Haw. Code R. § tit. 11, subtit. 1, ch. 179, Charge Slip
CENTER________________
COMMUNITY MENTAL HEALTH CENTER
Name of Provider Number Date of Service Walk
Name of Client___________CR #_________
PATIENT COMPLAINT:______________________________
________________________________________________
________________________________________________W9205-52 Clinic Visit - Group
___90620 Consultation, Initial, Compre. ___W9206 DHS Psych. Diag./Evaluation
___90630 Consultation, Initial, Complex___ _____Occupational Therapy
___90640 F/U Consultation, Brief
___90641 F/U Consultation, Limited
PRESCRIPTION
RX NO. NATIONAL DRUG CODE QUANTITY DAYS SUPPLY REFILL CHARGES DEDUCTIBLE BALANCE
SUMMARY/SYNOPSIS OF VISIT:__________
________________________
Provider Signature:_____________________________
12/1/90
CLINIC
RATE SCHEDULE
PROC. CODE DESCRIPTION RATE
90000 OFV, BRIEF, NEW 40.00
90010 OFV, LIMITED, NEW 73.75
90015 OFV, INTERMEDIATE, NEW 116.00
90020 OFV, COMPREHENSIVE, NEW 159.00
90030 OFV, MINIMAL, ESTABLISHED 32.60
90040 OFV, BRIEF, ESTABLISHED 44.00
90050 OFV, LIMITED, ESTABLISHED 58.00
90060 OFV, INTERMEDIATE, ESTABLISHED 70.00
90070 OFV, EXTENDED, ESTABLISHED 110.00
90080 OFV, COMPREHENSIVE, ESTABLISHED 127.00
90200 INITIAL HOSP. CARE - BRIEF 100.00
90215 INITIAL HOSP. CARE - INTERMEDIATE 166.00
90220 INITIAL HOSP. CARE - COMPREHENSIVE 209.00
90600 CONSULTATION, INITIAL, LIMITED 114.00
90605 CONSULTATION, INITIAL, INTERMEDIATE 131.00
90610 CONSULTATION, INITIAL, EXTENDED 151.00
90620 CONSULTATION, INITIAL, COMPREHENSIVE 169.00
90630 CONSULTATION, INITIAL, COMPLEX 190.00
90640 CONSULTATION, FOLLOW-UP, BRIEF 42.00
90641 CONSULTATION, FOLLOW-UP, LIMITED 59.00
90642 CONSULTATION, FOLLOW-UP, INTERMEDIATE 85.00
90643 CONSULTATION, FOLLOW-UP, COMPLEX 109.00
90801 PSYCHIATRIC DIAGNOSTIC EVALUATION 141.00
90801-22 PSYCH. EVAL DIAGNOSTIC EVALUATION 180.00
90801-52 PSYCHIATRIC DIAGNOSTIC EVALUATION 70.00
90825 PSYCHIATRIC EVAL. OF HOSP. RECORDS 142.00
90830 PSYCHOLOGICAL TESTING 141.00
90841 PSYCHO-THERAPY (UP TO 15 MINUTES) 40.00
90843 PSYCHO-THERAPY (UP TO 35 MINUTES) 73.20
90844 PSYCHO-THERAPY (UP TO 50 MINUTES) 133.40
90847 FAMILY/CONJOINT PSYCHO-THERAPY 148.00
90853 GROUP PSYCHO-THERAPY 67.00
90782 THER. INJECT. INTRAMUSCULAR 5.00
90849 MULTI-FAMILY GROUP THERAPY 48.33
W9205 CLINIC VISIT 45.00
W9205-52 CLINIC VISIT 27.00
W9206 PSYCH. EVAL/DIAGNOSIS 141.00
Haw. Code R. tit. 11, subtit. 1, ch. 179, Charge Slip