Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END G0055 GLUCOSE POST DOSE (INCLUDES GLUCOSE) DIRECT MEASUREMENT BY A GLUCOSE TESTING DEV $5.53 19990701 99999999 G0056 GLUCOSE TOLERANCE TEST (GTT), BY DIRECT MEASUREMENT BY GLUCOSE TESTING DEVICE AP $15.68 19990701 99999999 G0057 GLUCOSE TOLERANCE TEST (GTT), BY DIRECT MEASUREMENT BY A GLUCOSE TESTING DEVICE $4.64 19990701 99999999 G0058 AUTOMATED MULTICHANNEL TEST; 20 CLINICAL CHEMISTRY TESTS $15.78 19990701 99999999 G0059 AUTOMATED MULTICHANNEL TEST; 21 CLINICAL CHEMISTRY TESTS $16.27 19990701 99999999 G0060 AUTOMATED MULTICHANNEL TEST, 22 CLINICAL CHENISTRY TESTS $16.77 19990701 99999999 G0062 PERIPHERAL SKELETAL BONE MINERAL DENSITY STUDIES (E.G., RADIUS, WRIST, HEEL). $41.19 19990701 99999999 G0063 CENTRAL SKELETAL BONE MINERAL DENSITY STUDIES (E.G., SPINE, PELVIS). $137.13 19990701 99999999 G0064 PHYSICIAN SUPERVISION OF A PATIENT UNDER CARE OF A HOME HEALTH AGENCY (PATIENT N $80.26 19990701 99999999 G0065 PHYSICIAN SUPERVISION OF A HOSPICE PATIENT (PATIENT NOT PRESENT) REQUIRING COMPL $80.26 19990701 99999999 G0071 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $50.43 19990701 99999999 G0072 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $61.59 19990701 99999999 G0073 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $78.43 19990701 99999999 G0074 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $86.80 19990701 99999999 G0075 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $133.61 19990701 99999999 G0076 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $145.70 19990701 99999999 G0077 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPR $64.06 19990701 99999999 G0078 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPR $76.16 19990701 99999999 G0079 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE IN AN OFFICE OR OUTPATIENT FACILITY, APPRO $84.84 19990701 99999999 G0080 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPR $93.83 19990701 99999999 G0081 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPR $119.25 19990701 99999999 G0082 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPR $132.27 19990701 99999999 G0083 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $54.46 19990701 99999999 G0084 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $72.61 19990701 99999999 G0085 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $84.94 19990701 99999999 G0086 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $94.24 19990701 99999999 G0087 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $143.84 19990701 99999999 G0088 INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE $157.48 19990701 99999999 G0089 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITA $57.25 19990701 99999999 G0090 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITA $70.89 19990701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 34
PROC-CODE DESC MAC BEG END G0091 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITA $89.28 19990701 99999999 G0092 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITA $99.51 19990701 99999999 G0093 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITA $140.70 19990701 99999999 G0094 INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITA $156.83 19990701 99999999 G0101 CERVICAL OR VAGINAL CANCER SCREENING; PELVIC AND CLINICAL BREAST EXAMINATION $23.84 20060701 99999999 G0102 PROSTATE CANCER SCREENING; DIGITAL RECTAL EXAMINATION $9.02 20060701 99999999 G0103 PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA), TOTAL $25.42 20060701 99999999 G0104 COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY $55.97 20060701 99999999 G0105 COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK $189.81 20060701 99999999 G0106 COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARI $140.76 20060701 99999999 G0107 COLORECTAL CANCER SCREENING; FECAL-OCCULT BLOOD TEST, 1-3 SIMULTANEOUS DETERMINA $4.49 19990701 99999999 G0108 DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING SERVICES, INDIVIDUAL, PER SESSION $34.21 20060701 99999999 G0109 DIABETES SELF-MANAGEMENT TRAINING SERVICES, GROUP SESSION, PER INDIVIDUAL $20.15 20060701 99999999 G0110 NETT PULM-REHAB; EDUCATION/SKILLS TRAINING, INDIVIDUAL $46.33 20030401 99999999 G0111 NETT PULM-REHAB; EDUCATION/SKILLS TRAINING, GROUP $14.52 20030401 99999999 G0112 NETT PULM-REHAB; NUTRITIONAL GUIDANCE, INITIAL $91.66 20030401 99999999 G0113 NETT PULM-REHAB; NUTRITIONAL GUIDANCE, SUBSEQUENT $65.90 20030401 99999999 G0114 NETT PULM-REHAB; PSYCHOSOCIAL CONSULTATION $60.64 20030401 99999999 G0115 NETT PULM-REHAB; PSYCHOLOGICAL TESTING $60.95 20030401 99999999 G0116 NETT PULM-REHAB; PSYCHOSOCIAL COUNSELLING $55.99 20030401 99999999 G0117 GLAUCOMA SCREENING FOR HIGH RISK PATIENTS FURNISHED BY AN OPTOMETRIST OR OPHTHAL $25.39 20060701 99999999 G0118 GLAUCOMA SCREENING FOR HIGH RISK PATIENT FURNISHED UNDER THE DIRECT SUPERVISION $9.29 20060701 99999999 G0120 COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0105, SCREENING COLONOSCOPY, BARIUM $140.76 20060701 99999999 G0121 COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR $211.36 20060701 99999999 G0123 SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED I $28.00 20060701 99999999 G0124 SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED I $22.89 20060701 99999999 G0125 PET LUNG IMAGING OF SOLITARY PULMONARY MODULES, USING 2{FLOURINE 18}FLUORO 2 DEO $2,397.11 19990701 99999999 G0126 PET LUNG IMAGING OF SOLITARY PULMONARY NODULES USING 2 {FLUORINE 18} FLUORO 2 DE $2,418.09 19990701 99999999 G0127 TRIMMING OF DYSTROPHIC NAILS, ANY NUMBER $8.27 20060701 99999999 G0128 DIRECT (FACE TO FACE) WITH PATIENT SKILLED NURSING SERVICES OF A REGISTERED NURS $4.41 19990701 99999999 G0130 SINGLE ENERGY X-RAY (SEXA) ABSORPTIOMETRY BONE DENSITY STUDYONE OR MORE SITES $45.36 20060701 99999999 G0131 COMPUTERIZED TOMOGRAPHY BONE MINERAL DENSITY STUDAY, ONE OR MORE SITES, AXIAL SK $116.32 19990701 99999999 G0132 COMPUTERIZED TOMOGRAPHY BONE MATERIAL DENSITY STUDY, ONE OR MORE SITES APPENDICU $46.07 19980701 99999999 G0141 SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, PERFORMED BY AUTOMATED SYST $21.72 20060701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 35
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