Exhibit_B-1_-_Rate_Sheet_(FINAL4-5-16).xlsx
XLSX spreadsheet 128 KB Posted
- Attached to
- Staff Medical Monitoring
- Solicitation number
- 600001895
- Issued by
- California
About this file
This is a rate sheet (Exhibit B-1) for Staff Medical Monitoring Services for the California Department of Corrections and Rehabilitation (CDCR), covering 13 different institutional groups across California state prisons and correctional facilities. The document outlines detailed medical examination services, individual medical/test services, and additional services required at each facility group. The State reserves the right to extend the agreement for two optional one-year terms with no increase in service costs.
The rate sheet is structured to allow bidders to bid on one or more institutional groups, with each group requiring bids on all items within that group. The pricing includes CPT codes for each service and is divided into three sections: Physical Examinations (items 1-12), Individual Medical/Test Services (items 13-70), and Additional Services (items 71-75). The State offers a discount of at least 1% or $50 minimum on invoices paid within 30 days. Contractors will be reimbursed for actual costs plus 20% and applicable taxes for services not specifically identified in the rate sheet, subject to prior approval and cost substantiation.
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| Addendum_Number_1.pdf | ||
| Addendum_No._2.pdf | ||
| 14_Ex_H_-_Licensing_Compliance_Summary.xlsx | XLSX spreadsheet | |
| 18_STD_204_-_Payee_Data_Record_(rev_6-03).pdf | ||
| IFB_No._6000001895_package.pdf | ||
| Exhibit_B-1_-_Rate_Sheet,_Addendum__3_(protected).xlsx | XLSX spreadsheet | |
| Addendum_No._3_Notification.pdf |
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Text version
Sheet1
REVISED
STAFF MEDICAL MONITORING SERVICES
Electronic bid packages include an Excel version of this Rate Sheet (Exhibit B-1) in addition to the PDF file in order to assist bidders in computing accurate totals. Bidders should download the Excel version and complete all highlighted cells. Bidders are also required to include a Compact Disk (CD) of the completed Excel version of the Rate Sheet along with the printed version when submitting their bid.
NOTE: Bidders may bid on one or more Institution groups. Your bid shall be for all locations within that group. Bidders are not required to bid on all groups. However, bidders are required to bid each item within the Group. Failure to indicate a dollar amount (BLANK CELL) in any item may be grounds to reject the entire group bid. A zero dollar amount ($0.00) listed for any and/or all items shall be interpreted and understood by the State to mean that the bidder shall perform any such services at no cost to the State.
For each Group the Contractor is not providing a bid, the Contractor shall type "NO BID" in the yellow highlighted cell. ONLY TYPED BID SHEETS WILL BE CONSIDERED. HANDWRITTEN SHEETS WILL BE DEEMED NON-RESPONSIVE AND WILL BE REJECTED.
The quantities listed on Exhibit B-1, Rate Sheet, are the State's estimates only and are offered as a basis for comparison of bids. The State does not expressly or by implication agree that the actual amount of work will correspond therewith and reserves the right to increase/omit portions of the work as may be deemed necessary or advisable by the State. Any and all services performed outside the Scope of Work, Exhibit A, shall be at the sole risk and expense of the Contractor.
If it is determined to be in the best interest of the State, the State may extend this Agreement, with no increase in service cost, for two (2), optional one (1) year terms. The rates applied for this additional term are specified in this Exhibit B-1, Rate Sheet. The Contractor is obligated to this extended term of service at the time of bid.
Contractor may offer a discount to the amount paid on invoices received and accepted by the CDCR in order for the invoices to be paid within thirty (30) days of receipt. Discount offered on invoices must be at least one percent of the invoice amount and a minimum of $50.00.
*Discount offered on invoices paid within 30 days of receipt = %
*The percent of discount (highest prevails) may be used in the event of tie bids. Refer to the Notice to Prospective Bidders, Bid Submission Requirements.
** The Basis for Award shall be based on the Average Rate of services. The "Basis for Award" is strictly used for bidding purposes only to determine the lowest responsible bidder.
*** Upon approval of any services not specifically identified in Exhibit B-1, Rate Sheet, the Contractor will be reimbursed for actual cost plus 20% and applicable taxes. The Contractor must include cost substantiation as specified in Exhibit A, Scope of Work.
| Group 1: Avenal State Prison (ASP) | |||
| ***SERVICES DESCRIPTION | CPT | RATE | |
| A. PHYSICAL EXAMINATION (ITEMS 1-12) | |||
| 1 | RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (A) Medical Questionnaire submitted by mail. Letter of Clearance to wear a respirator, OR referral for completion of Section B below if unable to clear via review of questionnaire alone. | 99202 | |
| 2 | RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (B) In addition to Medical Questionnaire above, Physical Exam and Letter of Clearance to wear a respirator. If additional tests are necessary to clear individual tests below. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) | 99204 | |
