PRIVACY PRACTICES

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Innova Primary Care Notice of Privacy Practices

Innova Primary Care Notice of CMS MSSP ACO

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Non-Covered Services (08/07/2023)	Innova Fee
Each page of medical paperwork, letters or forms for completion within 5 business days.	$10.00
Expedited processing for medical paperwork, letters or forms for completion within 2 business days.	$25.00
Each Clinical response to a patient portal inquiry outside of an appointment or Medicare e-visit.	$15.00
Results already provided on the portal, printed and mailed outside an appointment	$15.00

Non-Service Fees (8/8/2023)	Innova Fee
Patient late cancellation fee (less than 24 hours notice/10 minutes late for appointment)	$25.00
No-show fee for missing a routine appointment	$50.00
No-Show of an Annual Wellness Visit	$100.00

*Some of the most commonly provided services at Innova	Innova Fee	CPT Code
*Established Patient Office Visit Level 3	$111.00	99213
*Established Patient Office Visit Level 4	$157.00	99214
*Injection in deep muscle or subcutis	$29.00	96372
*Medical Service provided on holiday eve, holiday or weekend	$28.00	99051
*Chronic Care Management (Medicare program)	$61.00	99490
*Established Patient Preventive Care for Age 18 - 39 years old	$123.00	99395
*Established Patient Preventive Care for Age 40-64 years old	$134.00	99396
*In office Flu Swab	$17.00	87804
*Immunization injection administered	$29.00	90471
*Steroid (Injectable) Medication	$8.00	J0702
Treatment of used to clear a skin lesion of pus to start the healing process	$177.00	10060
Treatment of used to clear a skin lesion of pus to start the healing process	$306.00	10061
Procedure where a small round piece of tissue is sent to the lab for biopsy	$180.00	11104
Skin tag removal of 1 lesion	$128.00	11200
Skin tag removal of more than 1 lesion	$27.00	11201
Shave removal of skin lesion on midsection less than 0.5 cm	$145.00	11300
Shave removal of skin lesion on midsection 0.6 cm to 1.0 cm	$174.00	11301
Shave removal of skin lesion on midsection 1.0 to 1.2 cm	$197.00	11302
Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia	$153.00	11305
Shave removal of a single lesion, scalp, neck, hands, feet, genitalia	$175.00	11306
Shave removal of a single lesion, face, ears, eyelids, nose, lips less than 0.5 cm	$166.00	11310
Shave removal of a single lesion, face, ears, eyelids, nose, lips 0.6 cm to 1 cm	$196.00	11311
Shave removal of a single lesion, face, ears, eyelids, nose, lips 1.0 cm to 2.0 cm	$223.00	11312
Excision of benign (normal) lesion including margins 0.6 cm to 1 cm	$223.00	11401
Nailbed removal	$164.00	11730
Removal of Implanted Device	$191.00	11982
Wound or cut greater or equal to 2 cm	$134.00	12001
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet)	$162.00	12002
Other Repair (Closure) Procedures on the Integumentary System	$99.00	15851
Removal of first lesion	$96.00	17000
Removal of 2 to 14 skin lesions (1 additional unit for each)	$10.00	17003
Removal of 15 or more skin lesions	$238.00	17004
Removal of skin lesions	$485.00	17106
Removal of 1 to 14 skin lesions	$160.00	17110
Destruction (laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags	$187.00	17111
Chemical Cauterization of Skin	$127.00	17250
Cryo (freezing) treatment of skin	$76.00	17340
Small joint or bursa injection	$73.00	20600
Intermediate joint or bursa injection	$79.00	20605
Marge joint or bursa injection	$93.00	20610
Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method	$398.00	30802
Incision Procedures on the Vulva, Perineum and Introitus	$215.00	56405
Nerve Block Injection	$109.00	64405
Removal of unspecified object from eye	$70.00	65205
Removal of unspecified object from ear	$114.00	69200
Removal of impacted ear wax	$21.00	69209
Ear Cleaning	$69.00	69210
Imaging Exam	$43.00	76000
Ultrasound of abdomen complete including kidneys	$114.00	76770
Ultrasound of tendon or a muscle	$59.00	76882
Urine Drug Screening	$12.00	80305
In office urinalysis	$3.00	81002
In office urine pregnancy test	$3.00	81025
In office blood sugar test	$3.00	82962
Skin injection to test for tuberculosis	$6.00	86580
In office blood test for Mono	$12.00	87449
COVID-19 infectious agent antigen detection by immunoassay (quick test)	$36.00	87426
COVID-19/Flu-A/Flu-B infectious agent antigen detection by immunoassay (quick test)	$39.00	87428
Pediatric injection administered (given)	$29.00	90460
Additional pediatric injection administered	$20.00	90461
Additional Immunization injections administered	$22.00	90472
Menactra Vaccine	$167.00	90619
Hepatitis A vaccine injection for pediatric and adolescent	$38.00	90633
Hepatitis A and B Vaccine Adult	$127.00	90636
HIB Vaccine	$13.00	90648
Gardasil or HPV vaccine for ages 9 to 26	$161.00	90649
Gardasil Vaccine	$288.00	90651
High Dose Flu Vaccine for patients over 65 years old	$84.00	90662
Pneumonia Vaccine in vial	$227.00	90670
Pneumonia vaccine injection, 20 valent	$299.00	90677
Rotavirus vaccine	$96.00	90680
Dtap vaccine for ages 6 and younger	$29.00	90700
MMR Vaccine Injection	$93.00	90707
IPV Vaccine Injection	$43.00	90713
