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North Carolina Breast and Cervical Cancer Control Program <br /> Maximum Allowable Fees-WISEWOMAN <br /> For the Period 07/01/2016-06/30/2017 <br /> Revised: 05/26/2016 <br /> Reviewed 06/08/2016 <br /> Procedures CPT Code Fee <br /> Automated Lipid Panel * 80061 $ 18.24 <br /> Lipid Panel(CLIA waived)] 80061QW $ 18.24 <br /> Cholesterol,Total Serum 82465 $ 5.92 <br /> Cholesterol, Total Serum(CLIA waived) 82465QW $ 5.92 <br /> Lipoprotein(HDL) 83718 $ 11.16 <br /> Lipoprotein(HDL)(CLIA waived) 83718QW $ 11.16 <br /> Glucose,blood,quantitative 82947 $ 5.35 <br /> Glucose,blood,quantitative(CLIA waived) 82947QW $ 5.35 <br /> Glucose,blood,reagent strip 82948 $ 4.32 <br /> Glucose,tolerance test,three specimens 82951 $ 17.53 <br /> Glucose,tolerance test,three specimens(CLIA waived) 82951QW $ 17.53 <br /> Hemoglobin A I C 83036 $ 13.22 <br /> Hemoglobin A I C (CLIA waived) 83036QW $ 13.22 <br /> Basic Metabolic Profile ** 80048 $ 10.92 <br /> Basic Metabolic Profile(CLIA waived)** 80048QW $ 10.92 <br /> Other <br /> Routine venipuncture 36415 $ 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 $ 41.87 <br /> New Patient,Limited 99202 $ 71.79 <br /> New Patient,Intermediate 99203 $ 103.91 <br /> New Patient,Limited(Comprehensive) 99204 $ 159.32 <br /> New Patient,Intermediate(Comprehensive) 99205 $ 200.06 <br /> Established Patient,Brief 99211 $ 19.04 <br /> Established Patient,Limited 99212 $ 41.59 <br /> Established Patient,Intermediate 99213 $ 70.29 <br /> Note: Office Visits listed above may be used to reimburse for consultations associated with WISEWOMAN <br /> referrals,when applicable. <br /> *Lipid Panel tests are: Total Serum Cholesterol,Lipoprotein(HDL and LDL)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 <br /> established by the statute. CLIA waived tests employ methodologies that are so simple and accurate as to <br /> render the likelihood of erroneous results negligible;pose no reasonable risk of harm to the patient if the <br /> test is performed incorrectly; and/or are cleared by the Food and Drug Administration for home use. <br />