ANEURYSMAL BONE CYST PELVIC REGION AND THIGH 15,405.00
10,783.50
4,621.50
M85.6 OTHER CYST OF BONE 15,405.00
10,783.50
4,621.50
M85.63 OTHER CYST OF BONE FOREARM 15,405.00
10,783.50
4,621.50
M85.65 OTHER CYST OF BONE PELVIC REGION AND THIGH 15,405.00
10,783.50
4,621.50
M85.8 OTHER SPECIFIED DISORDERS OF BONE DENSITY AND STRUCTURE; HYPEROSTOSIS OF BONES, EXCEPT SKULL 15,405.00
10,783.50
4,621.50
M85.88 OTHER SPECIFIED DISORDERS OF BONE DENSITY AND STRUCTURE; HYPEROSTOSIS OF BONES, EXCEPT SKULL OTHER 15,405.00
10,783.50
4,621.50
M86.0 ACUTE HAEMATOGENOUS OSTEOMYELITIS 25,350.00
17,745.00
7,605.00
M86.1 OTHER ACUTE OSTEOMYELITIS 25,350.00
17,745.00
7,605.00
M86.15 OTHER ACUTE OSTEOMYELITIS PELVIC REGION AND THIGH 25,350.00
17,745.00
7,605.00
M86.17 OTHER ACUTE OSTEOMYELITIS ANKLE AND FOOT 25,350.00
17,745.00
7,605.00
M86.19 OTHER ACUTE OSTEOMYELITIS SITE UNSPECIFIED 25,350.00
17,745.00
7,605.00
M86.2 SUBACUTE OSTEOMYELITIS 25,350.00
17,745.00
7,605.00
M86.29 SUBACUTE OSTEOMYELITIS SITE UNSPECIFIED 25,350.00
17,745.00
7,605.00
M86.4 CHRONIC OSTEOMYELITIS WITH DRAINING SINUS 25,350.00
17,745.00
7,605.00
M86.5 OTHER CHRONIC HAEMATOGENOUS OSTEOMYELITIS 25,350.00
17,745.00
7,605.00
M86.50 OTHER CHRONIC HAEMATOGENOUS OSTEOMYELITIS MULTIPLE SITE 25,350.00
17,745.00
7,605.00
M86.6 OTHER CHRONIC OSTEOMYELITIS 25,350.00
17,745.00
7,605.00
M86.60 OTHER CHRONIC OSTEOMYELITIS MULTIPLE SITE 25,350.00
17,745.00
7,605.00
M86.61 OTHER CHRONIC OSTEOMYELITIS SHOULDER REGION 25,350.00
17,745.00
7,605.00
M86.62 OTHER CHRONIC OSTEOMYELITIS UPPER ARM 25,350.00
17,745.00
7,605.00
M86.63 OTHER CHRONIC OSTEOMYELITIS FOREARM 25,350.00
17,745.00
7,605.00
M86.65 OTHER CHRONIC OSTEOMYELITIS PELVIC REGION AND THIGH 25,350.00
17,745.00
7,605.00
M86.66 OTHER CHRONIC OSTEOMYELITIS LOWER LEG 25,350.00
17,745.00
7,605.00
M86.67 OTHER CHRONIC OSTEOMYELITIS ANKLE AND FOOT 25,350.00
17,745.00
7,605.00
M86.68 OTHER CHRONIC OSTEOMYELITIS OTHER 25,350.00
17,745.00
7,605.00
M86.69 OTHER CHRONIC OSTEOMYELITIS SITE UNSPECIFIED 25,350.00
17,745.00
7,605.00
M86.8 OTHER OSTEOMYELITIS; BRODIE'S ABSCESS 25,350.00
17,745.00
7,605.00
Page 64 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate M86.80 OTHER OSTEOMYELITIS; BRODIE'S ABSCESS MULTIPLE SITE 25,350.00
17,745.00
7,605.00
M86.81 OTHER OSTEOMYELITIS; BRODIE'S ABSCESS SHOULDER REGION 25,350.00
17,745.00
7,605.00
M86.88 OTHER OSTEOMYELITIS; BRODIE'S ABSCESS OTHER 25,350.00
17,745.00
7,605.00
M86.9 OSTEOMYELITIS, UNSPECIFIED; INFECTION OF BONE NOS; PERIOSTITIS WITHOUT MENTION OF OSTEOMYELITIS 25,350.00
17,745.00
7,605.00
M86.90 OSTEOMYELITIS, UNSPECIFIED; INFECTION OF BONE NOS; PERIOSTITIS WITHOUT MENTION OF OSTEOMYELITIS MULTIPLE SITE 25,350.00
17,745.00
7,605.00
M86.91 OSTEOMYELITIS, UNSPECIFIED; INFECTION OF BONE NOS; PERIOSTITIS WITHOUT MENTION OF OSTEOMYELITIS SHOULDER REGION 25,350.00
17,745.00
7,605.00
M86.92 OSTEOMYELITIS, UNSPECIFIED; INFECTION OF BONE NOS; PERIOSTITIS WITHOUT MENTION OF OSTEOMYELITIS UPPER ARM 25,350.00
17,745.00
7,605.00
M86.94 OSTEOMYELITIS, UNSPECIFIED; INFECTION OF BONE NOS; PERIOSTITIS WITHOUT MENTION OF OSTEOMYELITIS HAND 25,350.00
17,745.00
7,605.00
M86.95 OSTEOMYELITIS, UNSPECIFIED; INFECTION OF BONE NOS; PERIOSTITIS WITHOUT MENTION OF OSTEOMYELITIS PELVIC REGION AND THIGH 25,350.00
17,745.00
7,605.00
M86.96 OSTEOMYELITIS, UNSPECIFIED; INFECTION OF BONE NOS; PERIOSTITIS WITHOUT MENTION OF OSTEOMYELITIS LOWER LEG 25,350.00
17,745.00
7,605.00
M86.97 OSTEOMYELITIS, UNSPECIFIED; INFECTION OF BONE NOS; PERIOSTITIS WITHOUT MENTION OF OSTEOMYELITIS ANKLE AND FOOT 25,350.00
17,745.00
7,605.00
M86.98 OSTEOMYELITIS, UNSPECIFIED; INFECTION OF BONE NOS; PERIOSTITIS WITHOUT MENTION OF OSTEOMYELITIS OTHER 25,350.00
17,745.00
7,605.00
M86.99 OSTEOMYELITIS, UNSPECIFIED; INFECTION OF BONE NOS; PERIOSTITIS WITHOUT MENTION OF OSTEOMYELITIS SITE UNSPECIFIED 25,350.00
17,745.00
7,605.00
M87.05 IDIOPATHIC ASEPTIC NECROSIS OF BONE PELVIC REGION AND THIGH 25,350.00
17,745.00
7,605.00
M87.2 OSTEONECROSIS DUE TO PREVIOUS TRAUMA 25,350.00
17,745.00
7,605.00
M87.8 OTHER OSTEONECROSIS 25,350.00
17,745.00
7,605.00
M87.85 OTHER OSTEONECROSIS PELVIC REGION AND THIGH 25,350.00
17,745.00
7,605.00
M87.86 OTHER OSTEONECROSIS LOWER LEG 25,350.00
17,745.00
7,605.00
M87.9 OSTEONECROSIS, UNSPECIFIED 25,350.00
17,745.00
7,605.00
M87.90 OSTEONECROSIS, UNSPECIFIED MULTIPLE SITE 25,350.00
17,745.00
7,605.00
M87.91 OSTEONECROSIS, UNSPECIFIED SHOULDER REGION 25,350.00
17,745.00
7,605.00
M87.95 OSTEONECROSIS, UNSPECIFIED PELVIC REGION AND THIGH 25,350.00
17,745.00
7,605.00
M87.99 OSTEONECROSIS, UNSPECIFIED SITE UNSPECIFIED 25,350.00
17,745.00
7,605.00
M88.0 PAGET'S DISEASE OF SKULL 25,350.00
17,745.00
7,605.00
M88.9 PAGET'S DISEASE OF BONE, UNSPECIFIED 25,350.00
17,745.00
7,605.00
M89.0 ALGONEURODYSTROPHY; SHOULDER-HAND SYNDROME; SUDECK'S ATROPHY; SYMPATHETIC REFLEX DYSTROPHY 17,160.00
12,012.00
5,148.00
M89.01
ALGONEURODYSTROPHY; SHOULDER-HAND SYNDROME;
SUDECK'S ATROPHY; SYMPATHETIC REFLEX DYSTROPHY
SHOULDER REGION
17,160.00
12,012.00
5,148.00
M89.2 OTHER DISORDERS OF BONE DEVELOPMENT AND GROWTH 17,160.00
12,012.00
5,148.00
M89.38 HYPERTROPHY OF BONE OTHER 15,405.00
10,783.50
4,621.50
M89.4 OTHER HYPERTROPHIC OSTEOARTHROPATHY; MARIE- BAMBERGER DISEASE; PACHYDERMOPERIOSTOSIS 17,160.00
12,012.00
5,148.00
M89.48 OTHER HYPERTROPHIC OSTEOARTHROPATHY; MARIE- BAMBERGER DISEASE; PACHYDERMOPERIOSTOSIS OTHER 17,160.00
12,012.00
5,148.00
M89.5 OSTEOLYSIS 17,160.00
12,012.00
5,148.00
M89.54 OSTEOLYSIS HAND 17,160.00
12,012.00
5,148.00
M89.6 OSTEOPATHY AFTER POLIOMYELITIS 17,160.00
12,012.00
5,148.00
M89.8 OTHER SPECIFIED DISORDERS OF BONE; INFANTILE CORTICAL HYPEROSTOSES; POST-TRAUMATIC SUBPERIOSTEAL OSSIFICATION 17,160.00
12,012.00
5,148.00
M89.85 OTHER SPECIFIED DISORDERS OF BONE; INFANTILE CORTICAL HYPEROSTOSES; POST-TRAUMATIC SUBPERIOSTEAL OSSIFICATION PELVIC REGION AND THIGH 17,160.00
12,012.00
5,148.00
M89.86 OTHER SPECIFIED DISORDERS OF BONE; INFANTILE CORTICAL HYPEROSTOSES; POST-TRAUMATIC SUBPERIOSTEAL OSSIFICATION LOWER LEG 17,160.00
12,012.00
5,148.00
M89.87 OTHER SPECIFIED DISORDERS OF BONE; INFANTILE CORTICAL HYPEROSTOSES; POST-TRAUMATIC SUBPERIOSTEAL OSSIFICATION ANKLE AND FOOT 17,160.00
12,012.00
5,148.00
M89.88 OTHER SPECIFIED DISORDERS OF BONE; INFANTILE CORTICAL HYPEROSTOSES; POST-TRAUMATIC SUBPERIOSTEAL OSSIFICATION OTHER 17,160.00
12,012.00
5,148.00
M89.89 OTHER SPECIFIED DISORDERS OF BONE; INFANTILE CORTICAL HYPEROSTOSES; POST-TRAUMATIC SUBPERIOSTEAL OSSIFICATION SITE UNSPECIFIED 17,160.00
12,012.00
5,148.00
M89.95 DISORDER OF BONE, UNSPECIFIED PELVIC REGION AND THIGH 17,160.00
12,012.00
5,148.00
M89.98 DISORDER OF BONE, UNSPECIFIED OTHER 17,160.00
12,012.00
5,148.00
M89.99 DISORDER OF BONE, UNSPECIFIED SITE UNSPECIFIED 17,160.00
12,012.00
5,148.00
M91.1 JUVENILE OSTEOCHONDROSIS OF HEAD OF FEMUR [LEGG-CALVÉ- PERTHES] 17,160.00
12,012.00
5,148.00
M91.8 OTHER JUVENILE OSTEOCHONDROSIS OF HIP AND PELVIS; JUVENILE OSTEOCHONDROSIS AFTER REDUCTION OF CONGENITAL DISLOCATION OF HIP 17,160.00
12,012.00
5,148.00
Page 65 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate M94.0 CHONDROCOSTAL JUNCTION SYNDROME [TIETZE] 17,160.00
12,012.00
5,148.00
M94.8 OTHER SPECIFIED DISORDERS OF CARTILAGE 17,160.00
12,012.00
5,148.00
M96.8 OTHER POSTPROCEDURAL MUSCULOSKELETAL DISORDERS 11,505.00
8,053.50
3,451.50
M99.0 SEGMENTAL AND SOMATIC DYSFUNCTION, RIB CAGE 15,210.00
10,647.00
4,563.00
M99.1 SUBLUXATION COMPLEX (VERTEBRAL) 15,210.00
10,647.00
4,563.00
M99.3 OSSEOUS STENOSIS OF NEURAL CANAL 15,210.00
10,647.00
4,563.00
M99.5 INTERVERTEBRAL DISC STENOSIS OF NEURAL CANAL 15,210.00
10,647.00
4,563.00
M99.7 CONNECTIVE TISSUE AND DISC STENOSIS OF INTERVERTEBRAL FORAMINA 15,210.00
10,647.00
4,563.00
M99.8 OTHER BIOMECHANICAL LESIONS 17,160.00
12,012.00
5,148.00
M99.9 BIOMECHANICAL LESION, UNSPECIFIED 17,160.00
12,012.00
5,148.00
N00.0 ACUTE NEPHRITIC SYNDROME INCLUDING ACUTE GLOMERULAR DISEASE, ACUTE GLOMERULONEPHRITIS, ACUTE NEPHRITIS, ACUTE RENAL DISEASE NOS, WITH MINOR GLOMERULAR ABNORMALITY 19,500.00
13,650.00
5,850.00
N00.1
ACUTE NEPHRITIC SYNDROME INCLUDING ACUTE GLOMERULAR
DISEASE, ACUTE GLOMERULONEPHRITIS, ACUTE NEPHRITIS,
ACUTE RENAL DISEASE NOS, WITH FOCAL AND SEGMENTAL
GLOMERULAR LESIONS (WITH FOCAL AND SEGMENTAL
HYALINOSIS; FOCAL AND SEGMENTAL SCLEROSIS) & FOCAL GLOM
19,500.00
13,650.00
5,850.00
N00.2
ACUTE NEPHRITIC SYNDROME INCLUDING ACUTE GLOMERULAR
DISEASE, ACUTE GLOMERULONEPHRITIS, ACUTE NEPHRITIS,
ACUTE RENAL DISEASE NOS WITH DIFFUSE MEMBRANOUS
GLOMERULONEPHRITIS
19,500.00
13,650.00
5,850.00
N00.3
ACUTE NEPHRITIC SYNDROME INCLUDING ACUTE GLOMERULAR
DISEASE, ACUTE GLOMERULONEPHRITIS, ACUTE NEPHRITIS,
ACUTE RENAL DISEASE NOS WITH DIFFUSE MESANGIAL
PROLIFERATIVE GLOMERULONEPHRITIS
19,500.00
13,650.00
5,850.00
N00.4 ACUTE NEPHRITIC SYNDROME INCLUDING ACUTE GLOMERULAR DISEASE, ACUTE GLOMERULONEPHRITIS, ACUTE NEPHRITIS, ACUTE RENAL DISEASE NOS WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N00.5 ACUTE NEPHRITIC SYNDROME INCLUDING ACUTE GLOMERULAR DISEASE, ACUTE GLOMERULONEPHRITIS, ACUTE NEPHRITIS, ACUTE RENAL DISEASE NOS WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS (MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS, TYPES 1 AND 3, OR NOS) 19,500.00
13,650.00
5,850.00
N00.7 ACUTE NEPHRITIC SYNDROME INCLUDING ACUTE GLOMERULAR DISEASE, ACUTE GLOMERULONEPHRITIS, ACUTE NEPHRITIS, ACUTE RENAL DISEASE NOS WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS (EXTRACPILLARY GLOMERULONEPHRITIS) 19,500.00
13,650.00
5,850.00
N00.8
ACUTE NEPHRITIC SYNDROME INCLUDING ACUTE GLOMERULAR
DISEASE, ACUTE GLOMERULONEPHRITIS, ACUTE NEPHRITIS,
ACUTE RENAL DISEASE NOS WITH OTHER (PROLIFERATIVE
GLOMERULONEPHRITIS NOS)
19,500.00
13,650.00
5,850.00
N00.9 ACUTE NEPHRITIC SYNDROME INCLUDING ACUTE GLOMERULAR DISEASE, ACUTE GLOMERULONEPHRITIS, ACUTE NEPHRITIS, ACUTE RENAL DISEASE NOS, UNSPECIFIED RENAL BIOPSY 19,500.00
13,650.00
5,850.00
N01.0 RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME; RAPIDLY PROGRESSIVE GLOMERULAR DISEASE; RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS; RAPIDLY PROGRESSIVE NEPHRITIS, MINOR GLOMERULAR ABNORMALITY 19,500.00
13,650.00
5,850.00
N01.1 RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME; RAPIDLY PROGRESSIVE GLOMERULAR DISEASE; RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS; RAPIDLY PROGRESSIVE NEPHRITIS, FOCAL AND SEGMENTAL GLOMERULAR LESIONS 19,500.00
13,650.00
5,850.00
N01.3 RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME; RAPIDLY PROGRESSIVE GLOMERULAR DISEASE; RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS; RAPIDLY PROGRESSIVE NEPHRITIS, DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N01.5 RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME; RAPIDLY PROGRESSIVE GLOMERULAR DISEASE; RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS; RAPIDLY PROGRESSIVE NEPHRITIS, DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N01.8 RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME; RAPIDLY PROGRESSIVE GLOMERULAR DISEASE; RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS; RAPIDLY PROGRESSIVE NEPHRITIS, OTHER 19,500.00
13,650.00
5,850.00
N01.9 RAPIDLY PROGRESSIVE NEPHRITIC SYNDROME; RAPIDLY PROGRESSIVE GLOMERULAR DISEASE; RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS; RAPIDLY PROGRESSIVE NEPHRITIS, UNSPECIFIED 19,500.00
13,650.00
5,850.00
N02.0 RECURRENT AND PERSISTENT HAEMATURIA INCLUDING BENIGN FAMILIAL HAEMATURIA; BENIGN FAMILIAL HAEMATURIA OF CHILDHOOD; HAEMATURIA WITH MORPHOLOGICAL LESION SPECIFIED WITH MINOR GLOMERULAR ABNORMALITY 19,500.00
13,650.00
5,850.00
Page 66 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate N02.1 RECURRENT AND PERSISTENT HAEMATURIA INCLUDING BENIGN FAMILIAL HAEMATURIA; BENIGN FAMILIAL HAEMATURIA OF CHILDHOOD; HAEMATURIA WITH MORPHOLOGICAL LESION SPECIFIED WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS 19,500.00
13,650.00
5,850.00
N02.2 RECURRENT AND PERSISTENT HAEMATURIA INCLUDING BENIGN FAMILIAL HAEMATURIA; BENIGN FAMILIAL HAEMATURIA OF CHILDHOOD; HAEMATURIA WITH MORPHOLOGICAL LESION SPECIFIED WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N02.5 RECURRENT AND PERSISTENT HAEMATURIA INCLUDING BENIGN FAMILIAL HAEMATURIA; BENIGN FAMILIAL HAEMATURIA OF CHILDHOOD; HAEMATURIA WITH MORPHOLOGICAL LESION SPECIFIED WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N02.8 RECURRENT AND PERSISTENT HAEMATURIA INCLUDING BENIGN FAMILIAL HAEMATURIA; BENIGN FAMILIAL HAEMATURIA OF CHILDHOOD; HAEMATURIA WITH MORPHOLOGICAL LESION SPECIFIED WITH OTHER (PROLIFERATIVE GLOMERULONEPHRITIS NOS) 19,500.00
13,650.00
5,850.00
N02.9 RECURRENT AND PERSISTENT HAEMATURIA INCLUDING BENIGN FAMILIAL HAEMATURIA; BENIGN FAMILIAL HAEMATURIA OF CHILDHOOD; HAEMATURIA WITH MORPHOLOGICAL LESION SPECIFIED WITH UNSPECIFIED RENAL BIOPSY 19,500.00
13,650.00
5,850.00
N03.0
CHRONIC NEPHRITIC SYNDROME INCLUDING CHRONIC
GLOMERULAR DISEASE, CHRONIC GLOMERULONEPHRITIS,
CHRONIC NEPHRITIS, CHRONIC RENAL DISEASE NOS, WITH
MINOR GLOMERULAR ABNORMALITY
19,500.00
13,650.00
5,850.00
N03.1
CHRONIC NEPHRITIC SYNDROME INCLUDING CHRONIC
GLOMERULAR DISEASE, CHRONIC GLOMERULONEPHRITIS,
CHRONIC NEPHRITIS, CHRONIC RENAL DISEASE NOS, WITH FOCAL
AND SEGMENTAL GLOMERULAR LESIONS
19,500.00
13,650.00
5,850.00
N03.2
CHRONIC NEPHRITIC SYNDROME INCLUDING CHRONIC
GLOMERULAR DISEASE, CHRONIC GLOMERULONEPHRITIS,
CHRONIC NEPHRITIS, CHRONIC RENAL DISEASE NOS,
WITHDIFFUSE MEMBRANOUS GLOMERULONEPHRITIS
19,500.00
13,650.00
5,850.00
N03.3
CHRONIC NEPHRITIC SYNDROME INCLUDING CHRONIC
GLOMERULAR DISEASE, CHRONIC GLOMERULONEPHRITIS,
CHRONIC NEPHRITIS, CHRONIC RENAL DISEASE NOS, WITH
DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS
19,500.00
13,650.00
5,850.00
N03.4
CHRONIC NEPHRITIC SYNDROME INCLUDING CHRONIC
GLOMERULAR DISEASE, CHRONIC GLOMERULONEPHRITIS,
CHRONIC NEPHRITIS, CHRONIC RENAL DISEASE NOS, WITH
DIFFUSE ENDOCAPILLARY PROLIFERATIVE
GLOMERULONEPHRITIS
19,500.00
13,650.00
5,850.00
N03.5
CHRONIC NEPHRITIC SYNDROME INCLUDING CHRONIC
GLOMERULAR DISEASE, CHRONIC GLOMERULONEPHRITIS,
CHRONIC NEPHRITIS, CHRONIC RENAL DISEASE NOS, WITH
DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS
19,500.00
13,650.00
5,850.00
N03.7
CHRONIC NEPHRITIC SYNDROME INCLUDING CHRONIC
GLOMERULAR DISEASE, CHRONIC GLOMERULONEPHRITIS,
CHRONIC NEPHRITIS, CHRONIC RENAL DISEASE NOS, WITH
DIFFUSE CRESCENTIC GLOMERULONEPHRITIS
19,500.00
13,650.00
5,850.00
N03.8
CHRONIC NEPHRITIC SYNDROME INCLUDING CHRONIC
GLOMERULAR DISEASE, CHRONIC GLOMERULONEPHRITIS,
CHRONIC NEPHRITIS, CHRONIC RENAL DISEASE NOS, WITH
OTHER (PROLIFERATIVE GLOMERULONEPHRITIS NOS)
19,500.00
13,650.00
5,850.00
N03.9
CHRONIC NEPHRITIC SYNDROME INCLUDING CHRONIC
GLOMERULAR DISEASE, CHRONIC GLOMERULONEPHRITIS,
CHRONIC NEPHRITIS, CHRONIC RENAL DISEASE NOS, WITH
UNSPECIFIED RENAL BIOPSY
19,500.00
13,650.00
5,850.00
N04.0 NEPHROTIC SYNDROME: MINOR GLOMERULAR ABNORMALITY; MINIMAL CHANGE LESION 19,500.00
13,650.00
5,850.00
N04.1 NEPHROTIC SYNDROME: FOCAL AND SEGMENTAL GLOMERULAR LESIONS; FOCAL AND SEGMENTAL HYALINOSIS; FOCAL AND SEGMENTAL SCLEROSIS; FOCAL GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N04.2 NEPHROTIC SYNDROME: DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N04.3 NEPHROTIC SYNDROME: DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N04.4 NEPHROTIC SYNDROME: DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N04.5 NEPHROTIC SYNDROME: DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS; MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS, TYPES 1 AND 3, OR NOS 19,500.00
13,650.00
5,850.00
N04.7 NEPHROTIC SYNDROME: DIFFUSE CRESCENTIC GLOMERULONEPHRITIS; EXTRACAPILLARY GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N04.8 NEPHROTIC SYNDROME: OTHER 19,500.00
13,650.00
5,850.00
N04.9 NEPHROTIC SYNDROME:UNSPECIFIED 19,500.00
13,650.00
5,850.00
N05.0 UNSPECIFIED NEPHRITIC SYNDROME INCLUDING GLOMERULAR DISEASE, GLOMERULONEPHRITIS, NEPHRITIS NOS WITH MINOR GLOMERULAR ABNORMALITY, MINIMAL CHANGE LESION 19,500.00
13,650.00
5,850.00
Page 67 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate N05.1 UNSPECIFIED NEPHRITIC SYNDROME INCLUDING GLOMERULAR DISEASE, GLOMERULONEPHRITIS, NEPHRITIS NOS WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS (WITH FOCAL AND SEGMENTAL HYALINOSIS; FOCAL AND SEGMENTAL SCLEROSIS) & FOCAL GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N05.2 UNSPECIFIED NEPHRITIC SYNDROME INCLUDING GLOMERULAR DISEASE, GLOMERULONEPHRITIS, NEPHRITIS NOS WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N05.3 UNSPECIFIED NEPHRITIC SYNDROME INCLUDING GLOMERULAR DISEASE, GLOMERULONEPHRITIS, NEPHRITIS NOS WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N05.4 UNSPECIFIED NEPHRITIC SYNDROME INCLUDING GLOMERULAR DISEASE, GLOMERULONEPHRITIS, NEPHRITIS NOS WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N05.5
UNSPECIFIED NEPHRITIC SYNDROME INCLUDING GLOMERULAR
DISEASE, GLOMERULONEPHRITIS, NEPHRITIS NOS WITH
DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS,
MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS, TYPES 1 AND
3, OR NOS
19,500.00
13,650.00
5,850.00
N05.6 UNSPECIFIED NEPHRITIC SYNDROME INCLUDING GLOMERULAR DISEASE, GLOMERULONEPHRITIS, NEPHRITIS NOS WITH DENSE DEPOSIT DISEASE MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS, TYPE 2 19,500.00
13,650.00
5,850.00
N05.7 UNSPECIFIED NEPHRITIC SYNDROME INCLUDING GLOMERULAR DISEASE, GLOMERULONEPHRITIS, NEPHRITIS NOS WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS, EXTRACAPILLARY GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N05.8 UNSPECIFIED NEPHRITIC SYNDROME INCLUDING GLOMERULAR DISEASE, GLOMERULONEPHRITIS, NEPHRITIS NOS WITH OTHER (PROLIFERATIVE GLOMERULONEPHRITIS NOS) 19,500.00
13,650.00
5,850.00
N05.9 UNSPECIFIED NEPHRITIC SYNDROME INCLUDING GLOMERULAR DISEASE, GLOMERULONEPHRITIS, NEPHRITIS NOS WITH UNSPECIFIED RENAL BIOPSY 19,500.00
13,650.00
5,850.00
N06.0 ISOLATED PROTEINURIA WITH SPECIFIED MORPHOLOGICAL LESION WITH MORPHOLOGICAL LESION SPECIFIED WITH MINOR GLOMERULAR ABNORMALITY 19,500.00
13,650.00
5,850.00
N06.8 ISOLATED PROTEINURIA WITH SPECIFIED MORPHOLOGICAL LESION WITH OTHER (PROLIFERATIVE GLOMERULONEPHRITIS NOS) 19,500.00
13,650.00
5,850.00
N06.9 ISOLATED PROTEINURIA WITH SPECIFIED MORPHOLOGICAL LESION WITH UNSPECIFIED RENAL BIOPSY 19,500.00
13,650.00
5,850.00
N07.0 HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH MINOR GLOMERULAR ABNORMALITY 19,500.00
13,650.00
5,850.00
N07.1 HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS (WITH FOCAL AND SEGMENTAL HYALINOSIS; FOCAL AND SEGMENTAL SCLEROSIS) & FOCAL GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N07.2 HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N07.3 HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS 19,500.00
13,650.00
5,850.00
N07.5 HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS, MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS, TYPES 1 AND 3, OR NOS 19,500.00
13,650.00
5,850.00
N07.9 HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH UNSPECIFIED RENAL BIOPSY 19,500.00
13,650.00
5,850.00
N10 ACUTE TUBULO-INTERSTITIAL NEPHRITIS; PYELONEPHRITIS; ACUTE INFECTIOUS INTERSTITIAL NEPHRITIS; ACUTE PYELITIS; ACUTE PYELONEPHRITIS 19,500.00
13,650.00
5,850.00
N11.0 NONOBSTRUCTIVE REFLUX-ASSOCIATED CHRONIC PYELONEPHRITIS; CHRONIC PYELONEPHRITIS ASSOCIATED WITH VESICOURETERAL REFLUX 21,255.00
14,878.50
6,376.50
N11.1 CHRONIC OBSTRUCTIVE PYELONEPHRITIS; CHRONIC PYELONEPHRITIS ASSOCIATED WITH ANOMALY OF [PELVIURETERIC JUNCTION, PYELOURETERIC JUNCTION, URETER]; CHRONIC PYELONEPHRITIS ASSOCIATED WITH KINKING OF [PELVIURETERIC JUNCTION, PYELOURETERIC JUNCTION, URETER]; CHR 21,255.00
14,878.50
6,376.50
N11.8 OTHER CHRONIC TUBULO-INTERSTITIAL NEPHRITIS; NONOBSTRUCTIVE CHRONIC PYELONEPHRITIS NOS 21,255.00
14,878.50
6,376.50
N11.9 CHRONIC TUBULO-INTERSTITIAL NEPHRITIS, UNSPECIFIED; CHRONIC INTERSTITIAL NEPHRITIS NOS; CHRONIC PYELITIS NOS; CHRONIC PYELONEPHRITIS NOS 19,500.00
13,650.00
5,850.00
N12 TUBULO-INTERSTITIAL NEPHRITIS, NOT SPECIFIED AS ACUTE OR CHRONIC; INTERSTITIAL NEPHRITIS NOS; PYELITIS NOS; PYELONEPHRITIS NOS 19,500.00
13,650.00
5,850.00
N13.0 HYDRONEPHROSIS WITH URETEROPELVIC JUNCTION OBSTRUCTION 18,915.00
13,240.50
5,674.50
Page 68 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate N13.1 HYDRONEPHROSIS WITH URETERAL STRICTURE, NOT ELSEWHERE CLASSIFIED 18,915.00
13,240.50
5,674.50
N13.2 HYDRONEPHROSIS WITH RENAL AND URETERAL CALCULOUS OBSTRUCTION 18,915.00
13,240.50
5,674.50
N13.3 OTHER AND UNSPECIFIED HYDRONEPHROSIS 18,915.00
13,240.50
5,674.50
N13.4 HYDROURETER 18,915.00
13,240.50
5,674.50
N13.5 KINKING AND STRICTURE OF URETER WITHOUT HYDRONEPHROSIS 18,915.00
13,240.50
5,674.50
N13.6 PYONEPHROSIS; CONDITIONS IN N13.0-N13.5 WITH INFECTION; OBSTRUCTIVE UROPATHY WITH INFECTION 18,915.00
13,240.50
5,674.50
N13.7 VESICOURETERAL-REFLUX-ASSOCIATED UROPATHY; VESICOURETERAL REFLUX NOS; VESICOURETERAL REFLUX WITH SCARRING 18,915.00
13,240.50
5,674.50
N13.8 OTHER OBSTRUCTIVE AND REFLUX UROPATHY 18,915.00
13,240.50
5,674.50
N13.9 OBSTRUCTIVE AND REFLUX UROPATHY, UNSPECIFIED; URINARY TRACT OBSTRUCTION NOS 18,915.00
13,240.50
5,674.50
N14.0 ANALGESIC NEPHROPATHY 19,500.00
13,650.00
5,850.00
N14.1 NEPHROPATHY INDUCED BY OTHER DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES 19,500.00
13,650.00
5,850.00
N14.2 NEPHROPATHY INDUCED BY UNSPECIFIED DRUG, MEDICAMENT OR BIOLOGICAL SUBSTANCE 19,500.00
13,650.00
5,850.00
N14.4 TOXIC NEPHROPATHY, NOT ELSEWHERE CLASSIFIED 19,500.00
13,650.00
5,850.00
N15.0 BALKAN NEPHROPATHY; BALKAN ENDEMIC NEPHROPATHY 19,500.00
13,650.00
5,850.00
N15.1 RENAL AND PERINEPHRIC ABSCESS 27,105.00
18,973.50
8,131.50
N15.8 OTHER SPECIFIED RENAL TUBULO-INTERSTITIAL DISEASES 19,500.00
13,650.00
5,850.00
N15.9 RENAL TUBULO-INTERSTITIAL DISEASE, UNSPECIFIED; INFECTION OF KIDNEY NOS 19,500.00
13,650.00
5,850.00
N17.0 ACUTE RENAL FAILURE WITH TUBULAR NECROSIS; TUBULAR NECROSIS NOS; ACUTE TUBULAR NECROSIS ; RENAL TUBULAR NECROSIS 37,635.00
26,344.50
11,290.50
N17.1 ACUTE RENAL FAILURE WITH ACUTE CORTICAL NECROSIS; CORTICAL NECROSIS NOS; ACUTE CORTICAL NECROSIS ; RENAL CORTICAL NECROSIS 37,635.00
26,344.50
11,290.50
N17.2 ACUTE RENAL FAILURE WITH MEDULLARY NECROSIS; MEDULLARY PAPILLARY NECROSIS, NOS; ACUTE MEDULLARY PAPILLARY NECROSIS; RENAL MEDULLARY PAPILLARY NECROSIS 37,635.00
26,344.50
11,290.50
N17.8 OTHER ACUTE RENAL FAILURE 37,635.00
26,344.50
11,290.50
N17.9 ACUTE RENAL FAILURE, UNSPECIFIED; 37,635.00
26,344.50
11,290.50
N18.5 CHRONIC KIDNEY DISEASE, STAGE 5; CHRONIC URAEMIA; END STAGE KIDNEY DISEASE: IN ALLOGRAFT FAILURE, NOS, ON DIALYSIS, WITHOUT DIALYSIS OR TRANSPLANT; RENAL RETINITIS+(H32.8*); URAEMIC: APOPLEXIA+(I68.8*), DEMENTIA+(F02.8*), NEUROPATHY+(G63.8*), PARALYSIS+(G99.8*), PERICARDITIS+(I32.8*) 28,275.00
19,792.50
8,482.50
N18.9 CHRONIC KIDNEY DISEASE, UNSPECIFIED 28,275.00
19,792.50
8,482.50
N19 UNSPECIFIED KIDNEY FAILURE; RENAL INSUFFICIENCY NOS 28,275.00
19,792.50
8,482.50
N20.0 CALCULUS OF KIDNEY; NEPHROLITHIASIS NOS; RENAL CALCULUS OR STONE; STAGHORN CALCULUS; STONE IN KIDNEY 7,800.00
5,460.00
2,340.00
N20.1 CALCULUS OF URETER; URETERIC STONE 7,800.00
5,460.00
2,340.00
N20.2 CALCULUS OF KIDNEY WITH CALCULUS OF URETER 7,800.00
5,460.00
2,340.00
N20.9 URINARY CALCULUS, UNSPECIFIED; CALCULOUS PYELONEPHRITIS 7,800.00
5,460.00
2,340.00
N25.0 RENAL OSTEODYSTROPHY; AZOTAEMIC OSTEODYSTROPHY; PHOSPHATE-LOSING TUBULAR DISORDERS; RENAL RICKETS; RENAL SHORT STATURE 18,525.00
12,967.50
5,557.50
N25.1 NEPHROGENIC DIABETES INSIPIDUS 19,695.00
13,786.50
5,908.50
N25.8 OTHER DISORDERS RESULTING FROM IMPAIRED RENAL TUBULAR FUNCTION; LIGHTWOOD-ALBRIGHT SYNDROME; RENAL TUBULAR ACIDOSIS NOS; SECONDARY HYPERPARATHYROIDISM OF RENAL ORIGIN 18,525.00
12,967.50
5,557.50
N25.9 DISORDER RESULTING FROM IMPAIRED RENAL TUBULAR FUNCTION, UNSPECIFIED 18,525.00
12,967.50
5,557.50
N26 UNSPECIFIED CONTRACTED KIDNEY; ATROPHY OF KIDNEY (TERMINAL); RENAL SCLEROSIS NOS 22,035.00
15,424.50
6,610.50
N27.0 SMALL KIDNEY, UNILATERAL 22,035.00
15,424.50
6,610.50
N27.1 SMALL KIDNEY, BILATERAL 22,035.00
15,424.50
6,610.50
N27.9 SMALL KIDNEY, UNSPECIFIED 22,035.00
15,424.50
6,610.50
N28.0 ISCHAEMIA AND INFARCTION OF KIDNEY; EMBOLISM OF RENAL ARTERY; OBSTRUCTION OF RENAL ARTERY; OCCLUSION OF RENAL ARTERY; THROMBOSIS OF RENAL ARTERY; RENAL INFARCT 18,720.00
13,104.00
