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North Carolina Breast and Cervical Cancer Control Program <br /> Maximum Allowable Fees as WISEWOMAN Program <br /> For the Period : 01 /01 /2019 - 12/3 1 /2019 <br /> Revised : 01 /07/2019 <br /> Procedures CPT Code Fee <br /> Automated Lipid Panel * 80061 $ 14 . 88 <br /> Lipid Panel (CLIA waived) ' 80061QW $ 14 . 88 <br /> Cholesterol , Total Serum 82465 $ 4 . 84 <br /> Cholesterol , Total Serum (CLIA waived) 82465QW $ 4 . 84 <br /> Lipoprotein ( HDL) 83718 $ 9 . 10 <br /> Lipoprotein ( HDL) ( CLIA waived) 83718QW $ 9 . 10 <br /> Glucose , blood , quantitative 82947 $ 4 . 37 <br /> Glucose , blood , quantitative (CLIA waived) 82947QW $ 4 . 37 <br /> Glucose , blood , reagent strip 82948 $ 5 . 04 <br /> Glucose , tolerance test , three specimens 82951 $ 14 . 30 <br /> Glucose , tolerance test , three specimens ( CLIA waived) 82951QW $ 14 . 30 <br /> Hemoglobin A I C 83036 $ 10 . 79 <br /> Hemoglobin A I C ( CLIA waived) 83036QW $ 10 . 79 <br /> Basic Metabolic Profile * * 80048 $ 9 . 40 <br /> Basic Metabolic Profile ( CLIA waived) * * 80048QW $ 9 . 40 <br /> Other <br /> Routine venipuncture 36415 $ 3 . 00 <br /> Health Coaching ( HQ - Initial HC session is incorporated into screening visit , <br /> 2 additional HC sessions are advised and will be reimbursed as below : <br /> Individual HC , Face -to- face , 15 minutes 98960 $ 15 . 00 <br /> Individual HC , Phone , 15 minutes 98967 $ 15 . 00 <br /> Office Visits <br /> New Patients history, exam , 10 minutes 99201 $ 44 . 05 <br /> New Patient , expanded history, exam , 20 minutes 99202 $ 73 . 77 <br /> New Patient , detailed history , exam , 30 minutes 99203 $ 104 . 68 <br /> New Patient , comprehensive history, exam , 45 minutes 99204 $ 159 . 60 <br /> New Patient , comprehensive history, exam , 60 minutes 99205 $ 200 . 86 <br /> Established Patient ; evaluation and management ; 5 minutes 99211 $ 21 . 84 <br /> Established Patients history, exam ; 10 minutes 99212 $ 43 . 46 <br /> Established Patients expanded history, exam , 15 minutes 99213 $ 71 . 94 <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 Collection Container : 1 mL Serum / One SST Remarks : Includes NA , K , CL , CO2 , <br /> Metabolic 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 />