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f <br /> REF: North Carolina Breast and Cervical Cancer Control Program Exhibit B <br /> North Carolina Breast and Cervical Cancer Control Program <br /> Maximum Allowable Fees- WISEWOMAN <br /> For the Period 07/01/2014 -06/30/2015 <br /> Procedures Revised: 04/10/2014 <br /> Automated Lipid Panel * CPT Code Fee <br /> Lipid Panel (CLIA waived)' 80061 $ 18.27 <br /> Cholesterol,Total Serum 80061QW $ 18.27 <br /> Cholesterol,Total Serum(CLIA waived) 82465 $ 5.93 <br /> Lipoprotein(HDL) 82465QW $ 5.93 <br /> Lipoprotein (HDL)(CLIA waived) 83718 $ 1 1.17 <br /> Glucose,blood,quantitative 83718QW $ 11.17 <br /> Glucose, blood,quantitative(CLIA waived) 82947 $ 5.36 <br /> Glucose, blood, reagent strip 82947QW $ 5.36 <br /> Glucose, tolerance test,three specimens 82948 $ 4.32 <br /> Glucose, tolerance test, three specimens(CLIA waived) 82951 $ 17.56 <br /> Hemoglobin A1C 82951QW $ 17.56 <br /> Hemoglobin A I C(CLIA waived) 83036 $ 13.24 <br /> 83036QW $ 13.24 <br /> Basic Metabolic Profile ** <br /> 80048 $ 10.94 <br /> Other <br /> Routine venipuncture 36415 <br /> $ 3.00 <br /> Education and Training for Patient Self-Management <br /> Individual, Face-to-face, 30 minutes 98960 $ 30.00 <br /> Group, Face-to-face, 30 minutes 98961 $ 30.00 <br /> Individual, Phone, 15 minutes 98967 $ 15.00 <br /> Office Visits <br /> New Patient, Brief 99201 $ 30.96 <br /> New Patient, Limited 99202 $ 53.35 <br /> New Patient, Intermediate 99203 $ 77.39 <br /> New Patient, Limited(Comprehensive) 99204 $ 119.11 <br /> New Patient, Intermediate(Comprehensive) 99205 $ 148.63 <br /> Established Patient, Brief 99211 $ 14.32 <br /> Established Patient,Limited 99212 $ 31.21 <br /> Established Patient,Intermediate 99213 $ 52.39 <br /> Note: Office Visits or Consultation Visits listed above may be used to reimburse for <br /> consultations associated with WISEWOMAN referrals, when applicable. <br /> *Lipid Panel tests are: Total Serum Cholesterol, Lipoprotein (HDL)and Triglycerides. <br /> **Basic Metabolic Collection Container: 1 mL Serum/One SST Remarks: Includes NA, K,CL, CO2, <br /> Profile GLUC, BUN, CREA, CA <br /> The Clinical Laboratory Improvement Amendments of 1988 (CLIA)law specifies that laboratory <br /> requirements be based on the complexity of the test performed and established provisions for categorizing a <br /> test as waived. Tests may be waived from regulatory oversight if they meet certain requirements established <br /> by the statute. CLIA waived tests employ methodologies that are so simple and accurate as to render the <br /> likelihood of erroneous results negligible; pose no reasonable risk of harm to the patient if the test is <br /> performed incorrectly; and/or are cleared by the Food and Drug Administration for home use. <br /> 2 Effective January 1, 2010,Consultation Visit codes 99241 through 99255 have been eliminated. Codes <br /> 99201, 99202,and 99203 are to be used in their place. <br />