| 3 | LEAD MEDICAL EXAMINATION - CCR 1532.1/5198: Physical Exam, Blood Chemistry Panel, Blood Lead, CBC, Zinc Protoporphrin, Blood Urea Nitrogen, Serum Creatinine, Urinalysis, Letter of Clearance regarding the employee's ability to perform Lead Work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) | 99204, 80050, 83655, 85025, 84202, 84520, 82565, 81001 | |
| 4 | ABESTOS MEDICAL EXAMINATION - CCR 1529/5208: Physical Exam, Spirometry, Chest X-ray, Letter of Clearance regarding employee's ability to perform Asbestos work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 94010, 71030 | |
| 5 | HAZARDOUS SUBSTANCE EXAMINATION - CCR 5192: Physical Exam, Spirometry, Letter of Clearance regarding the employee's ability to perform Hazardous Materials work and ability to wear an air purifying respirator or self contained breathing apparatus. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 94010 | |
| 6 | CHROMIUM MEDICAL EXAMINATION - CCR 1532.2/5206: Physical Exam and Letter of Clearance relative to Chromium work and ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204 | |
| 7 | CADMIUM INITIAL EXAMINATION - CCR 1532/5207: Physical Exam, Cadmium in Urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 82300, 82232 | |
| 8 | CADMIUM PERIODIC MEDICAL SURVEILLANCE - CCR 1532/5207: Physical Exam, Chest X-ray, Pulmonary function tests, Cadmium in urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr) with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Blood Urea Nitrogen, Complete Blood Count, and Serum Creatinine. Urinalysis including the determination of albumin, glucose and total and low molecular weight proteins. Prostate Palpation. Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 71010, 94010, 82300, 82232, 84520, 85025, 82565, 81000 | |
| 9 | CADMIUM MEDICAL EXAMINATION FOR RESPIRATOR USE - CCR 1532/5207: Physical Exam including blood pressure test, Cadmium in Urine (CdU) standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 82300, 82232 | |
| 10 | AUDIOGRAM - CCR 1597: Physical Exam to establish a baseline audiogram for employees exposed at or about the action level, Report of audiometric test results. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 92552 | |
| 11 | CALIFORNIA COMMERCIAL DRIVERS EXAMINATION - 49CFR391.41 - 391.49 & CVC 12517.2 - Physical examination including visual acuity, hearing, blood pressure, pulse rate, urinalysis, etc., and complete CA DMV DL 51. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 81000 | |
| 12 | AEROSOL TRANSMISSIBLE DISEASE - CCR 5199: Physical Exam and Letter of Clearance to return to work (w/wo restricted activity). (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204 |
| B. INDIVIDUAL MEDICAL/TEST SERVICES (ITEMS 13-70) | CPT | RATE | |
| 13 | Spirometry Testing | 94010 | |
| 14 | Blood Chemistry Panel | 80050 | |
| 15 | Blood Lead Levels | 83655 | |
| 16 | Blood Chemistry CBC | 85025 | |
| 17 | Zinc Protoporphrin Test | 84202 | |
| 18 | Blood Urea Nitrogen Test | 84520 | |
| 19 | Serum Creatinine Test | 92565 | |
| 20 | Urinalysis Exam-automated, microscopy | 81001 | |
| 21 | Resting EKG | 93000 | |
| 22 | Exercise/Stress EKG | 93015 | |
| 23 | Chest X-ray read by a B Reader | 71030 | |
| 24 | Cadmium in urine | 82300 | |
| 25 | Beta-2 microglobulin in urine | 82232 | |
| 26 | Cadmium in blood | 82300 | |
| 27 | Chest X-ray-single view | 71010 | |
| 28 | Urinalysis Exam | 81000 | |
| 29 | Audiogram | 92552 | |
| 30 | Chickenpox Immunity Screening-IgG | 82784 | |
| 31 | Varicella (Chickenpox) Vaccine | 90716 | |
| 32 | Measles Immunity Screen | 82784 | |
| 33 | Measles/Mumps/Rubella Vaccine | 90707 | |
| 34 | Liver Panel - SGPT and SGOT | 80076 | |
| 35 | PPD Skin Test for TB | 86580 | |
| 36 | Cell Mediated Immunity Blood Test for TB | 86480 | |
| 37 | Chest X-ray for TB Infection | 71020 | |
| 38 | T-dap (Tetanus/Diphtheria/Pertussis) Vaccine | 90715 | |
| 39 | Influenza Vaccination (TIV) | 90656 | |
| 40 | Influenza Vaccination (TIV - egg free) | 90656 | |
| 41 | Influenza Vaccination Nasal (TIV) | 90656 | |
| 42 | Pregnancy Test | 84703 | |
| 43 | Male Fertility Test | 89310 | |
| 44 | Stool Guaiac | 82270 | |
| 45 | Limited Follow-up Exam. Established Patient | 99213 | |
| 46 | Detailed Follow-up Exam. Established Patient | 99214 | |
| 47 | Quantitative Fit Testing | N/A | |
| 48 | Hepatitis B Vaccine | 90746 | |
| 49 | HIV Test | 86701 | |
| 50 | HIV Blood Draw | 36415 | |
| 51 | Bloodborne Pathogen Assessment | 99214 | |
| 52 | TB Symptom Interview without TST | N/A | |
| 53 | CDPH compliant/PHB accepted risk assessment questionnaire (Ordered by PHB) | N/A | |
| 54 | TB skin testing (new employee) | 86480 x2 | |
| 55 | Laboratory Services (As Requested) | N/A | |
| 56 | Hepatitis B Surface Antigen | 87340 | |
| 57 | Hepatitis B Surface Antibody Titer | 86317 | |
| 58 | Hepatitis C Antibody | 86803 | |
| 59 | Hepatitis B Antigen Test | 87340 | |
| 60 | Mumps Immunity Screening | 86735 | |
| 61 | Rubella immunity Screening | 86762 | |
| 62 | Hepatitis B Core Antibody Test | 86705 | |
| 63 | Truvada (Single Pill-Blister Pack)-Medication | N/A | |
| 64 | Raltegravir (25 mg)-Medication | N/A | |
| 65 | Oseltamivir (75 mg)-Medication | N/A | |
| 66 | Isoniazid (300 mg)-Medication | N/A | |
| 67 | Rifapentine (150 mg)- Medication | N/A | |
| 68 | Pyridoxine (50 mg)-Medication | N/A | |
| 69 | Post Exposure Follow Up Consultation | N/A | |
| 70 | Reporting Contact Investigation (Exhibit A-3(a) Summary Report of Case Contact Investigation) | N/A | |
