NorthSTAR Service and Lab Codes

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					     NorthSTAR Contract for Services 11/1/07 through 8/31/09                                                                                             Appendix 22


                                                                  NORTHSTAR SERVICE CODES
                                                     HIPAA Svc
                                                     Codes Eff.
                     SERVICE                           101603       Modifiers                                Description                             Unit Value
                     Inpatient                          0100                                      Acute Room and Board Services                         Day
                     Inpatient                          0114                                      Acute Room and Board Services                         Day
                     Inpatient                          0120                                      Acute Room and Board Services                         Day
                     Inpatient                          0124                                      Acute Room and Board Services                         Day
                     Inpatient                          0128                                Rehabilitation Semi Private Room and Board                  Day
      Hospital Based Detoxification Service            H0009        HA or HB                Detoxification Services in a Hospital Setting               Day
      Hospital Based Detoxification Service             0126                                Detoxification Services in a Hospital Setting               Day
                Sub Acute Inpatient                     0190                                                MH Sub Acute                             Per Diem
                Observation Room                        0762                                             Observation Room                             Episode
                Observation Room                         760                                          Observation Room (PCDU)                         Episode
                Crisis Stabilization                    0154                                 Facility Based Crisis Stabilization Program             Per Diem
      Intensive Crisis Residential Services            H0018           TF                  24 Hour Residential and Stabilization Services            Per Diem
Residential Treatment Centers / Adult , Adolescent     H0018                                 24 Hour Specialized Living Arrangement**                Per Diem
               and Child Residential
Residential Treatment Centers / Adult , Adolescent     1001                                      Level One Residential Treatment                      Per Diem
               and Child Residential
  Medically Monitored 24 Hr Residential Detox          H0010        HA or HB           Medically Monitored 24 Hour Residential Detoxification            Day
                                                                                                              Services
    Specialized Female Services Residential            H2036          HD                      Specialized Female Residential Services                    Day
   24 Hour Residential Rehabilitation Program          H2036        HA or HB            24 Hour Residential Rehabilitation Program Services              Day
          Respite Services / Housing                   H0045                                              Respite Housing                                Day
             Personal Care Homes                       T1023                                           Personal Care Homes                            Per Diem
       Supported Housing (non-Medicaid)                H0044                                Temporary Rental Assistance (non-Medicaid)                Per Diem
            Therapeutic Foster Care                    S5145           HA                             Therapeutic Foster Care                         Per Diem
          Adult Foster Care Services                   S5140                                        Adult Foster Care Services                        Per Diem
            Methadone Maintenance                      H0020                         Pharmacological Maintenance - daily medication services             Day
            Methadone Maintenance                      H2035      HF & HA or HB     Outpatient Counseling - pharmacological maintenance setting     Per Diem/Visit

 Partial Hospitalization and Day Treatment (CD)        H0035        HA or HB                         MH Partial Hospitalization                       Per Diem

 Partial Hospitalization and Day Treatment (CD)        H0047      TG & HA or HB    Outpatient Counseling - Partial Hospitalization/Day Treatment,     Per Diem
                                                                                               Non-hospital based Program Setting
 Partial Hospitalization and Day Treatment (CD)        T1008        HA or HB         Chemical Dependency Day Treatment for Adults & Children             Day

              Day Treatment Acute                      G0177           AT                    MH Day Treatment for Acute Needs- Adult                    Hour
          Intensive Outpatient Program                 H0047      TF & HA or HB      CD Outpatient Counseling - Intensive Outpatient Program            Day
                                                                                                              Setting
         Intensive Outpatient Program                  0905                                          MH Intensive Outpatient                          Per Diem
        Specialized Female Services Day                H2035           HD           Outpatient Counseling - Specialized Female Services Setting         Day

         Supportive Outpatient Program                 H0047        HA or HB Page 1CD Outpatient Counseling - Outpatient Program Setting
                                                                                    of 13                                                                Day
NorthSTAR Contract for Services 11/1/07 through 8/31/09                                                                                  Appendix 22

