Medicaid Fee Schedule without Mods 200801

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PROC-CODE DESC MAC BEG END W0428 AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON EMERGENCY, PEDIATRIC TRANSPORT TEAM $102.38 20030401 99999999 W0430 OUT OF STATE AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT ONE-WAY $24,960.00 20030401 99999999 W0552 SKILLED NURSING SERVICES BY RN FOR EPSDT SERVICES IN THE HOME $50.00 19990701 99999999 W0553 SKILLED NURSING SERVICES BY LPN FOR EPSDT SERVICES IN THE HOME $31.20 20030401 99999999 W0554 SKILLED NURSING SERVICES BY RN FOR EPSDT SERVICES IN THE HOME;MULTIPLE PATIENTS $70.00 20030714 99999999 W0572 PERSONAL CARE SERVICES BY A NURSE AIDE FOR EPSDT SERVICES INTHE HOME $20.00 19990701 99999999 W0608 MEDICAID NEGOTIATED APNEA MONITOR (HOME USE ONLY) $208.00 20030401 99999999 W1402 SNF/ICF OXYGEN CONCENTRATION $171.60 20030401 99999999 W4206 INSULIN SYRINGE FOR HOME USE ONLY, EACH $0.21 20030401 99999999 W4335 DIAPERS, ADULT SMALL/ALL CHILDRENS, EACH $0.62 20030401 99999999 W4336 DIAPERS, ADULT EXTRA LARGE, EACH $0.69 20030401 99999999 W4554 UNDER PADS, SMALL, EACH $0.17 20030401 99999999 W4627 WAIVER CASE MANAGEMENT,COMPREHENSIVE,ALL INCLUSIVE,PER MONTH $564.82 19990701 99999999 W4631 HABILITAION;RESIDENTIAL HAB/INDEP.LIVING SKILLS DEVELOPMENT;EACH 15 MIN. $4.50 19990701 99999999 W4633 WAIVER SERVICE ASSESSMENT/POC DEVELOPMENT;INITIAL;EACH $135.00 19990701 99999999 W4635 HABILITATION SUPPORTED EMPLOYMENT,EACH 15 MINUTES $4.50 19990701 99999999 W4654 ADULT RESIDENTIAL CARE/COMM SUPP LIVING,ASSISTED LIVING;PER DAY $42.38 19990701 99999999 W4676 RESIDENTIAL/SUPPORTED LIVING;ROOM AND BOARD $22.58 19990701 99999999 W4927 STERILE GLOVES, PER PAIR $0.75 20030401 99999999 W4928 GLOVES, NON-STERILE, NON-LATEX; PER PAIR $0.27 20030401 99999999 W5942 PRENATAL AND POSTPARTUM CARE ONLY (COMPREHENSIVE CARE) $416.00 20030401 99999999 W5951 CESAREAN SECTION DELIVERY ONLY (INCL. IN-HOSPITAL POST- PARTUM VISITS) $1,000.00 19990701 99999999 W7890 DIAG RADIOPHARMACEUTICAL FLUORODEOXYGLUCOSE (FDG) FOR PET (POSITRON EMM TOMOGRA $600.00 19990701 99999999 W8390 HIV-1 DRUG RESISTANCE TESTING; GENOTYPING $420.00 19990701 99999999 W9000 MEDICAL CLINIC VISIT (ONLY DOH-TYPE CLINICS FOR NON-PHYSICIAN SERVICES) $10.40 20030401 99999999 W9070 EMERGENCY RESPONDER SYSTEM FOR USE IN HOME; MONTHLY RATE $31.47 19990701 99999999 W9100 VISION SCREENING $12.48 20030401 99999999 W9200 METHADONE TREATMENT (EXCLUDES COUNSELING) $5.72 20030401 99999999 W9204 PSYCHIATRIC CLINIC GROUP THERAPY BY NON-PHYSICIAN/NON- PSYCHOLOGIST (DOH ONLY) $15.00 19990701 99999999 W9205 PSYCHIATRIC CLINIC VISIT (DOH CLINICS ONLY) $15.00 19940801 99999999 W9206 DHS 1271 EVALUATION $93.60 19990701 99999999 W9213 TANF MENTAL/MEDICAL DISABILITY DETERINATION PERFORMED BY QUEST $77.00 19990701 99999999 W9775 INITIAL EVALUATION REPORT $55.02 20030401 99999999 W9776 RE-EVALUATION BY REPORT $48.05 20030401 99999999 W9778 INITIAL PEDIATRIC REHABILITATIVE EVALUATION FOR CHILD < 21 IN SUBACUTE LOC $104.00 20030401 99999999 W9779 PEDIATRIC REHABILITATIVE INTERVENTION FOR CHILD < 21 IN SUBACUTE LEVEL OF CARE $72.80 20030401 99999999 W9780 1270 GENERAL ASSISTANCE/AID TO THE DISABLED REVIEW COMMITTEEDISABILITY EVALUATIO $94.86 20030401 99999999 W9781 1270 GENERAL ASSISTANCE/AID TO DISABLES REVIEW COMMITTEE EVALUATION; COMPLEX $156.00 20030401 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 82