5,616.00
N28.1 CYST OF KIDNEY, ACQUIRED; MULTIPLE CYST OF KIDNEY, ACQUIRED; SOLITARY CYST OF KIDNEY, ACQUIRED 18,525.00
12,967.50
5,557.50
N28.8 OTHER SPECIFIED DISORDERS OF KIDNEY AND URETER; HYPERTROPHY OF KIDNEY, MEGALOURETER, NEPHROPTOSIS, PYELITIS CYSTICA, PYELOURETERITIS CYSTICA, URETERITIS CYSTICA, URETEROCELE 22,035.00
15,424.50
6,610.50
N28.9 DISORDER OF KIDNEY AND URETER, UNSPECIFIED; NEPHROPATHY NOS; RENAL DISEASE NOS 22,035.00
15,424.50
6,610.50
N29.8* OTHER DISORDERS OF KIDNEY AND URETER IN OTHER DISEASES CLASSIFIED ELSEWHERE 22,035.00
15,424.50
6,610.50
N30.0 ACUTE CYSTITIS 14,625.00
10,237.50
4,387.50
N30.1 CHRONIC INTERSTITIAL CYSTITIS 14,625.00
10,237.50
4,387.50
N30.2 OTHER CHRONIC CYSTITIS 14,625.00
10,237.50
4,387.50
Page 69 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate N30.3 TRIGONITIS; URETHROTRIGONITIS 14,625.00
10,237.50
4,387.50
N30.4 IRRADIATION CYSTITIS 7,800.00
5,460.00
2,340.00
N30.8 OTHER CYSTITIS; ABSCESS OF BLADDER 27,105.00
18,973.50
8,131.50
N30.9 CYSTITIS, UNSPECIFIED 14,625.00
10,237.50
4,387.50
N31.0 UNINHIBITED NEUROPATHIC BLADDER, NOT ELSEWHERE CLASSIFIED 17,550.00
12,285.00
5,265.00
N31.1 REFLEX NEUROPATHIC BLADDER, NOT ELSEWHERE CLASSIFIED 17,550.00
12,285.00
5,265.00
N31.2
FLACCID NEUROPATHIC BLADDER, NOT ELSEWHERE CLASSIFIED;
ATONIC MOTOR NEUROPATHIC BLADDER; SENSORY ATONIC
MOTOR NEUROPATHIC BLADDER; AUTONOMOUS NEUROPATHIC
BLADDER ; NONREFLEX NEUROPATHIC BLADDER
17,550.00
12,285.00
5,265.00
N31.8 OTHER NEUROMUSCULAR DYSFUNCTION OF BLADDER 17,550.00
12,285.00
5,265.00
N31.9 NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED; NEUROGENIC BLADDER DYSFUNCTION NOS 17,550.00
12,285.00
5,265.00
N32.9 BLADDER DISORDER, UNSPECIFIED 17,550.00
12,285.00
5,265.00
N34.0 URETHRAL ABSCESS; ABSCESS OF COWPER'S GLAND; ABSCESS OF LITTRé'S GLAND; PERIURETHRAL ABSCESS ; ABSCESS OF URETHRAL GLAND 27,105.00
18,973.50
8,131.50
N39.0 URINARY TRACT INFECTION, SITE NOT SPECIFIED 14,625.00
10,237.50
4,387.50
N39.1 PERSISTENT PROTEINURIA, UNSPECIFIED 19,500.00
13,650.00
5,850.00
N39.2 ORTHOSTATIC PROTEINURIA, UNSPECIFIED 19,500.00
13,650.00
5,850.00
N39.3 STRESS INCONTINENCE 17,550.00
12,285.00
5,265.00
N39.4 OTHER SPECIFIED URINARY INCONTINENCE; OVERFLOW INCONTINENCE, REFLEX INCONTINENCE, URGE INCONTINENCE 17,550.00
12,285.00
5,265.00
N40 HYPERPLASIA OF PROSTATE; ADENOFIBROMATOUS HYPERTROPHY OF PROSTATE; ADENOMA (BENIGN)OF PROSTATE ; ENLARGEMENT OF PROSTATE (BENIGN); FIBROADENOMA OF PROSTATE; FIBROMA OF PROSTATE; HYPERTROPHY OF PROSTATE (BENIGN); MYOMA OF PROSTATE; MEDIAN BAR (PROSTATE), 17,940.00
12,558.00
5,382.00
N41.0 ACUTE PROSTATITIS 17,940.00
12,558.00
5,382.00
N41.1 CHRONIC PROSTATITIS 17,940.00
12,558.00
5,382.00
N41.2 ABSCESS OF PROSTATE 17,940.00
12,558.00
5,382.00
N41.3 PROSTATOCYSTITIS 17,940.00
12,558.00
5,382.00
N41.8 OTHER INFLAMMATORY DISEASES OF PROSTATE 17,940.00
12,558.00
5,382.00
N41.9 INFLAMMATORY DISEASE OF PROSTATE, UNSPECIFIED; PROSTATITIS NOS 17,940.00
12,558.00
5,382.00
N42.0 CALCULUS OF PROSTATE; PROSTATIC STONE 17,940.00
12,558.00
5,382.00
N42.1 CONGESTION AND HAEMORRHAGE OF PROSTATE 17,940.00
12,558.00
5,382.00
N42.2 ATROPHY OF PROSTATE 17,940.00
12,558.00
5,382.00
N42.8 OTHER SPECIFIED DISORDERS OF PROSTATE 17,940.00
12,558.00
5,382.00
N42.9 DISORDER OF PROSTATE, UNSPECIFIED 17,940.00
12,558.00
5,382.00
N45.0 ORCHITIS, EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS WITH ABSCESS; ABSCESS OF EPIDIDYMIS OR TESTIS 15,405.00
10,783.50
4,621.50
N45.9 ORCHITIS, EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS WITHOUT ABSCESS; EPIDIDYMITIS NOS; ORCHITIS NOS 15,405.00
10,783.50
4,621.50
N47 REDUNDANT PREPUCE, PHIMOSIS AND PARAPHIMOSIS; ADHERENT PREPUCE; TIGHT FORESKIN 12,480.00
8,736.00
3,744.00
N48.0 LEUKOPLAKIA OF PENIS; BALANITIS XEROTICA OBLITERANS; KRAUROSIS OF PENIS 17,550.00
12,285.00
5,265.00
N48.1 BALANOPOSTHITIS; BALANITIS 17,550.00
12,285.00
5,265.00
N48.2 OTHER INFLAMMATORY DISORDERS OF PENIS; ABSCESS OF CORPUS CAVERNOSUM AND PENIS; BOIL OF CORPUS CAVERNOSUM AND PENIS; CARBUNCLE OF CORPUS CAVERNOSUM AND PENIS; CELLULITIS OF CORPUS CAVERNOSUM AND PENIS; CAVERNITIS (PENIS) OF CORPUS CAVERNOSUM AND PENIS 17,550.00
12,285.00
5,265.00
N48.5 ULCER OF PENIS 17,550.00
12,285.00
5,265.00
N48.6 INDURATIO PENIS PLASTICA; PEYRONIE'S DISEASE; PLASTIC INDURATION OF PENIS 17,550.00
12,285.00
5,265.00
N48.8 OTHER SPECIFIED DISORDERS OF PENIS; ATROPHYOF CORPUS CAVERNOSUM AND PENIS ; HYPERTROPHY OF CORPUS CAVERNOSUM AND PENIS ; THROMBOSIS OF CORPUS CAVERNOSUM AND PENIS 12,480.00
8,736.00
3,744.00
N49.0 INFLAMMATORY DISORDERS OF SEMINAL VESICLE; VESICULITIS NOS 17,550.00
12,285.00
5,265.00
N49.1 INFLAMMATORY DISORDERS OF SPERMATIC CORD, TUNICA VAGINALIS AND VAS DEFERENS; VASITIS 17,550.00
12,285.00
5,265.00
N49.2 INFLAMMATORY DISORDERS OF SCROTUM 17,550.00
12,285.00
5,265.00
N49.8 INFLAMMATORY DISORDERS OF OTHER SPECIFIED MALE GENITAL ORGANS; INFLAMMATION OF MULTIPLE SITES IN MALE GENITAL ORGANS 17,550.00
12,285.00
5,265.00
N49.9 INFLAMMATORY DISORDER OF UNSPECIFIED MALE GENITAL ORGAN; ABSCESS OF UNSPECIFIED MALE GENITAL ORGAN; BOIL OF UNSPECIFIED MALE GENITAL ORGAN; CARBUNCLE OF UNSPECIFIED MALE GENITAL ORGAN; CELLULITIS OF UNSPECIFIED MALE GENITAL ORGAN 17,550.00
12,285.00
5,265.00
N50.0 ATROPHY OF TESTIS 12,480.00
8,736.00
3,744.00
N50.1 VASCULAR DISORDERS OF MALE GENITAL ORGANS; HAEMATOCELE OF MALE GENITAL ORGANS NOS; HAEMORRHAGE OF MALE GENITAL ORGANS;, THROMBOSIS OF MALE GENITAL ORGANS 12,480.00
8,736.00
3,744.00
Page 70 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate N50.8 OTHER SPECIFIED DISORDERS OF MALE GENITAL ORGANS; ATROPHY OF SCROTUM, SEMINAL VESICLE, SPERMATIC CORD, TESTIS [EXCEPT ATROPHY], TUNICA VAGINALIS AND VAS DEFERENS; HYPERTROPHY OF SCROTUM, SEMINAL VESICLE, SPERMATIC CORD, TESTIS [EXCEPT ATROPHY], TUNICA VAG 12,480.00
8,736.00
3,744.00
N61
INFLAMMATORY DISORDERS OF BREAST; ACUTE ABSCESS OF NON
PUERPERAL AREOLA; ACUTE ABSCESS NONPUERPERAL BREAST;
CHRONIC ABSCESS OF NONPUERPERAL AREOLA; CHRONIC
ABSCESS OF NONPUERPERAL BREAST; CARBUNCLE OF BREAST;
ACUTE MASTITIS NONPUERPERAL, NOS; ACUTE INF
15,405.00
10,783.50
4,621.50
N70.0 ACUTE SALPINGITIS AND OOPHORITIS 17,550.00
12,285.00
5,265.00
N70.1 CHRONIC SALPINGITIS AND OOPHORITIS; HYDROSALPINX 17,550.00
12,285.00
5,265.00
N70.9 SALPINGITIS AND OOPHORITIS, UNSPECIFIED 17,550.00
12,285.00
5,265.00
N71.0 ACUTE INFLAMMATORY DISEASE OF UTERUS 17,550.00
12,285.00
5,265.00
N71.1 CHRONIC INFLAMMATORY DISEASE OF UTERUS 17,550.00
12,285.00
5,265.00
N71.9 INFLAMMATORY DISEASE OF UTERUS, UNSPECIFIED 17,550.00
12,285.00
5,265.00
N72 INFLAMMATORY DISEASE OF CERVIX UTERI; CERVICITIS WITH OR WITHOUT EROSION OR ECTROPION; ENDOCERVICITIS WITH OR WITHOUT EROSION OR ECTROPION; EXOCERVICITIS WITH OR WITHOUT EROSION OR ECTROPION 17,550.00
12,285.00
5,265.00
N73.0 ACUTE PARAMETRITIS AND PELVIC CELLULITIS; ACUTE ABCESS OF BROAD LIGAMENT; ACUTE ABSCESS OF PARAMETRIUM; ACUTE PELVIC CELLULITIS, FEMALE 17,550.00
12,285.00
5,265.00
N73.1 CHRONIC PARAMETRITIS AND PELVIC CELLULITIS 17,550.00
12,285.00
5,265.00
N73.2 UNSPECIFIED PARAMETRITIS AND PELVIC CELLULITIS 17,550.00
12,285.00
5,265.00
N73.3 FEMALE ACUTE PELVIC PERITONITIS 17,550.00
12,285.00
5,265.00
N73.4 FEMALE CHRONIC PELVIC PERITONITIS 17,550.00
12,285.00
5,265.00
N73.5 FEMALE PELVIC PERITONITIS, UNSPECIFIED 17,550.00
12,285.00
5,265.00
N73.6 FEMALE PELVIC PERITONEAL ADHESIONS 17,550.00
12,285.00
5,265.00
N73.8 OTHER SPECIFIED FEMALE PELVIC INFLAMMATORY DISEASES 17,550.00
12,285.00
5,265.00
N73.9 FEMALE PELVIC INFLAMMATORY DISEASE, UNSPECIFIED; FEMALE PELVIC INFECTION OR INFLAMMATION NOS 17,550.00
12,285.00
5,265.00
N74.8* FEMALE PELVIC INFLAMMATORY DISORDERS IN OTHER DISEASES CLASSIFIED ELSEWHERE 17,550.00
12,285.00
5,265.00
N80.0 ENDOMETRIOSIS OF UTERUS; ADENOMYOSIS 15,015.00
10,510.50
4,504.50
N80.1 ENDOMETRIOSIS OF OVARY 15,015.00
10,510.50
4,504.50
N80.2 ENDOMETRIOSIS OF FALLOPIAN TUBE 15,015.00
10,510.50
4,504.50
N80.3 ENDOMETRIOSIS OF PELVIC PERITONEUM 15,015.00
10,510.50
4,504.50
N80.4 ENDOMETRIOSIS OF RECTOVAGINAL SEPTUM AND VAGINA 15,015.00
10,510.50
4,504.50
N80.5 ENDOMETRIOSIS OF INTESTINE 15,015.00
10,510.50
4,504.50
N80.8 OTHER ENDOMETRIOSIS 15,015.00
10,510.50
4,504.50
N80.9 ENDOMETRIOSIS, UNSPECIFIED 15,015.00
10,510.50
4,504.50
N82.0 VESICOVAGINAL FISTULA 15,210.00
10,647.00
4,563.00
N83.0
FOLLICULAR CYST OF OVARY; CYST OF GRAAFIAN FOLLICLE;
HAEMORRHAGIC FOLLICULAR CYST OF OVARY
15,210.00
10,647.00
4,563.00
N83.1 CORPUS LUTEUM CYST; HAEMORRHAGIC CORPUS LUTEUM CYST 15,210.00
10,647.00
4,563.00
N83.2 OTHER AND UNSPECIFIED OVARIAN CYSTS; RETENTION OF OVARY; SIMPLE CYST OF OVARY 15,405.00
10,783.50
4,621.50
N83.3 ACQUIRED ATROPHY OF OVARY AND FALLOPIAN TUBE 15,210.00
10,647.00
4,563.00
N83.6 HAEMATOSALPINX 15,210.00
10,647.00
4,563.00
N83.7 HAEMATOMA OF BROAD LIGAMENT 15,210.00
10,647.00
4,563.00
N83.8 OTHER NONINFLAMMATORY DISORDERS OF OVARY, FALLOPIAN TUBE AND BROAD LIGAMENT; BROAD LIGAMENT LACERATION SYNDROME [ALLEN-MASTERS] 16,575.00
11,602.50
4,972.50
N83.9 NONINFLAMMATORY DISORDER OF OVARY, FALLOPIAN TUBE AND BROAD LIGAMENT, UNSPECIFIED 16,575.00
11,602.50
4,972.50
N84.0 POLYP OF CORPUS UTERI; POLYP OF ENDOMETRIUM; POLYP OF UTERUS NOS 10,140.00
7,098.00
3,042.00
N84.1 POLYP OF CERVIX UTERI; MUCOUS POLYP OF CERVIX 10,140.00
7,098.00
3,042.00
N84.2 POLYP OF VAGINA 10,140.00
7,098.00
3,042.00
N84.3 POLYP OF VULVA; POLYP OF LABIA 10,140.00
7,098.00
3,042.00
N84.8 POLYP OF OTHER PARTS OF FEMALE GENITAL TRACT 10,140.00
7,098.00
3,042.00
N84.9 POLYP OF FEMALE GENITAL TRACT, UNSPECIFIED 10,140.00
7,098.00
3,042.00
N85.7 HAEMATOMETRA; HAEMATOSALPINX WITH HAEMATOMETRA 15,210.00
10,647.00
4,563.00
N85.8 OTHER SPECIFIED NONINFLAMMATORY DISORDERS OF UTERUS; ATROPHY OF UTERUS, ACQUIRED; FIBROSIS OF UTERUS NOS 16,575.00
11,602.50
4,972.50
N85.9 NONINFLAMMATORY DISORDER OF UTERUS, UNSPECIFIED; DISORDER OF UTERUS NOS 16,575.00
11,602.50
4,972.50
N89.7 HAEMATOCOLPOS; HAEMATOCOLPOS WITH HAEMATOMETRA OR HAEMATOSALPINX 15,210.00
10,647.00
4,563.00
N91.0 PRIMARY AMENORRHOEA; FAILURE TO START MENSTRUATION AT PUBERTY. 12,870.00
9,009.00
3,861.00
N91.1 SECONDARY AMENORRHOEA; ABSENCE OF MENSTRUATION IN A WOMAN WHO HAD PREVIOUSLY MENSTRUATED. 12,870.00
9,009.00
3,861.00
N91.2 AMENORRHOEA, UNSPECIFIED; ABSENCE OF MENSTRUATION NOS 12,870.00
9,009.00
3,861.00
N91.5 OLIGOMENORRHOEA, UNSPECIFIED; HYPOMENORRHOEA NOS 12,870.00
9,009.00
3,861.00
N92.0 EXCESSIVE AND FREQUENT MENSTRUATION WITH REGULAR CYCLE; HEAVY PERIODS NOS; MENORRHAGIA NOS; POLYMENORRHOEA 12,870.00
9,009.00
3,861.00
Page 71 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate N92.1 EXCESSIVE AND FREQUENT MENSTRUATION WITH IRREGULAR CYCLE; IRREGULAR INTERMENSTRUAL BLEEDING; IRREGULAR, SHORTENED INTERVALS BETWEEN MENSTRUAL BLEEDING; MENOMETRORRHAGIA; METRORRHAGIA 12,870.00
9,009.00
3,861.00
N92.2 EXCESSIVE MENSTRUATION AT PUBERTY; EXCESSIVE BLEEDING ASSOCIATED WITH ONSET OF MENSTRUAL PERIODS; PUBERTAL MENORRHAGIA; PUBERTY BLEEDING 12,870.00
9,009.00
3,861.00
N92.3 OVULATION BLEEDING; REGULAR INTERMENSTRUAL BLEEDING 12,870.00
9,009.00
3,861.00
N92.4 EXCESSIVE BLEEDING IN THE PREMENOPAUSAL PERIOD; CLIMATERIC MENORRHAGIA OR METRORRHAGIA; MENOPAUSAL MENORRHAGIA OR METRORRHAGIA; PRECLIMATERIC MENORRHAGIA OR METRORRHAGIA; PREMENOPAUSAL MENORRHAGIA OR METRORRHAGIA 12,870.00
9,009.00
3,861.00
N92.5 OTHER SPECIFIED IRREGULAR MENSTRUATION 12,870.00
9,009.00
3,861.00
N92.6 IRREGULAR MENSTRUATION, UNSPECIFIED; IRREGULAR BLEEDING NOS; IRREGULAR PERIODS NOS 12,870.00
9,009.00
3,861.00
N93.0 POSTCOITAL AND CONTACT BLEEDING 12,870.00
9,009.00
3,861.00
N93.8 OTHER SPECIFIED ABNORMAL UTERINE AND VAGINAL BLEEDING; DYSFUNCTIONAL OR FUNCTIONAL UTERINE OR VAGINAL BLEEDING NOS 12,870.00
9,009.00
3,861.00
N93.9 ABNORMAL UTERINE AND VAGINAL BLEEDING, UNSPECIFIED 12,870.00
9,009.00
3,861.00
N94.0 MITTELSCHMERZ 9,360.00
6,552.00
2,808.00
N94.1 DYSPAREUNIA 9,360.00
6,552.00
2,808.00
N94.2 VAGINISMUS 9,360.00
6,552.00
2,808.00
N94.3 PREMENSTRUAL TENSION SYNDROME 9,360.00
6,552.00
2,808.00
N94.4 PRIMARY DYSMENORRHOEA 9,360.00
6,552.00
2,808.00
N94.5 SECONDARY DYSMENORRHOEA 9,360.00
6,552.00
2,808.00
N94.6 DYSMENORRHOEA, UNSPECIFIED 9,360.00
6,552.00
2,808.00
N94.8 OTHER SPECIFIED CONDITIONS ASSOCIATED WITH FEMALE GENITAL ORGANS AND MENSTRUAL CYCLE 12,870.00
9,009.00
3,861.00
N94.9 UNSPECIFIED CONDITION ASSOCIATED WITH FEMALE GENITAL ORGANS AND MENSTRUAL CYCLE 12,870.00
9,009.00
3,861.00
N95.0 POSTMENOPAUSAL BLEEDING 11,700.00
8,190.00
3,510.00
N99.0 POSTPROCEDURAL RENAL FAILURE 20,085.00
14,059.50
6,025.50
N99.1 POSTPROCEDURAL URETHRAL STRICTURE; POSTCATHETERIZATION URETHRAL STRICTURE 20,085.00
14,059.50
6,025.50
N99.4 POSTPROCEDURAL PELVIC PERITONEAL ADHESIONS 20,085.00
14,059.50
6,025.50
N99.8 OTHER POSTPROCEDURAL DISORDERS OF GENITOURINARY SYSTEM; RESIDUAL OVARY SYNDROME 20,085.00
14,059.50
6,025.50
N99.9 POSTPROCEDURAL DISORDER OF GENITOURINARY SYSTEM, UNSPECIFIED 20,085.00
14,059.50
6,025.50
O00.0 ABDOMINAL PREGNANCY 15,210.00
10,647.00
4,563.00
O00.1 TUBAL PREGNANCY; FALLOPIAN PREGNANCY; RUPTURE OF FALLOPIAN TUBE DUE TO PREGNANCY 15,210.00
10,647.00
4,563.00
O00.2 OVARIAN PREGNANCY 15,210.00
10,647.00
4,563.00
O00.8 OTHER ECTOPIC PREGNANCY; CERVICAL PREGNANCY; CORNUAL PREGNANCY; INTRALIGAMENTOUS PREGNANCY; MURAL PREGNANCY 15,210.00
10,647.00
4,563.00
O00.9 ECTOPIC PREGNANCY, UNSPECIFIED 15,210.00
10,647.00
4,563.00
O01.0 CLASSICAL HYDATIDIFORM MOLE; COMPLETE HYDATIDIFORM MOLE 12,870.00
9,009.00
3,861.00
O01.1 INCOMPLETE AND PARTIAL HYDATIDIFORM MOLE 12,870.00
9,009.00
3,861.00
O01.9 HYDATIDIFORM MOLE, UNSPECIFIED; TROPHOBLASTIC DISEASE NOS; VESICULAR MOLE NOS 12,870.00
9,009.00
3,861.00
O02.0 BLIGHTED OVUM AND NONHYDATIDIFORM MOLE; CARNEOUS MOLE; FLESHY MOLE; INTRAUTERINE MOLE NOS; PATHOLOGICAL OVUM 9,750.00
6,825.00
2,925.00
O02.1 MISSED ABORTION; EARLY FETAL DEATH WITH RETENTION OF DEAD FETUS 9,750.00
6,825.00
2,925.00
O02.8 OTHER SPECIFIED ABNORMAL PRODUCTS OF CONCEPTION 9,750.00
6,825.00
2,925.00
O02.9 ABNORMAL PRODUCT OF CONCEPTION, UNSPECIFIED 9,750.00
6,825.00
2,925.00
O03.0 SPONTANEOUS ABORTION, INCOMPLETE, COMPLICATED BY GENITAL TRACT AND PELVIC INFECTION WITH GENITAL TRACT AND PELVIC INFECTION FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; ENDOMETRITIS; OOPHORITIS; PARAMETRITIS; PELVIC PERITONITIS; SALPINGITIS; SALPIN 13,455.00
9,418.50
4,036.50
O03.1 SPONTANEOUS ABORTION, INCOMPLETE, COMPLICATED DELAYED OR EXCESSIVE HAEMORRHAGE WITH DELAYED OR EXCESSIVE HAEMORRHAGE FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; AFIBRINOGENAEMIA; DEFIBRINATION SYNDROME; INTRAVASCULAR COAGULATION 13,455.00
9,418.50
4,036.50
O03.2 SPONTANEOUS ABORTION, INCOMPLETE, COMPLICATED BY EMBOLISM WITH EMBOLISM NOS OR AIR EMBOLISM OR AMNIOTIC FLUID EMBOLISM OR BLOOD-CLOT EMBOLISM OR PULMONARY EMBOLISM OR PYAEMIC EMBOLISM OR SEPTIC OR SEPTICOPYAEMIC EMBOLISM OR SOAP EMBOLISM 13,455.00
9,418.50
4,036.50
O03.3 SPONTANEOUS ABORTION, INCOMPLETE, WITH OTHER AND UNSPECIFIED COMPLICATIONS WITH SHOCK FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; CIRCULATORY COLLAPASE; POSTOPERATIVE SHOCK; RENAL FAILURE FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; OLIGURI 13,455.00
9,418.50
4,036.50
Page 72 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate O03.4 SPONTANEOUS ABORTION, INCOMPLETE, WITHOUT COMPLICATION 9,750.00
6,825.00
2,925.00
O03.5 SPONTANEOUS ABORTION, COMPLETE, COMPLICATED BY GENITAL TRACT AND PELVIC INFECTION WITH GENITAL TRACT AND PELVIC INFECTION FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; ENDOMETRITIS; OOPHORITIS; PARAMETRITIS; PELVIC PERITONITIS; SALPINGITIS; SALPINGO 13,455.00
9,418.50
4,036.50
O03.6
SPONTANEOUS ABORTION, COMPLETE OR UNSPECIFIED,
COMPLICATED DELAYED OR EXCESSIVE HAEMORRHAGE WITH
DELAYED OR EXCESSIVE HAEMORRHAGE FOLLOWING ABORTION
AND ECTOPIC AND MOLAR PREGNANCY; AFIBRINOGENAEMIA;
DEFIBRINATION SYNDROME; INTRAVASCULAR COAGULATION
13,455.00
9,418.50
4,036.50
O03.7 SPONTANEOUS ABORTION, COMPLETE OR UNSPECIFIED, WITH OTHER COMPLICATED BY EMBOLISM WITH EMBOLISM FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; EMBOLISM NOS; AIR EMBOLISM; AMNIOTIC FLUID EMBOLISM; BLOOD-CLOT EMBOLISM; PULMONARY EMBOLISM; PYAEMIC EMBO 13,455.00
9,418.50
4,036.50
O03.8 SPONTANEOUS ABORTION, COMPLETE OR UNSPECIFIED, WITH OTHER AND UNSPECIFIED COMPLICATIONS WITH SHOCK FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; CIRCULATORY COLLAPASE; POSTOPERATIVE SHOCK; RENAL FAILURE FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREG 13,455.00
9,418.50
4,036.50
O03.9 SPONTANEOUS ABORTION, COMPLETE OR UNSPECIFIED, WITHOUT COMPLICATION 9,750.00
6,825.00
2,925.00
O05.0 OTHER ABORTION, INCOMPLETE, COMPLICATED BY GENITAL TRACT AND PELVIC INFECTION WITH ENDOMETRITIS AND/OR OOPHORITIS AND/OR PARAMETRITIS AND/OR PELVIC PERITONITIS AND/OR SALPINGITIS AND/OR SALPINGO- OOPHORITIS AND/OR SEPSIS AND/OR SEPTIC SHOCK AND/OR SEPTICAE 13,455.00
9,418.50
4,036.50
O05.1 OTHER ABORTION, INCOMPLETE, COMPLICATED DELAYED OR EXCESSIVE HAEMORRHAGE WITH DELAYED OR EXCESSIVE HAEMORRHAGE FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; AFIBRINOGENAEMIA; DEFIBRINATION SYNDROME; INTRAVASCULAR COAGULATION 13,455.00
9,418.50
4,036.50
O05.4 OTHER ABORTION, INCOMPLETE, WITHOUT COMPLICATION 9,750.00
6,825.00
2,925.00
O05.8 OTHER ABORTION, COMPLETE, WITH OTHER AND UNSPECIFIED COMPLICATIONS WITH SHOCK FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; CIRCULATORY COLLAPASE; POSTOPERATIVE SHOCK; RENAL FAILURE FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; OLIGURIA ACUTE 13,455.00
9,418.50
4,036.50
O05.9 OTHER ABORTION, COMPLETE OR UNSPECIFIED, WITHOUT COMPLICATION 9,750.00
6,825.00
2,925.00
O06.0 UNSPECIFIED ABORTION OR INDUCED ABORTION NOS, INCOMPLETE, COMPLICATED BY GENITAL TRACT AND PELVIC INFECTION WITH ENDOMETRITIS AND/OR OOPHORITIS AND/OR PARAMETRITIS AND/OR PELVIC PERITONITIS AND/OR SALPINGITIS AND/OR SALPINGO-OOPHORITIS AND/OR SEPSIS AND/ 13,455.00
9,418.50
4,036.50
O06.1 UNSPECIFIED ABORTION OR INDUCED ABORTION NOS, INCOMPLETE, COMPLICATED DELAYED OR EXCESSIVE HAEMORRHAGE WITH AFIBRINOGENAEMIA OR DEFIBRINATION SYNDROME OR INTRAVASCULAR COAGULATION 13,455.00
9,418.50
4,036.50
O06.2 UNSPECIFIED ABORTION OR INDUCED ABORTION NOS, INCOMPLETE, COMPLICATED BY EMBOLISM OR EMBOLISM NOS WITH AIR EMBOLISM OR AMNIOTIC FLUID EMBOLISM OR BLOOD- CLOT EMBOLISM OR PULMONARY EMBOLISM OR PYAEMIC EMBOLISM OR SEPTIC OR SEPTICOPYAEMIC EMBOLISM OR SOAP E 13,455.00
9,418.50
4,036.50
O06.3 UNSPECIFIED ABORTION OR INDUCED ABORTION NOS, INCOMPLETE, WITH OTHER AND UNSPECIFIED COMPLICATIONS WITH SHOCK FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; CIRCULATORY COLLAPASE; POSTOPERATIVE SHOCK; RENAL FAILURE FOLLOWING ABORTION AND ECTOPIC AND 13,455.00
9,418.50
4,036.50
O06.4 UNSPECIFIED ABORTION OR INDUCED ABORTION NOS, INCOMPLETE, WITHOUT COMPLICATION 9,750.00
6,825.00
2,925.00
O06.5 UNSPECIFIED ABORTION OR INDUCED ABORTION NOS, COMPLETE, OR UNSPECIFIED, COMPLICATED BY GENITAL TRACT AND PELVIC INFECTION OR ENDOMETRITIS AND/OR OOPHORITIS AND/OR PARAMETRITIS AND/OR PELVIC PERITONITIS AND/OR SALPINGITIS AND/OR SALPINGO-OOPHORITIS AND/OR 13,455.00
9,418.50
4,036.50
O06.6 UNSPECIFIED ABORTION OR INDUCED ABORTION NOS, COMPLETE, COMPLICATED BY DELAYED OR EXCESSIVE HAEMORRHAGE OR AFIBRINOGENAEMIA OR DEFIBRINATION SYNDROME OR INTRAVASCULAR COAGULATION 13,455.00
9,418.50
4,036.50
Page 73 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate O06.7 UNSPECIFIED ABORTION OR INDUCED ABORTION NOS, COMPLETE, COMPLICATED BY EMBOLISM OR EMBOLISM NOS OR AIR EMBOLISM OR AMNIOTIC FLUID EMBOLISM OR BLOOD-CLOT EMBOLISM OR PULMONARY EMBOLISM OR PYAEMIC EMBOLISM OR SEPTIC OR SEPTICOPYAEMIC EMBOLISM OR SOAP EMBOLI 13,455.00
9,418.50
4,036.50
O06.8 UNSPECIFIED ABORTION OR INDUCED ABORTION NOS, COMPLETE, WITH OTHER AND UNSPECIFIED COMPLICATIONS WITH SHOCK FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; CIRCULATORY COLLAPASE; POSTOPERATIVE SHOCK; RENAL FAILURE FOLLOWING ABORTION AND ECTOPIC AND M 13,455.00
9,418.50
4,036.50
O06.9 UNSPECIFIED ABORTION OR INDUCED ABORTION NOS, COMPLETE OR UNSPECIFIED, WITHOUT COMPLICATION 9,750.00
6,825.00
2,925.00
O07.0 FAILED MEDICAL ABORTION, COMPLICATED BY GENITAL TRACT AND PELVIC INFECTION WITH ENDOMETRITIS; OOPHORITIS; PARAMETRITIS; PARAMETRITIS; PELVIC PERITONITIS; SALPINGITIS; SALPINGO-OOPHORITIS; SEPSIS; SEPTIC SHOCK; SEPTICAEMIA 9,750.00
6,825.00
2,925.00
O07.1 FAILED MEDICAL ABORTION COMPLICATED BY DELAYED OR EXCESSIVE HAEMORRHAGE; AFIBRINOGENAEMIA WITH DELAYED OR EXCESSIVE HAEMORRHAGE FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; AFIBRINOGENAEMIA; DEFIBRINATION SYNDROME; INTRAVASCULAR COAGULATION 13,455.00
9,418.50
4,036.50
O07.3 FAILED MEDICAL ABORTION WITH OTHER AND UNSPECIFIED COMPLICATIONS WITH SHOCK FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; CIRCULATORY COLLAPASE; POSTOPERATIVE SHOCK; RENAL FAILURE FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; OLIGURIA ACUTE RE 9,750.00
6,825.00
2,925.00
O07.4 FAILED MEDICAL ABORTION WITHOUT COMPLICATION; FAILED MEDICAL ABORTION NOS 9,750.00
6,825.00
2,925.00
O07.5
OTHER AND UNSPECIFIED FAILED ATTEMPTED ABORTION
COMPLICATED BY GENITAL TRACT AND PELVIC INFECTION WITH
ENDOMETRITIS; OOPHORITIS; PARAMETRITIS; PELVIC
PERITONITIS; SALPINGITIS; SALPINGO-OOPHORITIS; SEPSI; SEPTIC
SHOCK; SEPTICAEMIA
13,455.00
9,418.50
4,036.50
O07.6 OTHER AND UNSPECIFIED FAILED ATTEMPTED ABORTION COMPLICATED BY DELAYED OR EXCESSIVE HAEMORRHAGE WITH DELAYED OR EXCESSIVE HAEMORRHAGE FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; AFIBRINOGENAEMIA; DEFIBRINATION SYNDROME; INTRAVASCULAR COAGULATION 13,455.00
9,418.50
4,036.50
O07.8 OTHER AND UNSPECIFIED FAILED ATTEMPTED ABORTION WITH OTHER AND UNSPECIFIED COMPLICATIONS WITH WITH SHOCK FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; CIRCULATORY COLLAPASE; POSTOPERATIVE SHOCK; RENAL FAILURE FOLLOWING ABORTION AND ECTOPIC AND MOLA 9,750.00
6,825.00
2,925.00
O07.9 OTHER AND UNSPECIFIED FAILED ATTEMPTED ABORTION WITHOUT COMPLICATION; FAILED ATTEMPTED ABORTION NOS 9,750.00
6,825.00
2,925.00
O08.0 GENITAL TRACT AND PELVIC INFECTION FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; ENDOMETRITIS; OOPHORITIS; PARAMETRITIS; PELVIC PERITONITIS; SALPINGITIS; SALPINGO-OOPHORITIS; SEPSIS; SEPTIC SHOCK; SEPTICAEMIA 17,550.00
12,285.00
5,265.00
O08.1 DELAYED OR EXCESSIVE HAEMORRHAGE FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; AFIBRINOGENAEMIA; DEFIBRINATION SYNDROME; INTRAVASCULAR COAGULATION 13,650.00
9,555.00
4,095.00
O08.2 EMBOLISM FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; EMBOLISM NOS; AIR EMBOLISM; AMNIOTIC FLUID EMBOLISM; BLOOD-CLOT EMBOLISM; PULMONARY EMBOLISM; PYAEMIC EMBOLISM; SEPTIC OR SEPTICOPYAEMIC EMBOLISM; SOAP EMBOLISM 18,135.00
12,694.50
5,440.50
O08.3 SHOCK FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; CIRCULATORY COLLAPASE; POSTOPERATIVE SHOCK 13,455.00
9,418.50
4,036.50
O08.4 RENAL FAILURE FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; OLIGURIA ACUTE RENAL FAILURE; OLIGURIA RENAL SHUTDOWN; OLIGURIA RENAL TUBULAR NECROSIS; OLIGURIA URAEMIA 37,635.00
26,344.50
11,290.50
O08.5 METABOLIC DISORDERS FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY 18,135.00
12,694.50
5,440.50
O08.8 OTHER COMPLICATIONS FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY; CARDIAC ARREST; URINARY TRACT INFECTION 13,455.00
9,418.50
4,036.50
O08.9 COMPLICATION FOLLOWING ABORTION AND ECTOPIC AND MOLAR PREGNANCY, UNSPECIFIED 18,135.00
12,694.50
5,440.50
O10.0 PRE-EXISTING ESSENTIAL HYPERTENSION COMPLICATING PREGNANCY CHILD BIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O10.1 PRE-EXISTING HYPERTENSIVE HEART DISEASE COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O10.2 PRE-EXISTING HYPERTENSIVE RENAL DISEASE COMPLICATING PREGNANCY CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
Page 74 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate O10.3 PRE-EXISTING HYPERTENSIVE HEART AND RENAL DISEASE COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O10.4 PRE-EXISTING SECONDARY HYPERTENSION COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O10.9 UNSPECIFIED PRE-EXISTING HYPERTENSION COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O11 PRE-EXISTING HYPERTENSIVE DISORDER WITH SUPERIMPOSED PROTEINURIA 13,260.00
9,282.00
3,978.00