| C. ADDITIONAL SERVICES (ITEMS 71-75) | CPT | RATE | |
| 71 | Physician Consultation (hourly rate) | N/A | |
| 72 | Medical Examination Team - Site Mobilization (per individual) | N/A | |
| 73 | TB Screening and Training (per individual, per test rate) | N/A | |
| 74 | Blood Borne Pathogen (BBP) Screening and Training (per individual, per test rate) | N/A | |
| 75 | Maintenance of Lockbox/Medications (flat rate) | N/A |
| Sum Total of Rates (A+B+C): | $0.00 |
| Divided by : | / |
| Total Number of Rates: | 75 |
| Average Rate for Group 1 (ASP): | $ - 0 |
| **Basis for Award |
| Group 2: Calipatria State Prison (CAL) and Centinela State Prison (CEN) | |||
| ***SERVICES DESCRIPTION | CPT | RATE | |
| A. PHYSICAL EXAMINATION (ITEMS 1-12) | |||
| 1 | RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (A) Medical Questionnaire submitted by mail. Letter of Clearance to wear a respirator, OR referral for completion of Section B below if unable to clear via review of questionnaire alone. | 99202 | |
| 2 | RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (B) In addition to Medical Questionnaire above, Physical Exam and Letter of Clearance to wear a respirator. If additional tests are necessary to clear individual tests below. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) | 99204 | |
| 3 | LEAD MEDICAL EXAMINATION - CCR 1532.1/5198: Physical Exam, Blood Chemistry Panel, Blood Lead, CBC, Zinc Protoporphrin, Blood Urea Nitrogen, Serum Creatinine, Urinalysis, Letter of Clearance regarding the employee's ability to perform Lead Work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) | 99204, 80050, 83655, 85025, 84202, 84520, 82565, 81001 | |
| 4 | ABESTOS MEDICAL EXAMINATION - CCR 1529/5208: Physical Exam, Spirometry, Chest X-ray, Letter of Clearance regarding employee's ability to perform Asbestos work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 94010, 71030 | |
| 5 | HAZARDOUS SUBSTANCE EXAMINATION - CCR 5192: Physical Exam, Spirometry, Letter of Clearance regarding the employee's ability to perform Hazardous Materials work and ability to wear an air purifying respirator or self contained breathing apparatus. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 94010 | |
| 6 | CHROMIUM MEDICAL EXAMINATION - CCR 1532.2/5206: Physical Exam and Letter of Clearance relative to Chromium work and ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204 | |
| 7 | CADMIUM INITIAL EXAMINATION - CCR 1532/5207: Physical Exam, Cadmium in Urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 82300, 82232 | |
| 8 | CADMIUM PERIODIC MEDICAL SURVEILLANCE - CCR 1532/5207: Physical Exam, Chest X-ray, Pulmonary function tests, Cadmium in urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr) with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Blood Urea Nitrogen, Complete Blood Count, and Serum Creatinine. Urinalysis including the determination of albumin, glucose and total and low molecular weight proteins. Prostate Palpation. Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 71010, 94010, 82300, 82232, 84520, 85025, 82565, 81000 | |
| 9 | CADMIUM MEDICAL EXAMINATION FOR RESPIRATOR USE - CCR 1532/5207: Physical Exam including blood pressure test, Cadmium in Urine (CdU) standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 82300, 82232 | |
| 10 | AUDIOGRAM - CCR 1597: Physical Exam to establish a baseline audiogram for employees exposed at or about the action level, Report of audiometric test results. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 92552 | |
| 11 | CALIFORNIA COMMERCIAL DRIVERS EXAMINATION - 49CFR391.41 - 391.49 & CVC 12517.2 - Physical examination including visual acuity, hearing, blood pressure, pulse rate, urinalysis, etc., and complete CA DMV DL 51. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 81000 | |
| 12 | AEROSOL TRANSMISSIBLE DISEASE - CCR 5199: Physical Exam and Letter of Clearance to return to work (w/wo restricted activity). (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204 |
| B. INDIVIDUAL MEDICAL/TEST SERVICES (ITEMS 13-70) | CPT | RATE | |
| 13 | Spirometry Testing | 94010 | |
| 14 | Blood Chemistry Panel | 80050 | |
| 15 | Blood Lead Levels | 83655 | |
| 16 | Blood Chemistry CBC | 85025 | |
| 17 | Zinc Protoporphrin Test | 84202 | |
| 18 | Blood Urea Nitrogen Test | 84520 | |
| 19 | Serum Creatinine Test | 92565 | |
| 20 | Urinalysis Exam-automated, microscopy | 81001 | |
| 21 | Resting EKG | 93000 | |
| 22 | Exercise/Stress EKG | 93015 | |
| 23 | Chest X-ray read by a B Reader | 71030 | |
| 24 | Cadmium in urine | 82300 | |
| 25 | Beta-2 microglobulin in urine | 82232 | |
| 26 | Cadmium in blood | 82300 | |
| 27 | Chest X-ray-single view | 71010 | |
| 28 | Urinalysis Exam | 81000 | |
| 29 | Audiogram | 92552 | |
| 30 | Chickenpox Immunity Screening-IgG | 82784 | |
| 31 | Varicella (Chickenpox) Vaccine | 90716 | |
| 32 | Measles Immunity Screen | 82784 | |
| 33 | Measles/Mumps/Rubella Vaccine | 90707 | |
| 34 | Liver Panel - SGPT and SGOT | 80076 | |
| 35 | PPD Skin Test for TB | 86580 | |
| 36 | Cell Mediated Immunity Blood Test for TB | 86480 | |
| 37 | Chest X-ray for TB Infection | 71020 | |
| 38 | T-dap (Tetanus/Diphtheria/Pertussis) Vaccine | 90715 | |
| 39 | Influenza Vaccination (TIV) | 90656 | |
| 40 | Influenza Vaccination (TIV - egg free) | 90656 | |
| 41 | Influenza Vaccination Nasal (TIV) | 90656 | |
| 42 | Pregnancy Test | 84703 | |
| 43 | Male Fertility Test | 89310 | |
| 44 | Stool Guaiac | 82270 | |
