ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
North Carolina Department of Health and Human Services
2
Division of Health Benefits
3
Mental Health Fee Schedule
4
5
 CPT Service Rates for Specialty 113
6
The inclusion of a rate on this table does not guarantee that a service is covered.  Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice Clinical Coverage Policies on the DHB Web site.
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Procedure CodeProcedure Code DescriptionBilling UnitNon-Facility RateFacility RateEffective DateEnd DateNotes 1Notes 2Notes 3Notes 4
22
90785Interactive Complexity Add-OnPer Event $ 3.96 $ 3.96 1/1/201312/31/9999
23
90791Psychiatric Diagnostic EvaluationPer Event $ 125.39 $ 98.54 1/1/201312/31/9999
24
90792Psychiatric Diagnostic Evaluation With Medical ServicesPer Event $ 104.58 $ 101.87 1/1/201312/31/9999
25
90832Psychotherapy, 16-37 MinutesPer Event $ 52.24 $ 41.39 1/1/201312/31/9999
26
90833Psychotherapy, 16-37 Minutes With E/M Service, Listed SeparatelyPer Event $ 34.91 $ 34.64 1/1/201312/31/9999
27
90834Psychotherapy, 38-52 MinutesPer Event $ 67.85 $ 62.15 1/1/201312/31/9999
28
90836Psychotherapy, 38-52 Minutes With E/M Service, Listed SeparatelyPer Event $ 56.72 $ 56.72 1/1/201312/31/9999
29
90837Psychotherapy, 53+ MinutesPer Event $ 99.42 $ 93.72 1/1/201312/31/9999
30
90838Psychotherapy, 53+ Minutes With E/M Service, Listed SeparatelyPer Event $ 91.59 $ 91.04 1/1/201312/31/9999
31
90839Psychotherapy For Crisis, 30-74 MinutesPer Event $ 125.28 $ 117.42 1/1/201312/31/9999
32
90840
Psychotherapy For Crisis, Each Additional 30 Minutes Beyond Initial 74Min, Up To Two Add-Ons Per 90839
Per Event $ 105.47 $ 97.86 1/1/201312/31/9999
33
90846Family Psytx W/O Pt 50 MinPer Event $ 72.24 $ 70.54 7/1/201212/31/9999Added procedure code
34
90847Family Psytx W/Pt 50 MinPer Event $ 89.70 $ 84.61 7/1/201212/31/9999Added procedure code
35
90853Group PsychotherapyPer Event $ 25.57 $ 24.15 7/1/201212/31/9999Added procedure code
36
92506Speech EvaluationPer Event $ 117.03 $ 35.90 7/1/201212/31/9999
37
92507Speech TherapyPer Event $ 66.88 $ 23.93 7/1/201212/31/9999
38
92508Speech Therapy GroupPer Event $ 23.40 $ 10.96 7/1/201212/31/9999
39
96101Psychological TestingPer Hour $ 69.95 $ 69.68 7/1/201212/31/2018End dated 2018
40
96372
Therapeutic, Prophylactic Or Diagnostic Injection (Specify Substance Or Drug); Subcutaneous Or Intramuscular
Per Event $ 16.70 $ 16.70 7/1/201212/31/9999
41
97001Physical Therapy EvalPer Event $ 57.14 $ 57.14 7/1/201212/31/9999
42
97002Physical Therapy Re-EvalPer Event $ 30.59 $ 30.59 7/1/201212/31/9999
43
97003Occupational Therapy EvalPer Event $ 60.44 $ 60.44 7/1/201212/31/9999
44
97004Occupational Therapy Re-EvalPer Event $ 34.83 $ 34.83 7/1/201212/31/9999
45
97110Physical TherapyPer 15 Mins $ 22.91 $ 22.91 7/1/201212/31/9999
46
97112Physical TherapyPer 15 Mins $ 23.55 $ 23.55 7/1/201212/31/9999
47
97113Physical Therapy Aquatic W/ExercisePer 15 Mins $ 27.78 $ 27.78 7/1/201212/31/9999
48
97116Gait TrainingPer 15 Mins $ 20.06 $ 20.06 7/1/201212/31/9999
49
97124Massage ThersapyPer 15 Mins $ 18.23 $ 18.23 7/1/201212/31/9999
50
97140Manual TherapyPer 15 Mins $ 21.24 $ 21.24 7/1/201212/31/9999
51
97530Therapeutic ActivitiesPer 15 Mins $ 24.10 $ 24.10 7/1/201212/31/9999
52
97750Physical Performance Test W/Report 15 MinPer 15 Mins $ 23.46 $ 23.46 7/1/201212/31/9999
53
97761Prosthetic Training, Upper And/Or Lower Extremity(S), Each 15 MinutesPer 15 Mins $ 23.18 $ 23.18 7/1/201212/31/9999
54