                                                         NORTHSTAR SERVICE CODES
                                           HIPAA Svc
                                           Codes Eff.
                SERVICE                      101603        Modifiers                                Description                       Unit Value
  Medically Monitored Outpatient Detox       H0012         HA or HB          Medically Monitored Outpatient Detoxification Services      Day
      Diversion Transitional Living          H0023           HZ                            Jail Diversion Crisis Housing                 Day
        Adult Intensive Case Mgt             T1017           HZ                 Adult Intensive Case Mgt Program Under Grant            Month
        Adult Intensive Case Mgt             T1017                                 Jail Diversion Intensive Case Management             Month
      Case Management Services               T1017          HA & TF                     Face to Face Contact - Child(ren)              15 min
      Case Management Services               T1017            TF                           Face to Face Contact - Adult                15 min
      Case Management Services               T1017          U1 & HM                Face to Face Contact - Child(ren) - CSSP            15 min
      Case Management Services               T1017          U2 & HM                   Face to Face Contact - Adult - CSSP              15 min
Intensive Case Management (kids Only)        T1017          TG & HA                     Face to Face Contact - Child(ren)              15 mins
Intensive Case Management (kids Only)        T1017          U3 & HM                Face to Face Contact - Child(ren) - CSSP            15 mins
          Enrollment Functions               T1023            HE                             SSI Enrollment Activities
      Crisis Intervention Services           H2011            HA                  Crisis Intervention by a Professional - CHILD        15 mins
      Crisis Intervention Services           H2011                                 Crisis Intervention by a professional - Adult       15 mins
    Medication Training and Support          H0034      HA & HN or HO or     Services by Professional - CHILD - CONSUMER ONLY          15 mins
                                                            HP or TD
    Medication Training and Support          H0034      HE & HN or HO or         Services by Professional- Individual- ADULT           15 mins
                                                            HP or TD
    Medication Training and Support          H0034      HR & HN or HO or  Services by Professional - CHILD WITH CONSUMER AND           15 mins
                                                            HP or TD                               OTHER
    Medication Training and Support          H0034      UK & HN or HO or  Services by Professional - CHILD WITHOUT CONSUMER            15 mins
                                                            HP or TD
    Medication Training and Support          H0034       U2 & HM or TE         Services by CSSP - CHILD - CONSUMER ONLY                15 mins
    Medication Training and Support          H0034       U1 & HM or TE              Services by CSSP - Individual - ADULT              15 mins
    Medication Training and Support          H0034       U3 & HM or TE   Services by CSSP - CHILD WITH CONSUMER AND OTHER              15 mins

    Medication Training and Support          H0034       U4 & HM or TE        Services by CSSP - CHILD WITHOUT CONSUMER                15 mins
    Medication Training and Support          H0034       U6 & HM or TE               Services by CSSP - GROUP CHILD                    15 mins
    Medication Training and Support          H0034       U5 & HM or TE               Services by CSSP - GROUP ADULT                    15 mins
    Medication Training and Support          H0034      U7 & HN or HO or           Services by Professional - GROUP CHILD              15 mins
                                                            HP or TD
    Medication Training and Support          H0034      HQ & HN or HO Or           Services by Professional- GROUP ADULT               15 mins
                                                            HP or TD
  Psychosocial Rehabilitation Services       H2017      HE & HN or HO or     Support Services by Professional- Individual - ADULTS     1/2 Hour
                                                            HP or TD
  Psychosocial Rehabilitation Services       H2017       U2 & HM or TE         Support Services by CSSP - Individual ADULTS            1/2 Hour
  Psychosocial Rehabilitation Services       H2017      HQ & HN or HO or     Support Services by Professional- GROUP - ADULTS          1/2 Hour
                                                            HP or TD
  Psychosocial Rehabilitation Services       H2017       U1 & HM or TE     Support Services by CSSP or Licensed Medical Personnel -    1/2 Hour
                                                                                              GROUP - ADULTS
Skills training and Development Services     H2014            HA             Services by Professional - CHILD - CONSUMER ONLY          15 mins

                                                                       Page 2 of 13
 NorthSTAR Contract for Services 11/1/07 through 8/31/09                                                                                    Appendix 22

                                                        NORTHSTAR SERVICE CODES
                                           HIPAA Svc
                                           Codes Eff.
                 SERVICE                     101603        Modifiers                              Description                            Unit Value
Skills training and Development Services     H2014      HE & HN or HO or          Services by Professional - Individual - ADULT           15 mins
                                                            HP or TD
Skills training and Development Services     H2014          HR & HA         Services by Professional - CHILD WITH CONSUMER AND            15 mins
                                                                                                     OTHER
Skills training and Development Services     H2014         UK & HA          Services by Professional - CHILD WITHOUT CONSUMER             15 mins
Skills training and Development Services     H2014       U1& HM or TE                 Services by CSSP - Individual - ADULT               15 mins
Skills training and Development Services     H2014       U2 & HM or TE           Services by CSSP - CHILD - CONSUMER ONLY                 15 mins
Skills training and Development Services     H2014       U3 & HM or TE     Services by CSSP - CHILD WITH CONSUMER AND OTHER               15 mins