| 45 | Limited Follow-up Exam. Established Patient | 99213 | |
| 46 | Detailed Follow-up Exam. Established Patient | 99214 | |
| 47 | Quantitative Fit Testing | N/A | |
| 48 | Hepatitis B Vaccine | 90746 | |
| 49 | HIV Test | 86701 | |
| 50 | HIV Blood Draw | 36415 | |
| 51 | Bloodborne Pathogen Assessment | 99214 | |
| 52 | TB Symptom Interview without TST | N/A | |
| 53 | CDPH compliant/PHB accepted risk assessment questionnaire (Ordered by PHB) | N/A | |
| 54 | TB skin testing (new employee) | 86480 x2 | |
| 55 | Laboratory Services (As Requested) | N/A | |
| 56 | Hepatitis B Surface Antigen | 87340 | |
| 57 | Hepatitis B Surface Antibody Titer | 86317 | |
| 58 | Hepatitis C Antibody | 86803 | |
| 59 | Hepatitis B Antigen Test | 87340 | |
| 60 | Mumps Immunity Screening | 86735 | |
| 61 | Rubella immunity Screening | 86762 | |
| 62 | Hepatitis B Core Antibody Test | 86705 | |
| 63 | Truvada (Single Pill-Blister Pack)-Medication | N/A | |
| 64 | Raltegravir (25 mg)-Medication | N/A | |
| 65 | Oseltamivir (75 mg)-Medication | N/A | |
| 66 | Isoniazid (300 mg)-Medication | N/A | |
| 67 | Rifapentine (150 mg)- Medication | N/A | |
| 68 | Pyridoxine (50 mg)-Medication | N/A | |
| 69 | Post Exposure Follow Up Consultation | N/A | |
| 70 | Reporting Contact Investigation (Exhibit A-3(a) Summary Report of Case Contact Investigation) | N/A | |
| C. ADDITIONAL SERVICES (ITEMS 71-75) | CPT | RATE | |
| 71 | Physician Consultation (hourly rate) | N/A | |
| 72 | Medical Examination Team - Site Mobilization (per individual) | N/A | |
| 73 | TB Screening and Training (per individual, per test rate) | N/A | |
| 74 | Blood Borne Pathogen (BBP) Screening and Training (per individual, per test rate) | N/A | |
| 75 | Maintenance of Lockbox/Medications (flat rate) | N/A |
| Sum Total of Rates (A+B+C): | $0.00 |
| Divided by : | / |
| Total Number of Rates: | 75 |
| Average Rate for Group 2 (CAL and CEN): | $ - 0 |
| **Basis for Award |
| Group 3: California Institution for Men (CIM), California Institution for Women (CIW) and Inmate Ward Labor (IWL)-Region III | |||
| ***SERVICES DESCRIPTION | CPT | RATE | |
| A. PHYSICAL EXAMINATION (ITEMS 1-12) | |||
| 1 | RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (A) Medical Questionnaire submitted by mail. Letter of Clearance to wear a respirator, OR referral for completion of Section B below if unable to clear via review of questionnaire alone. | 99202 | |
| 2 | RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (B) In addition to Medical Questionnaire above, Physical Exam and Letter of Clearance to wear a respirator. If additional tests are necessary to clear individual tests below. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) | 99204 | |
| 3 | LEAD MEDICAL EXAMINATION - CCR 1532.1/5198: Physical Exam, Blood Chemistry Panel, Blood Lead, CBC, Zinc Protoporphrin, Blood Urea Nitrogen, Serum Creatinine, Urinalysis, Letter of Clearance regarding the employee's ability to perform Lead Work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) | 99204, 80050, 83655, 85025, 84202, 84520, 82565, 81001 | |
| 4 | ABESTOS MEDICAL EXAMINATION - CCR 1529/5208: Physical Exam, Spirometry, Chest X-ray, Letter of Clearance regarding employee's ability to perform Asbestos work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 94010, 71030 | |
| 5 | HAZARDOUS SUBSTANCE EXAMINATION - CCR 5192: Physical Exam, Spirometry, Letter of Clearance regarding the employee's ability to perform Hazardous Materials work and ability to wear an air purifying respirator or self contained breathing apparatus. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 94010 | |
| 6 | CHROMIUM MEDICAL EXAMINATION - CCR 1532.2/5206: Physical Exam and Letter of Clearance relative to Chromium work and ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204 | |
| 7 | CADMIUM INITIAL EXAMINATION - CCR 1532/5207: Physical Exam, Cadmium in Urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 82300, 82232 | |
| 8 | CADMIUM PERIODIC MEDICAL SURVEILLANCE - CCR 1532/5207: Physical Exam, Chest X-ray, Pulmonary function tests, Cadmium in urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr) with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Blood Urea Nitrogen, Complete Blood Count, and Serum Creatinine. Urinalysis including the determination of albumin, glucose and total and low molecular weight proteins. Prostate Palpation. Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 71010, 94010, 82300, 82232, 84520, 85025, 82565, 81000 | |
| 9 | CADMIUM MEDICAL EXAMINATION FOR RESPIRATOR USE - CCR 1532/5207: Physical Exam including blood pressure test, Cadmium in Urine (CdU) standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 82300, 82232 | |
| 10 | AUDIOGRAM - CCR 1597: Physical Exam to establish a baseline audiogram for employees exposed at or about the action level, Report of audiometric test results. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 92552 | |
| 11 | CALIFORNIA COMMERCIAL DRIVERS EXAMINATION - 49CFR391.41 - 391.49 & CVC 12517.2 - Physical examination including visual acuity, hearing, blood pressure, pulse rate, urinalysis, etc., and complete CA DMV DL 51. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 81000 | |
| 12 | AEROSOL TRANSMISSIBLE DISEASE - CCR 5199: Physical Exam and Letter of Clearance to return to work (w/wo restricted activity). (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204 |
| B. INDIVIDUAL MEDICAL/TEST SERVICES (ITEMS 13-70) | CPT | RATE | |