O12.1 GESTATIONAL PROTEINURIA 13,260.00
9,282.00
3,978.00
O12.2 GESTATIONAL OEDEMA WITH PROTEINURIA 13,260.00
9,282.00
3,978.00
O13 GESTATIONAL [PREGNANCY-INDUCED] HYPERTENSION WIHTOUT SIGNIFICANT PROTEINURIA; GESTATIONAL HYPERTENSION NOS; MILD PRE-ECLAMPSIA 13,260.00
9,282.00
3,978.00
O14.0 MODERATE PRE-ECLAMPSIA 13,260.00
9,282.00
3,978.00
O14.1 SEVERE PRE-ECLAMPSIA 13,260.00
9,282.00
3,978.00
O14.9 PRE-ECLAMPSIA, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O15.0 ECLAMPSIA IN PREGNANCY 13,260.00
9,282.00
3,978.00
O15.1 ECLAMPSIA IN LABOUR 13,260.00
9,282.00
3,978.00
O15.2 ECLAMPSIA IN THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O15.9 ECLAMPSIA, UNSPECIFIED AS TO TIME PERIOD; ECLAMPSIA NOS 13,260.00
9,282.00
3,978.00
O16 UNSPECIFIED MATERNAL HYPERTENSION 13,260.00
9,282.00
3,978.00
O20.0 THREATENED ABORTION; HAEMORRHAGE SPECIFIED AS DUE TO THREATENED ABORTION 13,260.00
9,282.00
3,978.00
O20.8 OTHER HAEMORRHAGE IN EARLY PREGNANCY 13,260.00
9,282.00
3,978.00
O20.9 HAEMORRHAGE IN EARLY PREGNANCY, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O21.0 MILD HYPEREMESIS GRAVIDARUM; HYPEREMESIS GRAVIDARUM, MILD OR UNSPECIFIED, STARTING BEFORE THE END OF THE 22ND WEEK OF GESTATION 13,260.00
9,282.00
3,978.00
O21.1 HYPEREMESIS GRAVIDARUM WITH METABOLIC DISTURBANCE; HYPEREMESIS GRAVIDARUM, STARTING BEFORE THE END OF THE 22ND WEEK OF GESTATION, WITH METABOLIC DISTURBANCE SUCH AS CARBOHYDRATE DEPLETION, DEHYDRATION, ELCTROLYTE IMBALANCE 13,260.00
9,282.00
3,978.00
O21.2 LATE VOMITING OF PREGNANCY; EXCESSIVE VOMITING STARTING AFTER 22 COMPLETED WEEKS OF GESTATION 13,260.00
9,282.00
3,978.00
O21.8 OTHER VOMITING COMPLICATING PREGNANCY; VOMITING DUE TO DISEASE CLASSIFIED ELSEWHERE, COMPLICATING PREGNANCY 13,260.00
9,282.00
3,978.00
O21.9 VOMITING OF PREGNANCY, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O22.3 DEEP PHLEBOTHROMBOSIS IN PREGNANCY; DEEP-VEIN THROMBOSIS, ANTEPARTUM 13,260.00
9,282.00
3,978.00
O22.5 CEREBRAL VENOUS THROMBOSIS IN PREGNANCY; CEREBROVENOUS SINUS THROMBOSIS IN PREGNANCY 13,260.00
9,282.00
3,978.00
O22.9 VENOUS COMPLICATION IN PREGNANCY, UNSPECIFIED; GESTATIONAL PHLEBITIS NOS; GESTATIONAL PHLEBOPATHY NOS; GESTATIONAL THROMBOSIS NOS 13,260.00
9,282.00
3,978.00
O23.0 INFECTIONS OF KIDNEY IN PREGNANCY 13,260.00
9,282.00
3,978.00
O23.1 INFECTIONS OF BLADDER IN PREGNANCY 7,800.00
5,460.00
2,340.00
O23.2 INFECTIONS OF URETHRA IN PREGNANCY 7,800.00
5,460.00
2,340.00
O23.3 INFECTIONS OF OTHER PARTS OF URINARY TRACT IN PREGNANCY 13,260.00
9,282.00
3,978.00
O23.4 UNSPECIFIED INFECTION OF URINARY TRACT IN PREGNANCY 7,800.00
5,460.00
2,340.00
O23.5 INFECTIONS OF THE GENITAL TRACT IN PREGNANCY 7,800.00
5,460.00
2,340.00
O23.9 OTHER AND UNSPECIFIED GENITOURINARY TRACT INFECTION IN PREGNANCY; GENITOURINARY TRACT INFECTION IN PREGNANCY NOS 7,800.00
5,460.00
2,340.00
O24.0 PRE-EXISTING DIABETES MELLITUS, INSULIN-DEPENDENT 13,260.00
9,282.00
3,978.00
O24.1 PRE-EXISTING DIABETES MELLITUS, NON-INSULIN-DEPENDENT 13,260.00
9,282.00
3,978.00
O24.2 PRE-EXISTING MALNUTRITION-RELATED DIABETES MELLITUS 13,260.00
9,282.00
3,978.00
O24.3 PRE-EXISTING DIABETES MELLITUS, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O24.4 DIABETES MELLITUS ARISING IN PREGNANCY; GESTATIONAL DIABETES MELLITUS NOS 13,260.00
9,282.00
3,978.00
O24.9 DIABETES MELLITUS IN PREGNANCY, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O26.2 PREGNANCY CARE OF HABITUAL ABORTER 13,260.00
9,282.00
3,978.00
O26.3 RETAINED IN TRAUTERINE CONTRACEPTIVE DEVICE IN PREGNANCY 13,260.00
9,282.00
3,978.00
O26.4 HERPES GESTATIONIS 13,260.00
9,282.00
3,978.00
O26.5 MATERNAL HYPOTENSION SYNDROME; SUPINE HYPOTENSIVE SYNDROME 13,260.00
9,282.00
3,978.00
O26.6 LIVER DISORDERS IN PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O26.7 SUBLUXATION OF SYMPHYSIS (PUBIS) IN PREGNANCY CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O26.8 OTHER SPECIFIED PREGNANCY-RELATED CONDITIONS; EXHAUSTION AND FATIGUE PREGNANCY-RELATED; PERIPHERAL NEURITIS PREGNANCY-RELATED; RENAL DISEASE PREGNANCY- RELATED 13,260.00
9,282.00
3,978.00
O26.9 PREGNANCY-RELATEDCONDITION, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O28.0 ABNORMAL HAEMATOLOGICAL FINDING ON ANTENATAL SCREENING OF MOTHER 13,260.00
9,282.00
3,978.00
O28.3 ABNORMAL ULTRASONIC FINDING ON ANTENATAL SCREENING OF MOTHER 13,260.00
9,282.00
3,978.00
Page 75 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate O28.5 ABNORMAL CHROMOSOMAL AND GENETIC FINDING ON ANTENATAL SCREENING OF MOTHER 13,260.00
9,282.00
3,978.00
O28.8 OTHER ABNORMAL FINDINGS ON ANTENATAL SCREENING OF MOTHER 13,260.00
9,282.00
3,978.00
O28.9 ABNORMAL FINDING ON ANTENATAL SCREENING OF MOTHER, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O29.8 OTHER COMPLICATIONS OF ANAESTHESIA DURING PREGNANCY 13,260.00
9,282.00
3,978.00
O30.0 TWIN PREGNANCY 13,260.00
9,282.00
3,978.00
O30.1 TRIPLET PREGNANCY 13,260.00
9,282.00
3,978.00
O30.8 OTHER MULTIPLE GESTATION 13,260.00
9,282.00
3,978.00
O30.9 MULTIPLE GESTATION, UNSPECIFIED; MULTIPLE PREGNANCY NOS 13,260.00
9,282.00
3,978.00
O31.0 PAPYRACEOUS FETUS; FETUS COMPRESSUS 13,260.00
9,282.00
3,978.00
O31.1 CONTINUING PREGNANCY AFTER ABORTION OF ONE FETUS OR MORE 13,260.00
9,282.00
3,978.00
O31.2 CONTINUING PREGNANCY AFTER INTRAUTERINE DEATH OF ONE FETUS OR MORE 13,260.00
9,282.00
3,978.00
O31.8 OTHER COMPLICATIONS SPECIFIC TO MULTIPLE GESTATION 13,260.00
9,282.00
3,978.00
O32.0 MATERNAL CARE FOR UNSTABLE LIE 13,260.00
9,282.00
3,978.00
O32.1 MATERNAL CARE FOR BREECH PRESENTATION 13,260.00
9,282.00
3,978.00
O32.2 MATERNAL CARE FOR TRANSVERSE AND OBLIQUE LIE; OBLIQUE PRESENTATION; TRANSVERSE PRESENTATION 13,260.00
9,282.00
3,978.00
O32.3 MATERNAL CARE FOR FACE, BROW AND CHIN PRESENTATION 13,260.00
9,282.00
3,978.00
O32.4 MATERNAL CARE FOR HIGH HEAD AT TERM; FAILURE OF HEAD TO ENTER PELVIC BRIM 13,260.00
9,282.00
3,978.00
O32.5 MATERNAL CARE FOR MULTIPLE GESTATION WITH MALPRESENTATION OF ONE FETUS OR MORE 13,260.00
9,282.00
3,978.00
O32.6 MATERNAL CARE FOR COMPOUND PRESENTATION 13,260.00
9,282.00
3,978.00
O32.8 MATERNAL CARE FOR OTHER MALPRESENTATION OF FETUS 13,260.00
9,282.00
3,978.00
O32.9 MATERNAL CARE FOR MALPRESENTATION OF FETUS, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O33.0 MATERNAL CARE FOR DISPROPORTION DUE TO DEFORMITY OF MATERNAL PELVIC BONES; PELVIC DEFORMITY CAUSING DISPROPORTION NOS 13,260.00
9,282.00
3,978.00
O33.1 MATERNAL CARE FOR DISPROPORTION DUE TO GENERALLY CONTRACTED PELVIS; CONTRACTED PELVIS NOS CAUSING DISPROPORTION 13,260.00
9,282.00
3,978.00
O33.2 MATERNAL CARE FOR DISPROPORTION DUE TO INLET CONTRACTION OF PELVIS; INLET CONTRACTION (PELVIS) CAUSING DISPROPORTION 13,260.00
9,282.00
3,978.00
O33.3 MATERNAL CARE FOR DISPROPORTION DUE TO OUTLET CONTRACTION OF PELVIS; MID-CAVITY CONTRACTION PELVIS CAUSING DISPROPORTION; OUTLET CONTRACTION PELVIS CAUSING DISPROPORTION 13,260.00
9,282.00
3,978.00
O33.4 MATERNAL CARE FOR DISPROPORTION OF MIXED MATERNAL AND FETAL ORIGIN 13,260.00
9,282.00
3,978.00
O33.5 MATERNAL CARE FOR DISPROPORTION DUE TO UNUSUALLY LARGE FETUS; DISPROPORTION OF FETAL ORIGIN WITH NORMALLY FORMED FETUS; FETAL DISPROPORTION NOS 13,260.00
9,282.00
3,978.00
O33.6 MATERNAL CARE FOR DISPROPORTION DUE TO HYDROCEPHALIC FETUS 13,260.00
9,282.00
3,978.00
O33.7 MATERNAL CARE FOR DISPROPORTION DUE TO OTHER FETAL DEFORMITIES; CONJOINED TWINS; FETAL ASCITES CAUSING DISPROPORTION; FETAL HYDROPS CAUSING DISPROPORTION; FETAL MEANINGOMYELOCELE CAUSING DISPROPORTION; FETAL TUMOUR CAUSING DISPROPORTION 13,260.00
9,282.00
3,978.00
O33.9 MATERNAL CARE FOR DISPROPORTION, UNSPECIFIED; CEPHALOPELVIC DISPROPORTION NOS; FETOPELVIC DISPROPORTION NOS 13,260.00
9,282.00
3,978.00
O34.0 MATERNAL CARE FOR CONGENITAL MALFORMATION OF UTERUS; MATERNAL CARE FOR DOUBLE UTERUS; MATERNAL CARE FOR UTERUS BICORNIS 13,260.00
9,282.00
3,978.00
O34.1 MATERNAL CARE FOR TUMOUR OF CORPUS UTERI; MATERNAL FOR POLYP OF CORPUS UTERI; MATERNAL CARE FOR UTERINE FIBROID 13,260.00
9,282.00
3,978.00
O34.2 MATERNAL CARE DUE TO UTERINE SCAR FROM PREVIOUS SURGERY; MATERNAL CARE FOR SCAR FROM PREVIOUS 13,260.00
9,282.00
3,978.00
O34.3 MATERNAL CARE FOR CERVICAL INCOMPETENCE; MATERNAL CARE FOR CERCLAGE WITH OR WITHOUT MENTION OF CERVICAL INCOMPETENCE; MATERNAL CARE FOR SHIRODKAR SUTURE WITH OR WITHOUT MENTION OF CERVICAL INCOMPETENCE 13,260.00
9,282.00
3,978.00
O34.4 MATERNAL CARE FOR OTHER ABNORMALITIES OF CERVIX; MATERNAL CARE FOR POLYP OF CERVIX; MATERNAL CARE FOR PREVIOUS SURGERY TO CERVIX; MATERNAL CARE FOR STRICTURE OR STENOSIS OF CERVIX; MATERNAL CARE FOR TUMOUR OF CERVIX 13,260.00
9,282.00
3,978.00
O34.5 MATERNAL CARE FOR OTHER ABNORMALITIES OF GRAVID UTERUS; MATERNAL CARE FOR INCARCERATIION OF GRAVID UTERUS; MATERNAL CARE FOR PROLAPSE OF GRAVID UTERUS; MATERNAL CARE FOR RETROVERSION OF GRAVID UTERUS 13,260.00
9,282.00
3,978.00
Page 76 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate O34.6 MATERNAL CARE FOR ABNORMALITY OF VAGINA; MATERNAL CARE FOR PREVIOUS SURGERY TO VAGINA; MATERNAL CARE FOR SEPTATE VAGINA; MATERNAL CARE FOR ACQUIRED STENOSIS OF VAGINA; MATERNAL CARE FOR CONGENITAL STENOSIS OF VAGINA; MATERNAL CARE FOR TUMOUR OF VAGINA 13,260.00
9,282.00
3,978.00
O34.7 MATERNAL CARE FOR ABNORMALITY OF VULVA AND PERINEUM; MATERNAL CARE FOR FIBROSIS OF PERINEUM; MATERNAL CARE FOR PREVIOUS SURGERY TO PERINEUM OR VULVA; MATERNAL CARE FOR RIGID PERINEUM; MATERNAL CARE FOR TUMOUR OF VULVA 13,260.00
9,282.00
3,978.00
O34.8 MATERNAL CARE FOR OTHER ABNORMALITIES OF PELVIC ORGANS; MATERNAL CARE FOR CYSTOCELE; MATERNAL CARE FOR PREVIOUS PELVIC FLOOR REPAIR; MATERNAL CARE FOR PENDULOUS ABDOMEN; MATERNAL CARE FOR RECTOCELE; MATERNAL CARE FOR RIGID PELVIC FLOOR 13,260.00
9,282.00
3,978.00
O34.9 MATERNAL CARE FOR ABNORMALITY OF PELVIC ORGAN, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O35.0 MATERNAL CARE FOR (SUSPECTED) CENTRAL NERVOUS SYSTEM MALFORMATION IN FETUS; MATERNAL CARE FOR SUSPECTED FETAL ANENCEPHALY; MATERNAL CARE FOR SUSPECTED FETAL SPINA BIFIDA 13,260.00
9,282.00
3,978.00
O35.2 MATERNAL CARE FOR (SUSPECTED) HEREDITARY DISEASE IN FETUS 13,260.00
9,282.00
3,978.00
O35.3 MATERNAL CARE FOR (SUSPECTED) DAMAGE TO FETUS FROM VIRAL DISEASE IN MOTHER; MATERNAL CARE FOR SUSPECTED DAMAGE TO FETUS FROM MATERNAL CYTOMEGALOVIRUS INFECTION; MATERNAL CARE FOR SUSPECTED DAMAGE TO FETUS FROM MATERNAL RUBELLA 13,260.00
9,282.00
3,978.00
O35.5 MATERNAL CARE FOR (SUSPECTED) DAMAGE TO FETUS BY DRUGS; MATERNAL CARE FOR SUSPECTED DAMAGE TO FETUS FROM DRUG ADDICTION 13,260.00
9,282.00
3,978.00
O35.8 MATERNAL CARE FOR OTHER (SUSPECTED) FETAL ABNORMALITY AND DAMAGE; MATERNAL CARE FOR SUSPECTED DAMAGE TO FETUS FROM MATERNAL LISTERIOSIS; MATERNAL CARE FOR SUSPECTED DAMAGE TO FETUS FROM MATERNAL TOXOPLASMOSIS 13,260.00
9,282.00
3,978.00
O35.9 MATERNAL CARE FOR (SUSPECTED) FETAL ABNORMALITY AND DAMAGE, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O36.0 MATERNAL CARE FOR RHESUS ISOIMMUNIZATION; ANTI-D [RH] ANTIBODIES; RH INCOMPATIBILITY (WITH HYDROPS FETALIS) 13,260.00
9,282.00
3,978.00
O36.1 MATERNAL CARE FOR OTHER ISOIMMUNIZATION; ABO ISOIMMUNIZATION; ISOIMMUNIZATION NOS (WITH HYDROPS FETALIS) 13,260.00
9,282.00
3,978.00
O36.2 MATERNAL CARE FOR HYDROPS FETALIS; HYDROPS FETALIS NOS; HYDROPS FETALIS NOT ASSOCIATED WITH ISOIMMUNIZATION 13,260.00
9,282.00
3,978.00
O36.3 MATERNAL CARE FOR SIGNS OF FETAL HYPOXIA 13,260.00
9,282.00
3,978.00
O36.4 MATERNAL CARE FOR INTRAUTERINE DEATH 13,260.00
9,282.00
3,978.00
O36.5 MATERNAL CARE FOR POOR FETAL GROWTH; MATERNAL CARE FOR KNOWN OR SUSPECTED LIGHT-FOR-DATES; MATERNAL CARE FOR KNOWN OR SUSPECTED PLACENTAL INSUFFICIENCY; MATERNAL CARE FOR KNOWN OR SUSPECTED SMALL-FOR-DATES 13,260.00
9,282.00
3,978.00
O36.6 MATERNAL CARE FOR EXCESSIVE FETAL GROWTH; MATERNAL CARE FOR KNOWN OR SUSPECTED LARGE-FOR-DATES 13,260.00
9,282.00
3,978.00
O36.7 MATERNAL CARE FOR VIABLE FETUS IN ABDOMINAL PREGNANCY 15,210.00
10,647.00
4,563.00
O36.8 MATERNAL CARE FOR OTHER SPECIFIED FETAL PROBLEMS 13,260.00
9,282.00
3,978.00
O36.9 MATERNAL CARE FOR FETAL PROBLEM, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O40 POLYHYDRAMNIOS; HYDRAMNIOS 13,260.00
9,282.00
3,978.00
O41.0 OLIGOHYDRAMNIOS; OLIGOHYDRAMNIOS WITHOUT MENTION OF RUPTURE OF MEMBRANE 13,260.00
9,282.00
3,978.00
O41.1 INFECTION OF AMNIOTIC SAC AND MEMBRANES; AMNIONITIS; CHORIOAMNIONITIS; MEMBRANITIS; PLACENTITIS 13,260.00
9,282.00
3,978.00
O41.8 OTHER SPECIFIED DISORDERS OF AMNIOTIC FLUID AND MEMBRANES 13,260.00
9,282.00
3,978.00
O41.9 DISORDER OF AMNIOTIC FLUID AND MEMBRANES, UNSPECIFIED; PREMATURE RUPTURE OF MEMBRANES 13,260.00
9,282.00
3,978.00
O42.0 PREMATURE RUPTURE OF MEMBRANES ON SET OF LABOUR WITHIN 24 HOURS 13,260.00
9,282.00
3,978.00
O42.1 PREMATURE RUPTURE OF MEMBRANES ON SET OF LABOUR AFTER 24 HOURS 13,260.00
9,282.00
3,978.00
O42.2 PREMATURE RUPTURE OF MEMBRANES, LABOUR DELAYED BY THERAPY 13,260.00
9,282.00
3,978.00
O42.9 PREMATURE RUPTURE OF MEMBRANES, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O43.0 PLACENTAL TRANSFUSION SYNDROMES; FETOMATERNAL TRANSFUSION; MATERNOFETAL TRANSFUSION; TWIN-TO-TWIN TRANSFUSION 13,260.00
9,282.00
3,978.00
O43.1 MALFORMATION OF PLACENTA; ABNORMAL PLACENTA NOS; CIRCUMVALLATE PLACENTA 13,260.00
9,282.00
3,978.00
O43.8 OTHER PLACENTAL DISORDERS; PLACENTAL DYSFUNCTION; PLACENTAL INFARCTION 13,260.00
9,282.00
3,978.00
O43.9 PLACENTAL DISORDER, UNSPECIFIED 13,260.00
9,282.00
3,978.00
Page 77 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate O44.0 PLACENTA PRAEVIA SPECIFIED AS WITHOUT HAEMORRHAGE; LOW IMPLANTATION OF PLACENTA, NOS OR WITH HAEMORRHAGE 13,260.00
9,282.00
3,978.00
O44.1 PLACENTA PRAEVIA WITH HAEMORRHAGE; LOW IMPLANTATION OF PLACENTA, NOS OR WITH HAEMORRHAGE; PLACENTA PRAEVIA, MARGINAL NOS OR WITH HAEMORRHAGE; PLACENTA PRAEVIA, PARTIAL NOS OR WITH HAEMORRHAGE; PLACENTA PRAEVIA, TOTAL NOS OR WITH HAEMORRHAGE 13,260.00
9,282.00
3,978.00
O45.0
PREMATURE SEPARATION OF PLACENTA WITH COAGULATION
DEFECT; ABRUPTIO PLACENTAE WITH (EXCESSIVE)
HAEMORRHAGE ASSOCIATED WITH AFIBRINOGENAEMIA;
ABRUPTIO PLACENTAE WITH (EXCESSIVE) HAEMORRHAGE
ASSOCIATED WITH DISSEMINATED INTRAVASCULAR
COAGULATION; ABRUPTIO
13,260.00
9,282.00
3,978.00
O45.8 OTHER PREMATURE SEPARATION OF PLACENTA 13,260.00
9,282.00
3,978.00
O45.9 PREMATURE SEPARATION OF PLACENTA, UNSPECIFIED; ABRUPTIO PLACENTA NOS 13,260.00
9,282.00
3,978.00
O46.0 ANTEPARTUM HAEMORRHAGE WITH COAGULATION DEFECT; ANTEPARTUM HAEMORRHAGE (EXCESSIVE) ASSOCIATED WITH AFIBRINOGENAEMIA; ANTEPARTUM HAEMORRHAGE (EXCESSIVE) ASSOCIATED WITH DISSEMINATED INTRAVASCULAR COAGULATION; ANTEPARTUM HAEMORRHAGE (EXCESSIVE) ASSOCIATED W 13,260.00
9,282.00
3,978.00
O46.8 OTHER ANTEPARTUM HAEMORRHAGE 13,260.00
9,282.00
3,978.00
O46.9 ANTEPARTUM HAEMORRHAGE, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O47.0 FALSE LABOUR BEFORE 37 COMPLETED WEEKS OF GESTATION 13,260.00
9,282.00
3,978.00
O47.1 FALSE LABOUR AT OR AFTER 37 COMPLETED WEEKS OF GESTATION 13,260.00
9,282.00
3,978.00
O47.9 FALSE LABOUR, UNSPECIFIED 13,260.00
9,282.00
3,978.00
O48 PROLONGED PREGNANCY; POST-DATES; POST-TERM 13,260.00
9,282.00
3,978.00
O60.0 PRETERM LABOR, NOT RESULTING TO DELIVERY 13,260.00
9,282.00
3,978.00
O67.8 OTHER INTRAPARTUM HAEMORRHAGE; EXCESSIVE INTRAPARTUM HAEMORRHAGE 18,135.00
12,694.50
5,440.50
O71.0 RUPTURE OF UTERUS BEFORE ON SET OF LABOUR 18,135.00
12,694.50
5,440.50
O71.1 RUPTURE OF UTERUS DURING LABOUR; RUPTURE OF UTERUS NOT STATED AS OCCURING BEFORE ONSET OF LABOUR 18,135.00
12,694.50
5,440.50
O71.2 POST PARTUM INVERSION OF UTERUS 18,135.00
12,694.50
5,440.50
O71.3 OBSTETRIC LACERATION OF CERVIX; ANNULAR DETACHMENT OF CERVIX 18,135.00
12,694.50
5,440.50
O71.5 OTHER OBSTETRIC INJURY TO PELVIC ORGANS; OBSTETRIC INJURY TO BLADDER; OBSTETRIC INJURY TO URETHRA 18,135.00
12,694.50
5,440.50
O71.7 OBSTETRIC HAEMATOMA OF PELVIS; OBSTETRIC HAEMATOMA OF PERINEUM; OBSTETRIC HAEMATOMA OF VAGINA; OBSTETRIC HAEMATOMA OF VULVA 18,135.00
12,694.50
5,440.50
O71.8 OTHER SPECIFIED OBSTETRIC TRAUMA 18,135.00
12,694.50
5,440.50
O71.9 OBSTETRIC TRAUMA, UNSPECIFIED 18,135.00
12,694.50
5,440.50
O72.0 THIRD-STAGE HAEMORRHAGE; HAEMORRHAGE ASSOCIATED WITH RETAINED, TRAPPED OR ADHERENT PLACENTA; RETAINED PLACENTA NOS 13,650.00
9,555.00
4,095.00
O72.1 OTHER IMMEDIATE POSTPARTUM HAEMORRHAGE; HAEMORRHAGE FOLLOWING DELIVERY OF PLACENTA; POSTPARTUM ATOMIC HAEMORRHAGE NOS 13,650.00
9,555.00
4,095.00
O72.2 DELAYED AND SECONDARY POSTPARTUM HAEMORRHAGE; HAEMORRHAGE ASSOCIATED WITH RETAINED PORTIONS OF PLACENTA OR MEMBRANES; RETAINED PRODUCTS OF CONCEPCION NOS, FOLLOWING DELIVERY 13,650.00
9,555.00
4,095.00
O72.3 POSTPARTUM COAGULATION DEFECTS; AFIBRINOGENAEMIA POSTPARTUM; FIBRINOLYSIS POSTPARTUM 13,650.00
9,555.00
4,095.00
O73.0 RETAINED PLACENTA WITHOUT HAEMORRHAGE; PLACENTA ACCRETA WITHOUT HAEMORRHAGE 13,650.00
9,555.00
4,095.00
O73.1 RETAINED PORTIONS OF PLACENTA AND MEMBRANES WITHOUT HAEMORRHAGE; RETAINED PRODUCTS OF CONCEPTION FOLLOWING DELIVERY, WITHOUT HAEMORRHAGE 13,650.00
9,555.00
4,095.00
O74.0 ASPIRATION PNEUMONITIS DUE TO ANAESTHESIA DURING LABOUR AND DELIVERY; INHALATION OF STOMACH CONTENTS OR SECRETIONS NOS DUE TO ANAESTHESIA DURING LABOUR AND DELIVERY; MENDELSON'S SYNDROME DUE TO ANAESTHESIA DURING LABOUR AND DELIVERY 18,135.00
12,694.50
5,440.50
O74.2 CARDIAC COMPLICATIONS OF ANAESTHESIA DURING LABOUR AND DELIVERY; CARDIAC ARREST DUE TO ANAESTHESIA DURING LABOUR AND DELIVERY; CARDIAC FAILURE DUE TO ANAESTHESIA DURING LABOUR AND DELIVERY 18,135.00
12,694.50
5,440.50
O74.8 OTHER COMPLICATIONS OF ANAESTHESIA DURING LABOUR AND DELIVERY 18,135.00
12,694.50
5,440.50
O75.1 SHOCK DURING OR FOLLOWING LABOUR AND DELIVERY; OBSTETIC SHOCK 18,135.00
12,694.50
5,440.50
O75.8 OTHER SPECIFIED COMPLICATIONS OF LABOUR AND DELIVERY 18,135.00
12,694.50
5,440.50
O75.9 COMPLICATION OF LABOUR AND DELIVERY, UNSPECIFIED 18,135.00
12,694.50
5,440.50
O85
PUERPERAL SEPSIS; PUERPERAL ENDOMETRITIS; PUERPERAL
FEVER; PUERPERAL PERITONITIS; PUERPERAL SEPTICAEMIA
20,670.00
14,469.00
6,201.00
Page 78 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate O86.0 INFECTION OF OBSTETRIC SURGICAL WOUND; INFECTED CAESAREAN SECTION WOUND FOLLOWING DELIVERY; INFECTED PERINEAL REPAIR FOLLOWING DELIVERY 20,670.00
14,469.00
6,201.00
O86.1 OTHER INFECTION OF GENITAL TRACT FOLLOWING DELIVERY; CERVICITIS FOLLOWING DELIVERY; VAGINITIS FOLLOWING DELIVERY 20,670.00
14,469.00
6,201.00
O86.2 URINARY TRACT INFECTION FOLLOWING DELIVERY 20,670.00
14,469.00
6,201.00
O86.3 OTHER GENITOURINARY TRACT INFECTIONS FOLLOWING DELIVERY; PUERPERAL GENITOURINARY TRACT INFECTION NOS 20,670.00
14,469.00
6,201.00
O86.4 PYREXIA OF UNKNOWN ORIGIN FOLLOWING DELIVERY; PUERPERAL INFECTION NOS; PUERPERAL PYREXIA NOS 20,670.00
14,469.00
6,201.00
O86.8 OTHER SPECIFIED PUERPERA LINFECTIONS 20,670.00
14,469.00
6,201.00
O87.0 SUPERFICIAL THROMBOPHLEBITIS IN THE PUERPERIUM 20,670.00
14,469.00
6,201.00
O87.1 DEEP PHLEBOTHROMBOSIS IN THE PUERPERIUM; DEEP-VEIN THROMBOSIS, POSTPARTUM; PELVIC THROMBOPHLEBITIS, POSTPARTUM 20,670.00
14,469.00
6,201.00
O87.2 HAEMORRHOIDS IN THE PUERPERIUM 20,670.00
14,469.00
6,201.00
O87.8 OTHER VENOUS COMPLICATIONS IN THE PUERPERIUM; GENITAL VARICES IN THE PUERPERIUM 20,670.00
14,469.00
6,201.00
O87.9 VENOUS COMPLICATION IN THE PUERPERIUM, UNSPECIFIED; PUERPERAL PHLEBITIS NOS; PUERPERAL PHLEBOPATHY NOS; PUERPERAL THROMBOSIS NOS 18,135.00
12,694.50
5,440.50
O88.1 AMNIOTIC FLUID EMBOLISM 20,670.00
14,469.00
6,201.00
O88.2 OBSTETRIC BLOOD-CLOT EMBOLISM; OBSTETRIC PULMONARY EMBOLISM NOS; PUERPERAL PULMONARY EMBOLISM NOS 20,670.00
14,469.00
6,201.00
O89.0 PULMONARY COMPLICATIONS OF ANAESTHESIA DURING THE PUERPERIUM; ASPIRATION PNEUMONITIS DUE TO ANAESTHESIA DURING THE PUERPERIUM; INHALATION OF STOMACH CONTENTS OR SECRETIONS NOS DUE TO ANAESTHESIA DURING THE PUERPERIUM MENDELSON'S SYNDROME DUE TO ANAEST 20,670.00
14,469.00
6,201.00
O89.1 CARDIAC COMPLICATIONS OF ANAESTHESIA DURING THE PUERPERIUM; CARDIAC ARREST DUE TO ANAESTHESIA DURING THE PUERPERIUM; CARDIAC FAILURE DUE TO ANAESTHESIA DURING THE PUERPERIUM 20,670.00
14,469.00
6,201.00
O89.2 CENTRAL NERVOUS SYSTEM COMPLICATIONS OF ANAESTHESIA DURING THE PUERPERIUM; CEREBRAL ANOXIA DUE TO ANAESTHESIA DURING THE PUERPERIUM 20,670.00
14,469.00
6,201.00
O89.4 SPINAL AND EPIDURAL ANAESTHESIA-INDUCED HEADACHE DURING THE PUERPERIUM 20,670.00
14,469.00
6,201.00
O89.8 OTHER COMPLICATIONS OF ANAESTHESIA DURING THE PUERPERIUM 20,670.00
14,469.00
6,201.00
O89.9 COMPLICATION OF ANAESTHESIA DURING THE PUERPERIUM, UNSPECIFIED 20,670.00
14,469.00
6,201.00
O90.0 DISRUPTION OF CAESAREAN SECTION WOUND 20,670.00
14,469.00
6,201.00
O90.1 DISRUPTION OF PERINEAL OBSTETRIC WOUND; DISRUPTION OF WOUND OF EPISIOTOMY; DISRUPTION OF WOUND OF PERINEAL LACERATION; SECONDARY PERINEAL TEAR 20,670.00
14,469.00
6,201.00
O90.2 HAEMATOMA OF OBSTETRIC WOUND 20,670.00
14,469.00
6,201.00
O90.3 CARDIOMYOPATHY IN THE PUERPERIUM 20,670.00
14,469.00
6,201.00
O90.4 POSTPARTUM ACUTE RENAL FAILURE; HEPATORENAL SYNDROME FOLLOWING LABOUR AND DELIVERY 20,670.00
14,469.00
6,201.00
O90.5 POSTPARTUM THYROIDITIS 20,670.00
14,469.00
6,201.00
O90.8 OTHER COMPLICATIONS OF THE PUERPERIUM, NOT ELSEWHERE CLASSIFIED 20,670.00
14,469.00
6,201.00
O90.9 COMPLICATION OF THE PUERPERIUM, UNSPECIFIED 20,670.00
14,469.00
6,201.00
O91.0 INFECTION OF NIPPLE ASSOCIATED WITH CHILDBIRTH; GESTATIONAL ABSCESS OF NIPPLE; PUERPERAL ABSCESS OF NIPPLE 15,405.00
10,783.50
4,621.50
O91.1 ABSCESS OF BREAST ASSOCIATED WITH CHILDBIRTH; MAMMARY ABSCESS GESTATIONAL OR PUERPERAL; PURULENT MASTITIS GESTATIONAL OR PUERPERAL; SUBAREOLAR ABSCESS GESTATIONAL OR PUERPERAL 15,405.00
10,783.50
4,621.50
O91.2 NONPURULENT MASTITIS ASSOCIATED WITH CHILDBIRTH; LYMPHANGITIS OF BREAST GESTATIONAL OR PUERPERAL; MASTITIS NOS GESTATIONAL OR PUERPERAL; INTERSTITIAL MASTITIS GESTATIONAL OR PUERPERAL; PARENCHYMATOUS MASTITIS GESTATIONAL OR PUERPERAL 15,405.00
10,783.50
4,621.50
O92.0 RETRACTED NIPPLE ASSOCIATED WITH CHILDBIRTH 15,405.00
10,783.50
4,621.50
O92.1 CRACKED NIPPLE ASSOCIATED WITH CHILDBIRTH; FISSURE OF NIPPLE, GESTATIONAL OR PUERPERAL 15,405.00
10,783.50
4,621.50
O98.0 TUBERCULOSIS COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O98.1 SYPHILIS COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O98.2 GONORRHOEACOMPLICATINGPREGNANCYCHILDBIRTHANDTHEP UERPERIUM 13,260.00
9,282.00
3,978.00
O98.3 OTHER INFECTIONS WITH APREDOMINANTLY SEXUAL MODE OF TRANSMISSION COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O98.4 VIRAL HEPATITIS COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O98.5
OTHER VIRAL DISEASES COMPLICATING PREGNANCY,
CHILDBIRTH AND THE PUERPERIUM
13,260.00
9,282.00
3,978.00
Page 79 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate O98.6 PROTOZOAL DISEASES COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O98.8 OTHER MATERNAL INFECTIOUS AND PARASITIC DISEASES COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O98.9 UNSPECIFIED MATERNAL INFECTIOUS OR PARASITIC DISEASE COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O99.0 ANAEMIA COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O99.1 OTHER DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS AND CERTAIN DISORDERS INVOLVING THE IMMUNE MECHANISM COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O99.2 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O99.3 MENTAL DISORDERS AND DISEASES OF THE NERVOUS SYSTEM COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O99.4 DISEASES OF THE CIRCULATORY SYSTEM COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O99.5 DISEASES OF THE RESPIRATORY SYSTEM COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O99.6 DISEASES OF THE DIGESTIVE SYSTEM COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O99.7 DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
O99.8 OTHER SPECIFIED DISEASES AND CONDITIONS COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 13,260.00
9,282.00
3,978.00
P00.0 FETUS AND NEWBORN AFFECTED BY MATERNAL HYPERTENSIVE DISORDERS 15,015.00
10,510.50
4,504.50
P00.1 FETUS AND NEWBORN AFFECTED BY MATERNAL RENAL AND URINARY TRACT DISEASES 15,015.00
10,510.50
4,504.50
P00.2 FETUS AND NEWBORN AFFECTED BY MATERNAL INFECTIOUS AND PARASITIC DISEASES 15,015.00
10,510.50
4,504.50
P00.3 FETUS AND NEWBORN AFFECTED BY OTHER MATERNAL CIRCULATORY AND RESPIRATORY DISEASES 15,015.00
10,510.50
4,504.50
P00.4 FETUS AND NEWBORN AFFECTED BY MATERNAL NUTRITIONAL DISORDERS 15,015.00
