Federal subject to approval of CMS State Plan Amendment. Members and providers must be – notified in advance. Medically necessary services for children are required through EPSDT and may not be eliminated. State subject to approval of state rulemaking and changes to statute 22 MRSA §3174-Q. – Maintenance of Effort Requirements? ☐ Yes x No Procedures Performed and Billed to MaineCare by Code Number: Procedure Code Procedure Count of Procedure 25000 630 Anesth Incision Spine of Tendon Cord Sheath Surgery 1 1 25111 1992 Remove Anesth N Wrist Block/Inj Tendon Prone Lesion 9 3 Re-remove Wrist Tendon 25112 Lesion 1 11311 Shave Skin Lesion 1 Exc Face-Mm Malig+marg 11643 25130 Removal of Wrist Lesion 1 1 25215 Removal of Wrist Bones 1 11970 Replace Tissue Expander 1 13152 25310 Repair Transplant of Wound Forearm or Tendon Lesion 1 2 25447 13160 Repair Late Closure Wrist Joint(s) of Wound 2 1 25609 Treat Fx Radial 3+ Frag 2 15823 Revision of Upper Eyelid 8 26055 20525 Incise Removal Finger of Foreign Tendon Body Sheath 8 1 26075 Explore/Treat Finger Joint 1 20610 Drain/Inject Joint/Bursa 1 20680 26115 Exc Removal Hand of Les Support Sc < 1.5 Implant Cm 2 1 23120 26121 Partial Release Removal Palm Contracture Collar Bone 1 1 23410 26123 Repair Release Rotator Palm Contracture Cuff Acute 1 1 26145 23412 Tendon Repair Rotator Excision Cuff Palm/Finger Chronic 1 2 26160 Remove Tendon Sheath Lesion 5 24305 Arm Tendon Lengthening 2 26350 24359 Repair Repair Finger/Hand Elbow Deb/Attch Tendon Open 1 1 26356 Repair Finger/Hand Tendon 1 26418 Repair Finger Tendon 1 26426 Repair Finger/Hand Tendon 1 26520 Release Knuckle Contracture 1 26608 Treat Metacarpal Fracture 1 26860 Fusion of Finger Joint
Federal – subject to approval of CMS State Plan Amendment. Members and providers must be notified in advance. Medically necessary services for children are required through EPSDT and may not be eliminated. State – subject to approval of state rulemaking and changes to statute 22 MRSA §3174-Q. Maintenance of Effort Requirements? ☐ Yes x No Procedures Performed and Billed to MaineCare by Code Number: Procedure Code Procedure Count of Procedure 630 Anesth Spine Cord Surgery 1 1992 Anesth N Block/Inj Prone 3 11311 Shave Skin Lesion 1 11643 Exc Face-Mm Malig+marg 1 11970 Replace Tissue Expander 1 13152 Repair of Wound or Lesion 1 13160 Late Closure of Wound 1 15823 Revision of Upper Eyelid 8 20525 Removal of Foreign Body 1 20610 Drain/Inject Joint/Bursa 1 20680 Removal of Support Implant 2 23120 Partial Removal Collar Bone 1 23410 Repair Rotator Cuff Acute 1 23412 Repair Rotator Cuff Chronic 2 24305 Arm Tendon Lengthening 2 24359 Repair Elbow Deb/Attch Open 1 25000 Incision of Tendon Sheath 1 25111 Remove Wrist Tendon Lesion 9 25112 Re-remove Wrist Tendon Lesion 1 25130 Removal of Wrist Lesion 1 25215 Removal of Wrist Bones 1 25310 Transplant Forearm Tendon 2 25447 Repair Wrist Joint(s) 2 25609 Treat Fx Radial 3+ Frag 2 26055 Incise Finger Tendon Sheath 8 26075 Explore/Treat Finger Joint 1 26115 Exc Hand Les Sc < 1.5 Cm 1 26121 Release Palm Contracture 1 26123 Release Palm Contracture 1 26145 Tendon Excision Palm/Finger 1 26160 Remove Tendon Sheath Lesion 5 26350 Repair Finger/Hand Tendon 1 26356 Repair Finger/Hand Tendon 1 26418 Repair Finger Tendon 1 26426 Repair Finger/Hand Tendon 1 26520 Release Knuckle Contracture 1 26608 Treat Metacarpal Fracture 1 26860 Fusion of Finger Joint
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