Skills training and Development Services     H2014       U4 & HM or TE         Services by CSSP - CHILD WITHOUT CONSUMER                  15 mins
Skills training and Development Services     H2014          U5 & HM               Services by less than a Bachelor degree level           15 mins
Skills training and Development Services     H2014      HQ & HN or HO or        GROUP Services by Professional ADULTS ONLY                15 mins
                                                           HP or TD
Skills training and Development Services     H2014       U5 & HM or TE            GROUP Services by CSSP - ADULTS ONLY                    15 mins
Skills training and Development Services     H2014                                    Group/Group by a para professional                  15 mins
Skills training and Development Services     H2014       U6 & HM or TE            Group/Group by a para professional or CSSP              15 mins
Skills training and Development Services     H2014      U7 & HN or HO or                            Group                                 15 mins
                                                            HP or TD
         Supported Employement               H2023                                Assistance with Choosing/ Obtaining Employment          15 min
         Supported Employement               H2025                                     Assistance with Maintaining Employment             15 min
            Early Intervention               T1027                                              Parent Education Training                  Hour
            Respite Services                 S9125                                                   In Client Home                        Hour
            Respite Services                 S9125                                               Outside of Client Home                    Hour
Early Childhood Preschool Day Treatment      H2012            HA                                Parent Education Training                 Week
Children and Youth Wrap-Around Services      H2022                            Unique Wrap-Around Services not Included in any other       Week
                                                                                            NorthSTAR Service or Program
 Mental Health Services Birth to Age Six     T1025                                               Day Care Staff Training                   Week
    Treatment Foster Care Services           S5145                                          Treatment Foster Care Services                  Day
     Treatment Foster Care Housing           S5145                                          Treatment Foster Care Housing                   Day
     Single Portal Authority Services        T1023            HW                            Single Portal Authority Services                Day
Forensic ACT Services for SNOP program       H0040            HK            Assertive Community Treatment/Specialized Mental Health        Month
                                                                                                 Programs for High-Risk
         Professional Services               90806                           Individual Counseling Services by an LMSW-ACP or LPC          Hour
         Professional Services               90853                             Group Counseling Services by an LMSW-ACP or LPC             Hour
         Professional Services               90847                            Family Counseling Services by an LMSW - ACP or LPC           Hour
         Professional Services               90801                                     Initial Psychiatric Interview Examination           Hour
         Professional Services               90802                             Interactive Psychiatric Diagnostic Interview Using Play     Hour
                                                                                          Equipment, Physical Devices, etc.
         Professional Services               90804                                      Individual Psychotherapy (20 - 30 min)             Hour
         Professional Services               90805                              Individual Psychotherapy with Medical Evaluation and       Hour
                                                                                               Management (20 - 30 min)

                                                                     Page 3 of 13
NorthSTAR Contract for Services 11/1/07 through 8/31/09                                                                                        Appendix 22

                                                      NORTHSTAR SERVICE CODES
                                         HIPAA Svc
                                         Codes Eff.
             SERVICE                       101603         Modifiers                                Description                              Unit Value
       Professional Services               90806                            Individual Counseling Services by an LMSW-ACP or LPC              Hour
                                                                                            (Child or Adolescent only)
       Professional Services               90806             GV          Individual Psychotherapy (45 - 50 min) Attending Physician not       Hour
                                                                               employed or paid under arrangements by the patient

       Professional Services               90807                               Individual Psychotherapy with Medical Evaluation and           Hour
                                                                                               Management (45 - 50 min)
       Professional Services               90808                                       Individual Psychotherapy (75 - 80 min)                 Hour
       Professional Services               90809                               Individual Psychotherapy with Medical Evaluation and           Hour
                                                                                               Management (75 - 80 min)
       Professional Services               90810                                 Interactive Individual Psychotherapy (20 - 30 min)           Hour
       Professional Services               90811                           Interactive Individual Psychotherapy with Medical Evaluation       Hour
                                                                                            and Management (20 - 30 min)
       Professional Services               90812                                 Interactive Individual Psychotherapy (45 - 50 min)           Hour
       Professional Services               90813                           Interactive Individual Psychotherapy with Medical Evaluation       Hour
                                                                                            and Management (45 - 50 min)
       Professional Services               90814                                 Interactive Individual Psychotherapy (75 - 80 min)           Hour
       Professional Services               90815                           Interactive Individual Psychotherapy with Medical Evaluation       Hour
                                                                                            and Management (75 - 80 min)
       Professional Services               90801                                      Initial Psychiatric Interview Examination               Hour
       Professional Services               90816                         Inpatient, Partial or Residential Individual Psychotherapy (20 -     Hour
                                                                                                        30 min)
       Professional Services               90817                          Inpatient, Partial or Residential Individual Psychotherapy with     Hour
                                                                                 Medical Evaluation and Management (20 - 30 min)
       Professional Services               90818                         Inpatient, Partial or Residential Individual Psychotherapy (45 -     Hour
                                                                                                        50 min)
       Professional Services               90819                          Inpatient, Partial or Residential Individual Psychotherapy with     Hour
                                                                                 Medical Evaluation and Management (45 - 50 min)
       Professional Services               90821                         Inpatient, Partial or Residential Individual Psychotherapy (75 -     Hour
                                                                                                        80 min)
       Professional Services               90822                          Inpatient, Partial or Residential Individual Psychotherapy with     Hour
                                                                                 Medical Evaluation and Management (75 - 80 min)
       Professional Services               90823                                Interactive Inpatient, Partial or Residential Individual      Hour
                                                                                              Psychotherapy (20 - 30 min)
       Professional Services               90824                                Interactive Inpatient, Partial or Residential Individual      Hour
                                                                         Psychotherapy with Medical Evaluation and Management (20 -
                                                                                                        30 min)
       Professional Services               90826                             Interactive Inpatient, Partial or Residential Individual         Hour
                                                                                          Psychotherapy (45 - 50 min)
       Professional Services               90827                             Interactive Inpatient, Partial or Residential Individual         Hour
                                                                         Psychotherapy with Medical Evaluation and Management (45 -
                                                                                                     50 min)
       Professional Services               90828                              Interactive Inpatient, Partial or Residential Individual        Hour
                                                                      Page 4 of 13         Psychotherapy (75 - 80 min)
NorthSTAR Contract for Services 11/1/07 through 8/31/09                                                                                         Appendix 22

