Simple Fracture

Instructions to Plans and Issuers: Do not modify this tab. The numbers shown here roll up from the

Simple Fracture

Scenario tab.

Sample Care Costs
Other Facility Services
Ambulance
Professional Services: Emergency Departmen
Professional Services: Specialist
Professional Services: Physical Therapy
Diagnostic Services: Radiology
Durable Medical Equipment
Total (unrounded)

$37
$593
$557
$293
$216
$30
$199
$1,925

Assumptions
The following are assumptions that all group health plans and health insurance issuers must use for this scenario.
Standard Assumptions
These assumptions are standard across all scenarios.
Costs do not include premiums.
Condition was not excluded as a pre-existing condition.
There are no other medical expenses for any member covered under the plan or policy.
All care is in-network and considered first tier (or the tier associated with the lowest level of cost sharing), for those products that incorporate tiered provider networks.
No out-of-network charges or any other variation in Sample Care Costs.
All services occur in same policy period.
All prior authorizations were obtained.
All services were deemed medically necessary.
All costs (allowed amount, sample care costs, member costs) greater than $100 are rounded to the nearest hundredth.
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the nearest tenth.
All medications are covered as generic equivalents if available.
If the plan has a wellness program that varies the deductibles, copayments, coinsurance, or coverage for any of the services listed in a treatment scenario, the plan or issuer
must complete the calculations for that treatment scenario assuming that the patient is NOT participating in the wellness program.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

Medical Condition:

Simple Fracture

Note: Services on this tab are listed individually for classification and pricing purposes to facilitate the population of the “Sample care costs” section. HHS specifies the Category in order to roll up costs into that
category in the "Sample care costs" section so that those costs are uniform across all group health plans and health insurance issuers. However, some plans or issuers may classify an item or service under another
category. The plan or issuer should apply its cost sharing and benefit features for each plan or policy in order to complete the “You pay” section, but must leave as is the "Sample care costs" section. Examples of cost
sharing and benefit features include, but are not limited to:
• Payment of services based on the location such as inpatient, outpatient, or office; and
• Payment of items as prescription drugs vs. medical equipment.
Explanation of Scenario:
Total – the sum of allowed amounts for the listed items and services, which is cross-referenced in the "Label and Assumptions" tab, where it is rounded.
Date of Service – includes the day and month of service so plans and issuers understand the order in which items or services are rendered.
ICD-9 Diagnosis Code – includes the ICD-9 code for each item or service.
ICD-10 Diagnosis Code – includes the ICD-10 code for each item or service.
CPT, HCPCS or Other Billing Code – includes medical codes for each item or service. Over-the-counter medications are listed as OTC.
Provider Type – includes one of the types listed on the "Provider Types" tab to classify each item or service by provider.
Category – includes one of the categories listed on the "Categories" tab to classify each item or service so it rolls up into the same category in the "Label and Assumptions" tab.
Description – includes the short form descriptor for a CPT code, or an appropriate descriptor for a non-CPT billing code.
Allowed Amount – includes an estimated national average allowed amount for each item or service, which plans or issuers must use to calculate cost sharing.
CPT copyright 2010 American Medical Association. All rights reserved.
CPT is a registered trademark of the American Medical Association.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
Totals:

$1,925.04

Date of
Service

ICD-9
Diagnosis
Code

ICD-10
Diagnosis
Code

CPT©, HCPCS, or Other Billing Code

Provider Type

Category

Description

Allowed Amount

02-Jun

959.7

S99929A

A0425

Ambulance (land)

Ambulance

Ground mileage, per
statute mile

$75.95

02-Jun

959.7

S99929A

A0429

Ambulance (land)

Ambulance

Ambulance service, basic
life support, emergency
transport (bls-emergency)

$516.60

02-Jun

825.25

S92353A

99284

Emergency department
visit for evaluation and
management of patient,
Professional Services:
which req 3 key
Outpatient Hospital
Emergency
components. Usually,
Department
presenting problem(s) are
high severity, & require
urgent physician evaluation
but do not pose

