090 Medical Services Clinic

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					                                                  Local Code Crosswalk
                                                090 Medical Services Clinic

                 LOCAL CODE                                                     NATIONAL CODE
                                                                                                       Max
                                 Max                                                                  Units
                                Units     PA                                          Mod Mod Mod Mod Allowe    PA
 Code       Description        Allowed Indicator         Code           Description    1   2   3   4     d   Indicator
         ANTE PARTUM                                               ESTAB PT OFFICE
T5906    CARE PER VISIT                   N             99211      VISIT LEVEL 1      TH                            N
         PRESCRIBED                                                CONTRACEPTIVE
         ORAL                                                      PILLS FOR BIRTH
X1055    CONTRACEPTIVES          12         N           S4993      CONTROL                               12         N
                                                                   INJECTION,
                                                                   MEDROXYPROGES
                                                                   TERONE ACETATE
         INJ DEPO-                                                 FOR
         PROVERA                                                   CONTRACEPTIVE
X2510    150MG/ML                           N           J1055      USE, 150 MG                                      N
         INITIAL PRE
         NATAL VISIT                                               NEW PT OFFICE-
         INCLUDING EXAM                                            OUTPT VISIT LEVEL
X5905    AND HISTORY                        N           99201      1                 TH                             N
                                                                   PRENATAL CARE,
                                                                   AT RISK
         EXTEND SERV                                               ENHANCED
         PREG WOMEN - HE-                                          SERVICE CARE
X9090    W 548                              N           H1002      COORDINATION      TH                             N
                                                                   FAMILY TRAINING
         PRENATAL AND                                              AND COUNSELING
         CHILD/FAMILY                                              FOR CHILD
         HEALTH CARE                                               DEVELOPMENT,
X9091    SUPPORT                            N           T1027      PER 15 MINUTES    TH                             N
         SMOKING
         CESSATION - PNC
         BMCH                                                      SMOKING
         CONTRACTED                                                CESSATION
X9093    AGENCIES                 1         N           S9075      TREATMENT                                        N
                                                                   SCREENING TEST
                                                                   VISUAL ACUITY
         TITMUS VISION                                             QUANITATIVE
X9335    TEST                     1         N           99173      BILATERAL                              1         N
         FIRST TRIMESTER                                           PRENATAL CARE,
         PRENATAL RISK                                             AT-RISK
X9400    ASSESSMENT                         N           H1000      ASSESSMENT                                       N
         REPLACEMENT                                               SURGICAL
         COST LEAD SCRN                                            SUPPLIES,
X9840    KIT FROM NH DPH                    N           A4649      MISCELLANEOUS                                    N
                                                                   COORDINATED
         CARE                                                      CARE FEE,
X9906    COORDINATION                       N           S0302      MAINTENANCE                                      N




This publication is subject to changes and additions.           1 of 1                                        January 2004

				
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