                                                      NORTHSTAR SERVICE CODES
                                         HIPAA Svc
                                         Codes Eff.
             SERVICE                       101603         Modifiers                                 Description                             Unit Value
       Professional Services               90829                               Interactive Inpatient, Partial or Residential Individual       Hour
                                                                           Psychotherapy with Medical Evaluation and Management (75 -
                                                                                                       80 min)
       Professional Services               90845                                              Medical Psychoanalysis                           Hour
       Professional Services               90846                                      Family Psychotherapy without Patient                     Hour
       Professional Services               90847                                  Family Medical Psychotherapy (with patient)                  Hour
       Professional Services               90849                                 Multiple-Family Group Medical Psychotherapy                   Hour
       Professional Services               90853                                          Group Medical Psychotherapy                          Hour
       Professional Services               90857                                    Interactive Group Medical Psychotherapy                    Hour
       Professional Services               90865                                                   Narcosysthesis                              Hour
         Inpatient Services                99221                                          Initial Hospital Care (30 min.)                      Hour
         Inpatient Services                99222                                          Initial Hospital Care (50 min.)                      Hour
         Inpatient Services                99223                                          Initial Hospital Care (70 min.)                      Hour
         Inpatient Services                99231                                       Subsequent Hospital Care (15 min.)                      Hour
         Inpatient Services                99232                                       Subsequent Hospital Care (25 min.)                      Hour
         Inpatient Services                99233                                       Subsequent Hospital Care (35 min.)                      Hour
         Inpatient Services                99234                             Observation or Inpatient Hospital Care, Low Complexity            Hour
         Inpatient Services                99235                           Observation or Inpatient Hospital Care, Moderate Complexity         Hour

         Inpatient Services                99236                             Observation or Inpatient Hospital Care, High Complexity           Hour
         Inpatient Services                99238                             Hospital Discharge Day Management: 30 Minutes or Less             Hour
         Inpatient Services                99239                            Hospital Discharge Day Management: more than 30 Minutes            Hour

           Assessment                      H0001                            CD Clinical Assessment (should include clinical screening)         Hour

        Outpatient Services                H2035      HQ & HA or HB                       Outpatient Group Counseling                          Hour
        Outpatient Services                H2035        HA or HB                        Outpatient Individual Counseling                       Hour
             Testing                       96100                                             Psychological Testing                             Hour
             Testing                       96101                         Psychological Testing, interpretation and reporting per hour by       Hour
                                                                                                 a psychologist
              Testing                      96102                                Psychological Testing, per hour by a technician                Hour
              Testing                      96103                          Psychological Testing, by a computer, including time for the         Hour
                                                                                   psychologist's interpretation and reporting
              Testing                      96117                                           Neuropsychological testing                          Hour
              Testing                      96118                           Neuropsychological testing, interpretation and reporting per        Hour
                                                                                             hour by a psychologist
              Testing                      96119                              Neuropsychological testing, per hour by a technician             Hour
              Testing                      96120                          Neuropsychological testing, by a computer, including time for        Hour
                                                                                 the psychologist's interpretation and reporting
             Injections                    90782                         Therapeutic or Diagnostic Injection (Specify Material Injucted);   Visit / Unit
                                                                                        Subcutaneous or Intramuscular)
             Injections                    G0351                         Therapeutic or diagnostic injection (specify substance or drug);   Visit / Unit
                                                                      Page 5 of 13       subcutaneous or intramuscular
 NorthSTAR Contract for Services 11/1/07 through 8/31/09                                                                                      Appendix 22

                                                         NORTHSTAR SERVICE CODES
                                            HIPAA Svc
                                            Codes Eff.
               SERVICE                        101603       Modifiers                                Description                           Unit Value
               Injections                     90772                          Therapeutic, prophylactic or diagnostic injection (specify   Visit / Unit
                                                                               substance or drug); subcutaneous or intramuscular
                Injections                    J1631                                          Haldol DEC 50 MG/ML                          Visit / Unit
                Injections                    J2680                                          Prolixin DEC 25 MG/ML                        Visit / Unit
                Injections                    J1630                                           Haldol Up to 5 MG/ML                        Visit / Unit
                Injections                    J3490                                          Prolixin HCL 2.5 MG/ML                       Visit / Unit
                Injections                    J0515                                            Cogentin 1 MG/ML                           Visit / Unit
                Injections                    J2060                                              Ativan 2 MG/ML                           Visit / Unit
                Injections                    J1200                                            Benedryl 50 MG/ML                          Visit / Unit
Medication Administration, Monitoring and     90862                                       Pharmacologcal Management                          Hour
                Education
 Medication - Injection Related Services      99000                                          Specimen Bloodwork                              Hour
                                              93000                                    EKG (Technical Component Only)                        Hour
Medication Administration, Monitoring and     99211                          Medication administration and monitoring and education          Hour
                Education
      Emergency Room Services                  0450                                      Emergency Room (MH & CD)                          Episode
             Transportation                   T2003                                                  Routine                               Episode
             Transportation                   A0429                                               Emergency                                Episode
         Inpatient Consultations              99251                                          Inpatient Consultation                         Hour
                                                                                                    (20 min.)
         Inpatient Consultations              99252                                          Inpatient Consultation                          Hour
                                                                                                    (40 min.)
         Inpatient Consultations              99253                                          Inpatient Consultation                          Hour
                                                                                                    (55 min.)
         Inpatient Consultations              99254                                          Inpatient Consultation                          Hour
                                                                                                    (80 min.)
        Inpatient Consultations               99255                                    Inpatient Consultation (110 min.)                     Hour
        Inpatient Consultations               99261                               Follow-up Inpatient Consultation (10 min.)                 Hour
        Inpatient Consultations               99262                               Follow-up Inpatient Consultation (20 min.)                 Hour
        Inpatient Consultations               99263                               Follow-up Inpatient Consultation (30 min.)                 Hour
    Mental Health Treatment Room               0761                                           MH Treatment Room                            Episode
  Emergency Room Physician Services           99281                                 Emergency Department Visit, Focused                   Visit / Unit
  Emergency Room Physician Services           99282                         Emergency Department Visit, Expanded, Low Complexity          Visit / Unit
  Emergency Room Physician Services           99283                       Emergency Department Visit, Expanded, Moderate Complexity       Visit / Unit