02-Jun

825.25

S92353A

73630

Outpatient Hospital

Professional Services:
Emergency
Department

Radiologic examination,
foot; complete, minimum
of 3 views

$271.37

$33.92

02-Jun

02-Jun

02-Jun

825.25

825.25

S92353A

S92353A

V54.16

28470

L4387

E0114

Outpatient Hospital

Professional Services:
Closed treatment of
Emergency
metatarsal fracture;
Department
without manipulation, each

$252.12

Outpatient Hospital

Durable Medical
Equipment

Walking boot, nonpneumatic, with or without
joints, with or without
interface material,
prefabricated, off-the-shelf

$162.00

Pharmacy Retail

Durable Medical
Equipment

Crutches, underarm, other
than wood, adjustable or
fixed, pair, with pads, tips,
and handgrips

$36.61

$109.78

Professional Services: Application of short leg cast
(below knee to toes);
Specialist

$110.59

Cast supplies, short leg cast,
adult (11 years +), fiberglass

$37.14

Radiologic examination,
foot; 2 views

$30.20

16-Jun

825.25

S92353A

99203

Office or other outpatient
visit for the evaluation and
management of a new
Professional Services: patient, which requires at
Outpatient Hospital
Specialist
least 3 key components.
Physicians typically spend
30 minutes face-to-face
with the patient.

16-Jun

825.25

S92353A

29405

Outpatient Hospital

16-Jun

825.25

S92353A

Q4038

Outpatient Hospital Other Facility Services

28-Jul

825.25

S92353A

73600

28-Jul

825.25

S92353A

99213

Primary

Primary

Diagnostic Services:
Radiology

Office or other outpatient
visit for the evaluation and
management of an
Professional Services: established patient, which
Specialist
requires at least 2 of 3 key
components. Physicians
typically spend 15 minutes
face-to-face with the

$73.00

04-Aug

825.25

S92353A

97001

Physical Therapy

Professional Services:
Physical therapy evaluation
Physical Therapy

$75.00

Therapeutic procedure, 1
or more areas, each 15
minutes; therapeutic
Professional Services:
$46.92
exercises to develop
04-Aug
825.25
S92353A
97110
Physical Therapy
Physical Therapy
strength and endurance,
range of motion and
flexibility
Therapeutic procedure, 1
or more areas, each 15
minutes; therapeutic
Professional Services:
$46.92
11-Aug
825.25
S92353A
97110
Physical Therapy
exercises to develop
Physical Therapy
strength and endurance,
range of motion and
flexibility
Therapeutic procedure, 1
or more areas, each 15
minutes; therapeutic
Professional Services:
$46.92
18-Aug
825.25
S92353A
97110
Physical Therapy
exercises to develop
Physical Therapy
strength and endurance,
range of motion and
flexibility
** Inpatient costs were calculated based on national averages using the indicated DRG codes. Additional variances may occur based on how health plan hospital contracts are structured (e.g., case rate, per diems, percentage of billed charges, etc.)

The following are the provider types to use on the "Scenario" tab ~ "Provider Type" column to classify each service by provider type. This aids group
health plans and health insurance issuers in applying benefits to each item and service.
Provider Type
Ambulance (land)
Outpatient Hospital
Pharmacy Retail
Primary
Physical Therapy

What providers are covered under this Provider Type and other notes:

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

The following are the categories to use on the "Scenario" tab ~ "Category" column to classify each item and service so it rolls up to
the same category in the Coverage Example label on the "Label and Assumptions" tab. This facilitates consistency between the
"Scenario" tab and Coverage Example label.
Category
What services are covered under this Category and other notes:
Ambulance
Professional Services: Emergency Department
Other Facility Services
Durable Medical Equipment
Professional Services: Specialist
Diagnostic Services: Radiology
Professional Services: Physical Therapy
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146