| 13 | Spirometry Testing | 94010 | |
| 14 | Blood Chemistry Panel | 80050 | |
| 15 | Blood Lead Levels | 83655 | |
| 16 | Blood Chemistry CBC | 85025 | |
| 17 | Zinc Protoporphrin Test | 84202 | |
| 18 | Blood Urea Nitrogen Test | 84520 | |
| 19 | Serum Creatinine Test | 92565 | |
| 20 | Urinalysis Exam-automated, microscopy | 81001 | |
| 21 | Resting EKG | 93000 | |
| 22 | Exercise/Stress EKG | 93015 | |
| 23 | Chest X-ray read by a B Reader | 71030 | |
| 24 | Cadmium in urine | 82300 | |
| 25 | Beta-2 microglobulin in urine | 82232 | |
| 26 | Cadmium in blood | 82300 | |
| 27 | Chest X-ray-single view | 71010 | |
| 28 | Urinalysis Exam | 81000 | |
| 29 | Audiogram | 92552 | |
| 30 | Chickenpox Immunity Screening-IgG | 82784 | |
| 31 | Varicella (Chickenpox) Vaccine | 90716 | |
| 32 | Measles Immunity Screen | 82784 | |
| 33 | Measles/Mumps/Rubella Vaccine | 90707 | |
| 34 | Liver Panel - SGPT and SGOT | 80076 | |
| 35 | PPD Skin Test for TB | 86580 | |
| 36 | Cell Mediated Immunity Blood Test for TB | 86480 | |
| 37 | Chest X-ray for TB Infection | 71020 | |
| 38 | T-dap (Tetanus/Diphtheria/Pertussis) Vaccine | 90715 | |
| 39 | Influenza Vaccination (TIV) | 90656 | |
| 40 | Influenza Vaccination (TIV - egg free) | 90656 | |
| 41 | Influenza Vaccination Nasal (TIV) | 90656 | |
| 42 | Pregnancy Test | 84703 | |
| 43 | Male Fertility Test | 89310 | |
| 44 | Stool Guaiac | 82270 | |
| 45 | Limited Follow-up Exam. Established Patient | 99213 | |
| 46 | Detailed Follow-up Exam. Established Patient | 99214 | |
| 47 | Quantitative Fit Testing | N/A | |
| 48 | Hepatitis B Vaccine | 90746 | |
| 49 | HIV Test | 86701 | |
| 50 | HIV Blood Draw | 36415 | |
| 51 | Bloodborne Pathogen Assessment | 99214 | |
| 52 | TB Symptom Interview without TST | N/A | |
| 53 | CDPH compliant/PHB accepted risk assessment questionnaire (Ordered by PHB) | N/A | |
| 54 | TB skin testing (new employee) | 86480 x2 | |
| 55 | Laboratory Services (As Requested) | N/A | |
| 56 | Hepatitis B Surface Antigen | 87340 | |
| 57 | Hepatitis B Surface Antibody Titer | 86317 | |
| 58 | Hepatitis C Antibody | 86803 | |
| 59 | Hepatitis B Antigen Test | 87340 | |
| 60 | Mumps Immunity Screening | 86735 | |
| 61 | Rubella immunity Screening | 86762 | |
| 62 | Hepatitis B Core Antibody Test | 86705 | |
| 63 | Truvada (Single Pill-Blister Pack)-Medication | N/A | |
| 64 | Raltegravir (25 mg)-Medication | N/A | |
| 65 | Oseltamivir (75 mg)-Medication | N/A | |
| 66 | Isoniazid (300 mg)-Medication | N/A | |
| 67 | Rifapentine (150 mg)- Medication | N/A | |
| 68 | Pyridoxine (50 mg)-Medication | N/A | |
| 69 | Post Exposure Follow Up Consultation | N/A | |
| 70 | Reporting Contact Investigation (Exhibit A-3(a) Summary Report of Case Contact Investigation) | N/A | |
| C. ADDITIONAL SERVICES (ITEMS 71-75) | CPT | RATE | |
| 71 | Physician Consultation (hourly rate) | N/A | |
| 72 | Medical Examination Team - Site Mobilization (per individual) | N/A | |
| 73 | TB Screening and Training (per individual, per test rate) | N/A | |
| 74 | Blood Borne Pathogen (BBP) Screening and Training (per individual, per test rate) | N/A | |
| 75 | Maintenance of Lockbox/Medications (flat rate) | N/A |
| Sum Total of Rates (A+B+C): | $0.00 |
| Divided by : | / |
| Total Number of Rates: | 75 |
| Average Rate for Group 3 (CIM, CIW and IWL-Reg. III): | $ - 0 |
| **Basis for Award |
| Group 4: California Correctional Center (CCC) and High Desert State Prison (HDSP) | |||
| ***SERVICES DESCRIPTION | CPT | RATE | |
| A. PHYSICAL EXAMINATION (ITEMS 1-12) | |||
| 1 | RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (A) Medical Questionnaire submitted by mail. Letter of Clearance to wear a respirator, OR referral for completion of Section B below if unable to clear via review of questionnaire alone. | 99202 | |
| 2 | RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (B) In addition to Medical Questionnaire above, Physical Exam and Letter of Clearance to wear a respirator. If additional tests are necessary to clear individual tests below. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) | 99204 | |
| 3 | LEAD MEDICAL EXAMINATION - CCR 1532.1/5198: Physical Exam, Blood Chemistry Panel, Blood Lead, CBC, Zinc Protoporphrin, Blood Urea Nitrogen, Serum Creatinine, Urinalysis, Letter of Clearance regarding the employee's ability to perform Lead Work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) | 99204, 80050, 83655, 85025, 84202, 84520, 82565, 81001 | |
| 4 | ABESTOS MEDICAL EXAMINATION - CCR 1529/5208: Physical Exam, Spirometry, Chest X-ray, Letter of Clearance regarding employee's ability to perform Asbestos work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 94010, 71030 | |
| 5 | HAZARDOUS SUBSTANCE EXAMINATION - CCR 5192: Physical Exam, Spirometry, Letter of Clearance regarding the employee's ability to perform Hazardous Materials work and ability to wear an air purifying respirator or self contained breathing apparatus. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 94010 | |
| 6 | CHROMIUM MEDICAL EXAMINATION - CCR 1532.2/5206: Physical Exam and Letter of Clearance relative to Chromium work and ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204 | |
| 7 | CADMIUM INITIAL EXAMINATION - CCR 1532/5207: Physical Exam, Cadmium in Urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 82300, 82232 | |