  Emergency Room Physician Services           99284                                 Emergency Department Visit, Detailed                  Visit / Unit
  Emergency Room Physician Services           99285                               Emergency Department Visit, Comprehensive               Visit / Unit
             Laboratory                       36415                                         Routine Venipuncture                             Unit
             Laboratory                       80048                                         Basic Metabolic Panel                            Unit
             Laboratory                       80051                                           Electrolyte Panel                              Unit
             Laboratory                       80053                                    Comperhensive Metabolic Panel                         Unit
             Laboratory                       80061                                              Lipid Panel                                 Unit
                                                                       Page 6 of 13
NorthSTAR Contract for Services 11/1/07 through 8/31/09                                                                                  Appendix 22

                                                      NORTHSTAR SERVICE CODES
                                         HIPAA Svc
                                         Codes Eff.
            SERVICE                        101603         Modifiers                                Description                        Unit Value
            Laboratory                     80091                                                  Thyroid Panel                          Unit
            Laboratory                     80092                            Thyroid Panel with Thyroid Stimulating Hormone (TSH)         Unit
            Laboratory                     80076                                                Hepatic Function                         Unit
            Laboratory                     80100                              Drug Screen Multiple Drug Classes, Each Procedure          Unit
            Laboratory                     80101                               Drug Screen, Single Drug Class, Each Drug Class           Unit
            Laboratory                     80102                                      Drug Confirmation, Each Procedure                  Unit
            Laboratory                     80152                                              Amitriptyline (Elavil)                     Unit
            Laboratory                     80154                                                Benzodiazepines                          Unit
            Laboratory                     80156                                           Tegretol (Carbamzepine)                       Unit
            Laboratory                     80158                                                   Cyclosporine                          Unit
            Laboratory                     80160                                                    Desiprimine                          Unit
            Laboratory                     80162                                                      Digoxin                            Unit
            Laboratory                     80164                                           Valproic Acid (Depakene)                      Unit
            Laboratory                     80168                                                   Ethosuximide                          Unit
            Laboratory                     80174                                                    Imipramine                           Unit
            Laboratory                     80178                                                      Lithium                            Unit
            Laboratory                     80182                                                    Nortriptyline                        Unit
            Laboratory                     80184                                                  Phenobarbitol                          Unit
            Laboratory                     80185                                           Phenytoin, Total (Dilantin)                   Unit
            Laboratory                     80186                                                 Phenytoin, Free                         Unit
            Laboratory                     80188                                                     Primidone                           Unit
            Laboratory                     80194                                                     Quinidine                           Unit
            Laboratory                     80196                                                     Salicylate                          Unit
            Laboratory                     80198                                                   Theophylline                          Unit
            Laboratory                     80202                                                   Vancomycin                            Unit
            Laboratory                     80299                            Clomiprimine, Fluoxetine, or Trazadone, Clozaril Levels      Unit
            Laboratory                     81000                                  Urinalysis, non-automated with Microscopy              Unit
            Laboratory                     81001                                    Urinalysis, automated, with Mircroscopy              Unit
            Laboratory                     81003                                  Urinalysis, automated, without Mircroscopy             Unit
            Laboratory                     81005                              Urinalysis; Qualitative or Semi-Quantitative , Except      Unit
                                                                                                 Immunoassays
            Laboratory                     81025                          Urine Pregnancy Test by Visual Color Comparison Methods        Unit

            Laboratory                     82003                                               Acetaminophen                             Unit
            Laboratory                     82009                              Acetone or other ketone bodies, Serum, Qualitative         Unit
            Laboratory                     82040                                               Albumin, Serum                            Unit
            Laboratory                     82055                                               Alcohol (ethanol)                         Unit
            Laboratory                     82085                                                   Aldolase                              Unit
            Laboratory                     82103                                           Alpha-1-antitrypsin, total                    Unit
            Laboratory                     82128                               Amino Acids, multiple, qualitative, each specimen         Unit
            Laboratory                     82131                                Amino Acids, single, qualitative, each specimen          Unit
                                                                      Page 7 of 13
NorthSTAR Contract for Services 11/1/07 through 8/31/09                                                                                 Appendix 22

