Listed below is an explanation of the types of service found on this schedule.

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Dwain McGee
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1 RUN: 12/20/16 08:55:28 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: LEGEND Listed below are some aids we hope will help you understand this fee schedule. If, after reading the information below, you need further clarification of an item, please call Molina Provider Relations at COLUMN 1. TS (Type Service): Definition: Files on which codes are loaded and from which claims are paid. The file to which a claim goes for pricing is determined by, among other things, the type of provider who is billing and by the modifier appended to the procedure code. Listed below is an explanation of the types of service found on this schedule Take Charge Plus. Nurse Practitioners, Clinical Nurse Specialists, and Physician Assistants are paid at 80% of the fee listed for physician services except for physician administered injections, long-acting reversible contraceptives (LARC's), immunizations, and EPSDT preventative medical screenings which are reimbursed at 100% of the physician services fee. COLUMNS 2, 3 and 4. CODE, DESCRIPTION and FEE. COLUMN 5. AGE MIN and MAX: Codes with minimum or maximum age restrictions. If the recipient's age on the date of service is outside the minimum or maximum age, claims will deny. The fee schedule cannot display age restrictions in days or months; therefore providers should follow Current Procedural Terminology(CPT) coding guidelines based on the age of the recipient on the date of service. COLUMN 6. MED REV (Medical Review): Claims with some codes pend to Medical Review for review of the attachments or for manual pricing. COLUMN 7. PA (Prior Authorization): Some services must be prior authorized before they are rendered. If a PA request is approved, a PA number will be issued for inclusion on the claim. If a PA request is not approved, no payment for the service will be made. COLUMN 8. SEX (Restriction): Some procedure codes are indicated for only one sex. COLUMN 9. PSR (Provider Specialty Restriction): If a code has a provider specialty restriction, reimbursement for its performance will not be made to other specialties. COLUMN 10. SL (Service Limitation): Codes with frequency limitations. For example, this could include yearly or lifetime limits. COLUMN 11. BASE UNITS: The base units for anesthesia codes. COLUMN 12. X-OVERS (Only): These codes are payable for Medicare/Medicaid recipients only. COLUMN 13. UVS>001: An 'X' in this column means more than one unit of service per day may be billed.

2 RUN: 12/20/16 08:55:28 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: 1 58 A4216 STERILE WATER SALINE AND/OR DE X X 58 A4266 DIAGPHRAM FOR CONTRACEPTIVE USE F X 58 A4267 CONTRACEP SUPPLY/MALE CONDOM, EACH X X 58 A4268 CONTRACEP SUPPLY/FEMALE CONDOM, EACH X X 58 A4269 CONTRACEPTIVE SUPPLY, SPERMACIDE X X 58 G0123 SCREENING CYTOPATH, CERVICAL OR VAGI F 58 G0141 SCR C/V CYTO,AUTOSYS AND MD F 58 HR250 PHARMACY, GENERAL CLASSIFICATION CCR X X 58 HR258 PHARMACY, IV SOLUTIONS CCR X X 58 HR259 PHARMACY, OTHER PHARMACY CCR X 58 HR260 IV THERAPY CCR X X 58 HR270 MED/SURG SUPPLY/DEVICE-GEN CLS CCR X X 58 HR271 TEMPKIT/PROBE COVERS/SERVICE CCR X X 58 HR272 STERILE SUPPLY CCR X X 58 HR300 LABORATORY-GEN CLASSIFICATION CCR X 58 HR301 CHEMISTRY CCR X X 58 HR302 IMMUNOLOGY CCR X X 58 HR305 HEMATOLOGY CCR X X 58 HR306 LABORATORY-HEMATOLOGY CCR X X 58 HR307 LABORATORY-UROLOGY CCR X X 58 HR309 LABORATORY-OTHER LABORATORY CCR X X 58 HR310 LAB PATHOLOGICAL/GE CLASSIFICATION CCR X X 58 HR311 LABORATROY PATHOLOGIC/CYTOLOGY CCR X X 58 HR312 LAB PATHOLOGIC/HISTOLOGY CCR X X 58 HR320 RADILOLGY-DIAGNOSTIC GEN CLASS CCR X X 58 HR324 CHEST X-RAY CCR X X 58 HR360 OPERATING ROOM SERVICES GN CLA CCR X X 58 HR402 ULTRASOUND CCR F X X 58 HR490 AMBULATORY SURGICAL CARE GENERAL HCPC X X 58 HR510 CLINIC - GENERAL HCPC HR514 OB-GYN CLINIC HCPC X 58 HR517 FAMILY PRACTICE CLINIC HCPC X 58 HR636 DRUGS REQUIRING DETAILED CODING CCR X X 58 HR760 TREATMENT/OBSERVATION ROOM CCR X X 58 HR920 OTHER DIAG SERV GEN CLASSIFICATION CCR X X 58 HR925 PREGNANCY TEST CCR F X X 58 J0171 INJECTION ADRENALIN EPINEPHRINE X 58 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG X 58 J0558 INJECTION PENICILLIN G BENZATHINE A X 58 J0561 INJECTION PENICILLIN G BENZATHINE X 58 J0690 CEFAZOLIN SODIUM INJ 500MG X

