Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END 33512 CORONARY ARTERY BYPASS, AUTOGENOUS GRAFT, (EG, SAPHENOUS $1,769.08 20060701 99999999 33513 CORONARY ARTERY BYPASS, AUTOGENOUS GRAFT, (EG, SAPHENOUS $1,898.24 20060701 99999999 33514 CORONARY ARTERY BYPASS, AUTOGENOUS GRAFT, (EG, SAPHENOUS $2,005.59 20060701 99999999 33516 CORONARY ARTERY BYPASS, AUTOGENOUS GRAFT, (EG, SAPHENOUS $2,124.45 20060701 99999999 33517 CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S); SINGLE VEIN $137.41 20060701 99999999 33518 CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S); TWO VENOUS $259.37 20060701 99999999 33519 CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S); THREE VENOU $380.67 20060701 99999999 33521 CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S); FOUR VENOUS $503.04 20060701 99999999 33522 CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S); FIVE VENOUS $624.95 20060701 99999999 33523 CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S); SIX OR MORE $745.59 20060701 99999999 33530 REOPERATION, CORONARY ARTERY BYPASS PROCEDURE, MORE THAN ONE MONTH AFTER ORIGINA $313.28 20060701 99999999 33533 CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); SINGLE ARTERIAL GRAFT $1,847.57 20060701 99999999 33534 CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); TWO CORONARY ARTERIAL GRAFTS $1,718.37 20060701 99999999 33535 CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); THREE CORONARY ARTERIAL GRAFTS $1,875.81 20060701 99999999 33536 CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); FOUR OR MORE CORONARY ARTERIAL $2,031.76 20060701 99999999 33542 MYOCARDIAL RESECTION (EG, VENTRICULAR ANEURYSMECTOMY) $1,745.50 20060701 99999999 33545 REPAIR OF POSTINFARCTION VENTRICULAR SEPTAL DEFECT, $2,095.06 20060701 99999999 33548 SURGICAL VENTRICULAR RESTORATION PROCEDURE, INCLUDES PROSTHETIC PATCH, WHEN PERF $1,622.39 20060701 99999999 33572 CORONARY ENDARTERECTOMY, OPEN, ANY METHOD, OF LEFT ANTERIOR DESCENDING, CIRCUMFL $215.55 20060701 99999999 33600 CLOSURE OF ATRIOVENTRICULAR VALVE (MITRAL OR TRICUSPID) BY SUTURE OR PATCH $1,714.17 20060701 99999999 33602 CLOSURE OF SEMILUNAR VALVE (AORTIC OR PULMONARY) BY SUTURE OR PATCH $1,655.27 20060701 99999999 33606 ANASTOMOSIS OF PULMONARY ARTERY TO AORTA (DAMUS-KAYE- STANSEL PROCEDURE) $1,832.63 20060701 99999999 33608 REPAIR OF COMPLEX CARDIAC ANOMALY OTHER THAN PULMONARY ATRESIA WITH VENTRICULAR $1,906.45 20060701 99999999 33610 REPAIR OF COMPLEX CARDIAC ANOMALIES (EG, SINGLE VENTRICLE WITH SUBAORTIC OBSTRUC $1,863.63 20060701 99999999 33611 REPAIR OF DOUBLE OUTLET RIGHT VENTRICLE WITH INTRAVENTRICULAR TUNNEL REPAIR; $1,931.64 20060701 99999999 33612 REPAIR OF DOUBLE OUTLET RIGHT VENTRICLE WITH INTRAVENTRICULAR TUNNEL REPAIR; WIT $2,044.74 20060701 99999999 33615 REPAIR OF COMPLEX CARDIAC ANOMALIES (EG, TRICUSPID ATRESIA) BY CLOSURE OF ATRIAL $1,973.80 20060701 99999999 33617 REPAIR OF COMPLEX CARDIAC ANOMALIES (EG, SINGLE VENTRICLE) BY MODIFIED FONTAN PR $2,124.67 20060701 99999999 33619 REPAIR OF SINGLE VENTRICLE WITH AORTIC OUTFLOW OBSTRUCTION AND AORTIC ARCH HYPOP $2,393.57 20060701 99999999 33641 REPAIR ATRIAL SEPTAL DEFECT, SECUNDUM $1,283.21 20060701 99999999 33645 DIRECT OR PATCH CLOSURE, SINUS VENOSUS, WITH OR $1,525.81 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 148