                                                      NORTHSTAR SERVICE CODES
                                         HIPAA Svc
                                         Codes Eff.
            SERVICE                        101603         Modifiers                                Description                       Unit Value
            Laboratory                     82140                                                    Ammonia                             Unit
            Laboratory                     82150                                                     Amylase                            Unit
            Laboratory                     82157                                                 Androstenedione                        Unit
            Laboratory                     82180                                        Ascorbic Acid (Vitamin C), blood                Unit
            Laboratory                     82248                                            Bilirubin, total and direct                 Unit
            Laboratory                     82270                            Blood, occult, feces, 1-3 simultaneous determinations       Unit
            Laboratory                     82310                                                  Calcium, total                        Unit
            Laboratory                     82340                                  Calcium, urine quantitative, timed specimen           Unit
            Laboratory                     82374                                         Carbon dioxide (bicarbonate)                   Unit
            Laboratory                     82378                                       Carcinoembryonic antigen (CEA)                   Unit
            Laboratory                     82390                                                  Ceruloplasmin                         Unit
            Laboratory                     82435                                                  Chloride; blood                       Unit
            Laboratory                     82465                                            Cholesterol, serum total                    Unit
            Laboratory                     82486                                     Chromatography, qualitative, column                Unit
            Laboratory                     82525                                                      Copper                            Unit
            Laboratory                     82533                                                   Cortisol, total                      Unit
            Laboratory                     82550                                       Creatine kinase (CK), (CPK), total               Unit
            Laboratory                     82552                                   Creatine kinase (CK), (CPK), isoenzymes              Unit
            Laboratory                     82565                                                 Creatinine; Blood                      Unit
            Laboratory                     82575                                             Creatinine; Clearance                      Unit
            Laboratory                     82607                                        Cyanocobalamin (Vitamin B-12)                   Unit
            Laboratory                     82652                                           Dihydroxyvitamin D, 1, 25                    Unit
            Laboratory                     82670                                                     Estradiol                          Unit
            Laboratory                     82728                                                      Ferritin                          Unit
            Laboratory                     82746                                                Folic Acid, serum                       Unit
            Laboratory                     82803                         Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3      Unit

            Laboratory                     82947                                            Glucose, Quantitative                       Unit
            Laboratory                     82950                                         Glucose, post glucose dose                     Unit
            Laboratory                     82955                           Glucose-6-phosphate dehydrogenase (G6PD); quantitative       Unit

            Laboratory                     82977                                   Glutamyltransferase, gamma (GGT)                     Unit
            Laboratory                     83001                              Gonadotropin, Follicle Stimulating Hormone (FSH)          Unit
            Laboratory                     83002                                    Gonadotropin, Lutenizing Hormone                    Unit
            Laboratory                     83018                                      Heavy Metal: Quantitative, Each                   Unit
            Laboratory                     83036                                           Hemoglobin, glycated                         Unit
            Laboratory                     83540                                                     Iron                               Unit
            Laboratory                     83550                                            Iron binding capacity                       Unit
            Laboratory                     83615                                   Lactate Dehydrogenase (LD), (LDH)                    Unit
            Laboratory                     83655                                                     Lead                               Unit
            Laboratory                     83690                                                    Lipase                              Unit
                                                                      Page 8 of 13
NorthSTAR Contract for Services 11/1/07 through 8/31/09                                                                                         Appendix 22

                                                      NORTHSTAR SERVICE CODES
                                         HIPAA Svc
                                         Codes Eff.
            SERVICE                        101603         Modifiers                                  Description                             Unit Value
            Laboratory                     83718                            Lipoprotein, direct measurement; high density cholesterol           Unit
            Laboratory                     83735                                                     Magnesium                                  Unit
            Laboratory                     83930                                                 Osmolarity; blood                              Unit
            Laboratory                     83970                                      Parathormone (parathyroid hormone)                        Unit
            Laboratory                     84060                                             Phosphatase, acid, total                           Unit
            Laboratory                     84066                                           Phosphatase, acid, prostatic                         Unit
            Laboratory                     84075                                               Phosphatase, alkaline                            Unit
            Laboratory                     84080                                       Phosphatase, alkaline, isoenzymes                        Unit
            Laboratory                     84100                                        Phosphorus inorganic (phosphate)                        Unit
            Laboratory                     84132                                                 Potassium, serum                               Unit
            Laboratory                     84146                                                      Prolactin                                 Unit
            Laboratory                     84153                                      Prostate Specific Antigen (PSA), total                    Unit
            Laboratory                     84155                                        Protein, total, except refractometry                    Unit
            Laboratory                     84165                              Protein, electrophoretic fractionation and quantitation           Unit
            Laboratory                     84295                                                  Sodium, serum                                 Unit
            Laboratory                     84403                                                 Testoterone, total                             Unit
            Laboratory                     84436                                                  Thyroxine, total                              Unit
            Laboratory                     84439                                                   Thyroxine, free                              Unit
            Laboratory                     84443                                       Thyroid stimulating hormone (TSH)                        Unit
            Laboratory                     84450                                  Transferase, aspartate amino (AST) (SGOT)                     Unit
            Laboratory                     84460                                   Transferase, alanine amino (ALT) (SGPT)                      Unit
            Laboratory                     84478                                                    Triglycerides                               Unit
            Laboratory                     84479                         Thyroid hormone (T3 or T4) uptake or thyroid hormone binding           Unit
                                                                                                    ratio (THBR).
            Laboratory                     84481                                             Triiodothyronine T3, free                          Unit
            Laboratory                     84520                                            Urea nitrogen; quantitative                         Unit
            Laboratory                     84550                                                  Uric Acid, blood                              Unit
            Laboratory                     84590                                                      Vitamin A                                 Unit
            Laboratory                     84630                                                         Zinc                                   Unit
            Laboratory                     84702                                   Gonadotropin, chorionic (hCG), quantitative                  Unit
            Laboratory                     84703                                   Gonadotropin, chorionic (hCG), qualitative                   Unit
            Laboratory                     85014                                    Blood count, other than spun hematrocrit                    Unit
            Laboratory                     85018                                             Blood count, hemoglobin                            Unit
            Laboratory                     85025                             Blood count, hemogram and platelet count, automated,               Unit
                                                                                            complete differential WBC
            Laboratory                     85044                                     Blood count, reticulocyte count, manual                    Unit
            Laboratory                     85049                                             Platelet, automated count                          Unit
            Laboratory                     85060                         Blood smear, peripheral, interpretation by physician with written      Unit
                                                                                                        report
            Laboratory                     85610                                                 Prothrombin time                               Unit
            Laboratory                     85651                                Sedimentation rate, erythrocyte, non-automated                  Unit
            Laboratory                     85730                           9 of 13
                                                                      Page Thromboplastin time, partial (PTT); plasma or whole blood            Unit
NorthSTAR Contract for Services 11/1/07 through 8/31/09                                                                                            Appendix 22