| 8 | CADMIUM PERIODIC MEDICAL SURVEILLANCE - CCR 1532/5207: Physical Exam, Chest X-ray, Pulmonary function tests, Cadmium in urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr) with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Blood Urea Nitrogen, Complete Blood Count, and Serum Creatinine. Urinalysis including the determination of albumin, glucose and total and low molecular weight proteins. Prostate Palpation. Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 71010, 94010, 82300, 82232, 84520, 85025, 82565, 81000 | |
| 9 | CADMIUM MEDICAL EXAMINATION FOR RESPIRATOR USE - CCR 1532/5207: Physical Exam including blood pressure test, Cadmium in Urine (CdU) standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 82300, 82232 | |
| 10 | AUDIOGRAM - CCR 1597: Physical Exam to establish a baseline audiogram for employees exposed at or about the action level, Report of audiometric test results. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 92552 | |
| 11 | CALIFORNIA COMMERCIAL DRIVERS EXAMINATION - 49CFR391.41 - 391.49 & CVC 12517.2 - Physical examination including visual acuity, hearing, blood pressure, pulse rate, urinalysis, etc., and complete CA DMV DL 51. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 81000 | |
| 12 | AEROSOL TRANSMISSIBLE DISEASE - CCR 5199: Physical Exam and Letter of Clearance to return to work (w/wo restricted activity). (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204 |
| B. INDIVIDUAL MEDICAL/TEST SERVICES (ITEMS 13-70) | CPT | RATE | |
| 13 | Spirometry Testing | 94010 | |
| 14 | Blood Chemistry Panel | 80050 | |
| 15 | Blood Lead Levels | 83655 | |
| 16 | Blood Chemistry CBC | 85025 | |
| 17 | Zinc Protoporphrin Test | 84202 | |
| 18 | Blood Urea Nitrogen Test | 84520 | |
| 19 | Serum Creatinine Test | 92565 | |
| 20 | Urinalysis Exam-automated, microscopy | 81001 | |
| 21 | Resting EKG | 93000 | |
| 22 | Exercise/Stress EKG | 93015 | |
| 23 | Chest X-ray read by a B Reader | 71030 | |
| 24 | Cadmium in urine | 82300 | |
| 25 | Beta-2 microglobulin in urine | 82232 | |
| 26 | Cadmium in blood | 82300 | |
| 27 | Chest X-ray-single view | 71010 | |
| 28 | Urinalysis Exam | 81000 | |
| 29 | Audiogram | 92552 | |
| 30 | Chickenpox Immunity Screening-IgG | 82784 | |
| 31 | Varicella (Chickenpox) Vaccine | 90716 | |
| 32 | Measles Immunity Screen | 82784 | |
| 33 | Measles/Mumps/Rubella Vaccine | 90707 | |
| 34 | Liver Panel - SGPT and SGOT | 80076 | |
| 35 | PPD Skin Test for TB | 86580 | |
| 36 | Cell Mediated Immunity Blood Test for TB | 86480 | |
| 37 | Chest X-ray for TB Infection | 71020 | |
| 38 | T-dap (Tetanus/Diphtheria/Pertussis) Vaccine | 90715 | |
| 39 | Influenza Vaccination (TIV) | 90656 | |
| 40 | Influenza Vaccination (TIV - egg free) | 90656 | |
| 41 | Influenza Vaccination Nasal (TIV) | 90656 | |
| 42 | Pregnancy Test | 84703 | |
| 43 | Male Fertility Test | 89310 | |
| 44 | Stool Guaiac | 82270 | |
| 45 | Limited Follow-up Exam. Established Patient | 99213 | |
| 46 | Detailed Follow-up Exam. Established Patient | 99214 | |
| 47 | Quantitative Fit Testing | N/A | |
| 48 | Hepatitis B Vaccine | 90746 | |
| 49 | HIV Test | 86701 | |
| 50 | HIV Blood Draw | 36415 | |
| 51 | Bloodborne Pathogen Assessment | 99214 | |
| 52 | TB Symptom Interview without TST | N/A | |
| 53 | CDPH compliant/PHB accepted risk assessment questionnaire (Ordered by PHB) | N/A | |
| 54 | TB skin testing (new employee) | 86480 x2 | |
| 55 | Laboratory Services (As Requested) | N/A | |
| 56 | Hepatitis B Surface Antigen | 87340 | |
| 57 | Hepatitis B Surface Antibody Titer | 86317 | |
| 58 | Hepatitis C Antibody | 86803 | |
| 59 | Hepatitis B Antigen Test | 87340 | |
| 60 | Mumps Immunity Screening | 86735 | |
| 61 | Rubella immunity Screening | 86762 | |
| 62 | Hepatitis B Core Antibody Test | 86705 | |
| 63 | Truvada (Single Pill-Blister Pack)-Medication | N/A | |
| 64 | Raltegravir (25 mg)-Medication | N/A | |
| 65 | Oseltamivir (75 mg)-Medication | N/A | |
| 66 | Isoniazid (300 mg)-Medication | N/A | |
| 67 | Rifapentine (150 mg)- Medication | N/A | |
| 68 | Pyridoxine (50 mg)-Medication | N/A | |
| 69 | Post Exposure Follow Up Consultation | N/A | |
| 70 | Reporting Contact Investigation (Exhibit A-3(a) Summary Report of Case Contact Investigation) | N/A | |
| C. ADDITIONAL SERVICES (ITEMS 71-75) | CPT | RATE | |
| 71 | Physician Consultation (hourly rate) | N/A | |
| 72 | Medical Examination Team - Site Mobilization (per individual) | N/A | |
| 73 | TB Screening and Training (per individual, per test rate) | N/A | |
| 74 | Blood Borne Pathogen (BBP) Screening and Training (per individual, per test rate) | N/A | |
| 75 | Maintenance of Lockbox/Medications (flat rate) | N/A |
| Sum Total of Rates (A+B+C): | $0.00 |
| Divided by : | / |
| Total Number of Rates: | 75 |
| Average Rate for Group 4 (CCC and HDSP): | $ - 0 |
| **Basis for Award |
| Group 5: Folsom State Prison (FSP), California State Prison-Sacramento (SAC) and Inmate Ward Labor (IWL)-Region I | |||
| ***SERVICES DESCRIPTION | CPT | RATE | |
| A. PHYSICAL EXAMINATION (ITEMS 1-12) | |||
| 1 | RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (A) Medical Questionnaire submitted by mail. Letter of Clearance to wear a respirator, OR referral for completion of Section B below if unable to clear via review of questionnaire alone. | 99202 | |
| 2 | RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (B) In addition to Medical Questionnaire above, Physical Exam and Letter of Clearance to wear a respirator. If additional tests are necessary to clear individual tests below. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) | 99204 | |