3 RUN: 12/20/16 08:55:28 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: 2 58 J0694 CEFOXITIN SODIUM, 1GM X 58 J0696 CEFTRIAXONE SODIUM 250MG ROCEPHIN X 58 J0697 STERILE CEFUROXIME SODIUM 750MG X 58 J0698 CEFOTAXIME SODIUM/PER GM X 58 J0710 INJECTION CEPHAPIRIN SODIUM UP TO1GM X 58 J1050 INJECTION, MEDROXYPROGESTERONE ACETA F X 58 J1200 DIPHENHYDRAMINE HCL INJ(BENDARY)50MG X 58 J1840 KANAMYCIN SULFATE, UP TO 500MG X 58 J2460 OXYTETRACYCLINE,UP TO 50MG X 58 J2510 PCN G PROCAINE AQ, UP TO 600,000 U X 58 J2540 PCN G POTASSIUM,UP TO 600,000U X 58 J3000 STREPTOMYCIN, UP TO 1GM X 58 J7120 RINGERS INJ, UP TO 1000 CC X 58 J7297 LEVONORGESTREL-RELEASING INTRAUTERIN F 58 J7298 LEVONORGESTREL-RELEASING INTRAUTERIN F 58 J7300 INTRAUTERINE COPPER DEVICE F X 58 J7301 LEVONORGESTREL-RELEASING INTRAUTERIN F X 58 J7306 LEVONORGESTREL IMPLANT SYS X F 58 J7307 ETONOGESTREL (CONTRACEPTIVE) IMPLANT F X 58 Q0111 WET MOUNTS,PREPARATIONS OF VAGINAL F 58 Q0112 POTASSIUM MYDROXIDE PREPARATIONS S4993 CONTRACEP PILLS/BIRTH CONTROL-1 MTH F X X 58 T1001 NURSING ASSESSMENT X 58 Z5177 PROFIT LOCAL TRIP X X 58 Z5178 PROFIT NEGOTIATED TRIP X X 58 Z5179 CAPITATED REGULAR URBAN X 58 Z5180 CAPITATED REGULAR RURAL X 58 Z5181 FAMILY AND FRIENDS NEGOTIATED X 58 Z5182 ENHANCED CAPITATED >5 TRIPS PER WK X 58 Z5183 CAPITATED REMOTE RURAL X 58 Z5184 CAPITATED WHEELCHAIR RURAL X 58 Z5185 CAPITATED WHEELCHAIR URBAN X 58 Z5186 LOCAL PROFIT WHEELCHAIR X 58 Z5187 LOCAL NONPROFIT WHEELCHAIR X 58 Z5188 CAPITATED-NEGOTIATED NEMT X 58 Z9486 FAMILY AND FRIENDS TWO WAY TRIP X X 58 Z9494 FAMILY AND FRIENDS URBAN X 58 Z9498 NON PROFIT LOCAL TRIP X X 58 Z9500 NON PROFIT NEGOTIATED RATE.00 X ANES; TUBAL LIGATION/TRANSECTION X F X 6 X ANESTHESIA, VASECTOMY, UNILATERAL/BI M 3 X