10,510.50
4,504.50
P00.5 FETUS AND NEWBORN AFFECTED BY MATERNAL INJURY 15,015.00
10,510.50
4,504.50
P00.6 FETUS AND NEWBORN AFFECTED BY SURGICAL PROCEDURE ON MOTHER 15,015.00
10,510.50
4,504.50
P00.7 FETUS AND NEWBORN AFFECTED BY OTHER MEDICAL PROCEDURES ON MOTHER, NOT ELSEWHERE CLASSIFIED 15,015.00
10,510.50
4,504.50
P00.8 FETUS AND NEWBORN AFFECTED BY OTHER MATERNAL CONDITIONS 15,015.00
10,510.50
4,504.50
P00.9 FETUS AND NEWBORN AFFECTED BY UNSPECIFIED MATERNAL CONDITION 15,015.00
10,510.50
4,504.50
P01.0 FETUS AND NEWBORN AFFECTED BY INCOMPETENT CERVIX 15,015.00
10,510.50
4,504.50
P01.1 FETUS AND NEWBORN AFFECTED BY PREMATURE RUPTURE OF MEMBRANES 15,015.00
10,510.50
4,504.50
P01.2 FETUS AND NEWBORN AFFECTED BY OLIGOHYDRAMNIOS 15,015.00
10,510.50
4,504.50
P01.3 FETUS AND NEWBORN AFFECTED BY POLYHYDRAMNIOS; HYDRAMNIOS 15,015.00
10,510.50
4,504.50
P01.4 FETUS AND NEWBORN AFFECTED BY ECTOPIC PREGNANCY; ABDOMINAL PREGNANCY 15,015.00
10,510.50
4,504.50
P01.5 FETUS AND NEWBORN AFFECTED BY MULTIPLE PREGNANCY; TRIPLET PREGNANCE; TWIN PREGNANCY 15,015.00
10,510.50
4,504.50
P01.6 FETUS AND NEWBORN AFFECTED BY MATERNAL DEATH 15,015.00
10,510.50
4,504.50
P01.7 FETUS AND NEWBORN AFFECTED BY MALPRESENTATION BEFORE LABOUR; BREECH PRESENTATION BEFORE LABOR; EXTERNAL VERSION BEFORE LABOUR; FACE PRESENTATION BEFORE LABOUR; TRANSVERSE LIE BEFORE LABOUR; UNSTABLE LIE BEFORE LABOUR 15,015.00
10,510.50
4,504.50
P01.8 FETUS AND NEWBORN AFFECTED BY OTHER MATERNAL COMPLICATIONS OF PREGNANCY; SPONTANEOUS ABORTION, FETUS 15,015.00
10,510.50
4,504.50
P01.9 FETUS AND NEWBORN AFFECTED BY MATERNAL COMPLICATION OF PREGNANCY, UNSPECIFIED 15,015.00
10,510.50
4,504.50
P02.0 FETUS AND NEWBORN AFFECTED BY PLACENTA PRAEVIA 15,015.00
10,510.50
4,504.50
P02.1 FETUS AND NEWBORN AFFECTED BY OTHER FORMS OF PLACENTAL SEPARATION AND HAEMORRHAGE; ABRUPTIO PLACENTAE; ACCIDENTAL HAEMORRHAGE; ANTEPARTUM HAEMORRHAGE; DAMAGE TO PLACENTA FROM AMNIOCENTESIS, CAESARIAN SECTION OR SURGICAL INDUCTION; MATERNAL BLOOD LOSS; PRE 15,015.00
10,510.50
4,504.50
P02.2 FETUS AND NEWBORN AFFECTED BY OTHER AND UNSPECIFIED MORPHOLOGICAL AND FUNCTIONAL ABNORMALITIES OF PLACENTA; PLACENTAL DYSFUNCTION; PLACENTAL INFARCTION; PLACENTAL INSUFFICIENCY 15,015.00
10,510.50
4,504.50
P02.3 FETUS AND NEWBORN AFFECTED BY PLACENTAL TRANSFUSION SYNDROMES; PLACENTAL AND CORD ABNORMALITIES RESULTING IN TWIN-TO-TWIN OR OTHER TRANSPLACENTAL TRANSFUSION 15,015.00
10,510.50
4,504.50
P02.4 FETUS AND NEWBORN AFFECTED BY PROLAPSED CORD 15,015.00
10,510.50
4,504.50
Page 80 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate P02.5 FETUS AND NEWBORN AFFECTED BY OTHER COMPRESSION OF UMBILICAL CORD; CORD (TIGHTLY) AROUND NECK; ENTANGLEMENT OF CORD; KNOT IN CORD 15,015.00
10,510.50
4,504.50
P02.6 FETUS AND NEWBORN AFFECTED BY OTHER AND UNSPECIFIED CONDITIONS OF UMBILICAL CORD; SHORT CORD; VASA PRAEVIA 15,015.00
10,510.50
4,504.50
P02.7 FETUS AND NEWBORN AFFECTED BY CHORIOAMNIONITIS; AMNIONITIS; MEMBRANITIS; PLACENTITIS 15,015.00
10,510.50
4,504.50
P02.8 FETUS AND NEWBORN AFFECTED BY OTHER ABNORMALITIES OF MEMBRANES 15,015.00
10,510.50
4,504.50
P02.9 FETUS AND NEWBORN AFFECTED BY ABNORMALITY OF MEMBRANES, UNSPECIFIED 15,015.00
10,510.50
4,504.50
P03.0 FETUS AND NEWBORN AFFECTED BY BREECH DELIVERY AND EXTRACTION 15,015.00
10,510.50
4,504.50
P03.1 FETUS AND NEWBORN AFFECTED BY OTHER MALPRESENTATION, MALPOSITION AND DISPROPORTION DURING LABOUR AND DELIVERY; CONTRACTED PELVIS; PERSISTENT OCCIPITOPOSTERIOR; TRANSVERSE LIE 15,015.00
10,510.50
4,504.50
P03.2 FETUS AND NEWBORN AFFECTED BY FORCEPS DELIVERY 15,015.00
10,510.50
4,504.50
P03.3 FETUS AND NEWBORN AFFECTED BY DELIVERY BY VACUUM EXTRACTOR [VENTOUSE] 15,015.00
10,510.50
4,504.50
P03.4 FETUS AND NEWBORN AFFECTED BY CAESAREAN DELIVERY 15,015.00
10,510.50
4,504.50
P03.5 FETUS AND NEWBORN AFFECTED BY PRECIPITATE DELIVERY 15,015.00
10,510.50
4,504.50
P03.6 FETUS AND NEWBORN AFFECTED BY ABNORMAL UTERINE CONTRACTIONS 15,015.00
10,510.50
4,504.50
P03.8 FETUS AND NEWBORN AFFECTED BY OTHER SPECIFIED COMPLICATIONS OF LABOUR AND DELIVERY 15,015.00
10,510.50
4,504.50
P03.9 FETUS AND NEWBORN AFFECTED BY COMPLICATION OF LABOUR AND DELIVERY, UNSPECIFIED 15,015.00
10,510.50
4,504.50
P04.0 FETUS AND NEWBORN AFFECTED BY MATERNAL ANAESTHESIA AND ANALGESIA IN PREGNANCY, LABOUR AND DELIVERY 15,015.00
10,510.50
4,504.50
P04.1 FETUS AND NEWBORN AFFECTED BY OTHER MATERNAL MEDICATION; CANCER CHEMOTHERAPY; CYTOTOXIC DRUGS 15,015.00
10,510.50
4,504.50
P04.2 FETUS AND NEWBORN AFFECTED BY MATERNAL USE OF TOBACCO 15,015.00
10,510.50
4,504.50
P04.3 FETUS AND NEWBORN AFFECTED BY MATERNAL USE OF ALCOHOL 15,015.00
10,510.50
4,504.50
P04.5 FETUS AND NEWBORN AFFECTED BY MATERNAL USE OF NUTRITIONAL CHEMICAL SUBSTANCES 15,015.00
10,510.50
4,504.50
P04.8 FETUS AND NEWBORN AFFECTED BY OTHER MATERNAL NOXIOUS INFLUENCES 15,015.00
10,510.50
4,504.50
P05.0 LIGHT FOR GESTATIONAL AGE 32,955.00
23,068.50
9,886.50
P05.1 SMALL FOR GESTATIONAL AGE 32,955.00
23,068.50
9,886.50
P05.2 FETAL MALNUTRITION WITHOUT MENTION OF LIGHT OR SMALL FOR GESTATIONAL AGE 32,955.00
23,068.50
9,886.50
P05.9 SLOW FETAL GROWTH, UNSPECIFIED 32,955.00
23,068.50
9,886.50
P07.0 EXTREMELY LOW BIRTH WEIGHT; BIRTH WEIGHT 999 G OR LESS. 32,955.00
23,068.50
9,886.50
P07.1 OTHER LOW BIRTH WEIGHT; BIRTH WEIGHT 1000-2499 G. 32,955.00
23,068.50
9,886.50
P07.2 EXTREME IMMATURITY; LESS THAN 28 COMPLETED WEEKS (LESS THAN 196 COMPLETED DAYS) OF GESTATION. 32,955.00
23,068.50
9,886.50
P07.3 OTHER PRETERM INFANTS; 28 COMPLETED WEEKS OR MORE BUT LESS THAN 37 COMPLETED WEEKS (196 COMPLETED DAYS BUT LESS THAN 259 COMPLETED DAYS) OF GESTATION; PREMATURITY NOS 32,955.00
23,068.50
9,886.50
P08.0 EXCEPTIONALLY LARGE BABY; USUALLY IMPLIES A BIRTH WEIGHT OF 4500 G OR MORE. 13,650.00
9,555.00
4,095.00
P08.1 OTHER HEAVY FOR GESTATIONAL AGE INFANTS; OTHER FETUS OR INFANT HEAVY- OR LARGE-FOR-DATES REGARDLESS OF PERIOD OF GESTATION. 13,650.00
9,555.00
4,095.00
P08.2 POST-TERM INFANT, NOT HEAVY FOR GESTATIONAL AGE; FETUS OR INFANT WITH GESTATION PERIOD OF 42 COMPLETED WEEKS OR MORE (294 DAYS OR MORE), NOT HEAVY- OR LARGE-FOR-DATES; POSTMATURITY NOS 14,625.00
10,237.50
4,387.50
P10.0 SUBDURAL HAEMORRHAGE DUE TO BIRTH INJURY; SUBDURAL HAEMATOMA (LOCALIZED) DUE TO BIRTH INJURY 26,910.00
18,837.00
8,073.00
P10.1 CEREBRAL HAEMORRHAGE DUE TO BIRTH INJURY 26,910.00
18,837.00
8,073.00
P10.2 INTRAVENTRICULAR HAEMORRHAGE DUE TO BIRTH INJURY 26,910.00
18,837.00
8,073.00
P10.3 SUBARACHNOID HAEMORRHAGE DUE TO BIRTH INJURY 26,910.00
18,837.00
8,073.00
P10.4 TENTORIAL TEAR DUE TO BIRTH INJURY 26,910.00
18,837.00
8,073.00
P10.9 UNSPECIFIED INTRACRANIAL LACERATION AND HAEMORRHAGE DUE TO BIRTH INJURY 26,910.00
18,837.00
8,073.00
P11.1 OTHER SPECIFIED BRAIN DAMAGE DUE TO BIRTH INJURY 26,910.00
18,837.00
8,073.00
P11.2 UNSPECIFIED BRAIN DAMAGE DUE TO BIRTH INJURY 26,910.00
18,837.00
8,073.00
P11.9 BIRTH INJURY TO CENTRAL NERVOUS SYSTEM, UNSPECIFIED 26,910.00
18,837.00
8,073.00
P12.0 CEPHALHAEMATOMA DUE TO BIRTH INJURY 26,910.00
18,837.00
8,073.00
P12.3 BRUISING OF SCALP DUE TO BIRTH INJURY 26,910.00
18,837.00
8,073.00
P12.8 OTHER BIRTH INJURIES TO SCALP 26,910.00
18,837.00
8,073.00
P12.9 BIRTH INJURY TO SCALP, UNSPECIFIED 26,910.00
18,837.00
8,073.00
P13.2 BIRTH INJURY TO FEMUR 26,910.00
18,837.00
8,073.00
P13.4 FRACTURE OF CLAVICLE DUE TO BIRTH INJURY 26,910.00
18,837.00
8,073.00
P13.8 BIRTH INJURIES TO OTHER PARTS OF SKELETON 26,910.00
18,837.00
8,073.00
Page 81 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate P13.9 BIRTH INJURY TO SKELETON, UNSPECIFIED 26,910.00
18,837.00
8,073.00
P14.0 ERB'S PARALYSIS DUE TO BIRTH INJURY 26,910.00
18,837.00
8,073.00
P14.3 OTHER BRACHIAL PLEXUS BIRTH INJURIES 26,910.00
18,837.00
8,073.00
P15.4 BIRTH INJURY TO FACE; FACIAL CONGESTION DUE TO BIRTH INJURY 26,910.00
18,837.00
8,073.00
P15.5 BIRTH INJURY TO EXTERNAL GENITALIA 26,910.00
18,837.00
8,073.00
P15.8 OTHER SPECIFIED BIRTH INJURIES 26,910.00
18,837.00
8,073.00
P15.9 BIRTH INJURY, UNSPECIFIED 26,910.00
18,837.00
8,073.00
P20.0 INTRAUTERINE HYPOXIA FIRST NOTED BEFORE ONSET OF LABOUR 21,255.00
14,878.50
6,376.50
P20.1 INTRAUTERINE HYPOXIA FIRST NOTED DURING LABOUR AND DELIVERY 21,255.00
14,878.50
6,376.50
P20.9 INTRAUTERINE HYPOXIA, UNSPECIFIED 21,255.00
14,878.50
6,376.50
P21.0 SEVERE BIRTH ASPHYXIA; PULSE LESS THAN 100 PER MINUTE AT BIRTH AND FALLING OR STEADY, RESPIRATION ABSENT OR GASPING, COLOUR POOR, TONE ABSENT; ASPHYXIA WITH 1- MINUTE APGAR SCORE 0-3; WHITE ASPHYXIA 21,255.00
14,878.50
6,376.50
P21.1 MILD AND MODERATE BIRTH ASPHYXIA; NORMAL RESPIRATION NOT ESTABLISHED WITHIN ONE MINUTE, BUT HEART RATE 100 OR ABOVE, SOME MUSCLE TONE PRESENT, SOME RESPONSE TO STIMULATION; ASPHYXIA WITH 1-MINUTE APGAR SCORE 4-7; BLUE ASPHYXIA 21,255.00
14,878.50
6,376.50
P21.9 BIRTH ASPHYXIA, UNSPECIFIED; ANOXIA, NOS; ASPHYXIA, NOS; HYPOXIA, NOS 21,255.00
14,878.50
6,376.50
P22.0 RESPIRATORY DISTRESS SYNDROME OF NEWBORN; HYALINE MEMBRANE DISEASE 21,255.00
14,878.50
6,376.50
P22.1 TRANSIENT TACHYPNOEA OF NEWBORN 21,255.00
14,878.50
6,376.50
P22.8 OTHER RESPIRATORY DISTRESS OF NEWBORN 21,255.00
14,878.50
6,376.50
P22.9 RESPIRATORY DISTRESS OF NEWBORN, UNSPECIFIED 21,255.00
14,878.50
6,376.50
P23.0 CONGENITAL PNEUMONIA DUE TO VIRAL AGENT 24,765.00
17,335.50
7,429.50
P23.1 CONGENITAL PNEUMONIA DUE TO CHLAMYDIA 24,765.00
17,335.50
7,429.50
P23.2 CONGENITAL PNEUMONIA DUE TO STAPHYLOCOCCUS 24,765.00
17,335.50
7,429.50
P23.3 CONGENITAL PNEUMONIA DUE TO STREPTOCOCCUS, GROUP B 24,765.00
17,335.50
7,429.50
P23.4 CONGENITAL PNEUMONIA DUE TO ESCHERICHIA COLI 24,765.00
17,335.50
7,429.50
P23.5 CONGENITAL PNEUMONIA DUE TO PSEUDOMONAS 24,765.00
17,335.50
7,429.50
P23.6 CONGENITAL PNEUMONIA DUE TO OTHER BACTERIAL AGENTS; HAEMOPHILUS INFLUENZAE; KLEBSIELLA PNEUMONIA; MYCOPLASMA; STREPTOCOCCUS, EXCEPT GROUP B 24,765.00
17,335.50
7,429.50
P23.9 CONGENITAL PNEUMONIA 24,765.00
17,335.50
7,429.50
P24.0 NEONATAL ASPIRATION OF MECONIUM 21,255.00
14,878.50
6,376.50
P24.1 NEONATAL ASPIRATION OF AMNIOTIC FLUID AND MUCUS;ASPIRATION OF LIQUOR (AMNII) 21,255.00
14,878.50
6,376.50
P24.2 NEONATAL ASPIRATION OF BLOOD 21,255.00
14,878.50
6,376.50
P24.3 NEONATAL ASPIRATION OF MILK AND REGURGITATED FOOD 21,255.00
14,878.50
6,376.50
P24.8 OTHER NEONATAL ASPIRATION SYNDROMES 21,255.00
14,878.50
6,376.50
P24.9 NEONATAL ASPIRATION SYNDROME, UNSPECIFIED; NEONATAL ASPIRATION PNEUMONIA NOS 21,255.00
14,878.50
6,376.50
P25.0 INTERSTITIAL EMPHYSEMA ORIGINATING IN THE PERINATAL PERIOD 21,255.00
14,878.50
6,376.50
P25.1 PNEUMOTHORAX ORIGINATING IN THE PERINATAL PERIOD 21,255.00
14,878.50
6,376.50
P25.2 PNEUMOMEDIASTINUM ORIGINATING IN THE PERINATAL PERIOD 21,255.00
14,878.50
6,376.50
P25.8 OTHER CONDITIONS RELATED TO INTERSTITIAL EMPHYSEMA ORIGINATING IN THE PERINATAL PERIOD 21,255.00
14,878.50
6,376.50
P26.0 TRACHEOBRONCHIAL HAEMORRHAGE ORIGINATING IN THE PERINATAL PERIOD 21,255.00
14,878.50
6,376.50
P26.1 MASSIVE PULMONARY HAEMORRHAGE ORIGINATING IN THE PERINATAL PERIOD 21,255.00
14,878.50
6,376.50
P26.8 OTHER PULMONARY HAEMORRHAGES ORIGINATING IN THE PERINATAL PERIOD 21,255.00
14,878.50
6,376.50
P26.9 UNSPECIFIED PULMONARY HAEMORRHAGE ORIGINATING IN THE PERINATAL PERIOD 21,255.00
14,878.50
6,376.50
P27.0 WILSON-MIKITY SYNDROME; PULMONARY DYSMATURITY 21,255.00
14,878.50
6,376.50
P27.1 BRONCHOPULMONARY DYSPLASIA ORIGINATING IN THE PERINATAL PERIOD 21,255.00
14,878.50
6,376.50
P27.8 OTHER CHRONIC RESPIRATORY DISEASES ORIGINATING IN THE PERINATAL PERIOD; CONGENITAL PULMONARY FIBROSIS; VENTILATOR LUNG IN NEWBORN 21,255.00
14,878.50
6,376.50
P27.9 UNSPECIFIED CHRONIC RESPIRATORY DISEASE ORIGINATING IN THE PERINATAL PERIOD 21,255.00
14,878.50
6,376.50
P28.0 PRIMARY ATELECTASIS OF NEWBORN; PRIMARY FAILURE TO EXPAND TERMINAL RESPIRATORY UNITS; PULMONARY HYPOPLASIA ASSOCIATED WITH SHORT GESTATION; PULMONARY IMMATURITY NOS 21,255.00
14,878.50
6,376.50
P28.1 OTHER AND UNSPECIFIED ATELECTASIS OF NEWBORN; ATELECTASIS, NOS; ATELECTASIS, PARTIAL; ATELECTASIS, SECONDARY; RESORPTION ATELECTASIS WITHOUT RESPIRATORY DISTRESS SYNDROME 21,255.00
14,878.50
6,376.50
P28.2 CYANOTIC ATTACKS OF NEWBORN 21,255.00
14,878.50
6,376.50
P28.3 PRIMARY SLEEP APNOEA OF NEWBORN; LEEP APNOEA OF NEWBORN NOS 21,255.00
14,878.50
6,376.50
P28.4 OTHER APNOEA OF NEWBORN 21,255.00
14,878.50
6,376.50
P28.5 RESPIRATORY FAILURE OF NEWBORN 21,255.00
14,878.50
6,376.50
Page 82 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate P28.8 OTHER SPECIFIED RESPIRATORY CONDITIONS OF NEWBORN; CONGENITAL LARYNGEAL STRIDOR NOS; SNUFFLES IN NEWBORN 21,255.00
14,878.50
6,376.50
P29.0 NEONATAL CARDIAC FAILURE 44,265.00
30,985.50
13,279.50
P29.1 NEONATAL CARDIAC DYSRHYTHMIA 44,265.00
30,985.50
13,279.50
P29.2 NEONATAL HYPERTENSION 44,265.00
30,985.50
13,279.50
P29.3 PERSISTENT FETAL CIRCULATION; DELAYED CLOSURE OF DUCTUS ARTERIOSUS; PERSISTENT PULMONARY HYPERTENSION OF NEWBORN 21,255.00
14,878.50
6,376.50
P29.4 TRANSIENT MYOCARDIAL ISCHAEMIA OF NEWBORN 44,265.00
30,985.50
13,279.50
P29.8 OTHER CARDIOVASCULAR DISORDERS ORIGINATING IN THE PERINATAL PERIOD 44,265.00
30,985.50
13,279.50
P29.9 CARDIOVASCULAR DISORDER ORIGINATING IN THE PERINATAL PERIOD, UNSPECIFIED 21,255.00
14,878.50
6,376.50
P35.0 CONGENITAL RUBELLA SYNDROME; CONGENITAL RUBELLA PNEUMONITIS 24,765.00
17,335.50
7,429.50
P35.1 CONGENITAL CYTOMEGALOVIRUS INFECTION 24,765.00
17,335.50
7,429.50
P35.2 CONGENITAL HERPESVIRAL [HERPES SIMPLEX] INFECTION 24,765.00
17,335.50
7,429.50
P35.3 CONGENITAL VIRAL HEPATITIS 24,765.00
17,335.50
7,429.50
P35.8 OTHER CONGENITAL VIRAL DISEASES; CONGENITAL VARICELLA [CHICKENPOX] 24,765.00
17,335.50
7,429.50
P35.9 CONGENITAL VIRAL DISEASE, UNSPECIFIED 24,765.00
17,335.50
7,429.50
P37.0 CONGENITAL TUBERCULOSIS 24,765.00
17,335.50
7,429.50
P37.1 CONGENITAL TOXOPLASMOSIS; HYDROCEPHALUS DUE TO CONGENITAL TOXOPLASMOSIS 24,765.00
17,335.50
7,429.50
P37.3 CONGENITAL FALCIPARUM MALARIA 24,765.00
17,335.50
7,429.50
P37.8 OTHER SPECIFIED CONGENITAL INFECTIOUS AND PARASITIC DISEASES 24,765.00
17,335.50
7,429.50
P37.9 CONGENITAL INFECTIOUS AND PARASITIC DISEASE, UNSPECIFIED 24,765.00
17,335.50
7,429.50
P38 OMPHALITIS OF NEWBORN WITH OR WITHOUT MILD HAEMORRHAGE 24,765.00
17,335.50
7,429.50
P39.0 NEONATAL INFECTIVE MASTITIS 24,765.00
17,335.50
7,429.50
P39.1 NEONATAL CONJUNCTIVITIS AND DACRYOCYSTITIS; NEONATAL CHLAYDIAL CONJUNCTIVITIS; OPHTHALMIA NEONATORUM NOS 24,765.00
17,335.50
7,429.50
P39.2 INTRA-AMNIOTIC INFECTION OF FETUS, NOT ELSEWHERE CLASSIFIED 24,765.00
17,335.50
7,429.50
P39.3 NEONATAL URINARY TRACT INFECTION 24,765.00
17,335.50
7,429.50
P39.4 NEONATAL SKIN INFECTION; NEONATAL PYODERMA 24,765.00
17,335.50
7,429.50
P39.8 OTHER SPECIFIED INFECTIONS SPECIFIC TO THE PERINATAL PERIOD 24,765.00
17,335.50
7,429.50
P39.9 INFECTION SPECIFIC TO THE PERINATAL PERIOD, UNSPECIFIED 24,765.00
17,335.50
7,429.50
P50.0 FETAL BLOOD LOSS FROM VASA PRAEVIA 15,210.00
10,647.00
4,563.00
P50.1 FETAL BLOOD LOSS FROM RUPTURED CORD 15,210.00
10,647.00
4,563.00
P50.2 FETAL BLOOD LOSS FROM PLACENTA 15,210.00
10,647.00
4,563.00
P50.9 FETAL BLOOD LOSS, UNSPECIFIED; FETAL HAEMORRHAGE NOS 15,210.00
10,647.00
4,563.00
P51.9 UMBILICAL HAEMORRHAGE OF NEWBORN, UNSPECIFIED 15,210.00
10,647.00
4,563.00
P52.0 INTRAVENTRICULAR (NONTRAUMATIC) HAEMORRHAGE, GRADE 1, OF FETUS AND NEWBORN; SUBEPENDYMAL HAEMORRHAGE (WITHOUT INTRAVENTRICULAR EXTENSION) 49,920.00
34,944.00
14,976.00
P52.1 INTRAVENTRICULAR (NONTRAUMATIC) HAEMORRHAGE, GRADE 2, OF FETUS AND NEWBORN; SUBEPENDYMAL HAEMORRHAGE WITH INTRAVENTRICULAR EXTENSION 49,920.00
34,944.00
14,976.00
P52.3 UNSPECIFIED INTRAVENTRICULAR (NONTRAUMATIC) HAEMORRHAGE OF FETUS AND NEWBORN 49,920.00
34,944.00
14,976.00
P52.4 INTRACEREBRAL (NONTRAUMATIC) HAEMORRHAGE OF FETUS AND NEWBORN 49,920.00
34,944.00
14,976.00
P52.5 SUBARACHNOID (NONTRAUMATIC) HAEMORRHAGE OF FETUS AND NEWBORN 49,920.00
34,944.00
14,976.00
P52.6 CEREBELLAR (NONTRAUMATIC) AND POSTERIOR FOSSA HAEMORRHAGE OF FETUS AND NEWBORN 49,920.00
34,944.00
14,976.00
P52.8 OTHER INTRACRANIAL (NONTRAUMATIC) HAEMORRHAGES OF FETUS AND NEWBORN 49,920.00
34,944.00
14,976.00
P52.9 INTRACRANIAL (NONTRAUMATIC) HAEMORRHAGE OF FETUS AND NEWBORN, UNSPECIFIED 49,920.00
34,944.00
14,976.00
P53 HAEMORRHAGIC DISEASE OF FETUS AND NEWBORN; VITAMIN K DEFICIENCY OF NEWBORN 15,210.00
10,647.00
4,563.00
P54.0 NEONATAL HAEMATEMESIS 15,210.00
10,647.00
4,563.00
P54.2 NEONATAL RECTAL HAEMORRHAGE 15,210.00
10,647.00
4,563.00
P54.3 OTHER NEONATAL GASTROINTESTINAL HAEMORRHAGE 15,210.00
10,647.00
4,563.00
P54.4 NEONATAL ADRENAL HAEMORRHAGE 15,210.00
10,647.00
4,563.00
P54.5 NEONATAL CUTANEOUS HAEMORRHAGE; BRUISING IN FETUS OR NEWBORN; ECCHYMOSES IN FETUS OR NEWBORN; PETECHIAE IN FETUS OR NEWBORN; SUPERFICIAL HAEMATOMATA IN FETUS OR NEWBORN 15,210.00
10,647.00
4,563.00
P54.6 NEONATAL VAGINAL HAEMORRHAGE; PSEUDOMENSES 15,210.00
10,647.00
4,563.00
P54.8 OTHER SPECIFIED NEONATAL HAEMORRHAGES 15,210.00
10,647.00
4,563.00
P54.9 NEONATAL HAEMORRHAGE, UNSPECIFIED 15,210.00
10,647.00
4,563.00
P55.0 RH ISOIMMUNIZATION OF FETUS AND NEWBORN 15,210.00
10,647.00
4,563.00
P55.1 ABO ISOIMMUNIZATION OF FETUS AND NEWBORN 15,210.00
10,647.00
4,563.00
P55.8 OTHER HAEMOLYTIC DISEASES OF FETUS AND NEWBORN 15,210.00
10,647.00
4,563.00
P55.9 HAEMOLYTIC DISEASE OF FETUS AND NEWBORN, UNSPECIFIED 15,210.00
10,647.00
4,563.00
P56.0 HYDROPS FETALIS DUE TO ISOIMMUNIZATION 14,430.00
10,101.00
4,329.00
Page 83 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate P56.9 HYDROPS FETALIS DUE TO OTHER AND UNSPECIFIED HAEMOLYTIC DISEASE 14,430.00
10,101.00
4,329.00
P57.0 KERNICTERUS DUE TO ISOIMMUNIZATION 14,430.00
10,101.00
4,329.00
P57.8 OTHER SPECIFIED KERNICTERUS 14,430.00
10,101.00
4,329.00
P57.9 KERNICTERUS, UNSPECIFIED 14,430.00
10,101.00
4,329.00
P58.1 NEONATAL JAUNDICE DUE TO BLEEDING 14,430.00
10,101.00
4,329.00
P58.2 NEONATAL JAUNDICE DUE TO INFECTION 14,430.00
10,101.00
4,329.00
P58.3 NEONATAL JAUNDICE DUE TO POLYCYTHAEMIA 14,430.00
10,101.00
4,329.00
P58.4 NEONATAL JAUNDICE DUE TO DRUGS OR TOXINS TRANSMITTED FROM MOTHER OR GIVEN TO NEWBORN 14,430.00
10,101.00
4,329.00
P58.8 NEONATAL JAUNDICE DUE TO OTHER SPECIFIED EXCESSIVE HAEMOLYSIS 14,430.00
10,101.00
4,329.00
P58.9 NEONATAL JAUNDICE DUE TO EXCESSIVE HAEMOLYSIS, UNSPECIFIED 14,430.00
10,101.00
4,329.00
P59.0 NEONATAL JAUNDICE ASSOCIATED WITH PRETERM DELIVERY; HYPERBILIRUBINAEMIA OF PREMATURITY; JAUNDICE DUE TO DELAYED CONJUCATION ASSOCIATED WITH PRETERM DELIVERY 14,430.00
10,101.00
4,329.00
P59.1 INSPISSATED BILE SYNDROME 14,430.00
10,101.00
4,329.00
P59.2 NEONATAL JAUNDICE FROM OTHER AND UNSPECIFIED HEPATOCELLULAR DAMAGE 14,430.00
10,101.00
4,329.00
P59.3 NEONATAL JAUNDICE FROM BREAST MILK INHIBITOR 14,430.00
10,101.00
4,329.00
P59.8 NEONATAL JAUNDICE FROM OTHER SPECIFIED CAUSES 14,430.00
10,101.00
4,329.00
P59.9 NEONATAL JAUNDICE, UNSPECIFIED; INTENSE PHYSIOLOGICAL JAUNDICE, NOS; PROLONGED PHYSIOLOGICAL JAUNDICE, NOS 14,430.00
10,101.00
4,329.00
P60 DISSEMINATED INTRAVASCULAR COAGULATION OF FETUS AND NEWBORN; DEFIBRINATION SYNDROME OF FETUS OR NEWBORN 62,400.00
43,680.00
18,720.00
P61.0 TRANSIENT NEONATAL THROMBOCYTOPENIA; NEONATAL THROMBOCYTOPENIA DUE TO EXCHANGE TRANSFUSION; NEONATAL THROMBOCYTOPENIA DUE TO IDIOPHATIC MATERNAL THROMBOCYTOPENIA; NEONATAL THROMBOCYTOPENIA DUE TO ISOIMMUNIZATION 15,210.00
10,647.00
4,563.00
P61.1 POLYCYTHAEMIA NEONATORUM 15,210.00
10,647.00
4,563.00
P61.2 ANAEMIA OF PREMATURITY 29,640.00
20,748.00
8,892.00
P61.3 CONGENITAL ANAEMIA FROM FETAL BLOOD LOSS 29,640.00
20,748.00
8,892.00
P61.4 OTHER CONGENITAL ANAEMIAS, NOT ELSEWHERE CLASSIFIED; CONGENITAL ANAEMIA NOS 29,640.00
20,748.00
8,892.00
P61.5 TRANSIENT NEONATAL NEUTROPENIA 15,210.00
10,647.00
4,563.00
P61.6 OTHER TRANSIENT NEONATAL DISORDERS OF COAGULATION 15,210.00
10,647.00
4,563.00
P61.8 OTHER SPECIFIED PERINATAL HAEMATOLOGICAL DISORDERS 15,210.00
10,647.00
4,563.00
P61.9 PERINATAL HAEMATOLOGICAL DISORDER, UNSPECIFIED 15,210.00
10,647.00
4,563.00
P70.0 SYNDROME OF INFANT OF MOTHER WITH GESTATIONAL DIABETES 18,135.00
12,694.50
5,440.50
P70.1 SYNDROME OF INFANT OF A DIABETIC MOTHER; MATERNAL DIABETES MELLITUS (PRE-EXISTING) AFFECTING FETUS OR NEWBORN WITH HYPOGLYCAEMIA 18,135.00
12,694.50
5,440.50
P70.2 NEONATAL DIABETES MELLITUS 18,135.00
12,694.50
5,440.50
P70.3 IATROGENIC NEONATAL HYPOGLYCAEMIA 18,135.00
12,694.50
5,440.50
P70.4 OTHER NEONATAL HYPOGLYCAEMIA; TRANSITORY NEONATAL HYPOGLYCAEMIA 18,135.00
12,694.50
5,440.50
P70.9 TRANSITORY DISORDER OF CARBOHYDRATE METABOLISM OF FETUS AND NEWBORN, UNSPECIFIED 18,135.00
12,694.50
5,440.50
P71.0 COW'S MILK HYPOCALCAEMIA IN NEWBORN 18,135.00
12,694.50
5,440.50
P71.1 OTHER NEONATAL HYPOCALCAEMIA 18,135.00
12,694.50
5,440.50
P71.3 NEONATAL TETANY WITHOUT CALCIUM OR MAGNESIUM DEFICIENCY; NEONATAL TETANY NOS 18,135.00
12,694.50
5,440.50
P71.4 TRANSITORY NEONATAL HYPOPARATHYROIDISM 18,135.00
12,694.50
5,440.50
P71.9 TRANSITORY NEONATAL DISORDER OF CALCIUM AND MAGNESIUM METABOLISM, UNSPECIFIED 18,135.00
12,694.50
5,440.50
P72.0 NEONATAL GOITRE, NOT ELSEWHERE CLASSIFIED; TRANSITORY CONGENITAL GOITRE WITH NORMAL FUNCTION 18,135.00
12,694.50
5,440.50
P72.1 TRANSITORY NEONATAL HYPERTHYROIDISM; NEONATAL THYROTOXICOSIS 18,135.00
12,694.50
5,440.50
P72.2 OTHER TRANSITORY NEONATAL DISORDERS OF THYROID FUNCTION, NOT ELSEWHERE CLASSIFIED; TRANSITORY NEONATAL HYPOTHYROIDISM 18,135.00
12,694.50
5,440.50
P72.8 OTHER SPECIFIED TRANSITORY NEONATAL ENDOCRINE DISORDERS 18,135.00
12,694.50
5,440.50
P72.9 TRANSITORY NEONATAL ENDOCRINE DISORDER, UNSPECIFIED 18,135.00
12,694.50
5,440.50
P74.0 LATE METABOLIC ACIDOSIS OF NEWBORN 18,135.00
12,694.50
5,440.50
P74.1 DEHYDRATION OF NEWBORN 18,135.00
12,694.50
5,440.50
P74.2 DISTURBANCES OF SODIUM BALANCE OF NEWBORN 18,135.00
12,694.50
5,440.50
P74.4 OTHER TRANSITORY ELECTROLYTE DISTURBANCES OF NEWBORN 18,135.00
12,694.50
5,440.50
P74.8 OTHER TRANSITORY METABOLIC DISTURBANCES OF NEWBORN 18,135.00
12,694.50
5,440.50
P74.9 TRANSITORY METABOLIC DISTURBANCE OF NEWBORN, UNSPECIFIED 18,135.00
12,694.50
5,440.50
P76.0 MECONIUM PLUG SYNDROME 22,815.00
15,970.50
6,844.50
P76.1 TRANSITORY ILEUS OF NEWBORN 22,815.00
15,970.50
6,844.50
P76.8 OTHER SPECIFIED INTESTINAL OBSTRUCTION OF NEWBORN 22,815.00
15,970.50
6,844.50
P76.9 INTESTINAL OBSTRUCTION OF NEWBORN, UNSPECIFIED 22,815.00
15,970.50
6,844.50
Page 84 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate P77 NECROTIZING ENTEROCOLITIS OF FETUS AND NEWBORN 22,815.00
15,970.50
6,844.50
P78.0 PERINATAL INTESTINAL PERFORATION; MECONIUM PERITONITIS 22,815.00
15,970.50
6,844.50
P78.2 NEONATAL HAEMATEMESIS AND MELAENA DUE TO SWALLOWED MATERNAL BLOOD 22,815.00
15,970.50
6,844.50
P78.3 NONINFECTIVE NEONATAL DIARRHOEA; NEONATAL DIARRHOEA NOS 22,815.00
15,970.50
6,844.50
P78.8 OTHER SPECIFIED PERINATAL DIGESTIVE SYSTEM DISORDERS; CONGENITAL CIRRHOSIS OF LIVER; PEPTIC ULCER OF NEWBORN 22,815.00
15,970.50
6,844.50
P78.9 PERINATAL DIGESTIVE SYSTEM DISORDER, UNSPECIFIED 22,815.00
15,970.50
6,844.50
P80.9 HYPOTHERMIA OF NEWBORN, UNSPECIFIED 18,135.00
12,694.50
5,440.50
P81.0 ENVIRONMENTAL HYPERTHERMIA OF NEWBORN 18,135.00
12,694.50
5,440.50
P81.8 OTHER SPECIFIED DISTURBANCES OF TEMPERATURE REGULATION OF NEWBORN 18,135.00
12,694.50
5,440.50
P81.9 DISTURBANCE OF TEMPERATURE REGULATION OF NEWBORN, UNSPECIFIED; FEVER OF NEWBORN NOS 18,135.00
12,694.50
5,440.50
P83.1 NEONATAL ERYTHEMA TOXICUM 18,135.00
12,694.50
5,440.50
P83.2 HYDROPS FETALIS NOT DUE TO HAEMOLYTIC DISEASE; HYDROPS FETALIS NOS 18,135.00
12,694.50
5,440.50
P83.4 BREAST ENGORGEMENT OF NEWBORN; NONINFECTIVE MASTITIS OF NEWBORN 18,135.00
12,694.50
5,440.50
P83.8 OTHER SPECIFIED CONDITIONS OF INTEGUMENT SPECIFIC TO FETUS AND NEWBORN; BRONZE BABY SYNDROME; NEONATAL SCLERODERMA; URTICARIA NEONATORUM 18,135.00
12,694.50
5,440.50
P90 CONVULSIONS OF NEWBORN 23,400.00
16,380.00
7,020.00
P91.0 NEONATAL CEREBRAL ISCHAEMIA 50,310.00
35,217.00
15,093.00
P91.1 ACQUIRED PERIVENTRICULAR CYSTS OF NEWBORN 23,400.00
16,380.00
7,020.00
P91.2 NEONATAL CEREBRAL LEUKOMALACIA 23,400.00
16,380.00
7,020.00
P91.3 NEONATAL CEREBRAL IRRITABILITY 23,400.00
16,380.00
7,020.00
P91.4 NEONATAL CEREBRAL DEPRESSION 23,400.00
16,380.00
7,020.00
P91.6 HYPOXIC ISCHEMIC ENCEPHALOPATHY OF NEWBORN 23,400.00
16,380.00
7,020.00
P91.8 OTHER SPECIFIED DISTURBANCES OF CEREBRAL STATUS OF NEWBORN 23,400.00
16,380.00
7,020.00