| 3 | LEAD MEDICAL EXAMINATION - CCR 1532.1/5198: Physical Exam, Blood Chemistry Panel, Blood Lead, CBC, Zinc Protoporphrin, Blood Urea Nitrogen, Serum Creatinine, Urinalysis, Letter of Clearance regarding the employee's ability to perform Lead Work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) | 99204, 80050, 83655, 85025, 84202, 84520, 82565, 81001 | |
| 4 | ABESTOS MEDICAL EXAMINATION - CCR 1529/5208: Physical Exam, Spirometry, Chest X-ray, Letter of Clearance regarding employee's ability to perform Asbestos work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 94010, 71030 | |
| 5 | HAZARDOUS SUBSTANCE EXAMINATION - CCR 5192: Physical Exam, Spirometry, Letter of Clearance regarding the employee's ability to perform Hazardous Materials work and ability to wear an air purifying respirator or self contained breathing apparatus. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 94010 | |
| 6 | CHROMIUM MEDICAL EXAMINATION - CCR 1532.2/5206: Physical Exam and Letter of Clearance relative to Chromium work and ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204 | |
| 7 | CADMIUM INITIAL EXAMINATION - CCR 1532/5207: Physical Exam, Cadmium in Urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 82300, 82232 | |
| 8 | CADMIUM PERIODIC MEDICAL SURVEILLANCE - CCR 1532/5207: Physical Exam, Chest X-ray, Pulmonary function tests, Cadmium in urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr) with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Blood Urea Nitrogen, Complete Blood Count, and Serum Creatinine. Urinalysis including the determination of albumin, glucose and total and low molecular weight proteins. Prostate Palpation. Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 71010, 94010, 82300, 82232, 84520, 85025, 82565, 81000 | |
| 9 | CADMIUM MEDICAL EXAMINATION FOR RESPIRATOR USE - CCR 1532/5207: Physical Exam including blood pressure test, Cadmium in Urine (CdU) standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 82300, 82232 | |
| 10 | AUDIOGRAM - CCR 1597: Physical Exam to establish a baseline audiogram for employees exposed at or about the action level, Report of audiometric test results. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 92552 | |
| 11 | CALIFORNIA COMMERCIAL DRIVERS EXAMINATION - 49CFR391.41 - 391.49 & CVC 12517.2 - Physical examination including visual acuity, hearing, blood pressure, pulse rate, urinalysis, etc., and complete CA DMV DL 51. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 81000 | |
| 12 | AEROSOL TRANSMISSIBLE DISEASE - CCR 5199: Physical Exam and Letter of Clearance to return to work (w/wo restricted activity). (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204 |
| B. INDIVIDUAL MEDICAL/TEST SERVICES (ITEMS 13-70) | CPT | RATE | |
| 13 | Spirometry Testing | 94010 | |
| 14 | Blood Chemistry Panel | 80050 | |
| 15 | Blood Lead Levels | 83655 | |
| 16 | Blood Chemistry CBC | 85025 | |
| 17 | Zinc Protoporphrin Test | 84202 | |
| 18 | Blood Urea Nitrogen Test | 84520 | |
| 19 | Serum Creatinine Test | 92565 | |
| 20 | Urinalysis Exam-automated, microscopy | 81001 | |
| 21 | Resting EKG | 93000 | |
| 22 | Exercise/Stress EKG | 93015 | |
| 23 | Chest X-ray read by a B Reader | 71030 | |
| 24 | Cadmium in urine | 82300 | |
| 25 | Beta-2 microglobulin in urine | 82232 | |
| 26 | Cadmium in blood | 82300 | |
| 27 | Chest X-ray-single view | 71010 | |
| 28 | Urinalysis Exam | 81000 | |
| 29 | Audiogram | 92552 | |
| 30 | Chickenpox Immunity Screening-IgG | 82784 | |
| 31 | Varicella (Chickenpox) Vaccine | 90716 | |
| 32 | Measles Immunity Screen | 82784 | |
| 33 | Measles/Mumps/Rubella Vaccine | 90707 | |
| 34 | Liver Panel - SGPT and SGOT | 80076 | |
| 35 | PPD Skin Test for TB | 86580 | |
| 36 | Cell Mediated Immunity Blood Test for TB | 86480 | |
| 37 | Chest X-ray for TB Infection | 71020 | |
| 38 | T-dap (Tetanus/Diphtheria/Pertussis) Vaccine | 90715 | |
| 39 | Influenza Vaccination (TIV) | 90656 | |
| 40 | Influenza Vaccination (TIV - egg free) | 90656 | |
| 41 | Influenza Vaccination Nasal (TIV) | 90656 | |
| 42 | Pregnancy Test | 84703 | |
| 43 | Male Fertility Test | 89310 | |
| 44 | Stool Guaiac | 82270 | |
| 45 | Limited Follow-up Exam. Established Patient | 99213 | |
| 46 | Detailed Follow-up Exam. Established Patient | 99214 | |
| 47 | Quantitative Fit Testing | N/A | |
| 48 | Hepatitis B Vaccine | 90746 | |
| 49 | HIV Test | 86701 | |
| 50 | HIV Blood Draw | 36415 | |
| 51 | Bloodborne Pathogen Assessment | 99214 | |
| 52 | TB Symptom Interview without TST | N/A | |
| 53 | CDPH compliant/PHB accepted risk assessment questionnaire (Ordered by PHB) | N/A | |
| 54 | TB skin testing (new employee) | 86480 x2 | |
| 55 | Laboratory Services (As Requested) | N/A | |
| 56 | Hepatitis B Surface Antigen | 87340 | |
| 57 | Hepatitis B Surface Antibody Titer | 86317 | |
| 58 | Hepatitis C Antibody | 86803 | |
| 59 | Hepatitis B Antigen Test | 87340 | |
| 60 | Mumps Immunity Screening | 86735 | |
| 61 | Rubella immunity Screening | 86762 | |
| 62 | Hepatitis B Core Antibody Test | 86705 | |
| 63 | Truvada (Single Pill-Blister Pack)-Medication | N/A | |
| 64 | Raltegravir (25 mg)-Medication | N/A | |
| 65 | Oseltamivir (75 mg)-Medication | N/A | |
| 66 | Isoniazid (300 mg)-Medication | N/A | |
| 67 | Rifapentine (150 mg)- Medication | N/A | |
| 68 | Pyridoxine (50 mg)-Medication | N/A | |
| 69 | Post Exposure Follow Up Consultation | N/A | |