4 RUN: 12/20/16 08:55:28 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: ANESTHESIA, VAGINAL PROC, NOS F 3 X HYSTEROSCOPY/HYSTEROSALPINGOGRAPHY F 4 X DRAINAGE OF SKIN ABSCESS INCISE/DRAIN SIMPLE HEMATOMA EXCISE BENIGN LESION TO 0.5 CM X EXCISE BENIGN LESION 0.6 TO 1 CM X REMOVAL WITHOUT REINSERTION, IMPLANT F INSERTION,NON-BIODEGRADABLE DRUG DEL F REMOVAL,NON-BIODEGRADABLE DRUG DELIV F REMOVAL WITH REINSERTION,NON BIODEGR F DESTROY FLAT WARTS,ANY METHOD,T DESTRUCT LESION, 15 OR MORE COLLECTION OF VENOUS BLOOD BY VENIPU X X CAPILLARY BLOOD DRAW X REMOVAL OF ANAL LESION REMOVAL OF ANAL LESION CRYSOSURGERY-ANAL LESIONS, X DESTROY ANAL LESION(S)-SURG EXCISION DESTROY ANAL LESIONS,ANY METH,EXTEN LAPARO PROC, ABDM/PER/OMENT X F TREATMENT OF PENIS LESION M DESTROY PENILE LESION;CRYOSURGERY M BIOPSY OF PENIS M VASECTOMY, UNILATERAL OR BILATERAL X M LIGATION OF VAS DEFERENS X M INCISION AND DRAINAGE OF VULVA OR PE F INCISION AND DRAINAGE OF FEMALE GENI F X DESTROY VULVA LESION(S);SIMPLE F BIOPSY OF VULVA OR PERINEUM (SEPARAT F DESTROY VAGINAL LESIONS;SIMPLE F TREAT VAGINA INFECTION F X DIAPHRAGM FITTING WITH INSTRUCTIONS F EXAMINATION OF VAGINA F VAGINA EXAMINATION & BIOPSY F BIOPSY OF CERVIX W/SCOPE F ENDOCERV CURETTAGE W/SCOPE F COLPOSCOPY (VAGINOSCOPY); F CONZ OF CERVIX W/SCOPE,LEEP F ENDOCERVICAL CURETTAGE F CAUTERIZATION OF CERVIX F CRYOCAUTERY OF CERVIX F

5 RUN: 12/20/16 08:55:28 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: LASER SURGERY REVISION OF CERVIX F DILATION OF CERVICAL CANAL F BIOPSY OF UTERUS LINING F BX DONE W/COLPOSCOPY ADD-ON F DILATION AND CURETTAGE F INSERT INTRAUTERINE DEVICE F REMOVE INTRAUTERINE DEVICE F INJECT FOR UTERUS/TUBE X-RAY X F X HYSTEROSCOPY, REMOVE FB X F HYSTEROSCOPY, STERILIZATION 1, X F X DIVISION OF FALLOPIAN TUBE X F DIVISION OF FALLOPIAN TUBE X F LIG/TRANSEC FALLOP TUBE NOT SEP PROC X F X OCCLUSION OF FALLOPIAN TUBE, DEVICE X F LAPAROSCOPY, LYSIS X F LAPAROSCOPY, TUBAL CAUTERY X F LAPAROSCOPY, TUBAL BLOCK X F INJECTION(S), OF DIAGNOSTIC OR THERA INJECTION(S), INCLUDING INDWELLING C INJECTION FOR NERVE BLOCK X X X-RAY CHEST;POSTEROANTERIOR X X-RAY CHEST;TWO VIEWS X X-RAY EXAM OF PELVIS X-RAY EXAM OF ABDOMEN X X-RAY EXAM OF ABDOMEN X HYSTEROSALPINGOGRAPHY F ECHOGRAPHY, TRANSVAGINAL F ECHO EXAM, UTERUS F ECHOGRAPHY, PELVIC, REAL TIME F X ECHOGRAPHY, PELVIC,LIMITED OR FOLLOW US BONE DENSITY MEASURE COMPUTED TOMOGRAPHY, BONE MINERAL DE DUAL-ENERGY X-RAY ABSORPTIOMETRY (DX DUAL-ENERGY X-RAY ABSORPTIOMETRY (DX BASIC METABOLIC PANEL (CALCIUM, IONI BASIC METABOLIC PANEL (CALCIUM, TOTA GENERAL HEALTH PANEL BLOOD TEST PANEL FOR ELECTROLYTES (S BLOOD TEST, COMPREHENSIVE GROUP OF B LIPID PANEL