                                                      NORTHSTAR SERVICE CODES
                                         HIPAA Svc
                                         Codes Eff.
            SERVICE                        101603         Modifiers                                Description                                  Unit Value
            Laboratory                     86038                                          Antinuclear antibodies (ANA)                             Unit
            Laboratory                     86140                                                C-reactive protein                                 Unit
            Laboratory                     86157                                              Cold agglutinin; titer                               Unit
            Laboratory                     86225                             Deoxyribonucleic acid (DNA) antibody, native or double                Unit
                                                                                                     stranded
            Laboratory                     86308                                       Heterophile anitbodies; screening                           Unit
            Laboratory                     86320                                          Immoelectrophoresis; serum                               Unit
            Laboratory                     86325                               Immoelectrophoresis; other fluids (urine, CSF) with                 Unit
                                                                                                  concentration
            Laboratory                     86430                                         Rheumatoid factor; qualitative                            Unit
            Laboratory                     86592                                  Syphilis test; qualitative (VDRL, RPR, ART)                      Unit
            Laboratory                     86593                                            Syphilis test; quantitative                            Unit
            Laboratory                     86677                                           Antibody, heliobactor pylori                            Unit
            Laboratory                     86701                                                 Antibody; HIV-1                                   Unit
            Laboratory                     86703                                    Antibody, HIV-1 and HIV-2, single assay                        Unit
            Laboratory                     86762                                                 Antibody, rubella                                 Unit
            Laboratory                     86787                                            Antibody, varicella- zoster                            Unit
            Laboratory                     86849                                        Unlisted immunology procedure                              Unit
            Laboratory                     86880                          Antihuman globulin test (Coombs test), direct, each antiserum            Unit

            Laboratory                     86886                            Antihuman globulin test (Coombs test), indirect, titer, each           Unit
                                                                                                       antiserum
            Laboratory                     86900                                                  Blood typing, ABO                                Unit
            Laboratory                     87040                          Culture, Bacterial, Definitive, Blood (includes anaerobic screen)        Unit

            Laboratory                     87045                                         Culture, bacterial, definitive, stool                     Unit
            Laboratory                     87070                                   Culture, bacterial, defintive; any other source                 Unit
            Laboratory                     87081                              Culture, bacterial, screening only, for single organisms             Unit
            Laboratory                     87086                                Culture, bacterial, urine, quantitative, colony count              Unit
            Laboratory                     87088                                       Culture bacterial, urine, identification                    Unit
            Laboratory                     87101                               Culture, fungi, isolation (with or without presumptive              Unit
                                                                                                 identification); skin
            Laboratory                     87116                          Culture, tubercle or other acid-fast bacilli; any source, isolation      Unit
                                                                                                          only
            Laboratory                     87163                          Culture, any source, additional identification methods required          Unit

            Laboratory                     87177                               Ova and parsites, direct smears, concentration and                  Unit
                                                                                                     identification
            Laboratory                     87184                            Sensitivity studies, antibiotic, disk method, per plate ( 12 or        Unit
                                                                                                      fewer disks)
            Laboratory                     87205                            Smear, primary source, with interpretation, routine stain for          Unit
                                                                                             bacteria, fungi, or cell types
                                                                      Page 10 of 13
NorthSTAR Contract for Services 11/1/07 through 8/31/09                                                                                     Appendix 22