P91.9 DISTURBANCE OF CEREBRAL STATUS OF NEWBORN, UNSPECIFIED 23,400.00
16,380.00
7,020.00
P92.1 REGURGITATION AND RUMINATION IN NEWBORN 16,965.00
11,875.50
5,089.50
P92.2 SLOW FEEDING OF NEWBORN 16,965.00
11,875.50
5,089.50
P92.4 OVERFEEDING OF NEWBORN 16,965.00
11,875.50
5,089.50
P92.8 OTHER FEEDING PROBLEMS OF NEWBORN 16,965.00
11,875.50
5,089.50
P92.9 FEEDING PROBLEM OF NEWBORN, UNSPECIFIED 16,965.00
11,875.50
5,089.50
P94.0 TRANSIENT NEONATAL MYASTHENIA GRAVIS 22,620.00
15,834.00
6,786.00
P94.1 CONGENITAL HYPERTONIA 23,400.00
16,380.00
7,020.00
P94.2 CONGENITAL HYPOTONIA; NONSPECIFIC FLOPPY BABY SYNDROME 23,400.00
16,380.00
7,020.00
P94.9 DISORDER OF MUSCLE TONE OF NEWBORN, UNSPECIFIED 23,400.00
16,380.00
7,020.00
P96.0 CONGENITAL RENAL FAILURE; URAEMIA OF NEWBORN 17,745.00
12,421.50
5,323.50
P96.5 COMPLICATIONS OF INTRAUTERINE PROCEDURES, NOT ELSEWHERE CLASSIFIED 23,400.00
16,380.00
7,020.00
P96.8 OTHER SPECIFIED CONDITIONS ORIGINATING IN THE PERINATAL PERIOD 23,400.00
16,380.00
7,020.00
P96.9 CONDITION ORIGINATING IN THE PERINATAL PERIOD, UNSPECIFIED; CONGENITAL DEBILITY NOS 23,400.00
16,380.00
7,020.00
Q00.0 ANENCEPHALY; ACEPHALY; ACRANIA; AMYELENCEPHALY; HEMICEPHALY; HEMICEPHALY 25,350.00
17,745.00
7,605.00
Q01.0 FRONTAL ENCEPHALOCELE 25,350.00
17,745.00
7,605.00
Q01.1 NASOFRONTAL ENCEPHALOCELE 25,350.00
17,745.00
7,605.00
Q01.2 OCCIPITAL ENCEPHALOCELE 25,350.00
17,745.00
7,605.00
Q01.8 ENCEPHALOCELE OF OTHER SITES 25,350.00
17,745.00
7,605.00
Q02 MICROCEPHALY; HYDROMICROCEPHALY; MICRENCEPHALON 25,350.00
17,745.00
7,605.00
Q03.0 MALFORMATIONS OF AQUEDUCT OF SYLVIUS; ANOMALY OF AQUEDUCT OF SYLVIUS; OBSTRUCTION, CONGENITAL OF AQUEDUCT OF SYLVIUS; STENOSIS OF AQUEDUCT OF SYLVIUS 25,350.00
17,745.00
7,605.00
Q03.1 ATRESIA OF FORAMINA OF MAGENDIE AND LUSCHKA; DANDY- WALKER SYNDROME 25,350.00
17,745.00
7,605.00
Q03.8 OTHER CONGENITAL HYDROCEPHALUS 33,735.00
23,614.50
10,120.50
Q03.9 CONGENITAL HYDROCEPHALUS, UNSPECIFIED 33,735.00
23,614.50
10,120.50
Q04.0 CONGENITAL MALFORMATIONS OF CORPUS CALLOSUM; AGENESIS OF CORPUS CALLOSUM 25,350.00
17,745.00
7,605.00
Q04.2 HOLOPROSENCEPHALY 25,350.00
17,745.00
7,605.00
Q04.3 OTHER REDUCTION DEFORMITIES OF BRAIN; ABSENCE OF PART OF BRAIN; AGENESIS OF PART OF BRAIN; APLASIA OF PART OF BRAIN; HYPOPLASIA OF PART OF BRAIN ; AGYRIA; HYDRANENCEPHALY; LISSENCEPHALY; MICROGYRIA; PACHYGYRIA 25,350.00
17,745.00
7,605.00
Q04.4 SEPTO-OPTIC DYSPLASIA 25,350.00
17,745.00
7,605.00
Q04.6 CONGENITAL CEREBRAL CYSTS; PORENCEPHALY; SCHIZENCEPHALY 25,350.00
17,745.00
7,605.00
Q04.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF BRAIN; MACROGYRIA 25,350.00
17,745.00
7,605.00
Q04.9 CONGENITAL MALFORMATION OF BRAIN, UNSPECIFIED; CONGENITAL ANOMALY NOS OF BRAIN; CONGENITAL DEFORMITY NOS OF BRAIN; CONGENITAL DISEASE OF LESION NOS OF BRAIN; CONGENITAL MULTIPLE ANOMALIS NOS OF BRAIN 25,350.00
17,745.00
7,605.00
Page 85 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate Q05.1 THORACIC SPINA BIFIDA WITH HYDROCEPHALUS; DORSAL SPINA BIFIDA WITH HYDROCEPHALUS; THORACOLUMBAR SPINA BIFIDA WITH HYDROCEPHALUS 25,350.00
17,745.00
7,605.00
Q05.2 LUMBAR SPINA BIFIDA WITH HYDROCEPHALUS; LUMBOSACRAL SPINA BIFIDA WITH HYDROCEPHALUS 25,350.00
17,745.00
7,605.00
Q05.4 UNSPECIFIED SPINA BIFIDA WITH HYDROCEPHALUS 25,350.00
17,745.00
7,605.00
Q05.6 THORACIC SPINA BIFIDA WITHOUT HYDROCEPHALUS; DORSAL NOS SPINA BIFIDA; THORACOLUMBAR NOS SPINA BIFIDA 25,350.00
17,745.00
7,605.00
Q05.7 LUMBAR SPINA BIFIDA WITHOUT HYDROCEPHALUS; LUMBOSACRAL SPINA BIFIDA NOS 25,350.00
17,745.00
7,605.00
Q05.8 SACRAL SPINA BIFIDA WITHOUT HYDROCEPHALUS 25,350.00
17,745.00
7,605.00
Q05.9 SPINA BIFIDA, UNSPECIFIED 25,350.00
17,745.00
7,605.00
Q06.0 AMYELIA 25,350.00
17,745.00
7,605.00
Q06.2 DIASTEMATOMYELIA 25,350.00
17,745.00
7,605.00
Q06.4 HYDROMYELIA; HYDRORACHIS 25,350.00
17,745.00
7,605.00
Q06.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF SPINAL CORD 25,350.00
17,745.00
7,605.00
Q06.9 CONGENITAL MALFORMATION OF SPINAL CORD, UNSPECIFIED; CONGENITAL ANOMALY NOS OF SPINAL CORD OR MENINGES; CONGENITAL DEFORMITY NOS OF SPINAL CORD OR MENINGES; CONGENITAL DISEASE OR LESION NOS OF SPINAL CORD OR MENINGES 25,350.00
17,745.00
7,605.00
Q07.0 ARNOLD-CHIARI SYNDROME 25,350.00
17,745.00
7,605.00
Q07.9 CONGENITAL MALFORMATION OF NERVOUS SYSTEM, UNSPECIFIED; CONGENITAL ANOMALY NOS OF NERVOUS SYSTEM; CONGENITAL DEFORMITY NOS OF NERVOUS SYSTEM; CONGENITAL DISEASE OR LESION NOS OF NERVOUS SYSTEM 25,350.00
17,745.00
7,605.00
Q12.2 COLOBOMA OF LENS 8,385.00
5,869.50
2,515.50
Q12.4 SPHEROPHAKIA 8,385.00
5,869.50
2,515.50
Q13.4 OTHER CONGENITAL CORNEAL MALFORMATIONS; CONGENITAL MALFORMATION OF CORNEA NOS; MICROCORNEA; PETER'S ANOMALY 8,385.00
5,869.50
2,515.50
Q14.0 CONGENITAL MALFORMATION OF VITREOUS HUMOUR; CONGENITAL VITREOUS OPACITY 8,385.00
5,869.50
2,515.50
Q14.1 CONGENITAL MALFORMATION OF RETINA; CONGENITAL RETINAL ANEURYSM 8,385.00
5,869.50
2,515.50
Q14.9 CONGENITAL MALFORMATION OF POSTERIOR SEGMENT OF EYE, UNSPECIFIED 8,385.00
5,869.50
2,515.50
Q15.0 CONGENITAL GLAUCOMA; BUPHTHALMOS; GLAUCOMA OF NEWBORN; HYDROPHTHALMOS; KERATOGLOBUS, CONGENITAL, WITH GLAUCOMA; MACROCORNEA WITH GLAUCOMA; MACROPHTHALMOS IN CONGENITAL GLAUCOMA; MEGALOCORNEA WITH GLAUCOMA 8,385.00
5,869.50
2,515.50
Q15.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF EYE 8,385.00
5,869.50
2,515.50
Q15.9 CONGENITAL MALFORMATION OF EYE, UNSPECIFIED; CONGENITAL ANOMALY NOS OF EYE; CONGENITAL DEFORMITY NOS OF EYE 8,385.00
5,869.50
2,515.50
Q20.0 COMMON ARTERIAL TRUNK; PERSISTENT TRUNCUS ARTERIOSUS 22,620.00
15,834.00
6,786.00
Q20.1 DOUBLE OUTLET RIGHT VENTRICLE; TAUSSIG-BING SYNDROME 22,620.00
15,834.00
6,786.00
Q20.2 DOUBLE OUTLET LEFT VENTRICLE 22,620.00
15,834.00
6,786.00
Q20.3 DISCORDANT VENTRICULOARTERIAL CONNECTION; DEXTROTRANSPOSITION OF AORTA; TRANSPOSITION OF GREAT VESSELS (COMPLETE) 22,620.00
15,834.00
6,786.00
Q20.4 DOUBLE INLET VENTRICLE; COMMON VENTRICLE; COR TRILOCULARE BIATRIATUM; SINGLE VENTRICLE 22,620.00
15,834.00
6,786.00
Q20.5 DISCORDANT ATRIOVENTRICULAR CONNECTION; CORRECTED TRANSPOSITION; LAEVOTRANSPOSITION; VENTRICULAR INVERSION 22,620.00
15,834.00
6,786.00
Q20.9 CONGENITAL MALFORMATION OF CARDIAC CHAMBERS AND CONNECTIONS, UNSPECIFIED 22,620.00
15,834.00
6,786.00
Q21.0 VENTRICULAR SEPTAL DEFECT 22,620.00
15,834.00
6,786.00
Q21.1 ATRIAL SEPTAL DEFECT; CORONARY SINUS DEFECT; PATENT OR PERSISTENT FORAMEN OVALE; PATENT OR PERSISTENT OSTIUM SECUNDUM DEFECT (TYPE II); SINUS VENOSUS DEFECT 22,620.00
15,834.00
6,786.00
Q21.2 ATRIOVENTRICULAR SEPTAL DEFECT; COMMON ATRIOVENTRICULAR CANAL; ENDOCARDIAL CUSHION DEFECT; OSTIUM PRIMUM ATRIAL SEPTAL DEFECT (TYPE I) 22,620.00
15,834.00
6,786.00
Q21.3 TETRALOGY OF FALLOT; VENTRICULAR SEPTAL DEFECT WITH PULMONARY STENOSIS OR ATRESIA, DEXTROPOSITION OF AORTA AND HYPERTROPHY OF RIGHT VENTRICLE. 22,620.00
15,834.00
6,786.00
Q21.4 AORTOPULMONARY SEPTAL DEFECT; AORTIC SEPTAL DEFECT; AORTOPULMONARY WINDOW 22,620.00
15,834.00
6,786.00
Q21.8 OTHER CONGENITAL MALFORMATIONS OF CARDIAC SEPTA; EISENMENGER'S DEFECT; PENTALOGY OF FALLOT 22,620.00
15,834.00
6,786.00
Q21.9 CONGENITAL MALFORMATION OF CARDIAC SEPTUM, UNSPECIFIED; SEPTAL (HEART) DEFECT NOS 22,620.00
15,834.00
6,786.00
Q22.0 PULMONARY VALVE ATRESIA 22,620.00
15,834.00
6,786.00
Q22.1 CONGENITAL PULMONARY VALVE STENOSIS 22,620.00
15,834.00
6,786.00
Q22.2 CONGENITAL PULMONARY VALVE INSUFFICIENCY; CONGENITAL PULMONARY VALVE REGURGITATION 22,620.00
15,834.00
6,786.00
Q22.4 CONGENITAL TRICUSPID STENOSIS; TRICUSPID ATRESIA 22,620.00
15,834.00
6,786.00
Q22.5 EBSTEIN'S ANOMALY 22,620.00
15,834.00
6,786.00
Q22.6 HYPOPLASTIC RIGHT HEART SYNDROME 22,620.00
15,834.00
6,786.00
Page 86 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate Q22.8 OTHER CONGENITAL MALFORMATIONS OF TRICUSPID VALVE 22,620.00
15,834.00
6,786.00
Q23.0 CONGENITAL STENOSIS OF AORTIC VALVE; CONGENITAL AORTIC ATRESIA; CONGENITAL AORTIC STENOSIS 22,620.00
15,834.00
6,786.00
Q23.1 CONGENITAL INSUFFICIENCY OF AORTIC VALVE; BICUSPID AORTIC VALVE; CONGENITAL AORTIC INSUFFICIENCY 22,620.00
15,834.00
6,786.00
Q23.2 CONGENITAL MITRAL STENOSIS; CONGENITAL MITRAL ATRESIA 22,620.00
15,834.00
6,786.00
Q23.3 CONGENITAL MITRAL INSUFFICIENCY 22,620.00
15,834.00
6,786.00
Q23.4 HYPOPLASTIC LEFT HEART SYNDROME; ATRESIA, OR MARKED HYPOPLASIA OF AORTIC ORIFICE OR VALVE, WITH HYPOPLASIA OF ASCENDING AORTA AND DEFECTIVE DEVELOPMENT OF LEFT VENTRICLE (WITH MITRAL VALVE STENOSIS OR ATRESIA). 22,620.00
15,834.00
6,786.00
Q23.8 OTHER CONGENITAL MALFORMATIONS OF AORTIC AND MITRAL VALVES 22,620.00
15,834.00
6,786.00
Q23.9 CONGENITAL MALFORMATION OF AORTIC AND MITRAL VALVES, UNSPECIFIED 22,620.00
15,834.00
6,786.00
Q24.0 DEXTROCARDIA 22,620.00
15,834.00
6,786.00
Q24.2 COR TRIATRIATUM 22,620.00
15,834.00
6,786.00
Q24.3 PULMONARY INFUNDIBULAR STENOSIS 22,620.00
15,834.00
6,786.00
Q24.4 CONGENITAL SUBAORTIC STENOSIS 22,620.00
15,834.00
6,786.00
Q24.5 MALFORMATION OF CORONARY VESSELS; CONGENITAL CORONARY (ARTERY) ANEURYSM 22,620.00
15,834.00
6,786.00
Q24.6 CONGENITAL HEART BLOCK 22,620.00
15,834.00
6,786.00
Q24.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF HEART; CONGENITAL DIVERTICULUM OF LEFT VENTRICLE; CONGENITAL MALFORMATION OF MYOCARDIUM; CONGENITAL MALFORMATION OF PERICARDIUM; MALPOSITION OF HEART; UHL'S DISEASE 22,620.00
15,834.00
6,786.00
Q24.9 CONGENITAL MALFORMATION OF HEART, UNSPECIFIED; CONGENITAL ANOMALY NOS OF HEART; CONGENITAL DISEASE NOS OF HEART 22,620.00
15,834.00
6,786.00
Q25.0 PATENT DUCTUS ARTERIOSUS; PATENT DUCTUS BOTALLO; PERSISTENT DUCTUS ARTERIOSUS 22,620.00
15,834.00
6,786.00
Q25.1 COARCTATION OF AORTA; PREDUCTAL COARCTATION OF AORTA; POSTDUCTAL COARCTATION OF AORTA 22,620.00
15,834.00
6,786.00
Q25.2 ATRESIA OF AORTA 22,620.00
15,834.00
6,786.00
Q25.3 STENOSIS OF AORTA; SUPRAVALVULAR AORTIC STENOSIS 22,620.00
15,834.00
6,786.00
Q25.4 OTHER CONGENITAL MALFORMATIONS OF AORTA; ABSENCE OF AORTA; APLASIA OF AORTA; CONGENITAL ANEURYSM OF AORTA; CONGENITAL DILATATION OF AORTA; ANEURYSM OF SINUS OF VALSALVA (RUPTURE); DOUBLE AORTIC ARCH [VASCULAR RING OR AORTA]; HYPOPLASIA OF AORTA; PERSISTEN 22,620.00
15,834.00
6,786.00
Q25.5 ATRESIA OF PULMONARY ARTERY 22,620.00
15,834.00
6,786.00
Q25.6 STENOSIS OF PULMONARY ARTERY 22,620.00
15,834.00
6,786.00
Q25.7 OTHER CONGENITAL MALFORMATIONS OF PULMONARY ARTERY; ABERRANT PULMONARY ARTERY; AGENESIS OF PULMONARY ARTERY; ANEURYSM, CONGENITAL OF PULMONARY ARTERY; ANOMALY OF PULMONARY ARTERY; HYPOPLASIA OF PULMONARY ARTERY; PULMONARY ARTERIOVENOUS ANEURYSM 22,620.00
15,834.00
6,786.00
Q25.8 OTHER CONGENITAL MALFORMATIONS OF GREAT ARTERIES 22,620.00
15,834.00
6,786.00
Q25.9 CONGENITAL MALFORMATION OF GREAT ARTERIES, UNSPECIFIED 22,620.00
15,834.00
6,786.00
Q26.0 CONGENITAL STENOSIS OF VENA CAVA; CONGENITAL STENOSIS OF INFERIOR VENA CAVA; CONGENITAL STENOSIS OFSUPERIOR VENA CAVA 22,620.00
15,834.00
6,786.00
Q26.2 TOTAL ANOMALOUS PULMONARY VENOUS CONNECTION 22,620.00
15,834.00
6,786.00
Q26.4 ANOMALOUS PULMONARY VENOUS CONNECTION, UNSPECIFIED 22,620.00
15,834.00
6,786.00
Q26.8 OTHER CONGENITAL MALFORMATIONS OF GREAT VEINS; ABSENCE OF INFERIOR VENA CAVA ; ABSENCE OF SUPERIOR VENA CAVA ; AZYGOS CONTINUATION OF INFERIOR VENA CAVA; PERSISTENT LEFT POSTERIOR CARDINAL VEIN; SCIMITAR SYNDROME 22,620.00
15,834.00
6,786.00
Q26.9
CONGENITAL MALFORMATION OF GREAT VEIN, UNSPECIFIED;
ANOMALY OF INFERIOR VENA CAVA NOS; ANOMALY OF
SUPERIOR VENA CAVA NOS
22,620.00
15,834.00
6,786.00
Q27.1 CONGENITAL RENAL ARTERY STENOSIS 23,400.00
16,380.00
7,020.00
Q27.3 PERIPHERAL ARTERIOVENOUS MALFORMATION; ARTERIOVENOUS ANEURYSM 23,400.00
16,380.00
7,020.00
Q27.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF PERIPHERAL VASCULAR SYSTEM; ABERRANT SUBCLAVIAN ARTERY; ABSENCE OF ARTERY OR VEIN NEC; ATRESIA OF ARTERY OR VEIN NEC; CONGENITAL ANEURYSM (PERIPHERAL); CONGENITAL STRICTURE, ARTERY; CONGENITAL VARIX 23,400.00
16,380.00
7,020.00
Q27.9 CONGENITAL MALFORMATION OF PERIPHERAL VASCULAR SYSTEM, UNSPECIFIED; ANOMALY OF ARTERY OR VEIN NOS 23,400.00
16,380.00
7,020.00
Q28.0 ARTERIOVENOUS MALFORMATION OF PRECEREBRAL VESSELS; CONGENITAL ARTERIOVENOUS PRECEREBRAL ANEURYSM (NONRUPTURED) 23,400.00
16,380.00
7,020.00
Page 87 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate Q28.1 OTHER MALFORMATIONS OF PRECEREBRAL VESSELS; CONGENITAL MALFORMATION OF PRECEREBRAL VESSELS NOS; CONGENITAL PRECEREBRAL ANEURYSM (NONRUPTURED) 23,400.00
16,380.00
7,020.00
Q28.2 ARTERIOVENOUS MALFORMATION OF CEREBRAL VESSELS; ARTERIOVENOUS MALFORMATION OF BRAIN NOS; CONGENITAL ARTERIOVENOUS CEREBRAL ANEURYSM (NONRUPTURED) 23,400.00
16,380.00
7,020.00
Q28.3 OTHER MALFORMATIONS OF CEREBRAL VESSELS; CONGENITAL CEREBRAL ANEURYSM, NONRUPTURED; CONGENITAL MALFORMATION OF CEREBRAL VESSELS NOS 23,400.00
16,380.00
7,020.00
Q30.0
CHOANAL ATRESIA; ABSENCE OF ANTERIOR NARES; ABSENCE OF
POSTERIOR NARES; CONGENITAL STENOSIS OF ANTERIOR NARES;
CONGENITAL STENOSIS OF POSTERIOR NARES
21,450.00
15,015.00
6,435.00
Q30.1 AGENESIS AND UNDERDEVELOPMENT OF NOSE; CONGENITAL ABSENCE OF NOSE 21,450.00
15,015.00
6,435.00
Q30.2 FISSURED, NOTCHED AND CLEFT NOSE 21,450.00
15,015.00
6,435.00
Q31.3 LARYNGOCELE 21,450.00
15,015.00
6,435.00
Q31.5 CONGENITAL LARYNGOMALACIA 21,450.00
15,015.00
6,435.00
Q31.8 OTHER CONGENITAL MALFORMATIONS OF LARYNX; ABSENCE OF CRICOID CARTILAGE, EPIGLOTTIS, GLOTTIS, LARYNX OR THYROID CARTILAGE; AGENESIS OF CRICOID CARTILAGE, EPIGLOTTIS, GLOTTIS, LARYNX OR THYROID CARTILAGE; ATRESIA OF CRICOID CARTILAGE, EPIGLOTTIS, GLOTTIS, 21,450.00
15,015.00
6,435.00
Q31.9 CONGENITAL MALFORMATION OF LARYNX, UNSPECIFIED 21,450.00
15,015.00
6,435.00
Q32.0 CONGENITAL TRACHEOMALACIA 42,315.00
29,620.50
12,694.50
Q32.4 OTHER CONGENITAL MALFORMATIONS OF BRONCHUS; ABSENCE OF BRONCHUS; AGENESIS OF BRONCHUS; ATRESIA OF BRONCHUS; CONGENITAL MALFORMATION NOS OF BRONCHUS; DIVERTICULUM OF BRONCHUS; CONGENITAL MALFORMATIONS OF LUNG] OF BRONCHUS 42,315.00
29,620.50
12,694.50
Q33.0 CONGENITAL CYSTIC LUNG; CONGENITAL HONEYCOMB LUNG; CONGENITAL CYSTIC LUNG DISEASE; CONGENITAL POLYCYSTIC LUNG DISEASE 42,315.00
29,620.50
12,694.50
Q33.2 SEQUESTRATION OF LUNG 42,315.00
29,620.50
12,694.50
Q33.3 AGENESIS OF LUNG; ABSENCE OF LUNG, LOBE 42,315.00
29,620.50
12,694.50
Q33.4 CONGENITAL BRONCHIECTASIS 42,315.00
29,620.50
12,694.50
Q33.6 HYPOPLASIA AND DYSPLASIA OF LUNG 42,315.00
29,620.50
12,694.50
Q34.1 CONGENITAL CYST OF MEDIASTINUM 42,315.00
29,620.50
12,694.50
Q34.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF RESPIRATORY SYSTEM; ATRESIA OF NASOPHARYNX 42,315.00
29,620.50
12,694.50
Q34.9 CONGENITAL MALFORMATION OF RESPIRATORY SYSTEM, UNSPECIFIED; CONGENITAL ABSENCE OF RESPIRATORY ORGAN ; CONGENITAL ANOMALY NOS OF RESPIRATORY ORGAN 42,315.00
29,620.50
12,694.50
Q35.0 CLEFT HARD PALATE, BILATERAL; BILATERAL FISSURE OF HARD PALATE; BILATERAL PALATOSCHISIS OF HARD PALATE 15,210.00
10,647.00
4,563.00
Q35.1 CLEFT HARD PALATE 15,210.00
10,647.00
4,563.00
Q35.3 CLEFT SOFT PALATE 15,210.00
10,647.00
4,563.00
Q35.5 CLEFT HARD PALATE WITH CLEFT SOFT PALATE 15,210.00
10,647.00
4,563.00
Q35.7 CLEFT UVULA 15,210.00
10,647.00
4,563.00
Q35.8 CLEFT PALATE, UNSPECIFIED, BILATERAL 15,210.00
10,647.00
4,563.00
Q35.9 CLEFT PALATE, UNSPECIFIED 15,210.00
10,647.00
4,563.00
Q36.0 CLEFT LIP, BILATERAL 15,210.00
10,647.00
4,563.00
Q36.1 CLEFT LIP, MEDIAN 15,210.00
10,647.00
4,563.00
Q36.9 CLEFT LIP, UNILATERAL; CLEFT LIP NOS 15,210.00
10,647.00
4,563.00
Q37.0 CLEFT HARD PALATE WITH BILATERAL CLEFT LIP 15,210.00
10,647.00
4,563.00
Q37.1 CLEFT HARD PALATE WITH UNILATERAL CLEFT LIP; CLEFT HARD PALATE WITH CLEFT LIP NOS 15,210.00
10,647.00
4,563.00
Q37.2 CLEFT SOFT PALATE WITH BILATERAL CLEFT LIP 15,210.00
10,647.00
4,563.00
Q37.3 CLEFT SOFT PALATE WITH UNILATERAL CLEFT LIP; CLEFT SOFT PALATE WITH CLEFT LIP NOS 15,210.00
10,647.00
4,563.00
Q37.4 CLEFT HARD AND SOFT PALATE WITH BILATERAL CLEFT LIP 15,210.00
10,647.00
4,563.00
Q37.5 CLEFT HARD AND SOFT PALATE WITH UNILATERAL CLEFT LIP; CLEFT HARD AND SOFT PALATE WITH CLEFT LIP NOS 15,210.00
10,647.00
4,563.00
Q37.8 UNSPECIFIED CLEFT PALATE WITH BILATERAL CLEFT LIP 15,210.00
10,647.00
4,563.00
Q37.9 UNSPECIFIED CLEFT PALATE WITH UNILATERAL CLEFT LIP; CLEFT PALATE WITH CLEFT LIP NOS 15,210.00
10,647.00
4,563.00
Q38.2 MACROGLOSSIA 7,800.00
5,460.00
2,340.00
Q38.5 CONGENITAL MALFORMATIONS OF PALATE, NOT ELSEWHERE CLASSIFIED; ABSENCE OF UVULA; CONGENITAL MALFORMATION OF PALATE NOS; HIGH ARCHED PALATE 7,800.00
5,460.00
2,340.00
Q38.6 OTHER CONGENITAL MALFORMATIONS OF MOUTH; CONGENITAL MALFORMATION OF MOUTH NOS 7,800.00
5,460.00
2,340.00
Q38.8 OTHER CONGENITAL MALFORMATIONS OF PHARYNX; CONGENITAL MALFORMATION OF PHARYNX NOS 7,800.00
5,460.00
2,340.00
Q39.0 ATRESIA OF OESOPHAGUS WITHOUT FISTULA; ATRESIA OF OESOPHAGUS NOS 22,035.00
15,424.50
6,610.50
Q39.1 ATRESIA OF OESOPHAGUS WITH TRACHEO-OESOPHAGEAL FISTULA; ATRESIA OF OESOPHAGUS WITH BRONCHO- OESOPHAGEAL FISTULA 22,035.00
15,424.50
6,610.50
Q39.2 CONGENITAL TRACHEO-OESOPHAGEAL FISTULA WITHOUT ATRESIA; CONGENITAL TRACHEO-OESOPHAGEAL FISTULA NOS 22,035.00
15,424.50
6,610.50
Page 88 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate Q39.6 DIVERTICULUM OF OESOPHAGUS; OESOPHAGEAL POUCH 22,035.00
15,424.50
6,610.50
Q39.9 CONGENITAL MALFORMATION OF OESOPHAGUS, UNSPECIFIED 22,035.00
15,424.50
6,610.50
Q40.0 CONGENITAL HYPERTROPHIC PYLORIC STENOSIS; CONGENITAL OR INFANTILE CONSTRICTION OF PYLORUS; CONGENITAL OR INFANTILE HYPERTROPHY OF PYLORUS; CONGENITAL OR INFANTILE SPASM OF PYLORUS; CONGENITAL OR INFANTILE STENOSIS OF PYLORUS; CONGENITAL OR INFANTILE STRIC 22,035.00
15,424.50
6,610.50
Q40.1 CONGENITAL HIATUS HERNIA; DISPLACEMENT OF CARDIA THROUGH OESOPHAGEAL HIATUS 22,035.00
15,424.50
6,610.50
Q40.2 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF STOMACH; CONGENITAL DISPLACEMENT OF STOMACH; CONGENITAL DIVERTICULUM OF STOMACH; CONGENITAL HOURGLASS STOMACH; DUPLICATION OF STOMACH; MEGALOGASTRIA; MICROGASTRIA 22,035.00
15,424.50
6,610.50
Q40.9 CONGENITAL MALFORMATION OF UPPER ALIMENTARY TRACT, UNSPECIFIED; CONGENITAL ANOMALY NOS OF UPPER ALIMENTARY TRACT; CONGENITAL DEFORMITY NOS OF UPPER ALIMENTARY TRACT 22,035.00
15,424.50
6,610.50
Q41.0 CONGENITAL ABSENCE, ATRESIA AND STENOSIS OF DUODENUM 22,035.00
15,424.50
6,610.50
Q41.1 CONGENITAL ABSENCE, ATRESIA AND STENOSIS OF JEJUNUM; APPLE PEEL SYNDROME; IMPERFORATE JEJUNUM 22,035.00
15,424.50
6,610.50
Q41.2 CONGENITAL ABSENCE, ATRESIA AND STENOSIS OF ILEUM 22,035.00
15,424.50
6,610.50
Q41.9 CONGENITAL ABSENCE, ATRESIA AND STENOSIS OF SMALL INTESTINE, PART UNSPECIFIED; CONGENITAL ABSENCE, ATRESIA AND STENOSIS OF INTESTINE NOS 22,035.00
15,424.50
6,610.50
Q42.0 CONGENITAL ABSENCE, ATRESIA AND STENOSIS OF RECTUM WITH FISTULA 22,035.00
15,424.50
6,610.50
Q42.1 CONGENITAL ABSENCE, ATRESIA AND STENOSIS OF RECTUM WITHOUT FISTULA; IMPERFORATE RECTUM 22,035.00
15,424.50
6,610.50
Q42.2 CONGENITAL ABSENCE, ATRESIA AND STENOSIS OF ANUS WITH FISTULA 22,035.00
15,424.50
6,610.50
Q42.3 CONGENITAL ABSENCE, ATRESIA AND STENOSIS OF ANUS WITHOUT FISTULA; IMPERFORATE ANUS 22,035.00
15,424.50
6,610.50
Q42.9 CONGENITAL ABSENCE, ATRESIA AND STENOSIS OF LARGE INTESTINE, PART UNSPECIFIED 22,035.00
15,424.50
6,610.50
Q43.0 MECKEL'S DIVERTICULUM; PERSISTENT OMPHALOMESENTERIC DUCT; PERSISTENT VITELLINE DUCT 22,035.00
15,424.50
6,610.50
Q43.1 HIRSCHSPRUNG'S DISEASE; AGANGLIONOSIS; CONGENITAL (AGANGLIONIC) MEGACOLON 22,035.00
15,424.50
6,610.50
Q43.2 OTHER CONGENITAL FUNCTIONAL DISORDERS OF COLON; CONGENITAL DILATATION OF COLON 22,035.00
15,424.50
6,610.50
Q43.3 CONGENITAL MALFORMATIONS OF INTESTINAL FIXATION; CONGENITAL ANOMALOUS OMENTAL ADHESIONS [BANDS] ; CONGENITAL PERITONEAL ADHESIONS [BANDS]; JACKSON'S MEMBRANE; MALROTATION OF COLON; FAILURE OF ROTATION OF CAECUM AND COLON; INCOMPLETE ROTATION OF CAECUM A 22,035.00
15,424.50
6,610.50
Q43.4 DUPLICATION OF INTESTINE 22,035.00
15,424.50
6,610.50
Q43.5 ECTOPIC ANUS 22,035.00
15,424.50
6,610.50
Q43.6 CONGENITAL FISTULA OF RECTUM AND ANUS 22,035.00
15,424.50
6,610.50
Q43.7 PERSISTENT CLOACA; CLOACA NOS 22,035.00
15,424.50
6,610.50
Q43.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF INTESTINE; CONGENITAL BLIND LOOP SYNDROME; CONGENITAL DIVERTICULITIS, COLON; CONGENITAL DIVERTICULUM, INTESTINE; DOLICHOCOLON; MEGALOAPPENDIX; MEGALODUODENUM; MICROCOLON; TRANSPOSITION OF APPENDIX; TRANSPOSITIO 22,035.00
15,424.50
6,610.50
Q43.9 CONGENITAL MALFORMATION OF INTESTINE, UNSPECIFIED 22,035.00
15,424.50
6,610.50
Q44.0 AGENESIS, APLASIA AND HYPOPLASIA OF GALLBLADDER; CONGENITAL ABSENCE OF GALLBLADDER 22,035.00
15,424.50
6,610.50
Q44.1 OTHER CONGENITAL MALFORMATIONS OF GALLBLADDER; CONGENITAL MALFORMATION OF GALLBLADDER NOS; INTRAHEPATIC GALLBLADDER 22,035.00
15,424.50
6,610.50
Q44.2 ATRESIA OF BILE DUCTS 22,035.00
15,424.50
6,610.50
Q44.3 CONGENITAL STENOSIS AND STRICTURE OF BILE DUCTS 22,035.00
15,424.50
6,610.50
Q44.4 CHOLEDOCHAL CYST 22,035.00
15,424.50
6,610.50
Q44.5 OTHER CONGENITAL MALFORMATIONS OF BILE DUCTS; ACCESSORY HEPATIC DUCT; CONGENITAL MALFORMATION OF BILE DUCT NOS; BILIARY DUCT DUPLICATION; CYSTIC DUCT DUPLICATION 22,035.00
15,424.50
6,610.50
Q44.6 CYSTIC DISEASE OF LIVER; FIBROCYSTIC DISEASE OF LIVER 22,035.00
15,424.50
6,610.50
Q44.7 OTHER CONGENITAL MALFORMATIONS OF LIVER; ACCESSORY LIVER; ALAGILLE'S SYNDROME; CONGENITAL ABSENCE OF LIVER; CONGENITAL HEPATOMEGALY; CONGENITAL MALFORMATION OF LIVER NOS 22,035.00
15,424.50
6,610.50
Q45.0 AGENESIS, APLASIA AND HYPOPLASIA OF PANCREAS; CONGENITAL ABSENCE OF PANCREAS 22,035.00
15,424.50
6,610.50
Page 89 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate Q45.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF DIGESTIVE SYSTEM; ABSENCE OF ALIMENTARY TRACT NOS, COMPLETE; ABSENCE OF ALIMENTARY TRACT NOS, PARTIAL; DUPLICATION OF DIGESTIVE ORGANS NOS; MALPOSITION, CONGENITAL OF DIGESTIVE ORGANS NOS 22,035.00
15,424.50
6,610.50
Q45.9
CONGENITAL MALFORMATION OF DIGESTIVE SYSTEM,
UNSPECIFIED; CONGENITAL ANOMALY NOS OF DIGESTIVE SYSTEM
; CONGENITAL DEFORMITY NOS OF DIGESTIVE SYSTEM
22,035.00
15,424.50
6,610.50
Q50.1 DEVELOPMENTAL OVARIAN CYST 18,135.00
12,694.50
5,440.50
Q50.3 OTHER CONGENITAL MALFORMATIONS OF OVARY; ACCESSORY OVARY; CONGENITAL MALFORMATION OF OVARY NOS; OVARIAN STREAK 18,135.00
12,694.50
5,440.50
Q50.4 EMBRYONIC CYST OF FALLOPIAN TUBE; FIMBRIAL CYST 18,135.00
12,694.50
5,440.50
Q50.5
EMBRYONIC CYST OF BROAD LIGAMENT; CYST EPOOPHORON;
GARTNER'S DUCT CYST; PAROVARIAN CYST
18,135.00
12,694.50
5,440.50
Q50.6 OTHER CONGENITAL MALFORMATIONS OF FALLOPIAN TUBE AND BROAD LIGAMENT; ABSENCE OF FALLOPIAN TUBE OR BROAD LIGAMENT; ACCESSORY OF FALLOPIAN TUBE OR BROAD LIGAMENT; ATRESIA OF FALLOPIAN TUBE OR BROAD LIGAMENT; CONGENITAL MALFORMATION OF FALLOPIAN TUBE OR BRO 18,135.00
12,694.50
5,440.50
Q51.0 AGENESIS AND APLASIA OF UTERUS; CONGENITAL ABSENCE OF UTERUS 18,135.00
12,694.50
5,440.50
Q51.2 OTHER DOUBLING OF UTERUS' DOUBLING OF UTERUS NOS 15,210.00
10,647.00
4,563.00
Q51.3 BICORNATE UTERUS 15,210.00
10,647.00
4,563.00
Q51.8 OTHER CONGENITAL MALFORMATIONS OF UTERUS AND CERVIX; HYPOPLASIA OF UTERUS AND CERVIX 15,210.00
10,647.00
4,563.00
Q51.9 CONGENITAL MALFORMATION OF UTERUS AND CERVIX, UNSPECIFIED 18,135.00
12,694.50
5,440.50
Q52.1 DOUBLING OF VAGINA; SEPTATE VAGINA 15,210.00
10,647.00
4,563.00
Q52.2 CONGENITAL RECTOVAGINAL FISTULA 15,210.00
10,647.00
4,563.00
Q52.3 IMPERFORATE HYMEN 15,210.00
10,647.00
4,563.00
Q52.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF FEMALE GENITALIA 15,210.00
10,647.00
4,563.00
Q55.0 ABSENCE AND APLASIA OF TESTIS; MONORCHISM 12,480.00
8,736.00
3,744.00
Q55.1 HYPOPLASIA OF TESTIS AND SCROTUM; FUSION OF TESTES 12,480.00
8,736.00
3,744.00
Q55.2 OTHER CONGENITAL MALFORMATIONS OF TESTIS AND SCROTUM; CONGENITAL MALFORMATION OF TESTIS OR SCROTUM NOS; POLYORCHISM; RETRACTILE TESTIS; TESTIS MIGRANS 12,480.00
8,736.00
3,744.00
Q55.4 OTHER CONGENITAL MALFORMATIONS OF VAS DEFERENS, EPIDIDYMIS, SEMINAL VESICLES AND PROSTATE; ABSENCE OR APLASIA OF PROSTATE; ABSENCE OR APLASIA OF SPERMATIC CORD; CONGENITAL MALFORMATION OF VAS DEFERENS, EPIDIDYMIS, SEMINAL VESICLES OR PROSTATE NOS 12,480.00
8,736.00
3,744.00
Q55.6 OTHER CONGENITAL MALFORMATIONS OF PENIS; CONGENITAL MALFORMATION OF PENIS NOS; CURVATURE OF PENIS (LATERAL); HYPOPLASIA OF PENIS 12,480.00
8,736.00
3,744.00
Q55.9 CONGENITAL MALFORMATION OF MALE GENITAL ORGAN, UNSPECIFIED; CONGENITAL ANOMALYNOS OF MALE GENITAL ORGAN ; CONGENITAL DEFORMITY NOS OF MALE GENITAL ORGAN 12,480.00