6 RUN: 12/20/16 08:55:28 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: RENAL FUNCTION PANEL ACUTE HEPATITIS PANEL HEPATIC FUNCTION PANEL DRUG SCREEN, ANY NUMBER OF DRUG CLAS DRUG SCREEN, ANY NUMBER OF DRUG CLAS DRUG SCREEN, PRESUMPTIVE, SINGLE DRU URINALYSIS, BY DIP STICK OR TABLET X URINALYSIS, BY DIP STICK OR TABLET URINALYSIS, BY DIP STICK OR TABLET X URINALYSIS, BY DIP STICK OR TABLET URINALYSIS; QUALITATIVE RO SEMIQUANT X URINALYSIS; BACTERIURIA SCREEN, EXCE URINALYSIS; MICROSCOPY ONLY X URINALYSIS; 2 OR 3 GLASS TEST URINE PREGNANCY TEST, BY VISUAL COLO F ALBUMIN; SERUM, PLASMA OR WHOLE BLOO ALBUMIN; URINE OR OTHER SOURCE, QUAN ALBUMIN; URINE MICROALBUMIN, QUANTIT AMINES, VAGINAL FLUID, QUALITATIVE AMYLASE X BILIRUBIN; TOTAL CALCIUM; TOTAL X CALCIUM; IONIZED CHLORIDE; BLOOD X CHOLESTEROL, SERUM OR WHOLE BLOOD, T CREATINE KINASE (CK), (CPK); TOTAL X CREATINE KINASE (CK), (CPK); ISOENZY X CREATININE; BLOOD X CREATININE; OTHER SOURCE CREATININE; CLEARANCE CYANOCOBALAMIN (VITAMIN B-12); ESTRADIOL ESTROGENS; FRACTIONATED ESTROGENS; TOTAL ESTRIOL ESTRONE FERRITIN FOLIC ACID; SERUM GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT X GLUCOSE; BLOOD, REAGENT STRIP X GLUCOSE; POST GLUCOSE DOSE (INCLUDES

7 RUN: 12/20/16 08:55:28 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: GLUCOSE, BLOOD BY GLUCOSE MONITORING X GONADOTROPIN; FOLLICLE STIMULATING H GONADOTROPIN; LUTEINIZING HORMONE ASSAY HEMOGLOBIN X ASSAY BLOOD LIPASE PH; BODY FLUID, NOT OTHERWISE SPECIF X ASSAY ALKALINE PHOSPHATASE ASSAY BLOOD POTASSIUM X ASSAY PROGESTERONE RIA ASSAY FOR PROLACTIN ASSAY SERUM PROTEIN ASSAY OF PROTEIN, OTHER ASSAY VITAMIN B RECEPTOR ASSAY; ESTROGEN(ESTRADIOL) RECEPTOR ASSAY; PROGESTERONE ASSAY VITAMIN B ASSAY BLOOD SODIUM X TESTOSTERONE; ASSAY VITAMIN B RIA ASSAY OF TS HORMONE ASSAY BUN X ASSAY BLOOD URIC ACID GONADOTROPIN,CHORIONIC;QUANTITATIVE GONADOTROPIN,CHORIONIC;QUALITATIVE AUTOMATED DIFF WBC COUNT DIFFERENTIAL WBC COUNT X BLOOD COUNT; DIFFERENTIAL WBC COUNT X BLOOD COUNT; BLOOD COUNT OTHER THAN SPUN HEMATOCR X HEMOGLOBIN, COLORIMETRIC X BLOOD COUNT;HEMO.PLAT.COUNT,AUTO/AMT X HEMOGRAM,AUTOMATED W/PLATELET COUNT X MANUAL CELL COUNT, EACH X RED BLOOD CELL (RBC) COUNT X RETICULOCYTE COUNT FLOW CYTOMETRY WHITE BLOOD CELL (WBC) COUNT PROTHROMBIN TIME X RBC SEDIMENTATION RATE RBC SED RATE, AUTO THROMBOPLASTIN TIME, PARTIAL X