Tetanus and Whooping Cough Vaccine Injection	$39.00	90715
Chickenpox Vaccine Injection	$175.00	90716
Pediarix Vaccine Injection	$98.00	90723
Pneumonia Vaccine Injection	$118.00	90732
Menactra Vaccine Injection	$158.00	90734
Hepatitis B Pediatric Dose or Adult Dose	$28.00	90744
Hepatitis B Vaccine for Adult Injection	$67.00	90746
Shingles Vaccine Injection	$198.00	90750
Diabetic retinal screening	$44.00	92250
Complete EKG	$17.00	93000
EKG recorded and reviewed	$229.00	93268
Ambulatory Blood Pressure Monitoring	$53.00	93784
Cerebrovascular Arterial Ultrasound	$319.00	93890
Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries	$98.00	93922
Complete bilateral noninvasive physiologic studies of extremity arteries, 3 or more levels	$152.00	93923
Noninvasive physiologic studies of lower extremity arteries	$188.00	93924
Evaluation of arterial inflow and venous outflow of abdomen and/or pelvic organs	$319.00	93975
Lower extremity ultrasound with doppler	$140.00	93979
In office test used to assess how well your lungs work to diagnosis asthma and COPD	$31.00	94010
Nebulizer treatment in office	$13.00	94640
Pulse Oxygen	$4.00	94760
Immunotherapy Injection	$13.00	95117
Immunotherapy Observation	$162.00	95180
Blood Glucose Monitoring	$162.00	95250
Blood Glucose Monitoring	$68.00	95249
Glucose monitor for continuous	$42.00	95251
Brief emotional or behavioral assessment	$8.00	96127
IV initial	$48.00	96360
IV add on	$19.00	96361
Injection	$28.00	96373
After hours call/consult after 10PM	$28.00	99050
Screening Vision Test	$4.00	99173
New Patient Office Visit Level 3	$151.00	99203
New Patient Office Visit Level 4	$225.00	99204
New patient office visit level 5	$297.00	99205
Established Patient Office Visit Level 1	$34.00	99211
Established Patient Office Visit Level 5	$220.00	99215
New Patient Preventive Care for Age 1-4 years old	$158.00	99382
New Patient Preventive Care for Age 5-11 years old	$164.00	99383
New Patient Preventive Care for Age 12-17 years old	$186.00	99384
New Patient Preventive Care for Age 18 -39 years old	$180.00	99385
New Patient Preventive Care for Age 40 - 64 years old	$165.00	99386
Established Patient Preventive Care for less than 1 year old	$111.00	99391
Established Patient Preventive Care for Age 1-4 years old	$119.00	99392
Established Patient Preventive Care for Age 5-11 years old	$119.00	99393
Established Patient Preventive Care for Age 12-17 years old	$130.00	99394
Established Patient Preventive Care for Age 65 and over	$151.00	99397
Smoking and tobacco use counseling to the patient for 3-10 minutes	$21.00	99406
E-visit 5-10 minutes via portal	$15.00	99421
E-visit 11-20 minutes via portal	$30.00	99422
E-visit 21+ minutes via portal	$50.00	99423
CCM (Chronic Care Management) staff time additional 20 minutes	$64.00	99439
Provider Phone Evaluation	$98.00	99443
Providing care planning to individuals with cognitive impairment	$355.00	99483
First 60 minutes of non-face-to-face care by clinical staff for complex chonic care	$127.00	99487
Additional 30 minutes of non-face-to-face care by clinical staff for complex chronic care	$67.00	99489
Chronic Care (Medicare Program)	$65.00	99490
Chronic Care Management (Medicare program) Provider Call	$91.00	99491
Transition of Care Management Communication within 14 days of discharge	$274.00	99495
Transition of Care Management Communication within 7 days of discharge	$371.00	99496
Advanced Care Plan	$119.00	99497
Administration of Flu Vaccine	$29.00	G0008
Administration of Pneumonia Vaccine	$29.00	G0009
Administration of Hepatitis B Vaccine	$29.00	G0010
Diabetes self-management training services, group session (2 or more), per 30 minutes	$25.00	G0109
Physician service required to document the need for a power mobility device	$15.00	G0372
Initial Preventive Examination; face-to-face visit, new CMS patient during first 12mths	$231.00	G0402
EKG at the Welcome to Medicare Preventive Visit	$17.00	G0403
Annual Wellness Visit Initial Visit	$231.00	G0438
Annual Wellness Visit Visit	$180.00	G0439
Screening for alcohol misuse and brief behavioral counseling	$28.00	G0442
Screening for alcohol misuse and brief behavioral counseling	$42.00	G0443
Annual depression screening	$28.00	G0444
Personally performing CCM (Chronic Care Management) care planning	$64.00	G0506
Remote image submit by pt	$19.00	G2010
Brief check in by md/qhp	$23.00	G2012
Visit occuring in Primary Care setting	$17.00	G2211
Antibiotic medication injection	$1.00	J0696
Steroid (injectable) medication	$7.00	J0702
Osteoporosis treatment injection	$25.00	J0897
Steroid, anti-inflammatory (injectable) medication	$11.00	J1040
Testosterone medication injection	$1.00	J1071
Betamix Medication for injection	$1.00	J1100
Toradol medication injection- Nonsteroidal anti-inflammatory drug to treat pain	$1.00	J1885
Anti-nausea medication injection	$4.00	J2550
Vitamin B-12 Injection	$2.00	J3420
Saline solution for wound care cleaning	$3.00	J7030
CCM (Chronic Care Management) staff time additional 20 minutes	$47.00	99439
Diabetic Retinal Screening	$53.00	92250
Flublok Vaccine	$84.00	90673
COVID/RSV/FluA/FluB Four-plex PCR Test	$143	0241U