8,736.00
3,744.00
Q56.1 MALE PSEUDOHERMAPHRODITISM, NOT ELSEWHERE CLASSIFIED; MALE PSEUDOHERMAPHRODITISM NOS 12,480.00
8,736.00
3,744.00
Q56.3 PSEUDOHERMAPHRODITISM, UNSPECIFIED 12,480.00
8,736.00
3,744.00
Q60.0 RENAL AGENESIS, UNILATERAL 17,745.00
12,421.50
5,323.50
Q60.1 RENAL AGENESIS, BILATERAL 17,745.00
12,421.50
5,323.50
Q60.2 RENAL AGENESIS, UNSPECIFIED 17,745.00
12,421.50
5,323.50
Q60.3 RENAL HYPOPLASIA, UNILATERAL 17,745.00
12,421.50
5,323.50
Q60.5 RENAL HYPOPLASIA, UNSPECIFIED 17,745.00
12,421.50
5,323.50
Q60.6 POTTER'S SYNDROME 17,745.00
12,421.50
5,323.50
Q61.0 CONGENITAL SINGLE RENAL CYST; CONGENITAL CYST OF KIDNEY; SINGLE CYST OF KIDNEY 17,745.00
12,421.50
5,323.50
Q61.1 POLYCYSTIC KIDNEY, AUTOSOMAL RECESSIVE; POLYCYSTIC KIDNEY, INFANTILE TYPE 17,745.00
12,421.50
5,323.50
Q61.2 POLYCYSTIC KIDNEY, AUTOSOMAL DOMINANT; POLYCYSTIC KIDNEY, ADULT TYPE 17,745.00
12,421.50
5,323.50
Q61.3 POLYCYSTIC KIDNEY, UNSPECIFIED 17,745.00
12,421.50
5,323.50
Q61.4 RENAL DYSPLASIA 17,745.00
12,421.50
5,323.50
Q61.5 MEDULLARY CYSTIC KIDNEY; SPONGE KIDNEY NOS 17,745.00
12,421.50
5,323.50
Q61.8 OTHER CYSTIC KIDNEY DISEASES; FIBROCYSTIC KIDNEY; FIBROCYSTIC RENAL DEGENERATION OR DISEASE 17,745.00
12,421.50
5,323.50
Q61.9 CYSTIC KIDNEY DISEASE, UNSPECIFIED; MECKEL-GRUBER SYNDROME 17,745.00
12,421.50
5,323.50
Q62.0 CONGENITAL HYDRONEPHROSIS 17,745.00
12,421.50
5,323.50
Q62.1
ATRESIA AND STENOSIS OF URETER; CONGENITAL OCCLUSION OF
URETER; CONGENITAL OCCLUSION OF URETEROPELVIC
JUNCTION; CONGENITAL OCCLUSION OF URETEROVESICAL
ORIFICE; IMPERVIOUS URETER
17,745.00
12,421.50
5,323.50
Q62.2 CONGENITAL MEGALOURETER; CONGENITAL DILATATION OF URETER 17,745.00
12,421.50
5,323.50
Q62.3 OTHER OBSTRUCTIVE DEFECTS OF RENAL PELVIS AND URETER; CONGENITAL URETEROCELE 17,745.00
12,421.50
5,323.50
Q62.5 DUPLICATION OF URETER; ACCESSORY OF URETER, DOUBLE OF URETER 17,745.00
12,421.50
5,323.50
Page 90 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate Q62.6 MALPOSITION OF URETER; DEVIATION OF URETER OR URETERIC ORIFICE; DISPLACEMENT OF URETER OR URETERIC ORIFICE; ECTOPIC OF URETER OF URETERIC ORIFICE; IMPLANTATION, ANOMALOUS OF URETER OR URETERIC ORIFICE 17,745.00
12,421.50
5,323.50
Q62.7 CONGENITAL VESICO-URETERO-RENAL REFLUX 17,745.00
12,421.50
5,323.50
Q63.0 ACCESSORY KIDNEY 17,745.00
12,421.50
5,323.50
Q63.1 LOBULATED, FUSED AND HORSESHOE KIDNEY 17,745.00
12,421.50
5,323.50
Q63.2 ECTOPIC KIDNEY; CONGENITAL DISPLACED KIDNEY; MALROTATION OF KIDNEY 17,745.00
12,421.50
5,323.50
Q63.3 HYPERPLASTIC AND GIANT KIDNEY 17,745.00
12,421.50
5,323.50
Q63.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF KIDNEY; CONGENITAL RENAL CALCULI 17,745.00
12,421.50
5,323.50
Q64.1 EXSTROPHY OF URINARY BLADDER; ECTOPIA VESICAE; EXTROVERSION OF BLADDER 17,745.00
12,421.50
5,323.50
Q64.2 CONGENITAL POSTERIOR URETHRAL VALVES 17,745.00
12,421.50
5,323.50
Q64.3 OTHER ATRESIA AND STENOSIS OF URETHRA AND BLADDER NECK; CONGENITAL BLADDER NECK OBSTRUCTION; CONGENITAL STRICTURE OF URETHRA; CONGENITAL STRICTURE OF URINARY MEATUS; CONGENITAL STRICTURE OF VESICOURETHRAL ORIFICE; IMPERVIOUS URETHRA 17,745.00
12,421.50
5,323.50
Q64.4 MALFORMATION OF URACHUS; CYST OF URACHUS; PATENT URACHUS; PROLAPSE OF URACHUS 17,745.00
12,421.50
5,323.50
Q64.7 OTHER CONGENITAL MALFORMATIONS OF BLADDER AND URETHRA; ACCESSORY BLADDER; ACCESSORY URETHRA; CONGENITAL HERNIA OF BLADDER; CONGENITAL MALFORMATION OF BLADDER OR URETHRA NOS; CONGENITAL PROLAPSE OF BLADDER (MUCOSA); CONGENITAL PROLAPSE OF URETHRA; CONGENIT 17,745.00
12,421.50
5,323.50
Q64.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF URINARY SYSTEM 17,745.00
12,421.50
5,323.50
Q64.9 CONGENITAL MALFORMATION OF URINARY SYSTEM, UNSPECIFIED; CONGENITAL ANOMALY NOS OF URINARY SYSTEM; CONGENITAL DEFORMITY NOS OF URINARY SYSTEM 17,745.00
12,421.50
5,323.50
Q65.6 UNSTABLE HIP; DISLOCATABLE HIP; SUBLUXATABLE HIP 10,335.00
7,234.50
3,100.50
Q67.3 PLAGIOCEPHALY 10,335.00
7,234.50
3,100.50
Q67.4 OTHER CONGENITAL DEFORMITIES OF SKULL, FACE AND JAW; DEPRESSIONS IN SKULL; DEVIATION OF NASAL SEPTUM, CONGENITAL; HEMIFACIAL ATROPHY OR HYPERTROPHY; SQUASHED OR BENT NOSE, CONGENITAL 10,335.00
7,234.50
3,100.50
Q67.6 PECTUS EXCAVATUM; CONGENITAL FUNNEL CHEST 10,335.00
7,234.50
3,100.50
Q67.7 PECTUS CARINATUM; CONGENITAL PIGEON CHEST 10,335.00
7,234.50
3,100.50
Q68.0 CONGENITAL DEFORMITY OF STERNOCLEIDOMASTOID MUSCLE; CONGENITAL, STERNOMASTOID TORTICOLLIS; CONTRACTURE OF STERNOCLEIDOMASTOID MUSCLE; STERNOMASTOID TUMOUR, CONGENITAL 10,335.00
7,234.50
3,100.50
Q74.3 ARTHROGRYPOSIS MULTIPLEX CONGENITA 25,350.00
17,745.00
7,605.00
Q75.0 CRANIOSYNOSTOSIS; ACROCEPHALY; ]IMPERFECT FUSION OF SKULL; OXYCEPHALY; TRIGONOCEPHALY 25,350.00
17,745.00
7,605.00
Q75.1 CRANIOFACIAL DYSOSTOSIS; CROUZON'S DISEASE 25,350.00
17,745.00
7,605.00
Q75.2 HYPERTELORISM 25,350.00
17,745.00
7,605.00
Q75.4
MANDIBULOFACIAL DYSOSTOSIS; FRANCESCHETTI SYNDROME;
TREACHER COLLINS SYNDROME
25,350.00
17,745.00
7,605.00
Q75.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF SKULL AND FACE BONES; ABSENCE OF SKULL BONE, CONGENITAL; CONGENITAL DEFORMITY OF FOREHEAD; PLATYBASIA 25,350.00
17,745.00
7,605.00
Q75.9 CONGENITAL MALFORMATION OF SKULL AND FACE BONES, UNSPECIFIED; CONGENITAL ANOMALY OF FACE BONES NOS; CONGENITAL ANOMALY OF SKULL NOS 25,350.00
17,745.00
7,605.00
Q76.0 SPINA BIFIDA OCCULTA 25,350.00
17,745.00
7,605.00
Q76.3 CONGENITAL SCOLIOSIS DUE TO CONGENITAL BONY MALFORMATION; HEMIVERTEBRA FUSION OR FAILURE OF SEGMENTATION WITH SCOLIOSIS 10,335.00
7,234.50
3,100.50
Q76.4 OTHER CONGENITAL MALFORMATIONS OF SPINE, NOT ASSOCIATED WITH SCOLIOSIS; CONGENITAL ABSENCE OF VERTEBRA UNSPECIFIED OR NOT ASSOCIATED WITH SCOLIOSIS; CONGENITAL FUSION OF SPINE UNSPECIFIED OR NOT ASSOCIATED WITH SCOLIOSIS; CONGENITAL KYPHOSIS UNSPECIFIED O 25,350.00
17,745.00
7,605.00
Q78.0 OSTEOGENESIS IMPERFECTA; FRAGILITAS OSSIUM 10,335.00
7,234.50
3,100.50
Q78.2 OSTEOPETROSIS; ALBERS-SCHöNBERG SYNDROME 10,335.00
7,234.50
3,100.50
Q78.8 OTHER SPECIFIED OSTEOCHONDRODYSPLASIAS; OSTEOPOIKILOSIS 10,335.00
7,234.50
3,100.50
Q78.9 OSTEOCHONDRODYSPLASIA, UNSPECIFIED; CHONDRODYSTROPHY NOS; OSTEODYSTROPHY NOS 10,335.00
7,234.50
3,100.50
Q79.0 CONGENITAL DIAPHRAGMATIC HERNIA 22,035.00
15,424.50
6,610.50
Q79.1 OTHER CONGENITAL MALFORMATIONS OF DIAPHRAGM; ABSENCE OF DIAPHRAGM; CONGENITAL MALFORMATION OF DIAPHRAGM NOS; EVENTRATION OF DIAPHRAGM 22,035.00
15,424.50
6,610.50
Q79.2 EXOMPHALOS; OMPHALOCELE 22,035.00
15,424.50
6,610.50
Q79.3 GASTROSCHISIS 22,035.00
15,424.50
6,610.50
Q79.4 PRUNE BELLY SYNDROME 22,035.00
15,424.50
6,610.50
Q79.5 OTHER CONGENITAL MALFORMATIONS OF ABDOMINAL WALL 22,035.00
15,424.50
6,610.50
Q80.2 LAMELLAR ICHTHYOSIS; COLLODION BABY 23,010.00
16,107.00
6,903.00
Q80.9 CONGENITAL ICHTHYOSIS, UNSPECIFIED 23,010.00
16,107.00
6,903.00
Page 91 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate Q81.2 EPIDERMOLYSIS BULLOSA DYSTROPHICA 23,010.00
16,107.00
6,903.00
Q81.8 OTHER EPIDERMOLYSIS BULLOSA 23,010.00
16,107.00
6,903.00
Q81.9 EPIDERMOLYSIS BULLOSA, UNSPECIFIED 23,010.00
16,107.00
6,903.00
Q82.0 HEREDITARY LYMPHOEDEMA 23,010.00
16,107.00
6,903.00
Q82.2 MASTOCYTOSIS; URTICARIA PIGMENTOSA 23,010.00
16,107.00
6,903.00
Q82.3 INCONTINENTIA PIGMENTI 23,010.00
16,107.00
6,903.00
Q82.4 ECTODERMAL DYSPLASIA (ANHIDROTIC) 23,010.00
16,107.00
6,903.00
Q82.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF SKIN; ABNORMAL PALMAR CREASES; ACCESSORY SKIN TAGS; BENIGN FAMILIAL PEMPHIGUS [HAILEY-HAILEY]; CUTIS LAXA (HYPERELASTICA); DERMATOGLYPHIC ANOMALIES; INHERITED KERATOSIS PALMARIS ET PLANTARIS; KERATOSIS FOLLICULA 23,010.00
16,107.00
6,903.00
Q84.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF INTEGUMENT; APLASIA CUTIS CONGENITA 23,010.00
16,107.00
6,903.00
Q85.1 TUBEROUS SCLEROSIS; BOURNEVILLE'S DISEASE; EPILOIA 22,620.00
15,834.00
6,786.00
Q85.8
OTHER PHAKOMATOSES, NOT ELSEWHERE CLASSIFIED; PEUTZ-
JEGHERS SYNDROME; STURGE-WEBER(-DIMITRI)SYNDROME;
VON HIPPEL-LINDAU SYNDROME
21,060.00
14,742.00
6,318.00
Q85.9 PHAKOMATOSIS, UNSPECIFIED; HAMARTOSIS NOS 21,060.00
14,742.00
6,318.00
Q87.0
CONGENITAL MALFORMATION SYNDROMES PREDOMINANTLY
AFFECTING FACIAL APPEARANCE;
ACROCEPHALOPOLYSYNDACTYLY; ACROCEPHALOSYNDACTYLY
[APERT]; CRYPTOPHTHALMOS SYNDROME; CYCLOPIA; SYNDROME
GOLDENHAR; MOEBIUS SYNDROME; ORO-FACIAL-DIGITAL
SYNDROME; ROBIN SYNDROM
22,620.00
15,834.00
6,786.00
Q87.1
CONGENITAL MALFORMATION SYNDROMES PREDOMINANTLY
ASSOCIATED WITH SHORT STATURE; AARSKOG SYNDROME;
COCKAYNE SYNDROME; DE LANGE SYNDROME ; DUBOWITZ
SYNDROME; NOONAN; SYNDROME PRADER-WILLI SYNDROME;
ROBINOW-SILVERMAN-SMITH SYNDROME ;
RUSSELL-SILVER; SYN
22,620.00
15,834.00
6,786.00
Q87.2
CONGENITAL MALFORMATION SYNDROMES PREDOMINANTLY
INVOLVING LIMBS; HOLT-ORAM SYNDROME; KLIPPEL-
TRéNAUNAY-WEBER SYNDROME; NAIL PATELLA SYNDROME;
RUBINSTEIN-TAYBI SYNDROME; SIRENOMELIA SYNDROME;
THROMBOCYTOPENIA SYNDROME WITH ABSENT RADIUS [TAR];
VAT
22,620.00
15,834.00
6,786.00
Q87.3 CONGENITAL MALFORMATION SYNDROMES INVOLVING EARLY OVERGROWTH; BECKWITH-WIEDEMANN SYNDROME; SOTOS; SYNDROME WEAVER SYNDROME 22,620.00
15,834.00
6,786.00
Q87.4 MARFAN'S SYNDROME 22,620.00
15,834.00
6,786.00
Q87.5 OTHER CONGENITAL MALFORMATION SYNDROMES WITH OTHER SKELETAL CHANGES 10,335.00
7,234.50
3,100.50
Q87.8 OTHER SPECIFIED CONGENITAL MALFORMATION SYNDROMES, NOT ELSEWHERE CLASSIFIED; ALPOR SYNDROME; LAURENCE- MOON(-BARDET)-BIEDL SYNDROME; ZELLWEGER SYNDROME 22,620.00
15,834.00
6,786.00
Q89.0 CONGENITAL MALFORMATIONS OF SPLEEN; ASPLENIA (CONGENITAL); CONGENITAL SPLENOMEGALY 22,620.00
15,834.00
6,786.00
Q89.1 CONGENITAL MALFORMATIONS OF ADRENAL GLAND 22,620.00
15,834.00
6,786.00
Q89.2 CONGENITAL MALFORMATIONS OF OTHER ENDOCRINE GLANDS; CONGENITAL MALFORMATION OF PARATHYROID OR THYROID GLAND; PERSISTENT THYROGLOSSAL DUCT; THYROGLOSSAL CYST 22,620.00
15,834.00
6,786.00
Q89.3 SITUS INVERSUS; DEXTROCARDIA WITH SITUS INVERSUS; MIRROR- IMAGE ATRIAL ARRANGEMENT WITH SITUS INVERSUS; SITUS INVERSUS OR TRANSVERSES ABDOMINALIS; SITUS INVERSUS OR TRANSVERSUS THORACIS; TRANSPOSITION OF ABDOMINAL VISCERA; TRANSPOSITION OF THORACIC VISCE 13,065.00
9,145.50
3,919.50
Q89.4 CONJOINED TWINS; CRANIOPAGUS; DICEPHALY; DOUBLE MONSTER; PYGOPAGUS; THORACOPAGUS 22,620.00
15,834.00
6,786.00
Q89.7 MULTIPLE CONGENITAL MALFORMATIONS, NOT ELSEWHERE CLASSIFIED; MONSTER NOS; MULTIPLE CONGENITAL ANOMALIES NOS; MULTIPLE CONGENITAL DEFORMITIES NOS 22,620.00
15,834.00
6,786.00
Q89.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS 22,620.00
15,834.00
6,786.00
Q89.9 CONGENITAL MALFORMATION, UNSPECIFIED; CONGENITAL ANOMALY NOS; CONGENITAL DEFORMITY NOS 22,620.00
15,834.00
6,786.00
Q90.0 TRISOMY 21, MEIOTIC NONDISJUNCTION 24,765.00
17,335.50
7,429.50
Q90.2 TRISOMY 21, TRANSLOCATION 24,765.00
17,335.50
7,429.50
Q90.9 DOWN'S SYNDROME, UNSPECIFIED; TRISOMY 21 NOS 24,765.00
17,335.50
7,429.50
Q91.0 TRISOMY 18, MEIOTIC NONDISJUNCTION 24,765.00
17,335.50
7,429.50
Q91.2 TRISOMY 18, TRANSLOCATION 24,765.00
17,335.50
7,429.50
Q91.3 EDWARDS' SYNDROME, UNSPECIFIED 24,765.00
17,335.50
7,429.50
Q91.7 PATAU'S SYNDROME, UNSPECIFIED 24,765.00
17,335.50
7,429.50
Q92.9 TRISOMY AND PARTIAL TRISOMY OF AUTOSOMES, UNSPECIFIED 24,765.00
17,335.50
7,429.50
Q93.1 WHOLE CHROMOSOME MONOSOMY, MOSAICISM (MITOTIC NONDISJUNCTION) 24,765.00
17,335.50
7,429.50
Q93.2 CHROMOSOME REPLACED WITH RING OR DICENTRIC 24,765.00
17,335.50
7,429.50
Q93.4 DELETION OF SHORT ARM OF CHROMOSOME 5; CRI-DU-CHAT SYNDROME 24,765.00
17,335.50
7,429.50
Page 92 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate Q93.5 OTHER DELETIONS OF PART OF A CHROMOSOME; ANGELMAN SYNDROME 24,765.00
17,335.50
7,429.50
Q93.7 DELETIONS WITH OTHER COMPLEX REARRANGEMENTS 24,765.00
17,335.50
7,429.50
Q93.9 DELETION FROM AUTOSOMES, UNSPECIFIED 24,765.00
17,335.50
7,429.50
Q95.9 BALANCED REARRANGEMENT AND STRUCTURAL MARKER, UNSPECIFIED 24,765.00
17,335.50
7,429.50
Q96.9 TURNER'S SYNDROME, UNSPECIFIED 24,765.00
17,335.50
7,429.50
Q97.9 SEX CHROMOSOME ABNORMALITY, FEMALE PHENOTYPE, UNSPECIFIED 24,765.00
17,335.50
7,429.50
Q98.4 KLINEFELTER'S SYNDROME, UNSPECIFIED 24,765.00
17,335.50
7,429.50
Q99.2 FRAGILE X CHROMOSOME; FRAGILE X SYNDROME 24,765.00
17,335.50
7,429.50
Q99.8 OTHER SPECIFIED CHROMOSOME ABNORMALITIES 24,765.00
17,335.50
7,429.50
R02 GANGRENE, NOT ELSEWHERE CLASSIFIED 25,740.00
18,018.00
7,722.00
R29.0 TETANY; CARPOPEDAL SPASM 32,175.00
22,522.50
9,652.50
R32 UNSPECIFIED URINARY INCONTINENCE; ENURESIS NOS 17,550.00
12,285.00
5,265.00
R41.0 DISORIENTATION, UNSPECIFIED; CONFUSION NOS 15,990.00
11,193.00
4,797.00
R41.3 OTHER AMNESIA; AMNESIA NOS 15,990.00
11,193.00
4,797.00
R42 DIZZINESS AND GIDDINESS; LIGHT-HEADEDNESS; VERTIGO NOS 11,115.00
7,780.50
3,334.50
R50.9 FEVER, UNSPECIFIED; HYPERPYREXIA NOS; PYREXIA NOS 13,650.00
9,555.00
4,095.00
R51 HEADACHE; FACIAL PAIN NOS 10,725.00
7,507.50
3,217.50
R54 SENILITY; OLD AGE WITHOUT MENTION OF PSYCHOSIS; SENESCENCE WITHOUT MENTION OF PSYCHOSIS; SENILE ASTHENIA; SENILE DEBILITY 15,990.00
11,193.00
4,797.00
R56.0 FEBRILE CONVULSIONS 13,650.00
9,555.00
4,095.00
R56.8 OTHER AND UNSPECIFIED CONVULSIONS; FIT NOS; SEIZURE (CONVULSIVE) NOS 13,650.00
9,555.00
4,095.00
R57.0 CARDIOGENIC SHOCK 62,400.00
43,680.00
18,720.00
R57.1 HYPOVOLAEMIC SHOCK 62,400.00
43,680.00
18,720.00
R57.8 OTHER SHOCK; ENDOTOXIC SHOCK 62,400.00
43,680.00
18,720.00
R57.9 SHOCK, UNSPECIFIED; FAILURE OF PERIPHERAL CIRCULATION NOS 62,400.00
43,680.00
18,720.00
S00.0 SUPERFICIAL INJURY OF SCALP 7,800.00
5,460.00
2,340.00
S00.1 CONTUSION OF EYELID AND PERIOCULAR AREA; BLACK EYE 7,800.00
5,460.00
2,340.00
S00.2 OTHER SUPERFICIAL INJURIES OF EYELID AND PERIOCULAR AREA 7,800.00
5,460.00
2,340.00
S00.3 SUPERFICIAL INJURY OF NOSE 7,800.00
5,460.00
2,340.00
S00.4 SUPERFICIAL INJURY OF EAR 7,800.00
5,460.00
2,340.00
S00.5 SUPERFICIAL INJURY OF LIP AND ORAL CAVITY 7,800.00
5,460.00
2,340.00
S00.7 MULTIPLE SUPERFICIAL INJURIES OF HEAD 7,800.00
5,460.00
2,340.00
S00.8 SUPERFICIAL INJURY OF OTHER PARTS OF HEAD 7,800.00
5,460.00
2,340.00
S00.9 SUPERFICIAL INJURY OF HEAD, PART UNSPECIFIED 7,800.00
5,460.00
2,340.00
S01.0 OPEN WOUND OF SCALP 7,800.00
5,460.00
2,340.00
S01.1 OPEN WOUND OF EYELID AND PERIOCULAR AREA 7,800.00
5,460.00
2,340.00
S01.2 OPEN WOUND OF NOSE 7,800.00
5,460.00
2,340.00
S01.3 OPEN WOUND OF EAR 7,800.00
5,460.00
2,340.00
S01.4 OPEN WOUND OF CHEEK AND TEMPOROMANDIBULAR AREA 7,800.00
5,460.00
2,340.00
S01.5 OPEN WOUND OF LIP AND ORAL CAVITY 7,800.00
5,460.00
2,340.00
S01.7 MULTIPLE OPEN WOUNDS OF HEAD 7,800.00
5,460.00
2,340.00
S01.8 OPEN WOUND OF OTHER PARTS OF HEAD 7,800.00
5,460.00
2,340.00
S01.9 OPEN WOUND OF HEAD, PART UNSPECIFIED 7,800.00
5,460.00
2,340.00
S02.0 FRACTURE O F VAULT OF SKULL; FRACTURE OF FRONTAL BONE; FRACTURE OF PARIETAL BONE 20,865.00
14,605.50
6,259.50
S02.00 CLOSED FRACTURE OF VAULT OF SKULL/ FRONTAL BONE/ PARIETAL BONE 20,865.00
14,605.50
6,259.50
S02.01 OPEN FRACTURE OF VAULT OF SKULL/ FRONTAL BONE/ PARIETAL BONE 20,865.00
14,605.50
6,259.50
S02.1 FRACTURE OF BASE OF SKULL: FRACTURE OF ANTERIOR FOSSA, MIDDLE FOSSA, POSTERIOR FOSSA; FRACTURE OF OCCIPUT; FRACTURE OF ORBITAL ROOF; FRACTURE OF ETHMOID SINUS & FRONTAL SINUS; FRACTURE OF SPHENOID; FRACTURE OF TEMPORAL BONE 20,865.00
14,605.50
6,259.50
S02.10 CLOSED FRACTURE OF BASE OF SKULL/ ANTERIOR FOSSA/ MIDDLE FOSSA/ POSTERIOR FOSSA/ OCCIPUT/ ORBITAL ROOF/ ETHMOID SINUS/ FRONTAL SINUS/ SPHENOID/ TEMPORAL BONE 20,865.00
14,605.50
6,259.50
S02.11 OPEN FRACTURE OF BASE OF SKULL/ ANTERIOR FOSSA/ MIDDLE FOSSA/ POSTERIOR FOSSA/ OCCIPUT/ ORBITAL ROOF/ ETHMOID SINUS/ FRONTAL SINUS/ SPHENOID/ TEMPORAL BONE 20,865.00
14,605.50
6,259.50
S02.20 CLOSED FRACTURE OF NASAL BONES 20,865.00
14,605.50
6,259.50
S02.21 OPEN FRACTURE OF NASAL BONES 20,865.00
14,605.50
6,259.50
S02.30 CLOSED FRACTURE OF ORBITAL FLOOR 20,865.00
14,605.50
6,259.50
S02.31 OPEN FRACTURE OF ORBITAL FLOOR 20,865.00
14,605.50
6,259.50
S02.40 CLOSED FRACTURE OF MALAR AND MAXILLARY BONES 20,865.00
14,605.50
6,259.50
S02.41 OPEN FRACTURE OF MALAR AND MAXILLARY BONES 20,865.00
14,605.50
6,259.50
S02.50 CLOSED FRACTURE OF TOOTH 20,865.00
14,605.50
6,259.50
S02.60 CLOSED FRACTURE OF MANDIBLE 20,865.00
14,605.50
6,259.50
S02.61 OPEN FRACTURE OF MANDIBLE 20,865.00
14,605.50
6,259.50
S02.70 CLOSED MULTIPLE FRACTURES INVOLVING SKULL AND FACIAL BONES 20,865.00
14,605.50
6,259.50
S02.71 OPEN MULTIPLE FRACTURES INVOLVING SKULL AND FACIAL BONES 20,865.00
14,605.50
6,259.50
S02.80 CLOSED FRACTURES OF OTHER SKULL AND FACIAL BONES INCLUDING ALVEOLUS, ORBIT NOS, PALATE 20,865.00
14,605.50
6,259.50
S02.81 OPEN FRACTURES OF OTHER SKULL AND FACIAL BONES INCLUDING ALVEOLUS, ORBIT NOS, PALATE 20,865.00
14,605.50
6,259.50
S02.90 CLOSED FRACTURE OF SKULL AND FACIAL BONES, PART UNSPECIFIED 20,865.00
14,605.50
6,259.50
Page 93 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate S02.91 OPEN FRACTURE OF SKULL AND FACIAL BONES, PART UNSPECIFIED 20,865.00
14,605.50
6,259.50
S04.0 INJURY OF OPTIC NERVE AND PATHWAYS; INJURY OF OPTIC CHIASM; INJURY OF 2ND CRANIAL NERVE; INJURY OF VISUAL CORTEX 17,160.00
12,012.00
5,148.00
S04.1 INJURY OF OCULOMOTOR NERVE; INJURY OF 3RD CRANIAL NERVE 17,160.00
12,012.00
5,148.00
S04.4 INJURY OF ABDUCENT NERVE; INJURY OF 6TH CRANIAL NERVE 17,160.00
12,012.00
5,148.00
S04.5 INJURY OF FACIAL NERVE; INJURY OF 7TH CRANIAL NERVE 17,160.00
12,012.00
5,148.00
S04.6 INJURY OF ACOUSTIC NERVE; INJURY OF AUDITORY NERVE; INJURY OF 8TH CRANIAL NERVE 17,160.00
12,012.00
5,148.00
S04.8 INJURY OF OTHER CRANIAL NERVES; INJURY OF GLOSSOPHARYNGEAL [9TH] NERVE; INJURY OF HYPOGLOSSAL [12TH] NERVE; INJURY OF; INJURY OF OLFACTORY [1ST] NERVE; INJURY OF VAGUS [10TH] NERVE 17,160.00
12,012.00
5,148.00
S04.9 INJURY OF UNSPECIFIED CRANIAL NERVE 17,160.00
12,012.00
5,148.00
S05.0 INJURY OF CONJUNCTIVA AND CORNEAL ABRASION WITHOUT MENTION OF FOREIGN BODY 17,160.00
12,012.00
5,148.00
S06.00 CONCUSSION; COMMOTIO CEREBRI (WITHOUT OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.01 CONCUSSION; COMMOTIO CEREBRI (WITH OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.10 TRAUMATIC CEREBRAL OEDEMA (WITHOUT OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.20 DIFFUSE BRAIN INJURY; CEREBRAL CONTUSION NOS; CEREBRAL LACERATION NOS; TRAUMATIC COMPRESSION OF BRAIN NOS (WITHOUT OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.21 DIFFUSE BRAIN INJURY; CEREBRAL CONTUSION NOS; CEREBRAL LACERATION NOS; TRAUMATIC COMPRESSION OF BRAIN NOS (WITHOUT OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.30 FOCAL BRAIN INJURY; FOCAL CEREBRAL; FOCAL CEREBRAL CONTUSION; FOCAL CEREBRAL LACERATION; FOCAL TRAUMATIC INTRACEREBRAL HAEMORRHAGE (WITHOUT OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.31 FOCAL BRAIN INJURY; FOCAL CEREBRAL; FOCAL CEREBRAL CONTUSION; FOCAL CEREBRAL LACERATION; FOCAL TRAUMATIC INTRACEREBRAL HAEMORRHAGE (WITH OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.40 EPIDURAL HAEMORRHAGE; EXTRADURAL HAEMORRHAGE, TRAUMATIC (WITHOUT OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.41 EPIDURAL HAEMORRHAGE; EXTRADURAL HAEMORRHAGE, TRAUMATIC (WITH OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.50 TRAUMATIC SUBDURAL HAEMORRHAGE (WITHOUT OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.51 TRAUMATIC SUBDURAL HAEMORRHAGE (WITH OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.60 TRAUMATIC SUBARACHNOID HAEMORRHAGE (WITHOUT OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.61 TRAUMATIC SUBARACHNOID HAEMORRHAGE (WITH OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.70 INTRACRANIAL INJURY WITH PROLONGED COMA (WITHOUT OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.80 OTHER INTRACRANIAL INJURIES; TRAUMATIC HAEMORRHAGE CEREBELLAR; TRAUMATIC HAEMORRHAGE INTRACRANIAL NOS (WITHOUT OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.81 OTHER INTRACRANIAL INJURIES; TRAUMATIC HAEMORRHAGE CEREBELLAR; TRAUMATIC HAEMORRHAGE INTRACRANIAL NOS (WITH OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.90 INTRACRANIAL INJURY, UNSPECIFIED; BRAIN INJURY NOS (WITHOUT OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S06.91 INTRACRANIAL INJURY, UNSPECIFIED; BRAIN INJURY NOS (WITH OPEN INTRACRANIAL WOUND) 17,160.00
12,012.00
5,148.00
S09.0 INJURY OF BLOOD VESSELS OF HEAD, NOT ELSEWHERE CLASSIFIED 17,160.00
12,012.00
5,148.00
S09.1 INJURY OF MUSCLE AND TENDON OF HEAD 17,160.00
12,012.00
5,148.00
S09.2 TRAUMATIC RUPTURE OF EAR DRUM 17,160.00
12,012.00
5,148.00
S09.7 MULTIPLE INJURIES OF HEAD 17,160.00
12,012.00
5,148.00
S09.8 OTHER SPECIFIED INJURIES OF HEAD 17,160.00
12,012.00
5,148.00
S09.9 UNSPECIFIED INJURY OF HEAD; INJURY OF FACE NOS; INJURY OF EAR NOS; INJURY OF NOSE NOS 17,160.00
12,012.00
5,148.00
S14.0 CONCUSSION AND OEDEMA OF CERVICAL SPINAL CORD 35,880.00
25,116.00
10,764.00
S16 INJURY OF MUSCLE AND TENDON AT NECK LEVEL 14,040.00
9,828.00
4,212.00
S22.00 FRACTURE OF THORACIC VERTEBRA; FRACTURE OF THORACIC SPINE NOS (CLOSED) 16,965.00
11,875.50
5,089.50
S22.10 MULTIPLE FRACTURES OF THORACIC SPINE (CLOSED) 16,965.00
11,875.50
5,089.50
S22.2 FRACTURE OF STERNUM 16,965.00
11,875.50
5,089.50
S22.20 FRACTURE OF STERNUM (CLOSED) 16,965.00
11,875.50
5,089.50
S22.3 FRACTURE OF RIB 16,965.00
11,875.50
5,089.50
S22.30 FRACTURE OF RIB (CLOSED) 16,965.00
11,875.50
5,089.50
S22.31 FRACTURE OF RIB (OPEN) 16,965.00
11,875.50
5,089.50
S22.4 MULTIPLE FRACTURES OF RIBS 16,965.00
11,875.50
5,089.50
S22.40 MULTIPLE FRACTURES OF RIBS (CLOSED) 16,965.00
11,875.50
5,089.50
S22.41 MULTIPLE FRACTURES OF RIBS (OPEN) 16,965.00
11,875.50
5,089.50
S22.80 FRACTURE OF OTHER PARTS OF BONY THORAX (CLOSED) 16,965.00
11,875.50
5,089.50
S22.90 FRACTURE OF BONY THORAX, PART UNSPECIFIED (CLOSED) 16,965.00
11,875.50
5,089.50
S34.0 CONCUSSION AND OEDEMA OF LUMBAR SPINAL CORD 35,880.00
25,116.00
10,764.00
Page 94 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate S39.0 INJURY OF MUSCLE AND TENDON OF ABDOMEN, LOWER BACK AND PELVIS 14,040.00
9,828.00
4,212.00
S43.0 DISLOCATION OF SHOULDER JOINT; DISLOCATION OF GLENOHUMERAL JOINT 14,040.00
9,828.00
4,212.00
S43.4 SPRAIN AND STRAIN OF SHOULDER JOINT; SPRAIN AND STRAIN OF CORACOHUMERAL (LIGAMENT); SPRAIN AND STRAIN OF ROTATOR CUFF CAPSULE 14,040.00
9,828.00
4,212.00
S43.5 SPRAIN AND STRAIN OF ACROMIOCLAVICULAR JOINT; SPRAIN AND STRAIN OF ACROMIOCLAVICULAR LIGAMENT 14,040.00
9,828.00
4,212.00
S43.7 SPRAIN AND STRAIN OF OTHER AND UNSPECIFIED PARTS OF SHOULDER GIRDLE; SPRAIN AND STRAIN OF SHOULDER GIRDLE NOS 14,040.00
9,828.00
4,212.00
S46.0 INJURY OF TENDON OF THE ROTATOR CUFF OF SHOULDER 14,040.00
9,828.00
4,212.00
S46.1 INJURY OF MUSCLE AND TENDON OF LONG HEAD OF BICEPS 14,040.00
9,828.00
4,212.00
S46.2 INJURY OF MUSCLE AND TENDON OF OTHER PARTS OF BICEPS 14,040.00
9,828.00
4,212.00
S46.7 INJURY OF MULTIPLE MUSCLES AND TENDONS AT SHOULDER AND UPPER ARM LEVEL 14,040.00
9,828.00
4,212.00
S46.8 INJURY OF OTHER MUSCLES AND TENDONS AT SHOULDER AND UPPER ARM LEVEL 14,040.00
9,828.00
4,212.00
S46.9 INJURY OF UNSPECIFIED MUSCLE AND TENDON AT SHOULDER AND UPPER ARM LEVEL 14,040.00
9,828.00
4,212.00
S53.4 SPRAIN AND STRAIN OF ELBOW 14,040.00
9,828.00
4,212.00
S56.0 INJURY OF FLEXOR MUSCLE AND TENDON OF THUMB AT FOREARM LEVEL 14,040.00
9,828.00
4,212.00
S56.1 INJURY OF LONG FLEXOR MUSCLE AND TENDON OF OTHER FINGER(S) AT FOREARM LEVEL 14,040.00
9,828.00
4,212.00
S56.2 INJURY OF OTHER FLEXOR MUSCLE AND TENDON AT FOREARM LEVEL 14,040.00
9,828.00
4,212.00
S56.3 INJURY OF EXTENSOR OR ABDUCTOR MUSCLES AND TENDONS OF THUMB AT FOREARM LEVEL 14,040.00
9,828.00
4,212.00
S61.0 OPEN WOUND OF FINGER(S) WITHOUT DAMAGE TO NAIL; OPEN WOUND OF FINGER(S) NOS 7,800.00
5,460.00
2,340.00
S61.1 OPEN WOUND OF FINGER(S) WITH DAMAGE TO NAIL 7,800.00
5,460.00
2,340.00
S61.7 MULTIPLE OPEN WOUNDS OF WRIST AND HAND 7,800.00
5,460.00
2,340.00
S61.8 OPEN WOUND OF OTHER PARTS OF WRIST AND HAND 7,800.00
5,460.00
2,340.00
S61.9 OPEN WOUND OF WRIST AND HAND PART, PART UNSPECIFIED 7,800.00
5,460.00
2,340.00
S63.5 SPRAIN AND STRAIN OF WRIST; SPRAIN AND STRAIN OF CARPAL JOINT; SPRAIN AND STRAIN OF RADIOCARPAL JOINT; SPRAIN AND STRAIN OF RADIOCARPAL LIGAMENT 14,040.00
9,828.00
4,212.00
S63.6 SPRAIN AND STRAIN OF FINGER(S); SPRAIN AND STRAIN OF INTERPHALANGEAL JOINT, HAND; SPRAIN AND STRAIN METACARPOPHALANGEAL JOINT; SPRAIN AND STRAIN OF PHALANX, HAND; SPRAIN AND STRAIN OF THUMB 14,040.00
9,828.00
4,212.00