8 RUN: 12/20/16 08:55:28 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: FLUORESCENT ANTIBODY; SCREEN IMMUNOASSAY FOR CHEM. CONSTITUENT NEUTRALIZATION TEST, VIRAL PRECIPITIN (EG, LATEX BEAD) OR AGGLU SYPHILIS TEST(S),QUALITATIVE SYPHILIS TEST, QUANTITATIVE ANTIBODY; ANTIBODY; ANTIBODY; ANTIBODY; HTLVI, ANTIBODY DETECTION;IMMUNOASSA ANTIBODY; CONFIRMATORY TEST ANTIBODY; ANTIBODY; HERPES SIMPLEX TYPE ANTIBODY; ANTIBODY; ANTIBODY; ANTIBODY; HIV-1 AND HIV-2, SINGLE RE HEP B CORE AB TEST, IGG & M HEP B CORE AB TEST, IGM HEPATITIS B SURFACE AB TEST HEPATITIS BE AB TEST ANTIBODY; ANTIBODY; HEPATITIS C AB TEST HEP C AB TEST, CONFIRM BLOOD TYPING; BLOOD TYPING; BLOOD TYPING; X BLOOD TYPING; X SPECIMEN CONCENTRATION X BLOOD CULTURE FOR BACTERIA X CULTURE SPECIMEN, BACTERIA X CULTURE BACTERI AEROBIC OTHR CULTURE BACTERIA ANAEROBIC CULTURE SPECIMEN, BACTERIA X BACTERIA IDENTIFICATION CULTURE AEROBIC IDENTIFY X BACTERIA CULTURE SCREEN

9 RUN: 12/20/16 08:55:28 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: URINE CULTURE, COLONY COUNT URINE BACTERIA CULTURE FUNGUS ISOLATION CULTURE CULTURE,CHLAMYDIA CULTURE TYPING, SEROLOGIC DARK FIELD EXAMINATION ANTIBIOTIC SENSITIVITY, EACH X ANTIBIOTIC SENSITIVITY, MIC SMEAR, STAIN & INTERPRET X SMEAR, STAIN & INTERPRET X SMEAR, STAIN & INTERPRET X SMEAR, STAIN & INTERPRET X TISSUE EXAMINATION FOR FUNGI VIRUS ID;TISSUE CULT.INOCULATION/OBS VIRUS ID;TISS CULT,ADD STDY,@ ISOLAT X VIRUS INOCULATION, SHELL VIA X GENET VIRUS ISOLATE, HSV X CHYLMD TRACH AG, DFA HERPES SIMPLEX 2, AG, IF HERPES SIMPLEX AG, DFA CHYLMD TRACH AG, EIA HEPATITIS B SURFACE AG, EIA HEPATITIS B AG, EIA INFECTIOUS AGENT ANTIGEN DETECTION B HIV-1 AG, EIA HIV-2 AG, EIA BARTONELLA, DNA, DIR PROBE CANDIDA, DNA, DIR PROBE CANDIDA, DNA, AMP PROBE CHYLMD PNEUM, DNA, DIR PROBE CHYLMD PNEUM, DNA, AMP PROBE CHYLMD TRACH, DNA, DIR PROBE CHYLMD TRACH, DNA, AMP PROBE X CYTOMEG, DNA, DIR PROBE CYTOMEG, DNA, AMP PROBE CYTOMEG, DNA, QUANT GARDNER VAG, DNA, DIR PROBE F GARDNER VAG, DNA, AMP PROBE F HSV, DNA, DIR PROBE HSV, DNA, AMP PROBE HSV, DNA, QUANT