                                                      NORTHSTAR SERVICE CODES
                                         HIPAA Svc
                                         Codes Eff.
            SERVICE                        101603         Modifiers                                Description                           Unit Value
            Laboratory                     87230                        Toxin or antitoxin assay, tissue culture (Clostridium difficle      Unit
                                                                                                       toxin)
            Laboratory                     88180                                   Flow cytometry, each cell surface marker                 Unit
            Laboratory                     88304                             Level III- Surgical pathology, gross and microscopic           Unit
                                                                                                   examination
            Laboratory                     88305                             Level IV- Surgical pathology, gross and mirocrscopic           Unit
                                                                                                   examination
            Laboratory                     88325                          Consultation, comprehensive, with review of records and           Unit
                                                                                                    specimens
            Laboratory                     99199                                                    Stat Code                              Unit
       Peer Provided Service               H2014            UA                              Peer Provider skills training                 15 min.
       Peer Provided Service               H2014          UA & HQ                       Peer Provider skills training group               15 min.
       Peer Provided Service               H2017            UA                            Peer Provider support services                  15 min.
       Peer Provided Service               H2017          UA & HQ                     Peer Provider support services group                15 min.
       Peer Provided Service               H0034            UA                          Peer provided medication training                 15 min.
       Peer Provided Service               H0034          UA & HQ                   Peer provided medication training group               15 min.
            ACT Team                       H0040                                         Assertive Community Treatment                    Month
       Professional Services               90806                         Individual Counseling Services by an LMSW-ACP or LPC              Hour
       Professional Services               90853                           Group Counseling Services by an LMSW-ACP or LPC                 Hour
       Professional Services               90847                          Family Counseling Services by an LMSW - ACP or LPC               Hour
       Professional Services               90801                                    Initial Psychiatric Interview Examination              Hour
       Professional Services               90802                           Interactive Psychiatric Diagnostic Interview Using Play         Hour
                                                                                       Equipment, Physical Devices, etc.
       Professional Services               90804                                     Individual Psychotherapy (20 - 30 min)                Hour
       Professional Services               90805                            Individual Psychotherapy with Medical Evaluation and           Hour
                                                                                            Management (20 - 30 min)
       Professional Services               90806                                     Individual Psychotherapy (45 - 50 min)                Hour
       Professional Services               90807                            Individual Psychotherapy with Medical Evaluation and           Hour
                                                                                            Management (45 - 50 min)
       Professional Services               90808                                     Individual Psychotherapy (75 - 80 min)                Hour
       Professional Services               90809                            Individual Psychotherapy with Medical Evaluation and           Hour
                                                                                            Management (75 - 80 min)
       Professional Services               90810                              Interactive Individual Psychotherapy (20 - 30 min)           Hour
       Professional Services               90811                       Interactive Individual Psychotherapy with Medical Evaluation        Hour
                                                                                          and Management (20 - 30 min)
       Professional Services               90812                              Interactive Individual Psychotherapy (45 - 50 min)           Hour
       Professional Services               90813                       Interactive Individual Psychotherapy with Medical Evaluation        Hour
                                                                                          and Management (45 - 50 min)
       Professional Services               90814                              Interactive Individual Psychotherapy (75 - 80 min)           Hour
       Professional Services               90815                       Interactive Individual Psychotherapy with Medical Evaluation        Hour
                                                                                          and Management (75 - 80 min)
       Professional Services               90845                                             Medical Psychoanalysis                        Hour
       Professional Services               90846                  Page 11 of 13 Family Psychotherapy without Patient                       Hour
NorthSTAR Contract for Services 11/1/07 through 8/31/09                                                                                Appendix 22

                                                      NORTHSTAR SERVICE CODES
                                         HIPAA Svc
                                         Codes Eff.
             SERVICE                       101603         Modifiers                               Description                       Unit Value
       Professional Services               90847                                  Family Medical Psychotherapy (with patient)         Hour
       Professional Services               90849                                 Multiple-Family Group Medical Psychotherapy          Hour
       Professional Services               90853                                         Group Medical Psychotherapy                  Hour
       Professional Services               90857                                   Interactive Group Medical Psychotherapy            Hour
       Professional Services               90862                                         Pharmacologcal Management                    Hour
       Professional Services               90862             GT                          Pharmacologcal Management                    Hour
       Professional Services               90865                                                Narcosysthesis                        Hour
        Outpatient Services                H2035      HQ & HA or HB                       Outpatient Group Counseling                 Hour
        Outpatient Services                H2035        HA or HB                        Outpatient Individual Counseling              Hour
 Youth & Family Intensive Case Mgt         T1017           HY               Youth & Family Intensive Case Mgt Program Under Grant     Month
           TCADA 8-12                      H2035           TJ                Youth Chemical Dependency Treatment Program in an        Month
                                                                                               alternative setting
      340B Program Services                99420                                            Health Risk Assessment                   Episode
      340B Program Services                99212             GT                             Telemedicine Screening                   Episode
      340B Program Services                99371                                      Medical Coordination by a Physician            Episode




                                                                      Page 12 of 13
NorthSTAR Contract for Services 11/1/07 through 8/31/09                                                Appendix 22

                                                      NORTHSTAR SERVICE CODES
                                         HIPAA Svc
                                         Codes Eff.
            SERVICE                        101603         Modifiers                   Description   Unit Value




                                                                      Page 13 of 13

				
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