Labs	Innova Fee	CPT Code
Basic Metabolic Panel	$9.00	80048
General Health Panel	$31.00	80050
Electrolyte Panel	$7.00	80051
Comprehensive Metabolic Panel	$11.00	80053
Obstetric Panel	$45.00	80055
Lipid Panel	$14.00	80061
Hepatic Function Panel	$9.00	80076
Microalbumin-Quantitative	$6.00	82043
Assay of Vitamin D	$31.00	82306
Assay of CK (CPK)	$7.00	82550
Assay of Urine Creatinine	$6.00	82570
Vitamin B-12	$16.00	82607
Assay of Estradol	$29.00	82670
Assay of Ferritin	$14.00	82728
Assay Of GGT	$8.00	82977
Glycated Hemoglobin Test	$12.00	83036
Assay Of Insulin	$12.00	83525
Assay Of Iron	$7.00	83540
Lactate (Ld) (Ldh) Enzyme	$7.00	83615
Assay Of Magnesium	$7.00	83735
Assay Of Phosphorus	$5.00	84100
Assay Of Serum Potassium	$5.00	84132
Assay Of Progesterone	$22.00	84144
Assay Of PSA- Total	$19.00	84153
Assay Of Serum Sodium	$5.00	84295
Assay Of Free Thyroxine	$10.00	84439
Assay Thyroid Stim Hormone	$18.00	84443
Free Assay (Ft-3)	$18.00	84481
Assay Of Blood/Uric Acid	$5.00	84550
Complete Cbc W/Auto Diff Wbc	$8.00	85025