10 RUN: 12/20/16 08:55:28 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: HHV-6, DNA, DIR PROBE HHV-6, DNA, AMP PROBE HHV-6, DNA, QUANT HIV-1, DNA, DIR PROBE DETECTION TEST FOR HIV-1 VIRUS DETECTION TEST FOR HIV-1 VIRUS HIV-2, DNA, DIR PROBE DETECTION TEST FOR HIV-2 VIRUS N.GONORRHOEAE, DNA, DIR PROB N.GONORRHOEAE, DNA, AMP PROB X INFECTIOUS AGENT DETECTION BY NUCLEI INFECTIOUS AGENT DETECTION BY NUCLEI INFECTIOUS AGENT DETECTION BY NUCLEI TRICHOMONAS VAGIN, DIR PROBE F DETECT AGENT NOS, DNA, DIR DETECT AGNT MULT, DNA, DIREC DETECT AGNT MULT, DNA, AMPLI INFECTIOUS AGENT ANTIGEN DETECTION B INFECTIOUS AGENT ANTIGEN DETECTION B F CHYLMD TRACH ASSAY W/OPTIC N. GONORRHOEAE ASSAY W/OPTIC INFECTIOUS AGENT ENZYMATIC ACTIVITY CYTOPATHOLOGY, FLUIDS, WASHINGS OR B CYTOPATH CERV/VAG INTERPRET F CYTOPATH CERV/VAG THIN LAYER F CYTPATH C/VAG T/LAYER REDO F CYTPATH C/VAG AUTOMATED F CYTPATH C/VAG AUTO RESCREEN F CYTOPATHOLOGY, PAP SMEAR F X CYTOPATH CERV/VAG AUTO F CYTPATH C/VAG REDO F CYTPATH C/VAG SELECT F CYTOPATH,(PAP);W/ DEF.HORMONAL EVAL F X CYTOPATHOLOGY CYTOPATH...;PREP,SCREEN,INTERP CYTOPATH..;EXT.STUDY,+5 SLIDES,MULTI CYTPATH TBS C/VAG MANUAL F CYTPATH TBS C/VAG REDO F CYTPATH TBS C/VAG AUTO REDO F CYTPATH TBS C/VAG SELECT F CYTOPATHOLOGY, EVALUATION OF FINE NE

11 RUN: 12/20/16 08:55:28 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: FINE NEEDLE ASPIRATE..;INTERP/REPORT CYTOPATHOLOGY,CERVIAL OR VAGINAL COL F CYTOPATHOLOGY WITH SCREENING SURGICAL PATHOLOGY, GROSS X PATHOLOGY EXAMINATION OF TISSUE USIN X PATHOLOGY EXAMINATION OF TISSUE USIN X PATHOLOGY EXAMINATION OF TISSUE USIN SPECIAL STAIN INCLUDING INTERPRETATI SPECIAL STAIN INCLUDING INTERPRETATI IMMUNOCYTOCHEMISTRY (INCLUDING TISSU F IMMUNIZATION ADMIN, ONE VACC,(SC/IM) IMMUNIZATION ADMINS, EA ADDL VACCINE X HPV VACCINE 4 VALENT, IM HUMAN PAPILLOMA VIRUS (HPV) VACCINE, HUMAN PAPILLOVAVIRUS VACCINE TYPES ROUTINE ECG W/AT LEAST 12 LEADS X TIME OTHER THAN REG SCHED HRS MODERATE SEDATION SERVICES BY PHYSIC X NEW PATIENT OFFICE OR OTHER OUTPATIE NEW PATIENT OFFICE OR OTHER OUTPATIE NEW PATIENT OFFICE OR OTHER OUTPATIE NEW PATIENT OFFICE OR OTHER OUTPATIE NEW PATIENT OFFICE OR OTHER OUTPATIE OFFICE,EST PT, MINIMAL PROBLEMS X ESTABLISHED PATIENT OFFICE OR OTHER X ESTABLISHED PATIENT OFFICE OR OTHER ESTABLISHED PATIENT OFFICE OR OTHER ESTABLISHED PATIENT OFFICE OR OTHER INITIAL HOSPITAL INPATIENT CARE, TYP INITIAL HOSPITAL INPATIENT CARE, TYP INITIAL HOSPITAL INPATIENT CARE, TYP SUBSEQUENT HOSPITAL INPATIENT CARE, SUBSEQUENT HOSPITAL INPATIENT CARE, SUBSEQUENT HOSPITAL INPATIENT CARE, HOSPITAL DISCHARGE DAY MANAGEMENT HOSPITAL DISCHARGE DAY INIT COMP PREV MED YRS X INIT COMP PREV MED YRS X ESTABLISHED PATIENT PERIODIC PREVENT X ESTABLISHED PATIENT PERIODIC PREVENT X

LEGEND. COLUMN 6. MED REV (Medical Review): Claims with some codes pend to Medical Review for review of the attachments or for manual pricing.

LEGEND. COLUMN 6. MED REV (Medical Review): Claims with some codes pend to Medical Review for review of the attachments or for manual pricing. RUN: 12/31/2014 13:44:06 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: LEGEND ------------------------------------------------------------------------------------------------------------------------------------