S63.7 SPRAIN AND STRAIN OF OTHER AND UNSPECIFIED PARTS OF HAND 14,040.00
9,828.00
4,212.00
S66.1 INJURY OF FLEXOR MUSCLE AND TENDON OF OTHER FINGER AT WRIST AND HAND LEVEL 14,040.00
9,828.00
4,212.00
S66.3 INJURY OF EXTENSOR MUSCLE AND TENDON OF OTHER FINGER AT WRIST AND HAND LEVEL 14,040.00
9,828.00
4,212.00
S66.5 INJURY OF INTRINSIC MUSCLE AND TENDON OF OTHER FINGER AT WRIST AND HAND LEVEL 14,040.00
9,828.00
4,212.00
S66.6 INJURY OF MULTIPLE FLEXOR MUSCLES AND TENDONS AT WRIST AND HAND LEVEL 14,040.00
9,828.00
4,212.00
S66.8 INJURY OF OTHER MUSCLES AND TENDONS AT WRIST AND HAND LEVEL 14,040.00
9,828.00
4,212.00
S66.9 INJURY OF UNSPECIFIED MUSCLE AND TENDON AT WRIST AND HAND LEVEL 14,040.00
9,828.00
4,212.00
S73.1 SPRAIN AND STRAIN OF HIP 14,040.00
9,828.00
4,212.00
S76.1 INJURY OF QUADRICEPS MUSCLE AND TENDON; INJURY OF PATELLAR LIGAMENT (TENDON) 14,040.00
9,828.00
4,212.00
S76.2 INJURY OF ADDUCTOR MUSCLE AND TENDON OF THIGH 14,040.00
9,828.00
4,212.00
S76.3 INJURY OF MUSCLE AND TENDON OF THE POSTERIOR MUSCLE GROUP AT THIGH LEVEL 14,040.00
9,828.00
4,212.00
S76.4 INJURY OF OTHER AND UNSPECIFIED MUSCLES AND TENDONS AT THIGH LEVEL 14,040.00
9,828.00
4,212.00
S81.0 OPEN WOUND OF KNEE 7,800.00
5,460.00
2,340.00
S81.7 MULTIPLE OPEN WOUNDS OF LOWER LEG 7,800.00
5,460.00
2,340.00
S81.8 OPEN WOUND OF OTHER PARTS OF LOWER LEG 7,800.00
5,460.00
2,340.00
S81.9 OPEN WOUND OF LOWER LEG, PART UNSPECIFIED 7,800.00
5,460.00
2,340.00
S83.4 SPRAIN AND STRAIN INVOLVING FIBULAR COLLATERAL LIGAMENT OF KNEE; SPRAIN AND STRAIN INVOLVING TIBIAL COLLATERAL LIGAMENT OF KNEE 14,040.00
9,828.00
4,212.00
S83.5 SPRAIN AND STRAIN INVOLVING ANTERIOR CRUCIATE LIGAMENT OF KNEE; SPRAIN AND STRAIN INVOLVING POSTERIOR CRUCIATE LIGAMENT OF KNEE 14,040.00
9,828.00
4,212.00
S83.6 SPRAIN AND STRAIN OF OTHER AND UNSPECIFIED PARTS OF KNEE 14,040.00
9,828.00
4,212.00
S86.8 INJURY OF OTHER MUSCLES AND TENDONS AT LOWER LEG LEVEL 14,040.00
9,828.00
4,212.00
S86.9 INJURY OF UNSPECIFIED MUSCLE AND TENDON AT LOWER LEG LEVEL 14,040.00
9,828.00
4,212.00
S91.0 OPEN WOUND OF ANKLE 7,800.00
5,460.00
2,340.00
S91.1 OPEN WOUND OF TOE(S) WITHOUT DAMAGE TO NAIL; OPEN WOUND OF TOE (S) NOS 7,800.00
5,460.00
2,340.00
S91.2 OPEN WOUND OF TOE(S) WITH DAMAGE TO NAIL 7,800.00
5,460.00
2,340.00
Page 95 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate S91.3 OPEN WOUND OF OTHER PARTS OF FOOT; OPEN WOUND OF FOOT NOS 7,800.00
5,460.00
2,340.00
S91.7 MULTIPLE OPEN WOUNDS OF ANKLE AND FOOT 7,800.00
5,460.00
2,340.00
S93.4 SPRAIN AND STRAIN OF ANKLE INCLUDING CALCANEOFIBULAR (LIGAMENT), DELTOID (LIGAMENT), INTERNAL COLLATERAL (LIGAMENT), TALOFIBULAR (LIGAMENT), TIBIOFIBULAR , DISTAL (LIGAMENT) 14,040.00
9,828.00
4,212.00
S93.5 SPRAIN AND STRAIN OF TOE(S) INCLUDING INTERPHALANGEAL (JOINT(S), METATARSOPHALANGEAL (JOINT(S) 14,040.00
9,828.00
4,212.00
S93.6 SPRAIN AND STRAIN OF OTHER AND UNSPECIFIED PARTS OF FOOT INCLUDING TARSAL (LIGAMENT), TARSOMETATARSAL (LIGAMENT) 14,040.00
9,828.00
4,212.00
S96.0 INJURY OF MUSCLE AND TENDON OF LONG FLEXOR MUSCLE OF TOE AT ANKLE AND FOOT LEVEL 14,040.00
9,828.00
4,212.00
S96.9 INJURY OF UNSPECIFIED MUSCLE AND TENDON AT ANKLE AND FOOT LEVEL 14,040.00
9,828.00
4,212.00
T00.0 SUPERFICIAL INJURIES INVOLVING HEAD WITH NECK 7,800.00
5,460.00
2,340.00
T00.1 SUPERFICIAL INJURIES INVOLVING THORAX WITH ABDOMEN LOWER BACK AND PELVIS 7,800.00
5,460.00
2,340.00
T00.2 SUPERFICIAL INJURIES INVOLVING MULTIPLE REGIONS OF UPPER LIMB(S) 7,800.00
5,460.00
2,340.00
T00.3 SUPERFICIAL INJURIES INVOLVING MULTIPLE REGIONS OF LOWER LIMB(S) 7,800.00
5,460.00
2,340.00
T00.6 SUPERFICIAL INJURIES INVOLVING MULTIPLE REGIONS OF UPPER LIMB(S) WITH LOWER LIMB(S) 7,800.00
5,460.00
2,340.00
T00.8 SUPERFICIAL INJURIES INVOLVING OTHER COMBINATIONS OF BODY REGIONS 7,800.00
5,460.00
2,340.00
T00.9 MULTIPLE SUPERFICIAL INJURIES, UNSPECIFIED; MULTIPLE ABRASIONS NOS; MULTIPLE NONTHERMAL BLISTERS NOS; MULTIPLE BRUISES NOS; MULTIPLE CONTUSIONS NOS; MULTIPLE HAEMATOMAS NOS; MULTIPLE NONVENOMOUS INSECT BITE NOS 7,800.00
5,460.00
2,340.00
T03.9 MULTIPLE DISLOCATIONS, SPRAINS AND STRAINS, UNSPECIFIED 14,040.00
9,828.00
4,212.00
T20.2 BURN OF SECOND DEGREE OF HEAD AND NECK 20,670.00
14,469.00
6,201.00
T20.3 BURN OF THIRD DEGREE OF HEAD AND NECK 20,670.00
14,469.00
6,201.00
T20.4 CORROSION OF UNSPECIFIED DEGREE OF HEAD AND NECK 16,575.00
11,602.50
4,972.50
T20.6 CORROSION OF SECOND DEGREE OF HEAD AND NECK 20,670.00
14,469.00
6,201.00
T21.0 BURN OF UNSPECIFIED DEGREE OF TRUNK 16,575.00
11,602.50
4,972.50
T21.2 BURN OF SECOND DEGREE OF TRUNK 16,575.00
11,602.50
4,972.50
T21.3 BURN OF THIRD DEGREE OF TRUNK 31,395.00
21,976.50
9,418.50
T21.5 CORROSION OF FIRST DEGREE OF TRUNK 16,575.00
11,602.50
4,972.50
T21.6 CORROSION OF SECOND DEGREE OF TRUNK 16,575.00
11,602.50
4,972.50
T22.2 BURN OF SECOND DEGREE OF SHOULDER AND UPPER LIMB, EXCEPT WRIST AND HAND 16,575.00
11,602.50
4,972.50
T22.3 BURN OF THIRD DEGREE OF SHOULDER AND UPPER LIMB, EXCEPT WRIST AND HAND 20,670.00
14,469.00
6,201.00
T22.5 CORROSION OF FIRST DEGREE OF SHOULDER AND UPPER LIMB, EXCEPT WRIST AND HAND 16,575.00
11,602.50
4,972.50
T22.6 CORROSION OF SECOND DEGREE OF SHOULDER AND UPPER LIMB, EXCEPT WRIST AND HAND 16,575.00
11,602.50
4,972.50
T23.2 BURN OF SECOND DEGREE OF WRIST AND HAND 16,575.00
11,602.50
4,972.50
T23.3 BURN OF THIRD DEGREE OF WRIST AND HAND 20,670.00
14,469.00
6,201.00
T23.4 CORROSION OF UNSPECIFIED DEGREE OF WRIST AND HAND 16,575.00
11,602.50
4,972.50
T23.6 CORROSION OF SECOND DEGREE OF WRIST AND HAND 20,670.00
14,469.00
6,201.00
T23.7 CORROSION OF THIRD DEGREE OF WRIST AND HAND 20,670.00
14,469.00
6,201.00
T24.2 BURN OF SECOND DEGREE OF HIP AND LOWER LIMB, EXCEPT ANKLE AND FOOT 16,575.00
11,602.50
4,972.50
T24.3 BURN OF THIRD DEGREE OF HIP AND LOWER LIMB, EXCEPT ANKLE AND FOOT 20,670.00
14,469.00
6,201.00
T24.5 CORROSION OF FIRST DEGREE OF HIP AND LOWER LIMB, EXCEPT ANKLE AND FOOT 16,575.00
11,602.50
4,972.50
T24.6 CORROSION OF SECOND DEGREE OF HIP AND LOWER LIMB, EXCEPT ANKLE AND FOOT 16,575.00
11,602.50
4,972.50
T24.7 CORROSION OF THIRD DEGREE OF HIP AND LOWER LIMB, EXCEPT ANKLE AND FOOT 20,670.00
14,469.00
6,201.00
T25.2 BURN OF SECOND DEGREE OF ANKLE AND FOOT 16,575.00
11,602.50
4,972.50
T25.3 BURN OF THIRD DEGREE OF ANKLE AND FOOT 20,670.00
14,469.00
6,201.00
T25.5 CORROSION OF FIRST DEGREE OF ANKLE AND FOOT 16,575.00
11,602.50
4,972.50
T26.0 BURN OF EYELID AND PERIOCULAR AREA 16,575.00
11,602.50
4,972.50
T26.1 BURN OF CORNEA AND CONJUNCTIVAL SAC 20,670.00
14,469.00
6,201.00
T26.2 BURN WITH RESULTING RUPTURE AND DESTRUCTION OF EYEBALL 20,670.00
14,469.00
6,201.00
T26.3 BURN OF OTHER PARTS OF EYE AND ADNEXA 20,670.00
14,469.00
6,201.00
T26.4 BURN OF EYE AND ADNEXA, PART UNSPECIFIED 16,575.00
11,602.50
4,972.50
T26.6 CORROSION OF CORNEA AND CONJUNCTIVAL SAC 20,670.00
14,469.00
6,201.00
T26.9 CORROSION OF EYE AND ADNEXA, PART UNSPECIFIED 16,575.00
11,602.50
4,972.50
T27.0 BURN OF LARYNX AND TRACHEA 20,670.00
14,469.00
6,201.00
T27.2 BURN OF OTHER PARTS OF RESPIRATORY TRACT; THORACIC CAVITY 20,670.00
14,469.00
6,201.00
T27.3 BURN OF RESPIRATORY TRACT, PART UNSPECIFIED 16,575.00
11,602.50
4,972.50
T27.7 CORROSION OF RESPIRATORY TRACT, PART UNSPECIFIED 16,575.00
11,602.50
4,972.50
T28.0 BURN OF MOUTH AND PHARYNX 20,670.00
14,469.00
6,201.00
T28.1 BURN OF OESOPHAGUS 20,670.00
14,469.00
6,201.00
T28.2 BURN OF OTHER PARTS OF ALIMENTARY TRACT 20,670.00
14,469.00
6,201.00
T28.3 BURN OF INTERNAL GENITOURINARY ORGANS 20,670.00
14,469.00
6,201.00
T28.5 CORROSION OF MOUTH AND PHARYNX 20,670.00
14,469.00
6,201.00
T28.6 CORROSION OF OESOPHAGUS 20,670.00
14,469.00
6,201.00
Page 96 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate T28.7 CORROSION OF OTHER PARTS OF ALIMENTARY TRACT 20,670.00
14,469.00
6,201.00
T28.8 CORROSION OF INTERNAL GENITOURINARY ORGANS 20,670.00
14,469.00
6,201.00
T28.9 CORROSION OF OTHER AND UNSPECIFIED INTERNAL ORGANS 16,575.00
11,602.50
4,972.50
T29.1 BURNS OF MULTIPLE REGIONS, NO MORE THAN FIRST-DEGREE BURNS MENTIONED 16,575.00
11,602.50
4,972.50
T29.2 BURNS OF MULTIPLE REGIONS, NO MORE THAN SECOND-DEGREE BURNS MENTIONED 20,670.00
14,469.00
6,201.00
T29.3 BURNS OF MULTIPLE REGIONS, AT LEAST ONE BURN OF THIRD DEGREE MENTIONED 20,670.00
14,469.00
6,201.00
T29.6 CORROSIONS OF MULTIPLE REGIONS, NO MORE THAN SECOND- DEGREE CORROSIONS MENTIONED 20,670.00
14,469.00
6,201.00
T30.0 BURN OF UNSPECIFIED BODY REGION, UNSPECIFIED DEGREE; BURN NOS 16,575.00
11,602.50
4,972.50
T30.2 BURN OF SECOND DEGREE, BODY REGION UNSPECIFIED; SECODN- DEGREE BURN NOS 16,575.00
11,602.50
4,972.50
T30.3 BURN OF THIRD DEGREE, BODY REGION UNSPECIFIED; THIRD- DEGREE BURN NOS 16,575.00
11,602.50
4,972.50
T30.4 CORROSION OF UNSPECIFIED BODY REGION, UNSPECIFIED DEGREE; CORROSION NOS 16,575.00
11,602.50
4,972.50
T30.5 CORROSION OF FIRST DEGREE, BODY REGION UNSPECIFIED; FIRST- DEGREE CORROSION NOS 16,575.00
11,602.50
4,972.50
T30.6 CORROSION OF SECOND DEGREE, BODY REGION UNSPECIFIED; SECOND-DEGREE CORROSION NOS 16,575.00
11,602.50
4,972.50
T30.7 CORROSION OF THIRD DEGREE, BODY REGION UNSPECIFIED; THRID-DEGREE CORROSION NOS 16,575.00
11,602.50
4,972.50
T31.0 BURNS INVOLVING LESS THAN 10% OF BODY SURFACE 16,575.00
11,602.50
4,972.50
T31.1 BURNS INVOLVING 10-19% OF BODY SURFACE 16,575.00
11,602.50
4,972.50
T31.2 BURNS INVOLVING 20-29% OF BODY SURFACE 20,670.00
14,469.00
6,201.00
T31.3 BURNS INVOLVING 30-39% OF BODY SURFACE 20,670.00
14,469.00
6,201.00
T31.4 BURNS INVOLVING 40-49% OF BODY SURFACE 20,670.00
14,469.00
6,201.00
T31.5 BURNS INVOLVING 50-59% OF BODY SURFACE 20,670.00
14,469.00
6,201.00
T31.6 BURNS INVOLVING 60-69% OF BODY SURFACE 31,395.00
21,976.50
9,418.50
T31.7 BURNS INVOLVING 70-79% OF BODY SURFACE 31,395.00
21,976.50
9,418.50
T31.8 BURNS INVOLVING 80-89% OF BODY SURFACE 31,395.00
21,976.50
9,418.50
T31.9 BURNS INVOLVING 90% OR MORE OF BODY SURFACE 31,395.00
21,976.50
9,418.50
T32.0 CORROSIONS INVOLVING LESS THAN 10% OF BODY SURFACE 16,575.00
11,602.50
4,972.50
T32.1 CORROSIONS INVOLVING 10-19% OF BODY SURFACE 16,575.00
11,602.50
4,972.50
T32.2 CORROSIONS INVOLVING 20-29% OF BODY SURFACE 20,670.00
14,469.00
6,201.00
T32.3 CORROSIONS INVOLVING 30-39% OF BODY SURFACE 20,670.00
14,469.00
6,201.00
T32.4 CORROSIONS INVOLVING 40-49% OF BODY SURFACE 20,670.00
14,469.00
6,201.00
T32.9 CORROSIONS INVOLVING 90% OR MORE OF BODY SURFACE 31,395.00
21,976.50
9,418.50
T34.1 FROSTBITE WITH TISSUE NECROSIS OF NECK 16,575.00
11,602.50
4,972.50
T34.9 FROSTBITE WITH TISSUE NECROSIS OF OTHER AND UNSPECIFIED SITES; FROSBITE WITH TISSUE NECROSIS NOS; FROSBITE WITH TISSUE OF LEG NOS; FROSBITE WITH TISSUE NECROSIS OF TRUNK NOS 20,670.00
14,469.00
6,201.00
T35.0 SUPERFICIAL FROSTBITE INVOLVING MULTIPLE BODY REGIONS; MULTIPLE SUPERFICIAL FROSBITE NOS 16,575.00
11,602.50
4,972.50
T35.1 FROSTBITE WITH TISSUE NECROSIS INVOLVING MULTIPLE BODY REGIONS; MULTIPLE FROSBITE WITH TISSUE NECROSIS NOS 16,575.00
11,602.50
4,972.50
T36.0 POISONING BY PENICILLINS 14,235.00
9,964.50
4,270.50
T36.1 POISONING BY CEFALOSPORINS AND OTHER ß-LACTAM ANTIBIOTICS 14,235.00
9,964.50
4,270.50
T36.2 POISONING BY CHLORAMPHENICOL GROUP 14,235.00
9,964.50
4,270.50
T36.3 POISONING BY MACROLIDES 14,235.00
9,964.50
4,270.50
T36.4 POISONING BY TETRACYCLINES 14,235.00
9,964.50
4,270.50
T36.5 POISONING BY AMINOGLYCOSIDES; STREPTOMYCIN 14,235.00
9,964.50
4,270.50
T36.6 POISONING BY RIFAMYCINS 14,235.00
9,964.50
4,270.50
T36.8 POISONING BY OTHER SYSTEMIC ANTIBIOTICS 14,235.00
9,964.50
4,270.50
T36.9 POISONING BY SYSTEMIC ANTIBIOTIC, UNSPECIFIED 14,235.00
9,964.50
4,270.50
T37.0 POISONING BY SULFONAMIDES 14,235.00
9,964.50
4,270.50
T37.1 POISONING BY ANTIMYCOBACTERIAL DRUGS 14,235.00
9,964.50
4,270.50
T37.2 POISONING BY ANTIMALARIALS AND DRUGS ACTING ON OTHER BLOOD PROTOZOA 14,235.00
9,964.50
4,270.50
T37.4 POISONING BY ANTHELMINTHICS 14,235.00
9,964.50
4,270.50
T37.5 POISONING BY ANTIVIRAL DRUGS 14,235.00
9,964.50
4,270.50
T37.8 POISONING BY OTHER SPECIFIED SYSTEMIC ANTI-INFECTIVES AND ANTIPARASITICS; POISONING BY HYDROXYQUINOLINE DERIVATIVES 14,235.00
9,964.50
4,270.50
T37.9 POISONING BY SYSTEMIC ANTI-INFECTIVE AND ANTIPARASITIC, UNSPECIFIED 14,235.00
9,964.50
4,270.50
T38.0 POISONING BY GLUCOCORTICOIDS AND SYNTHETIC ANALOGUES 16,575.00
11,602.50
4,972.50
T38.1 POISONING BY THYROID HORMONES AND SUBSTITUTES 16,575.00
11,602.50
4,972.50
T38.2 POISONING BY ANTITHYROID DRUGS 16,575.00
11,602.50
4,972.50
T38.3 POISONING BY INSULIN AND ORAL HYPOGLYCAEMIC [ANTIDIABETIC] DRUGS 16,575.00
11,602.50
4,972.50
T38.4 POISONING BY ORAL CONTRACEPTIVES; POISONING BY MULTIPLE- AND-SINGLE-INGREDIENT PREPARATIONS 16,575.00
11,602.50
4,972.50
T38.5 POISONING BY OTHER ESTROGENS AND PROGESTOGENS; MIXTURES AND SUBSTITUTES 16,575.00
11,602.50
4,972.50
T38.6 POISONING BY ANTIGONADOTROPHINS, ANTIESTROGENS, ANTIANDROGENS, NOT ELSEWHERE CLASSIFIED; POISONING BY TAMOXIFEN 16,575.00
11,602.50
4,972.50
T38.7 POISONING BY ANDROGENS AND ANABOLIC CONGENERS 16,575.00
11,602.50
4,972.50
T39.0 POISONING BY SALICYLATES 14,430.00
10,101.00
4,329.00
Page 97 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate T39.1 POISONING BY 4-AMINOPHENOL DERIVATIVES 14,430.00
10,101.00
4,329.00
T39.3 POISONING BY OTHER NONSTEROIDAL ANTI-INFLAMMATORY DRUGS [NSAID] 14,430.00
10,101.00
4,329.00
T39.8 POISONING BY OTHER NONOPIOID ANALGESICS AND ANTIPYRETICS, NOT ELSEWHERE CLASSIFIED 14,430.00
10,101.00
4,329.00
T39.9 POISONING BY NONOPIOID ANALGESIC, ANTIPYRETIC AND ANTIRHEUMATIC, UNSPECIFIED 14,430.00
10,101.00
4,329.00
T40.2 POISONING BY OTHEROPIOIDS; POISONING BY CODEINE; POISONING BY MORPHINE 13,065.00
9,145.50
3,919.50
T40.4 POISONING BY OTHER SYNTHETIC NARCOTICS; POISONING BY PETHIDINE 13,065.00
9,145.50
3,919.50
T40.6 POISONING BY OTHER AND UNSPECIFIED NARCOTICS 13,065.00
9,145.50
3,919.50
T40.7 POISONING BY CANNABIS (DERIVATIVES) 13,065.00
9,145.50
3,919.50
T40.9 POISONING BY OTHER AND UNSPECIFIED PSYCHODYSLEPTICS [HALLUCINOGENS]; POISONING BY MESCALINE; POISONING BY PSILOCIN; POISONING BY PSILOCYBINE 13,065.00
9,145.50
3,919.50
T41.0 POISONING BY INHALED ANAESTHETICS 13,065.00
9,145.50
3,919.50
T41.1 POISONING BY INTRAVENOUS ANAESTHETICS; THIOBARBITURATES 13,065.00
9,145.50
3,919.50
T41.3 POISONING BY LOCAL ANAESTHETICS 13,065.00
9,145.50
3,919.50
T41.5 POISONING BY THERAPEUTIC GASES; CARBON DIOXIDE; OXYGEN 13,065.00
9,145.50
3,919.50
T42.0 POISONING BY HYDANTOIN DERIVATIVES 13,065.00
9,145.50
3,919.50
T42.1 POISONING BY IMINOSTILBENES; CARBAMAZEPINE 13,065.00
9,145.50
3,919.50
T42.2 POISONING BY SUCCINIMIDES AND OXAZOLIDINEDIONES 13,065.00
9,145.50
3,919.50
T42.3 POISONING BY BARBITURATES 13,065.00
9,145.50
3,919.50
T42.4 POISONING BY BENZODIAZEPINES 13,065.00
9,145.50
3,919.50
T42.6
POISONING BY OTHER ANTIEPILEPTIC AND SEDATIVE-
HYPNOTICDRUGS; POISONING BY METHAQUALONE;POISONING BY
VALPROIC ACID
13,065.00
9,145.50
3,919.50
T42.7 POISONING BY ANTIEPILEPTIC AND SEDATIVE-HYPNOTIC DRUGS, UNSPECIFIED; POISONING BY DRAUGHT SLEEPING NOS; POISONING BY SLEEPING DRUG NOS;POISONING BY SLEEPING TABLET NOS 13,065.00
9,145.50
3,919.50
T42.8 POISONING BY ANTIPARKINSONISM DRUGS AND OTHER CENTRAL MUSCLE-TONE DEPRESSANTS; POISONING BY AMANTADINE 13,065.00
9,145.50
3,919.50
T43.2 POISONING BY OTHER AND UNSPECIFIED ANTIDEPRESSANTS 13,065.00
9,145.50
3,919.50
T43.3 POISONING BY PHENOTHIAZINE ANTIPSYCHOTICS AND NEUROLEPTICS 13,065.00
9,145.50
3,919.50
T43.4 POISONING BY BUTYROPHENONE AND THIOXANTHENE NEUROLEPTICS 13,065.00
9,145.50
3,919.50
T43.5 POISONING BY OTHER AND UNSPECIFIED ANTIPSYCHOTICS AND NEUROLEPTICS 13,065.00
9,145.50
3,919.50
T43.6 POISONING BY PSYCHOSTIMULANTS WITH ABUSE POTENTIAL 13,065.00
9,145.50
3,919.50
T43.9 POISONING BY PSYCHOTROPIC DRUG, UNSPECIFIED 13,065.00
9,145.50
3,919.50
T44.1 POISONING BY OTHER PARASYMPATHOMIMETICS [CHOLINERGICS] 13,065.00
9,145.50
3,919.50
T44.2 POISONING BY GANGLIONIC BLOCKING DRUGS, NOT ELSEWHERE CLASSIFIED 13,065.00
9,145.50
3,919.50
T44.3 POISONING BY OTHER PARASYMPATHOLYTICS [ANTICHOLINERGICS AND ANTIMUSCARINICS] AND SPASMOLYTICS, NOT ELSEWHERE CLASSIFIED; POISONING BYPAPAVERINE 13,065.00
9,145.50
3,919.50
T44.4 POISONING BY PREDOMINANTLY ?-ADRENORECEPTOR AGONISTS, NOT ELSEWHERE CLASSIFIED; POISONING BY METARAMINOL 13,065.00
9,145.50
3,919.50
T44.5 POISONING BY PREDOMINANTLY ß-ADRENORECEPTOR AGONISTS, NOT ELSEWHERE CLASSIFIED 13,065.00
9,145.50
3,919.50
T44.6 POISONING BY ?-ADRENORECEPTOR ANTAGONISTS, NOT ELSEWHERE CLASSIFIED 13,065.00
9,145.50
3,919.50
T44.7 POISONING BY ß-ADRENORECEPTOR ANTAGONISTS, NOT ELSEWHERE CLASSIFIED 13,065.00
9,145.50
3,919.50
T44.9 POISONING BY OTHER AND UNSPECIFIED DRUGS PRIMARILY AFFECTING THE AUTONOMIC NERVOUS SYSTEM; DRUG STIMULATING BOTH ?-AND ß-ADRENORECEPTORS 13,065.00
9,145.50
3,919.50
T45.0 POISONING BY ANTIALLERGIC AND ANTIEMETIC DRUGS 13,065.00
9,145.50
3,919.50
T45.1 POISONING BY ANTINEOPLASTIC AND IMMUNOSUPPRESSIVE DRUGS; POISONING BY ANTINEOPLASTIC ANTIBIOTICS; POISONING BY CYTARABINE 13,065.00
9,145.50
3,919.50
T45.2 POISONING BY VITAMINS, NOT ELSEWHERE CLASSIFIED 13,065.00
9,145.50
3,919.50
T45.3 POISONING BY ENZYMES, NOT ELSEWHERE CLASSIFIED 13,065.00
9,145.50
3,919.50
T45.4 POISONING BY IRON AND ITS COMPOUNDS 14,235.00
9,964.50
4,270.50
T45.5 POISONING BY ANTICOAGULANTS 14,235.00
9,964.50
4,270.50
T45.6 POISONING BY FIBRINOLYSIS-AFFECTING DRUGS 14,235.00
9,964.50
4,270.50
T45.7 POISONING BY ANTICOAGULANT ANTAGONISTS, VITAMIN K AND OTHER COAGULANTS 14,235.00
9,964.50
4,270.50
T45.8 POISONING BY OTHER PRIMARILY SYSTEMIC AND HAEMATOLOGICAL AGENTS; POISONING BY LIVER PREPARATIONS AND OTHER ANTIANAEMIC AGENTS; POISONING BY NATURAL BLOOD AND BLOOD PRODUCTS; POISONING BY PLASMA SUBSTITUTE 14,235.00
9,964.50
4,270.50
T45.9 PRIMARILY SYSTEMIC AND HAEMATOLOGICAL AGENT, UNSPECIFIED 14,235.00
9,964.50
4,270.50
Page 98 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate T46.0 POISONING BY CARDIAC-STIMULANT GLYCOSIDES AND DRUGS OF SIMILAR ACTION 24,375.00
17,062.50
7,312.50
T46.1 POISONING BY CALCIUM-CHANNEL BLOCKERS 24,375.00
17,062.50
7,312.50
T46.2 POISONING BY OTHER ANTIDYSRHYTHMIC DRUGS, NOT ELSEWHERE CLASSIFIED 24,375.00
17,062.50
7,312.50
T46.3 POISONING BY CORONARY VASODILATORS, NOT ELSEWHERE CLASSIFIED; POISONING BY DIPYRIDAMOLE 24,375.00
17,062.50
7,312.50
T46.5 POISONING BY OTHER ANTIHYPERTENSIVE DRUGS, NOT ELSEWHERE CLASSIFIED; POISONING BY CLONIDINE;POISONING BY GUANETHIDINE; POISONING BY RAUWOLFIA 24,375.00
17,062.50
7,312.50
T46.6 POISONING BY ANTIHYPERLIPIDAEMIC AND ANTIARTERIOSCLEROTIC DRUGS 24,375.00
17,062.50
7,312.50
T46.7 POISONING BY PERIPHERAL VASODILATORS;POISONING BY NICOTIMIC ACID (DERIVATIVES) 24,375.00
17,062.50
7,312.50
T46.9 POISONING BY OTHER AND UNSPECIFIED AGENTS PRIMARILY AFFECTING THE CARDIOVASCULAR SYSTEM 24,375.00
17,062.50
7,312.50
T47.0 POISONING BY HISTAMINEH2-RECEPTOR ANTAGONISTS 16,185.00
11,329.50
4,855.50
T47.1 POISONING BY OTHER ANTACIDS AND ANTI-GASTRIC-SECRETION DRUGS 16,185.00
11,329.50
4,855.50
T47.2 POISONING BY STIMULANT LAXATIVES 16,185.00
11,329.50
4,855.50
T47.3 POISONING BY SALINE AND OSMOTIC LAXATIVES 16,185.00
11,329.50
4,855.50
T47.4 POISONING BY OTHER LAXATIVES; POISONING BY INTESTINAL ATONIA DRUGS 16,185.00
11,329.50
4,855.50
T47.5 POISONING BY DIGESTANTS 16,185.00
11,329.50
4,855.50
T47.6 POISONING BY ANTIDIARRHOEAL DRUGS 16,185.00
11,329.50
4,855.50
T47.8 POISONING BY OTHER AGENTS PRIMARILY AFFECTING THE GASTROINTESTINAL SYSTEM 16,185.00
11,329.50
4,855.50
T47.9 POISONING BY AGENT PRIMARILY AFFECTING THE GASTROINTESTINAL SYSTEM, UNSPECIFIED 16,185.00
11,329.50
4,855.50
T48.1 POISONING BY SKELETAL MUSCLE RELAXANTS [NEUROMUSCULAR BLOCKING AGENTS] 16,185.00
11,329.50
4,855.50
T48.3 POISONING BY ANTITUSSIVES 12,090.00
8,463.00
3,627.00
T48.4 POISONING BY EXPECTORANTS 12,090.00
8,463.00
3,627.00
T48.5 POISONING BY ANTI-COMMON-COLD DRUGS 12,090.00
8,463.00
3,627.00
T48.6 POISONING BY ANTIASTHMATICS, NOT ELSEWHERE CLASSIFIED; ?- ADRENORECEPTOR AGONISTS USED IN ASTHMA THERAPHY; POISONING BY SALBUTAMOL 12,090.00
8,463.00
3,627.00
T49.2 POISONING BY LOCAL ASTRINGENTS AND LOCAL DETERGENTS 10,335.00
7,234.50
3,100.50
T49.3 POISONING BY EMOLLIENTS, DEMULCENTS AND PROTECTANTS 10,335.00
7,234.50
3,100.50
T49.4 POISONING BY KERATOLYTICS, KERATOPLASTICS AND OTHER HAIR TREATMENT DRUGS AND PREPARATIONS 10,335.00
7,234.50
3,100.50
T49.5 POISONING BY OPHTHALMOLOGICAL DRUGS AND PREPARATIONS; POISONING BY EYE, NOSE AND THROAT ANTI-INFECTIVES 10,335.00
7,234.50
3,100.50
T49.7 POISONING BY DENTAL DRUGS, TOPICALLY APPLIED 10,335.00
7,234.50
3,100.50
T49.8 OTHERTOPICAL AGENTS; SPERMICIDES 10,335.00
7,234.50
3,100.50
T49.9 POISONING BY TOPICAL AGENT, UNSPECIFIED 10,335.00
7,234.50
3,100.50
T50.0 POISONING BY MINERALOCORTICOIDS AND THEIR ANTAGONISTS 12,285.00
8,599.50
3,685.50
T50.1 POISONING BY LOOP [HIGH-CEILING] DIURETICS 12,285.00
8,599.50
3,685.50
T50.2 POISONING BY CARBONIC-ANHYDRASE INHIBITORS, BENZOTHIADIAZIDES AND OTHER DIURETICS;POISONING BY ACETAZOLAMIDE 12,285.00
8,599.50
3,685.50
T50.4 POISONING BY DRUGS AFFECTING URIC ACID METABOLISM 12,285.00
8,599.50
3,685.50
T50.7 POISONING BY ANALEPTICS AND OPIOID RECEPTOR ANTAGONISTS 13,065.00
9,145.50
3,919.50
T50.9 POISONING BY OTHER AND UNSPECIFIED DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES; POISONING BY ACIDIFYING AGENTS; POISONING BY ALKALIZING AGENTS; POISONING BY IMMUNOGLOBULIN; POISONING BY IMMUNOLOGICALS; POISONING BY LIPOTROPIC DRUGS; POISONING BY PARATHY 12,285.00
8,599.50
3,685.50
T51.0 TOXIC EFFECT OF ETHANOL;TOXIC EFFECT OF ETHYL ALCOHOL 12,480.00
8,736.00
3,744.00
T51.2 TOXIC EFFECT OF 2-PROPANOL; TOXIC EFFECT OF ISOPROPHYL ACLOHOL 12,480.00
8,736.00
3,744.00
T51.3 TOXIC EFFECT OF FUSEL OIL; TOXIC EFFECT OF AMYL ALCOHOL; TOXIC EFFECT OF BUTYL ALCOHOL [1-BUTANOL]; TOXIC EFFECT OF PROPYL ALCOHOL [1-PROPONOL] 12,480.00
8,736.00
3,744.00
T51.8 TOXIC EFFECT OF OTHER ALCOHOLS 12,480.00
8,736.00
3,744.00
T51.9 TOXIC EFFECT OF ALCOHOL, UNSPECIFIED 12,480.00
8,736.00
3,744.00
T52.0
TOXIC EFFECT OF PETROLEUM PRODUCTS; TOXIC EFFECT OF
GASOLINE [PETROL]; TOXIC EFFECT OF KEROSINE [PARAFFIN
OIL]; TOXIC EFFECT OF PARAFFIN WAX; TOXIC EFFECT OF
PETROLEUM ETHER; TOXIC EFFECT OF PETROLEUM NAPHTHA;
TOXIC EFFECT OF PETROLEUM SPIRITS
12,480.00
8,736.00
3,744.00
T52.2 TOXIC EFFECT OF HOMOLOGUES OF BENZENE; TOXIC EFFECT OF TOLUENE [METHYLBENZENE]; TOXIC EFFECT OF XYLENE [DIMETHYLBENZENE] 12,480.00
8,736.00
3,744.00
T52.4 TOXIC EFFECT OF KETONES 12,480.00
8,736.00
3,744.00
T52.8 TOXIC EFFECT OF OTHER ORGANIC SOLVENTS 12,480.00
8,736.00
3,744.00
T52.9 TOXIC EFFECT OF ORGANIC SOLVENT, UNSPECIFIED 12,480.00
8,736.00
3,744.00
T53.0
TOXIC EFFECT OF CARBON TETRACHLORIDE;TOXIC EFFECT OF
TETRACHLOROMETHANE
12,480.00
8,736.00
3,744.00
Page 99 of 105 of Annex A
Case Rate
Health Facility Fee
Professional Fee
ICD Code
Description
First Case Rate
T53.1
TOXIC EFFECT OF CHLOROFORM; TOXIC EFFECT OF
TRICHLOROMETHANE
12,480.00
8,736.00
3,744.00
T53.4
TOXIC EFFECT OF DICHLOROMETHANE;TOXIC EFFECT OF
METHYLENE CHLORIDE
12,480.00
8,736.00
3,744.00
T53.6 TOXIC EFFECT OF OTHER HALOGEN DERIVATIVES OF ALIPHATIC HYDROCARBONS 12,480.00
8,736.00
3,744.00
T53.9 TOXIC EFFECT OF HALOGEN DERIVATIVE OF ALIPHATIC AND AROMATIC HYDROCARBONS, UNSPECIFIED 12,480.00
8,736.00
3,744.00
T54.1 TOXIC EFFECT OF OTHER CORROSIVE ORGANIC COMPOUNDS 12,480.00
8,736.00
3,744.00
T54.2 TOXIC EFFECT OF CORROSIVE ACIDS AND ACID-LIKE SUBSTANCES; TOXIC EFFECT OF ACID HYDROCHLORIE;TOXIC EFFECT OF ACID SULFURIE 12,480.00
8,736.00
3,744.00
T54.3 TOXIC EFFECT OF CORROSIVE ALKALIS AND ALKALI-LIKE SUBSTANCES; TOXIC EFFECT OF POTASSIUM HYDROXIDE;TOXIC EFFECT OF SODIUM HYDROXIDE 12,480.00
8,736.00
3,744.00
T54.9 TOXIC EFFECT OF CORROSIVE SUBSTANCE, UNSPECIFIED 12,480.00
8,736.00
3,744.00
T55 TOXIC EFFECT OF SOAPS AND DETERGENTS 12,480.00
8,736.00
3,744.00
T56.0 TOXIC EFFECT OF LEAD AND ITS COMPOUNDS 12,480.00
8,736.00
3,744.00
T56.1 TOXIC EFFECT OF MERCURY AND ITS COMPOUNDS 12,480.00
8,736.00
3,744.00
T56.5 TOXIC EFFECT OF ZINC AND ITS COMPOUNDS 12,480.00
8,736.00
3,744.00
T56.8 TOXIC EFFECT OF OTHER METALS 12,480.00
8,736.00
3,744.00
T57.0 TOXIC EFFECT OF ARSENIC AND ITS COMPOUNDS 12,480.00
8,736.00
3,744.00
T57.1 TOXIC EFFECT OF PHOSPHORUS AND ITS COMPOUNDS 12,480.00
8,736.00
3,744.00
T57.3 TOXIC EFFECT OF HYDROGEN CYANIDE 12,480.00
8,736.00
3,744.00
T57.8 TOXIC EFFECT OF OTHER SPECIFIED IN ORGANIC SUBSTANCES 12,480.00
8,736.00
3,744.00
T57.9 TOXIC EFFECT OF INORGANIC SUBSTANCE, UNSPECIFIED 12,480.00