97762Checkout For Orthotic/Prosthetic Use, Established Patient, Each 15 MinutesPer 15 Mins $ 26.40 $ 26.40 7/1/201212/31/9999
55
99201Ov New Pt Minor-Phys Time Approx. 10 MinutesPer Time Limit $ 32.52 $ 21.00 7/1/201212/31/9999
56
99202Ov New Pt,Moderate-Phys Time Approx 20 MinutesPer Time Limit $ 56.39 $ 40.55 7/1/201212/31/9999
57
99203Ov New Pt, Moderate-Phys Time Approx 30 MinutesPer Time Limit $ 81.69 $ 61.20 7/1/201212/31/9999
58
99204Ov New Pt, Complex-Phys Time Approx 45 MinutesPer Time Limit $ 126.68 $ 102.77 7/1/201212/31/9999
59
99205Ov New Pt, Severe-Phys Time Approx 60 MinutesPer Time Limit $ 160.14 $ 133.74 7/1/201212/31/9999
60
99211Ov Estab Pt, Minimal W/Wo Phys, Time Approx 5 MinPer Time Limit $ 16.48 $ 7.78 7/1/201212/31/9999
61
99212Ov Established Pt, Minor-Phys Time Approx 10 Min.Per Time Limit $ 32.83 $ 20.72 7/1/201212/31/9999
62
99213Ov Estab. Pt, Moderate. Phys Time Approx 15 Min.Per Time Limit $ 54.82 $ 40.54 7/1/201212/31/9999
63
99214Ov Estab. Pt, Severe. Phys Time Approx 25 Min.Per Time Limit $ 82.60 $ 62.72 7/1/201212/31/9999
64
99215Ov Estab. Pt, Severe. Phys Time Approx 40 Min.Per Time Limit $ 111.72 $ 89.05 7/1/201212/31/9999
65
99222Initial Hosp Care,Moderate-Phys Time Approx 50 MinPer Time Limit $ 111.07 $ 111.07 7/1/201212/31/9999
66
99223Initial Hosp Care, Severe-Phys Time Approx 70 MinPer Time Limit $ 163.55 $ 163.55 7/1/201212/31/9999
67
99231Hosp Visit, Stable. Phys Time Approx 15 MinutesPer Time Limit $ 33.61 $ 33.61 7/1/201212/31/9999
68
99232Hosp Visit, Moderate. Phys Time Approx 25 MinutesPer Time Limit $ 60.57 $ 60.57 7/1/201212/31/9999
69
99233Hosp Visit, Complex. Phys Time Approx 35 MinutesPer Time Limit $ 86.76 $ 86.76 7/1/201212/31/9999
70
99235Observation Or Inpatient Hospital Care, For The Evaluation And Management Of APer Event $ 150.84 $ 150.84 7/1/201212/31/9999
71
99236Observation Or Inpatient Hospital Care, For The Evaluation And Management Of APer Event $ 187.46 $ 187.46 7/1/201212/31/9999
72
99238Hospital Discharge Day Management; 30 Minutes Or LessPer Time Limit $ 59.89 $ 59.89 7/1/201212/31/9999
73
99239Hospital Discharge Day Management; More Than 30 MinutesPer Time Limit $ 87.03 $ 87.03 7/1/201212/31/9999
74
99243Outpt. Consult, Severe- Phys Time Approx 40 Min.Per Time Limit $ 100.95 $ 79.47 7/1/201212/31/9999
75
99244Outpt. Consult, Severe- Phys Time Approx 60 Min.Per Time Limit $ 149.94 $ 126.19 7/1/201212/31/9999
76
99245Outpt. Consult, Severe- Phys Time Approx 80 Min.Per Time Limit $ 184.27 $ 157.42 7/1/201212/31/9999
77
99251Initial Inpt Consult- Phys Time Approx 20 Min.Per Time Limit $ 40.00 $ 40.00 7/1/201212/31/9999
78
99252Initial Inpt Consult- Phys Time Approx 40 Min.Per Time Limit $ 61.99 $ 61.99 7/1/201212/31/9999
79
99253Initial Inpt Consult- Phys Time Approx 55 Min.Per Time Limit $ 94.11 $ 94.11 7/1/201212/31/9999
80
99254Initial Inpt Consult- Phys Time Approx 80 Min.Per Time Limit $ 136.11 $ 136.11 7/1/201212/31/9999
81
99255Initial Inpt Consult- Phys Time Approx 110 Min.Per Time Limit $ 165.85 $ 165.85 7/1/201212/31/9999
82
J2315Naltrexone, Depot Form, 1 Mg, Injection $ 1.79 $ 1.79 1/1/202212/31/9999
83
J2358Olanzapine Long-Acting, 1 Mg (Zyprexa Relprevv) $ 2.62 $ 2.62 1/1/202212/31/9999
84
J2426Paliperidone Palmitate Extended Release, 1 Mg, (Invega Sustenna) $ 6.21 $ 6.21 1/1/202212/31/9999
85
J2680Fluphenazine Decanoate, Up To 25 Mg, Injection (Prolixin) $ 2.26 $ 2.26 1/1/202212/31/9999
86
J3230Chlorpromazine Hcl, Up To 50 Mg, Injection (Thorazine) $ 3.07 $ 3.07 1/1/202212/31/9999
87
88
89
90
91
92
93
94
95
96
97
98
99
100