PROC-CODE DESC MAC BEG END 33647 REPAIR OF ATRIAL SEPTAL DEFECT AND VENTRICULAR SEPTAL DEFECT, $1,769.42 20060701 99999999 33660 PATCH CLOSURE, ENDOCARDIAL CUSHION DEFECT, WITH OR $1,588.62 20060701 99999999 33665 PATCH CLOSURE, ENDOCARDIAL CUSHION DEFECT, WITH OR $1,750.26 20060701 99999999 33670 REPAIR OF COMPLETE ATRIOVENTRICULAR CANAL, WITH $1,818.87 20060701 99999999 33675 CLOSURE OF MULTIPLE VENTRICULAR SEPTAL DEFECTS; $1,489.58 20070101 99999999 33676 CLOSURE OF MULTIPLE VENTRICULAR SEPTAL DEFECTS; WITH PULMONARY VALVOTOMY OR INFU $1,534.13 20070101 99999999 33677 CLOSURE OF MULTIPLE VENTRICULAR SEPTAL DEFECTS; WITH REMOVAL OF PULMONARY ARTERY $1,594.33 20070101 99999999 33681 CLOSURE VENTRICULAR SEPTAL DEFECT $1,726.34 20060701 99999999 33684 CLOSURE VENTRICULAR SEPTAL DEFECT $1,775.76 20060701 99999999 33688 CLOSURE VENTRICULAR SEPTAL DEFECT $1,672.44 20060701 99999999 33690 BANDING OF PULMONARY ARTERY $1,225.68 20060701 99999999 33692 TOTAL REPAIR TETRALOGY OF FALLOT $1,820.78 20060701 99999999 33694 TOTAL REPAIR TETRALOGY OF FALLOT $1,849.26 20060701 99999999 33697 COMPLETE REPAIR TETRALOGY OF FALLOT WITH PULMONARY ATRESIA INCLUDING CONSTRUCTIO $1,979.80 20060701 99999999 33702 REPAIR SINUS OF VALSALVA FISTULA, WITH $1,647.23 20060701 99999999 33710 REPAIR SINUS OF VALSALVA FISTULA, WITH $1,765.77 20060701 99999999 33720 REPAIR SINUS OF VALSALVA ANEURYSM, WITH $1,626.27 20060701 99999999 33722 CLOSURE OF AORTICO-LEFT VENTRICULAR TUNNEL $1,702.46 20060701 99999999 33724 REPAIR OF ISOLATED PARTIAL ANOMALOUS PULMONARY VENOUS RETURN (EG, SCIMITAR SYNDR $1,055.96 20070101 99999999 33726 REPAIR OF PULMONARY VENOUS STENOSIS $1,390.51 20070101 99999999 33730 COMPLETE REPAIR OF ANOMALOUS VENOUS RETURN $1,794.03 20060701 99999999 33732 REPAIR OF COR TRIATRIATUM OR SUPRAVALVULAR MITRAL RING BY RESECTION OF LEFT ATRI $1,697.63 20060701 99999999 33735 ATRIAL SEPTECTOMY OR SEPTOSTOMY $1,246.81 20060701 99999999 33736 ATRIAL SEPTECTOMY OR SEPTOSTOMY; OPEN HEART WITH CARDIOPULMONARY BYPASS $1,477.64 20060701 99999999 33737 ATRIAL SEPTECTOMY OR SEPTOSTOMY $1,289.88 20060701 99999999 33750 SHUNT $1,209.87 20060701 99999999 33755 SHUNT $1,183.11 20060701 99999999 33762 SHUNT $1,222.85 20060701 99999999 33764 SHUNT $1,224.42 20060701 99999999 33766 SHUNT $1,372.33 20060701 99999999 33767 SHUNT; SUPERIOR VENA CAVA TO PULMONARY ARTERY FOR FLOW TO BOTH LUNGS (BIDIRECTIO $1,399.73 20060701 99999999 33768 ANASTOMOSIS, CAVOPULMONARY, SECOND SUPERIOR VENA CAVA (LIST SEPARATELY IN ADDITI $302.83 20060701 99999999 33770 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES WITH VENTRICULAR SEPTAL DEFECT AND $1,914.82 20060701 99999999 33771 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES WITH VENTRICULAR SEPTAL DEFECT AND $1,886.31 20060701 99999999 33774 RPR TRANSPSTN GRT VESSLS ARTRL BAFFE PROC;W/BYPASS $1,742.27 20060701 99999999 33775 RPR TRNSPSTN GRT VSSLS MUSTRD TYPE;W/RMVL BND $1,707.99 20060701 99999999 33776 RPR TRNSPSTN GRT VSSLS MSTED TYPE;W/CLSR SPTL DFCT $1,832.83 20060701 99999999 33777 REPAIR TRANSPOSITION OF GRT ARTERIES ATRIAL BAFFLE PROC W/CA $1,751.14 20060701 99999999 33778 RPR TRANS; AORTIC PULM ART RECONST $2,074.92 20060701 99999999 33779 REPAIR TRANSPOSITION OF GRT ARTERIES AORTIC PULMONARY ARTERY $2,006.94 20060701 99999999 33780 REPAIR TRANSPOSITION OF GRT ARTERIES AORTIC PULMONARY ARTERY $2,080.11 20060701 99999999 33781 REPAIR TRANSPOSITION OF GRT ARTERIES AORTIC PULMONARY ARTERY $1,970.50 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 149
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