8,736.00
3,744.00
T58 TOXIC EFFECT OF CARBON MONOXIDE FROM ALL SOURCES 12,480.00
8,736.00
3,744.00
T59.0 TOXIC EFFECT OF NITROGEN OXIDES 12,480.00
8,736.00
3,744.00
T59.2 TOXIC EFFECT OF FORMAL DEHYDE 12,480.00
8,736.00
3,744.00
T59.3 TOXIC EFFECT OF LACRIMOGENIC GAS; TOXIC EFFECT OF TEAR GAS 12,480.00
8,736.00
3,744.00
T59.4 TOXIC EFFECT OF CHLORINE GAS 12,480.00
8,736.00
3,744.00
T59.7 TOXIC EFFECT OF CARBON DIOXIDE 12,480.00
8,736.00
3,744.00
T59.8 TOXIC EFFECT OF OTHER SPECIFIED GASES, FUMES AND VAPOURS 12,480.00
8,736.00
3,744.00
T59.9 TOXIC EFFECT OF GASES, FUMES AND VAPOURS, UNSPECIFIED 12,480.00
8,736.00
3,744.00
T60.0 TOXIC EFFECT OF ORGANOPHOSPHATE AND CARBAMATE INSECTICIDES 12,480.00
8,736.00
3,744.00
T60.1 TOXIC EFFECT OF HALOGENATED INSECTICIDES 12,480.00
8,736.00
3,744.00
T60.2 TOXIC EFFECT OF OTHER INSECTICIDES 12,480.00
8,736.00
3,744.00
T60.3 TOXIC EFFECT OF HERBICIDES AND FUNGICIDES 12,480.00
8,736.00
3,744.00
T60.4 TOXIC EFFECT OF RODENTICIDES; TOXIC EFFECT OF THALLIUM 12,480.00
8,736.00
3,744.00
T60.8 TOXIC EFFECT OF OTHER PESTICIDES 12,480.00
8,736.00
3,744.00
T60.9 TOXIC EFFECT OF PESTICIDE, UNSPECIFIED 12,480.00
8,736.00
3,744.00
T61.0 TOXIC EFFECT OF CIGUATERA FISH POISONING 11,115.00
7,780.50
3,334.50
T61.1
TOXIC EFFECT OF SCOMBROID FISH POISONING;TOXIC EFFECT OF
HISTAMINE-LIKE SYNDROME
11,115.00
7,780.50
3,334.50
T61.2 TOXIC EFFECT OF OTHER FISH AND SHELLFISH POISONING 11,115.00
7,780.50
3,334.50
T61.8 TOXIC EFFECT OF OTHER SEAFOODS 11,115.00
7,780.50
3,334.50
T61.9 TOXIC EFFECT OF UNSPECIFIED SEAFOOD 11,115.00
7,780.50
3,334.50
T62.0 TOXIC EFFECT OF INGESTED MUSHROOMS 11,115.00
7,780.50
3,334.50
T62.1 TOXIC EFFECT OF INGESTED BERRIES 11,115.00
7,780.50
3,334.50
T62.2 TOXIC EFFECT OF OTHER INGESTED (PARTS OF) PLANT(S) 11,115.00
7,780.50
3,334.50
T62.8 TOXIC EFFECT OF OTHER SPECIFIED NOXIOUS SUBSTANCES EATEN AS FOOD 11,115.00
7,780.50
3,334.50
T62.9 TOXIC EFFECT OF NOXIOUS SUBSTANCE EATEN AS FOOD, UNSPECIFIED 11,115.00
7,780.50
3,334.50
T63.0 TOXIC EFFECT OF SNAKE VENOM;TOXIC EFFECT OF SEA-SNAKE VENOM 11,115.00
7,780.50
3,334.50
T63.1
TOXIC EFFECT OF VENOM OF OTHER REPTILES; TOXIC EFFECT OF
LIZARD VENOM
11,115.00
7,780.50
3,334.50
T63.2 TOXIC EFFECT OF VENOM OF SCORPION 11,115.00
7,780.50
3,334.50
T63.3 TOXIC EFFECT OF VENOM OF SPIDER 11,115.00
7,780.50
3,334.50
T63.4 TOXIC EFFECT OF VENOM OF OTHER ARTHROPODS;TOXIC EFFECT OF INSECT BITE OR STING, VENOMOUS 11,115.00
7,780.50
3,334.50
T63.5 TOXIC EFFECT OF CONTACT WITH FISH 11,115.00
7,780.50
3,334.50
T63.6 TOXIC EFFECT OF CONTACT WITH OTHER MARINE ANIMALS; JELLYFISH; SEA ANEMONE; SHELLFISH; STARFISH 11,115.00
7,780.50
3,334.50
T63.8 TOXIC EFFECT OF CONTACT WITH OTHER VENOMOUS ANIMALS; VENOM OF AMPHIBIAN 11,115.00
7,780.50
3,334.50
T63.9 TOXIC EFFECT OF CONTACT WITH UNSPECIFIED VENOMOUS ANIMAL 11,115.00
7,780.50
3,334.50
T64 TOXIC EFFECT OF AFLATION AND OTHER MYCOTOXIN FOOD CONTAMINANTS 11,115.00
7,780.50
3,334.50
T65.0 TOXIC EFFECT OF CYANIDES 12,480.00
8,736.00
3,744.00
T65.2 TOXIC EFFECT OF TOBACCO AND NICOTINE 11,115.00
7,780.50
3,334.50
T65.3 TOXIC EFFECT OF NITRO DERIVATIVES AND AMINODERIVATIVES OF BENZENE AND ITS HOMOLOGUES; TOXIC EFFECT OF ANILINE [BENZENAMINE]; TOXIC EFFECT OF NITROBENZENE; TOXIC EFFECT OF TRINITROTOLUENE 12,480.00
8,736.00
3,744.00
T65.4 TOXIC EFFECT OF CARBONDISULFIDE 12,480.00
8,736.00
3,744.00
T65.6 TOXIC EFFECT OF PAINTS AND DYES, NOT ELSEWHERE CLASSIFIED 12,480.00
8,736.00
3,744.00
Page 100 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate T65.8 TOXIC EFFECT OF OTHER SPECIFIED SUBSTANCES 12,480.00
8,736.00
3,744.00
T66 UNSPECIFIED EFFECTS OF RADIATION 18,135.00
12,694.50
5,440.50
T67.0 HEAT STROKE AND SUNSTROKE; HEAT APOPLEXY; HEAT PYREXIA; SIRIASIS; THERMOPLEGIA 12,675.00
8,872.50
3,802.50
T67.1 HEAT SYNCOPE; HEAT COLLAPSE 12,675.00
8,872.50
3,802.50
T67.2 HEAT CRAMP 12,675.00
8,872.50
3,802.50
T67.3 HEAT EXHAUSTION, ANHYDROTIC; HEAT PROSTRATION DUE TO WATER DEPLETION 12,675.00
8,872.50
3,802.50
T67.4 HEAT EXHAUSTION DUE TO SALT DEPLETION; HEAT PROSTATION DUE TO SALT (AND WATER) DEPLETION 12,675.00
8,872.50
3,802.50
T67.5 HEAT EXHAUSTION, UNSPECIFIED; HEAT PROSTRATION NOS 12,675.00
8,872.50
3,802.50
T67.6 HEAT FATIGUE, TRANSIENT 18,135.00
12,694.50
5,440.50
T67.8 OTHER EFFECTS OF HEAT AND LIGHT 18,135.00
12,694.50
5,440.50
T67.9 EFFECT OF HEAT AND LIGHT, UNSPECIFIED 12,675.00
8,872.50
3,802.50
T68 HYPOTHERMIA 18,135.00
12,694.50
5,440.50
T69.0 IMMERSION HAND AND FOOT; TRENCH FOOT 18,135.00
12,694.50
5,440.50
T69.9 EFFECT OF REDUCED TEMPERATURE, UNSPECIFIED 18,135.00
12,694.50
5,440.50
T70.0 OTITIC BAROTRAUMA; AERO-OTITIS MEDIA; EFFECTS OF CHANGE IN AMBIENT ATMOSPHERIC PRESSURE ON SINUSES 18,135.00
12,694.50
5,440.50
T70.2 OTHER AND UNSPECIFIED EFFECTS OF HIGH ALTITUDE; ALPINE SICKNESS; ANOXIA DUE TO HIGH ALTITUDE; BAROTRAUMA NOS; HYPOBAROPATHY; MOUNTAIN SICKNESS 18,135.00
12,694.50
5,440.50
T70.3 CAISSON DISEASE [DECOMPRESSION SICKNESS]; COMPRESSED-AIR DISEASE; DIVER'S PALSY OR PARALYSIS 18,135.00
12,694.50
5,440.50
T70.4 EFFECTS OF HIGH-PRESSURE FLUIDS; TRAUMATIC JET INJECTION (INDUSTRIAL) 18,135.00
12,694.50
5,440.50
T70.8 OTHER EFFECTS OF AIR PRESSURE AND WATER PRESSURE; BLAST INJURY SYNDROME 18,135.00
12,694.50
5,440.50
T70.9 EFFECT OF AIR PRESSURE AND WATER PRESSURE, UNSPECIFIED 18,135.00
12,694.50
5,440.50
T75.0 EFFECTS OF LIGHTNING; SHOCK FROM LIGHTNING; STRUCK BY LIGHTNING NOS 10,530.00
7,371.00
3,159.00
T75.1 DROWNING AND NONFATAL SUBMERSION; IMMERSION; SWIMMER'S CRAMP 13,845.00
9,691.50
4,153.50
T75.2 EFFECTS OF VIBRATION; PNEUMATIC HAMMER SYNDROME; TRAUMATIC VASOSPASTIC SYNDROME; VARTIGO FROM INFRASOUND 18,135.00
12,694.50
5,440.50
T75.4 EFFECTS OF ELECTRIC CURRENT; ELECTROCUTION; SHOCK FROM ELECTRIC CURRENT 10,530.00
7,371.00
3,159.00
T75.8 OTHER SPECIFIED INJURIES DUE TO ENVIRONMENTAL AND OTHER EXTERNAL FACTORS CAUSES; EFFECTS OF ABNORMAL GRAVITATION [G] FORCES; EFFECTS OF WEIGHTLESSNESS 18,135.00
12,694.50
5,440.50
T78.0 ANAPHYLACTIC SHOCK DUE TO ADVERSE FOOD REACTION 14,820.00
10,374.00
4,446.00
T78.1 OTHER ADVERSE FOOD REACTIONS, NOT ELSEWHERE CLASSIFIED 12,090.00
8,463.00
3,627.00
T78.2 ANAPHYLACTIC SHOCK, UNSPECIFIED; ALLERGIC SHOCK NOS; ANAPHYLACTIC REACTION NOS; ANAPHYLAXIS NOS 14,820.00
10,374.00
4,446.00
T78.3 ANGIONEUROTIC OEDEMA; GIANT URTICARIA; QUINKE'S OEDEMA 12,090.00
8,463.00
3,627.00
T78.4 ALLERGY, UNSPECIFIED; ALLERGIC REACTION NOS; HYPERSENSITIVITY NOS; IDIOSYNCRACY NOS 12,090.00
8,463.00
3,627.00
T78.8 OTHER ADVERSE EFFECTS, NOT ELSEWHERE CLASSIFIED 12,090.00
8,463.00
3,627.00
T78.9 ADVERSE EFFECT, UNSPECIFIED 12,090.00
8,463.00
3,627.00
T79.0 AIR EMBOLISM (TRAUMATIC) 18,135.00
12,694.50
5,440.50
T79.1 FAT EMBOLISM (TRAUMATIC) 18,135.00
12,694.50
5,440.50
T79.2 TRAUMATIC SECONDARY AND RECURRENT HAEMORRHAGE 18,135.00
12,694.50
5,440.50
T79.3 POST-TRAUMATIC WOUND INFECTION, NOT ELSEWHERE CLASSIFIED 18,135.00
12,694.50
5,440.50
T79.4 TRAUMATIC SHOCK; IMMEDIATE SHOCK FOLLOWING INJURY; DELAYED SHOCK FOLLOWING INJURY 18,135.00
12,694.50
5,440.50
T79.5 TRAUMATIC ANURIA; CRUSH SYNDROME; RENAL FAILURE FOLLOWING CRUSHING 18,135.00
12,694.50
5,440.50
T79.6 TRAUMATIC ISCHAEMIA OF MUSCLE; COMPARTMENT SYNDROME; VOLKMANN'S ISCHAEMIC CONTRACTURE 18,135.00
12,694.50
5,440.50
T79.7 TRAUMATIC SUBCUTANEOUS EMPHYSEMA 18,135.00
12,694.50
5,440.50
T79.8 OTHER EARLY COMPLICATIONS OF TRAUMA 18,135.00
12,694.50
5,440.50
T81.0 HAEMORRHAGE AND HAEMATOMA COMPLICATING A PROCEDURE, NOT ELSEWHERE CLASSIFIED; HAEMORRHAGE AT ANY SITE RESULTING FROM A PROCEDURE 20,085.00
14,059.50
6,025.50
T81.1 SHOCK DURING OR RESULTING FROM A PROCEDURE NOT ELSEWHERE CLASSIFIED; COLLAPSE NOS DURING OR FOLLOWING A PROCEDURE; ENDOTOXIC SHOCK DURING OR FOLLOWING A PROCEDURE; HYPOVOLAEMIC DURING OR FOLLOWING A PROCEDURE; SEPTIC SHOCK DURING OR FOLLOWING A PROCEDURE; 20,085.00
14,059.50
6,025.50
T81.2 ACCIDENTAL PUNCTURE AND LACERATION DURING A PROCEDURE NOT ELSEWHERE CLASSIFIED; ACCIDENTAL PERFORATION OF BLOOD VESSEL BY CATHETER, ENDOSCOPE, INSTRUMENT, PROBE DURING A PROCEDURE; ACCIDENTAL PERFORATION OF NERVE BY CATHETER, ENDOSCOPE, INSTRUMENT, PROBE 20,085.00
14,059.50
6,025.50
T81.3 DISRUPTION OF OPERATION WOUND, NOT ELSEWHERE CLASSIFIED; DEHISCENE OF OPERATION WOUND; RUPTURE OF OPERATION WOUND 20,085.00
14,059.50
6,025.50
Page 101 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate T81.4 INFECTION FOLLOWING A PROCEDURE, NOT ELSEWHERE CLASSIFIED; INTRA-ABDOMINAL ABSCESS POSTPROCEDURAL ABCESS; INTRA-ABDOMINAL STITCH POSTPROCEDURAL ABSCESS; INTRA-ABDOMINAL SUBPHRENIC POSTPROCEDURAL ABCESS; INTRA-ABDOMINAL WOUND POSTPROCEDURAL ABCESS; SEPTICA 20,085.00
14,059.50
6,025.50
T81.8 OTHER COMPLICATIONS OF PROCEDURES, NOT ELSEWHERE CLASSIFIED; COMPLICATION OF INHALATION THERAPY; EMPHYSEMA (SUBCUTANEOUS) RESULTING FROM A PROCEDURE; PERSISTENT POSTOPERATIVE FISTULA 20,085.00
14,059.50
6,025.50
T82.0 MECHANICAL COMPLICATION OF HEART VALVE PROSTHESIS; MECHANICAL BREAKDOWN DUE TO HEART VALVE PROSTHESIS; DISPLACEMENT DUE TO HEART VALVE PROSTHESIS; FAILURE DUE TO HEART VALVE PROSTHESIS; LEAKAGE DUE TO HEART VALVE PROSTHESIS; MALPOSITION DUE TO HEART VALVE 20,085.00
14,059.50
6,025.50
T82.1 MECHANICAL COMPLICATION OF CARDIAC ELECTRONIC DEVICE; CONDITIONS LISTED IN T82.0 DUE TO ELECTRODES; CONDITIONS LISTED IN T82.0 DUE TO PULSE GENERATOR (BATTERY) 20,085.00
14,059.50
6,025.50
T82.2 MECHANICAL COMPLICATION OF CORONARY ARTERY BYPASS AND VALVE GRAFTS 20,085.00
14,059.50
6,025.50
T82.3 MECHANICAL COMPLICATION OF OTHER VASCULAR GRAFTS; CONDITION LISTED IN T82.0 DUE TO AORTIC (BIFURCATION) GRAFT (REPLACEMENT); CONDITION LISTED IN T82.0 DUE TO ARTERIAL (CAROTID) (FEMORAL) GRAFT (BYPASS) 20,085.00
14,059.50
6,025.50
T82.4 MECHANICAL COMPLICATION OF VASCULAR DIALYSIS CATHETER 20,085.00
14,059.50
6,025.50
T82.5 MECHANICAL COMPLICATION OF OTHER CARDIAC AND VASCULAR DEVICES AND IMPLANTS; CONDITIONS LISTED IN T82.0 DUE TO ARTERIOVENOUS FISTULA SURGICALLY CREATED; ARTERIVENOUS SHUNT SURGICALLY CREATED; ARTIFICIAL HEART; BALLON COUNTERPULSATION DEVICE; INFUSION CAT 20,085.00
14,059.50
6,025.50
T82.7 INFECTION AND INFLAMMATORY REACTION DUE TO OTHER CARDIAC AND VASCULAR DEVICES, IMPLANTS AND GRAFTS 20,085.00
14,059.50
6,025.50
T82.8 OTHER COMPLICATIONS OF CARDIAC AND VASCULAR PROSTHETIC DEVICES, IMPLANTS AND GRAFTS; COMPLICATION DUE TO CARDIAC AND VASCULAR PROSTHETIC DEVICES, IMPLANTS AND GRAFTS; EMBOLISM DUE TO CARDIAC AND VASCULAR PROSTHETIC DEVICES, IMPLANTS AND GRAFTS; FIBROSIS D 20,085.00
14,059.50
6,025.50
T83.1 MECHANICAL COMPLICATION OF OTHER URINARY DEVICES AND IMPLANTS; CONCDITIONS LISTED IN T82.0 DUE TO URINARY ELECTRONIC STIMULTOR DEVICE; URINARY SPHINCTER IMPLANT; URINARY STENT 20,085.00
14,059.50
6,025.50
T83.2 MECHANICAL COMPLICATION OF GRAFT OF URINARY ORGAN 20,085.00
14,059.50
6,025.50
T83.3 MECHANICAL COMPLICATION OF INTRAUTERINE CONTRACEPTIVE DEVICE 20,085.00
14,059.50
6,025.50
T83.5 INFECTION AND INFLAMMATORY REACTION DUE TO PROSTHETIC DEVICE, IMPLANT AND GRAFT IN URINARY SYSTEM 20,085.00
14,059.50
6,025.50
T83.8 OTHER COMPLICATIONS OF GENITOURINARY PROSTHETIC DEVICES, IMPLANTS AND GRAFTS 20,085.00
14,059.50
6,025.50
T83.9 UNSPECIFIED COMPLICATION OF GENITOURINARY PROSTHETIC DEVICE, IMPLANTS AND GRAFTS 20,085.00
14,059.50
6,025.50
T84.0 MECHANICAL COMPLICATION OF INTERNAL JOINT PROSTHESIS 20,085.00
14,059.50
6,025.50
T84.1 MECHANICAL COMPLICATION OF INTERNAL FIXATION DEVICE OF BONES OF LIMB 20,085.00
14,059.50
6,025.50
T84.2 MECHANICAL COMPLICATION OF INTERNAL FIXATION DEVICE OF OTHER BONES 20,085.00
14,059.50
6,025.50
T84.4 MECHANICAL COMPLICATION OF OTHER INTERNAL ORTHOPAEDIC DEVICES, IMPLANTS AND GRAFTS 20,085.00
14,059.50
6,025.50
T84.5 INFECTION AND INFLAMMATORY REACTION DUE TO INTERNAL JOINT PROSTHESIS 20,085.00
14,059.50
6,025.50
T84.6 INFECTION AND INFLAMMATORY REACTION DUE TO INTERNAL FIXATION DEVICE [ANY SITE] 20,085.00
14,059.50
6,025.50
T84.7 INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL ORTHOPAEDIC PROSTHETIC DEVICES, IMPLANTS AND GRAFTS 20,085.00
14,059.50
6,025.50
T84.8 OTHER COMPLICATIONS OF INTERNAL ORTHOPAEDIC PROSTHETIC DEVICES, IMPLANTS AND GRAFTS 20,085.00
14,059.50
6,025.50
T84.9 UNSPECIFIED COMPLICATION OF INTERNAL ORTHOPAEDIC PROSTHETIC DEVICE, IMPLANT AND GRAFT 20,085.00
14,059.50
6,025.50
T85.0 MECHANICAL COMPLICATION OF VENTRICULAR INTRACRANIAL (COMMUNICATING) SHUNT 20,085.00
14,059.50
6,025.50
T85.3 MECHANICAL COMPLICATION OF OTHER OCULAR PROSTHETIC DEVICES, IMPLANTS AND GRAFTS CONDITIONS LISTED IN T82.0 DUE TO CORNEAL GRAFT; CONDITIONS LISTED IN T82.0 DUE TO PROSTHETIC ORBIT OF EYE 20,085.00
14,059.50
6,025.50
T85.5 MECHANICALCOMPLICATIONOFGASTROINTESTINALPROSTHETICD EVICESIMPLANTSAND; CONDITIONS LISTED IN T82.0 DUE TO BILE- DUCT PROSTHESIS; CONDITIONS LISTED IN T82.0 OESOPHAGEAL ANTI-REFLUX DEVICE 20,085.00
14,059.50
6,025.50
Page 102 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate T85.6 MECHANICAL COMPLICATION OF OTHER SPECIFIED INTERNAL PROSTHETIC DEVICES, IMPLANTS AND GRAFTS; CONDITIONS LISTED IN T82.0 DUE TO EPIDURAL AND SUBDURAL INFUSION CATHETER; CONDITIONS LISTED IN T82.0 DUE TO INTRAPERITONAEL DIALYSIS CATHETER; CONDITIONS LISTED 20,085.00
14,059.50
6,025.50
T85.7 INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL PROSTHETIC DEVICES, IMPLANTS AND GRAFTS 20,085.00
14,059.50
6,025.50
T85.8 OTHER COMPLICATIONS OF INTERNAL PROSTHETIC DEVICES, IMPLANTS AND GRAFTS, NOT ELSEWHERE CLASSIFIED 20,085.00
14,059.50
6,025.50
T85.9 UNSPECIFIED COMPLICATION OF INTERNAL PROSTHETIC DEVICE, IMPLANT AND GRAFT; COMPLICATION OF INTERNAL PROSTHETIC DEVICE, IMPLANTS AND GRAFT NOS 20,085.00
14,059.50
6,025.50
T88.2 SHOCK DUE TO ANAESTHESIA; SHOCK DUE TO ANAESTHESIA IN WHICH THE CORRECT SUSTANCE WAS PROPERLY ADMINISTERED 62,400.00
43,680.00
18,720.00
T88.6 ANAPHYLACTIC SHOCK DUE TO ADVERSE EFFECT OF CORRECT DRUG OR MEDICAMENT PROPERLY ADMINISTERED 14,820.00
10,374.00
4,446.00
T88.7 UNSPECIFIED ADVERSE EFFECT OF DRUG OR MEDICAMENT; ADVERSE EFFECT OF CORRECT DRUG OR MEDICAMENT PROPERLY ADMINISTERED; ALLERGIC REACTIION TO CORRECT DRUG OR MEDICAMENT PROPERLY ADMINISTERED; HYPERSENSITIVITY TO CORRECT DRUG OR MEDICAMENT PROPERLY ADMINISTE 12,090.00
8,463.00
3,627.00
T90.0 SEQUELAE OF SUPERFICIAL INJURY OF HEAD 16,575.00
11,602.50
4,972.50
T90.1 SEQUELAE OF OPEN WOUND OF HEAD 16,575.00
11,602.50
4,972.50
T90.2 SEQUELAE OF FRACTURE OF SKULL AND FACIAL BONES 16,575.00
11,602.50
4,972.50
T90.5 SEQUELAE OF INTRA CRANIAL INJURY 16,575.00
11,602.50
4,972.50
T90.8 SEQUELAE OF OTHER SPECIFIED INJURIES OF HEAD 16,575.00
11,602.50
4,972.50
T90.9 SEQUELAE OF UNSPECIFIED INJURY OF HEAD 16,575.00
11,602.50
4,972.50
T91.0 SEQUELAE OF SUPERFICIAL INJURY AND OPEN WOUND OF NECK AND TRUNK 16,575.00
11,602.50
4,972.50
T91.1 SEQUELAE OF FRACTURE OF SPINE 16,575.00
11,602.50
4,972.50
T91.2 SEQUELAE OF OTHER FRACTURE OF THORAX AND PELVIS 16,575.00
11,602.50
4,972.50
T91.3 SEQUELAE OF INJURY OF SPINAL CORD 16,575.00
11,602.50
4,972.50
T92.0 SEQUELAE OF OPEN WOUND OF UPPER LIMB 16,575.00
11,602.50
4,972.50
T92.1 SEQUELAE OF FRACTURE OF ARM 16,575.00
11,602.50
4,972.50
T92.8 SEQUELAE OF OTHER SPECIFIED INJURIES OF UPPER LIMB 16,575.00
11,602.50
4,972.50
T93.0 SEQUELAE OF OPEN WOUND OF LOWER LIMB 16,575.00
11,602.50
4,972.50
T93.1 SEQUELAE OF FRACTURE OF FEMUR 16,575.00
11,602.50
4,972.50
T93.2 SEQUELAE OF OTHER FRACTURES OF LOWER LIMB 16,575.00
11,602.50
4,972.50
T93.3 SEQUELAE OF DISLOCATION SPRAIN AND STRAIN OF LOWER LIMB 16,575.00
11,602.50
4,972.50
T93.8 SEQUELAE OF OTHER SPECIFIED INJURIES OF LOWER LIMB 16,575.00
11,602.50
4,972.50
T94.0 SEQUELAE OF INJURIES INVOLVING MULTIPLE BODY REGIONS 16,575.00
11,602.50
4,972.50
T94.1 SEQUELAE OF INJURIES, NOT SPECIFIED BY BODY REGIONS 16,575.00
11,602.50
4,972.50
T95.0 SEQUELAE OF BURN, CORROSION AND FROSTBITE OF HEAD AND NECK 16,575.00
11,602.50
4,972.50
T95.2 SEQUELAE OF BURN, CORROSION AND FROSTBITE OF UPPER LIMB 16,575.00
11,602.50
4,972.50
T95.3 SEQUELAE OF BURN, CORROSION AND FROSTBITE OF LOWER LIMB 16,575.00
11,602.50
4,972.50
T95.8 SEQUELAE OF OTHER SPECIFIED BURN CORROSION AND FROSTBITE 16,575.00
11,602.50
4,972.50
T95.9 SEQUELAE OF UNSPECIFIED BURN, CORROSION AND FROSTBITE 16,575.00
11,602.50
4,972.50
T98.2 SEQUELAE OF CERTAIN EARLY COMPLICATIONS OF TRAUMA 16,575.00
11,602.50
4,972.50
Y40.0 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: SYSTEMIC ANTIBIOTICS: PENICILLINS 14,235.00
9,964.50
4,270.50
Y40.1 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: SYSTEMIC ANTIBIOTICS: CEFALOSPORINS AND OTHER BETA- LACTAM ANTIBIOTICS 14,235.00
9,964.50
4,270.50
Y40.2 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: SYSTEMIC ANTIBIOTICS: CHLORAMPHENICOL GROUP 14,235.00
9,964.50
4,270.50
Y40.4 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: SYSTEMIC ANTIBIOTICS: TETRACYCLINES 14,235.00
9,964.50
4,270.50
Y40.6 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: SYSTEMIC ANTIBIOTICS: RIFAMYCINS 14,235.00
9,964.50
4,270.50
Y40.8 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: SYSTEMIC ANTIBIOTICS: OTHER SYSTEMIC ANTIBIOTICS 14,235.00
9,964.50
4,270.50
Y40.9 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: SYSTEMIC ANTIBIOTICS: SYSTEMIC ANTIBIOTIC, UNSPECIFIED 14,235.00
9,964.50
4,270.50
Y41.0 SULFONAMIDES 14,235.00
9,964.50
4,270.50
Page 103 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate Y41.1 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: SYSTEMIC ANTIBIOTICS: ANTIMYCOBACTERIAL DRUGS 14,235.00
9,964.50
4,270.50
Y41.5 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: SYSTEMIC ANTIBIOTICS: ANTIVIRAL DRUGS 14,235.00
9,964.50
4,270.50
Y41.8 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: SYSTEMIC ANTIBIOTICS: OTHER SPECIFIED SYSTEMIC ANTI-INFECTIVES AND ANTIPARASITICS; HYDROXYQUINOLINE DERIVATIVES 14,235.00
9,964.50
4,270.50
Y41.9 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: SYSTEMIC ANTI-INFECTIVE AND ANTIPARASITIC, UNSPECIFIED 14,235.00
9,964.50
4,270.50
Y42.0 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: GLUCOCORTICOIDS AND SYNTHETIC ANALOGUES 16,575.00
11,602.50
4,972.50
Y42.2 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: ANTITHYROID DRUGS 16,575.00
11,602.50
4,972.50
Y42.3 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: INSULIN AND ORAL HYPOGLYCAEMIC [ANTIDIABETIC] DRUGS 16,575.00
11,602.50
4,972.50
Y42.4 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: ORAL CONTRACEPTIVES;MULTIPLE-AND SINGLE- INGREDIENT PREPARATIONS 16,575.00
11,602.50
4,972.50
Y42.5 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: OTHER ESTROGENS AND PROGESTOGENS;MIXTURES AND SUBSTITUTES 16,575.00
11,602.50
4,972.50
Y43.0 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: ANTIALLERGIC AND ANTIEMETIC DRUGS 16,185.00
11,329.50
4,855.50
Y44.2 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: ANTICOAGULANTS 14,235.00
9,964.50
4,270.50
Y44.3 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: ANTICOAGULANT ANTAGONISTS, VITAMIN K AND OTHER COAGULANTS 14,235.00
9,964.50
4,270.50
Y45.1 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: SALICYLATES 16,575.00
11,602.50
4,972.50
Y45.2 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: PROPIONIC ACID DERIVATIVES;PROPANOIC ACID DERIVATIVES 16,575.00
11,602.50
4,972.50
Y45.3 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: OTHER NONSTEROIDAL ANTI-INFLAMMATORY DRUGS [NSAID] 16,575.00
11,602.50
4,972.50
Y45.5 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: 4-AMINOPHENOL DERIVATIVES 16,575.00
11,602.50
4,972.50
Y45.8 OTHER ANALGESICS AND ANTIPYRETICS 14,430.00
10,101.00
4,329.00
Y45.9 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: ANALGESIC, ANTIPYRETIC AND ANTI-INFLAMMATORY DRUG, UNSPECIFIED 14,430.00
10,101.00
4,329.00
Y46.2 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: HYDANTOIN DERIVATIVES 13,065.00
9,145.50
3,919.50
Y46.6 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: OTHER AND UNSPECIFIED ANTIEPILEPTICS 13,065.00
9,145.50
3,919.50
Y47.0 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: BARBITURATES, NOT ELSEWHERE CLASSIFIED 13,065.00
9,145.50
3,919.50
Y47.1 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: BENZODIAZEPINES 13,065.00
9,145.50
3,919.50
Y47.9 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: SEDATIVE, HYPNOTIC AND ANTIANXIETY DRUG, UNSPECIFIED;SLEEPING DRAUGHT NOS;SLEEPING DRUG NOS;SLEEPING TABLET NOS 13,065.00
9,145.50
3,919.50
Y49.5 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: OTHER ANTIPSYCHOTICS AND NEUROLEPTICS 13,065.00
9,145.50
3,919.50
Y49.6 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: PSYCHODYSLEPTICS [HALLUCINOGENS] 13,065.00
9,145.50
3,919.50
Page 104 of 105 of Annex A
Case Rate Health Facility Fee Professional Fee ICD Code Description First Case Rate Y51.3 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: OTHER PARASYMPATHOLYTICS [ANTICHOLINERGICS AND ANTIMUSCARINICS] AND SPASMOLYTICS, NOT ELSEWHERE CLASSIFIED;PAPAVERINE 13,065.00
9,145.50
3,919.50
Y51.7 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: BETA-ADRENORECEPTOR ANTAGONISTS, NOT ELSEWHERE CLASSIFIED 13,065.00
9,145.50
3,919.50
Y52.0 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: CARDIAC-STIMULANT GLYCOSIDES AND DRUGS OF SIMILAR ACTION 24,375.00
17,062.50
7,312.50
Y52.2 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: OTHER ANTIDYSRHYTHMIC DRUGS, NOT ELSEWHERE CLASSIFIED 24,375.00
17,062.50
7,312.50
Y53.8 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: OTHER AGENTS PRIMARILY AFFECTING THE GASTROINTESTINAL SYSTEM 16,185.00
11,329.50
4,855.50
Y54.3 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: BENZOTHIADIAZINE DERIVATIVES 16,185.00
11,329.50
4,855.50
Y54.8 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: AGENTS AFFECTING URIC ACID METABOLISM 16,185.00
11,329.50
4,855.50
Y55.0 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: OXYTOCIC DRUGS;ERGOT ALKALOIDS 16,185.00
11,329.50
4,855.50
Y55.3 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: ANTITUSSIVES 12,090.00
8,463.00
3,627.00
Y55.4 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: EXPECTORANTS 12,090.00
8,463.00
3,627.00
Y55.6 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: ANTIASTHMATICS, NOT ELSEWHERE CLASSIFIED: AMINOPHYLLINE, SALBUTAMOL, THEOBROMINE;THEOPHYLLINE 12,090.00
8,463.00
3,627.00
Y56.0 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: LOCAL ANTIFUNGAL, ANTI-INFECTIVE AND ANTI- INFLAMMATORY DRUGS, NOT ELSEWHERE CLASSIFIED 14,235.00
9,964.50
4,270.50
Y56.2 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: LOCAL ASTRINGENTS AND LOCAL DETERGENTS 10,335.00
7,234.50
3,100.50
Y56.3 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: EMOLLIENTS, DEMULCENTS AND PROTECTANTS 10,335.00
7,234.50
3,100.50
Y56.6 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: OTORHINOLARYNGOLOGICAL DRUGS AND PREPARATIONS 16,185.00
11,329.50
4,855.50
Y58.0 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: BCG VACCINE 16,185.00
11,329.50
4,855.50
Y58.4 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: TETANUS VACCINE 16,185.00
11,329.50
4,855.50
Y59.9 DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE: VACCINE OR BIOLOGICAL SUBSTANCE, UNSPECIFIED 16,185.00
11,329.50
4,855.50
Z34.0 SUPERVISION OF NORMAL FIRST PREGNANCY 13,260.00
9,282.00
3,978.00
Z34.8 SUPERVISION OF OTHER NORMAL PREGNANCY 13,260.00
9,282.00
3,978.00
Z34.9 SUPERVISION OF NORMAL PREGNANCY, UNSPECIFIED 13,260.00
9,282.00
3,978.00
Z35.0 SUPERVISION OF PREGNANCY WITH HISTORY OF INFERTILITY 13,260.00
9,282.00
3,978.00
Z35.1 SUPERVISION OF PREGNANCY WITH HISTORY OF ABORTIVE OUTCOME 13,260.00
9,282.00
3,978.00
Z35.2 SUPERVISION OF PREGNANCY WITH OTHER POOR REPRODUCTIVE OR OBSTETRIC HISTORY 13,260.00
9,282.00
3,978.00
Z35.4 SUPERVISION OF PREGNANCY WITH GRAND MULTIPARITY 13,260.00
9,282.00
3,978.00
Z35.5 SUPERVISION OF ELDERLY PRIMIGRAVIDA 13,260.00
9,282.00
3,978.00
Z35.6 SUPERVISION OF VERY YOUNG PRIMIGRAVIDA 13,260.00
9,282.00
3,978.00
Z35.7 SUPERVISION OF HIGH-RISK PREGNANCY DUE TO SOCIAL PROBLEMS 13,260.00
9,282.00
3,978.00
Z35.8 SUPERVISION OF OTHER HIGH-RISK PREGNANCIES 13,260.00
9,282.00
3,978.00
Z35.9 SUPERVISION OF HIGH-RISK PREGNANCY, UNSPECIFIED 13,260.00
9,282.00
3,978.00
Z39.0 CARE AND EXAMINATION IMMEDIATELY AFTER DELIVERY 3,900.00
2,730.00
1,170.00
Page 105 of 105 of Annex A