PROC-CODE DESC MAC BEG END W9801 QUEST PSYCHIATRIC EVALUATION FOR THE DETERMINATION OF SMI, 1HOUR $104.00 20030401 99999999 W9802 QUEST PSYCHIATRIC EVALUATION FOR DETERMINATION OF SMI, 2 HOURS $208.00 20030401 99999999 W9803 QUEST PSYCHIATRIC EVALUATION FOR THE DETERMINATION OF SMI, 3HOURS $312.00 20030401 99999999 W9880 CASE MGMT, INPATIENT HOSPITAL FOR VENT DEPENDENT/TRACH CHILDPRIOR TO INITIAL $1,260.00 20030401 99999999 W9881 CASE MGMT FOR VENT DEPENDENT/TRACH CHILD LIVING AT HOME $840.00 20030401 99999999 W9882 CASE MGMT FOR NON-VENT DEPENDENT/NON-TRACH CHILD WITH SIGNIFICANT MEDICAL $336.00 20030401 99999999 W9883 CASE MANAGEMENT FOR CHILD WITH SIGNIFICANT MEDICAL NEEDS $84.00 20030401 99999999 W9884 ADDITIONAL OR UNUSUAL CASE MGMT SERVICES TO ADDRESS CHANGINGMEDICAL NEEDS, UNIT $28.00 20030401 99999999 W9890 CASE ASSESSMENT $9.75 19990701 99999999 W9891 CASE PLANNING $9.75 19990701 99999999 W9892 ONGOING MONITORING AND SERVICE COORDINATION $9.75 19990701 99999999 W9900 ALL INCLUSINVE FAMILY PLANNING SERVICE $48.16 19990701 99999999 W9970 SPECIALTY MOLDED UPPER EXTREMITY SPLINT FOR CHILD < 21 IN SUBACUTE LEVEL OF CARE $148.00 19990701 99999999 W9971 SPECIALTY MOLDED LOWER EXTREMITY SPLINT FOR CHILD < 21 IN SUBACUTE LEVEL OF CARE $168.00 19990701 99999999 Z9020 TAX $0.01 19990701 99999999 Z9060 QUEST ENABLING SERVICE, LANGUAGE TRANSLATION, PER 15 MINUTES $9.36 20030401 99999999 Z9415 NOSE PADS $8.32 20030401 99999999 Z9416 EYEGLASSES CASE $1.56 20030401 99999999 00100 ANESTHESIA FOR PROCEDURES ON INTEGUMENTARY SYSTEM OF HEAD AND/ OR SALIVARY GLAND $22.80 19990701 99999999 00102 ANESTHESIA FOR PROCEDURES ON INTEGUMENTARY SYSTEM OF HEAD AND/ OR SALIVARY GLAND $22.80 19990701 99999999 00103 ANESTHESIA FOR PROCEDURES ON INTEGUMENTARY SYSTEM OF HEAD AND/ OR SALIVARY GLAND $22.80 19990701 99999999 00104 ANESTHESIA FOR ELECTROCONVULSIVE THERAPY $22.80 19990701 99999999 00120 PERIODIC ORAL EXAMINATION $22.80 19990701 99999999 00124 ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING BIOPSY; O $22.80 19990701 99999999 00126 ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING BIOPSY; T $22.80 19990701 99999999 00140 ANESTHESIA FOR PROCEDURES ON EYE; NOT OTHERWISE SPECIFIED $22.80 19990701 99999999 00142 ANESTHESIA FOR PROCEDURES ON EYE; LENS SURGERY $22.80 19990701 99999999 00144 ANESTHESIA FOR PROCEDURES ON EYE; CORNEAL TRANSPLANT $22.80 19990701 99999999 00145 ANESTHESIA FOR PROCEDURES ON EYE; VITRECTOMY $22.80 19990701 99999999 00147 ANESTHESIA FOR PROCEDURES ON EYE; IRIDECTOMY $22.80 19990701 99999999 00148 ANESTHESIA FOR PROCEDURES ON EYE; OPHTHALMOSCOPY $22.80 19990701 99999999 00160 ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; NOT OTHERWISE SPECIFIED $22.80 19990701 99999999 00162 ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; RADICAL SURGERY $22.80 19990701 99999999 00164 ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; BIOPSY, SOFT TISSUE $22.80 19990701 99999999 00170 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; NOT OTHERWISE SPECIFIED $22.80 19990701 99999999 00172 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; REPAIR OF CLEFT PALATE $22.80 19990701 99999999 00174 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; EXCISION OF RETROPHARYNGE $22.80 19990701 99999999 Hawaii Medicaid Fee Schedule without Mods 01/2008 83
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