| 70 | Reporting Contact Investigation (Exhibit A-3(a) Summary Report of Case Contact Investigation) | N/A | |
| C. ADDITIONAL SERVICES (ITEMS 71-75) | CPT | RATE | |
| 71 | Physician Consultation (hourly rate) | N/A | |
| 72 | Medical Examination Team - Site Mobilization (per individual) | N/A | |
| 73 | TB Screening and Training (per individual, per test rate) | N/A | |
| 74 | Blood Borne Pathogen (BBP) Screening and Training (per individual, per test rate) | N/A | |
| 75 | Maintenance of Lockbox/Medications (flat rate) | N/A |
| Sum Total of Rates (A+B+C): | $0.00 |
| Divided by : | / |
| Total Number of Rates: | 75 |
| Average Rate for Group 5 (FSP, SAC, IWL-Reg. I): | $ - 0 |
| **Basis for Award |
| Group 6: California Medical Facility (CMF) and California State Prison-Solano (SOL) | |||
| ***SERVICES DESCRIPTION | CPT | RATE | |
| A. PHYSICAL EXAMINATION (ITEMS 1-12) | |||
| 1 | RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (A) Medical Questionnaire submitted by mail. Letter of Clearance to wear a respirator, OR referral for completion of Section B below if unable to clear via review of questionnaire alone. | 99202 | |
| 2 | RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (B) In addition to Medical Questionnaire above, Physical Exam and Letter of Clearance to wear a respirator. If additional tests are necessary to clear individual tests below. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) | 99204 | |
| 3 | LEAD MEDICAL EXAMINATION - CCR 1532.1/5198: Physical Exam, Blood Chemistry Panel, Blood Lead, CBC, Zinc Protoporphrin, Blood Urea Nitrogen, Serum Creatinine, Urinalysis, Letter of Clearance regarding the employee's ability to perform Lead Work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) | 99204, 80050, 83655, 85025, 84202, 84520, 82565, 81001 | |
| 4 | ABESTOS MEDICAL EXAMINATION - CCR 1529/5208: Physical Exam, Spirometry, Chest X-ray, Letter of Clearance regarding employee's ability to perform Asbestos work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 94010, 71030 | |
| 5 | HAZARDOUS SUBSTANCE EXAMINATION - CCR 5192: Physical Exam, Spirometry, Letter of Clearance regarding the employee's ability to perform Hazardous Materials work and ability to wear an air purifying respirator or self contained breathing apparatus. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 94010 | |
| 6 | CHROMIUM MEDICAL EXAMINATION - CCR 1532.2/5206: Physical Exam and Letter of Clearance relative to Chromium work and ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204 | |
| 7 | CADMIUM INITIAL EXAMINATION - CCR 1532/5207: Physical Exam, Cadmium in Urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 82300, 82232 | |
| 8 | CADMIUM PERIODIC MEDICAL SURVEILLANCE - CCR 1532/5207: Physical Exam, Chest X-ray, Pulmonary function tests, Cadmium in urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr) with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Blood Urea Nitrogen, Complete Blood Count, and Serum Creatinine. Urinalysis including the determination of albumin, glucose and total and low molecular weight proteins. Prostate Palpation. Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 71010, 94010, 82300, 82232, 84520, 85025, 82565, 81000 | |
| 9 | CADMIUM MEDICAL EXAMINATION FOR RESPIRATOR USE - CCR 1532/5207: Physical Exam including blood pressure test, Cadmium in Urine (CdU) standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 82300, 82232 | |
| 10 | AUDIOGRAM - CCR 1597: Physical Exam to establish a baseline audiogram for employees exposed at or about the action level, Report of audiometric test results. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 92552 | |
| 11 | CALIFORNIA COMMERCIAL DRIVERS EXAMINATION - 49CFR391.41 - 391.49 & CVC 12517.2 - Physical examination including visual acuity, hearing, blood pressure, pulse rate, urinalysis, etc., and complete CA DMV DL 51. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204, 81000 | |
| 12 | AEROSOL TRANSMISSIBLE DISEASE - CCR 5199: Physical Exam and Letter of Clearance to return to work (w/wo restricted activity). (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.) | 99204 |
| B. INDIVIDUAL MEDICAL/TEST SERVICES (ITEMS 13-70) | CPT | RATE | |
| 13 | Spirometry Testing | 94010 | |
| 14 | Blood Chemistry Panel | 80050 | |
| 15 | Blood Lead Levels | 83655 | |
| 16 | Blood Chemistry CBC | 85025 | |
| 17 | Zinc Protoporphrin Test | 84202 | |
| 18 | Blood Urea Nitrogen Test | 84520 | |
| 19 | Serum Creatinine Test | 92565 | |
| 20 | Urinalysis Exam-automated, microscopy | 81001 | |
| 21 | Resting EKG | 93000 | |
| 22 | Exercise/Stress EKG | 93015 | |
| 23 | Chest X-ray read by a B Reader | 71030 | |
| 24 | Cadmium in urine | 82300 | |
| 25 | Beta-2 microglobulin in urine | 82232 | |
| 26 | Cadmium in blood | 82300 | |
| 27 | Chest X-ray-single view | 71010 | |
| 28 | Urinalysis Exam | 81000 | |
| 29 | Audiogram | 92552 | |
| 30 | Chickenpox Immunity Screening-IgG | 82784 | |
| 31 | Varicella (Chickenpox) Vaccine | 90716 | |
| 32 | Measles Immunity Screen | 82784 | |
| 33 | Measles/Mumps/Rubella Vaccine | 90707 | |
| 34 | Liver Panel - SGPT and SGOT | 80076 | |
| 35 | PPD Skin Test for TB | 86580 | |
| 36 | Cell Mediated Immunity Blood Test for TB | 86480 | |
| 37 | Chest X-ray for TB Infection | 71020 | |
| 38 | T-dap (Tetanus/Diphtheria/Pertussis) Vaccine | 90715 | |
| 39 | Influenza Vaccination (TIV) | 90656 | |
| 40 | Influenza Vaccination (TIV - egg free) | 90656 | |
| 41 | Influenza Vaccination Nasal (TIV) | 90656 | |
| 42 | Pregnancy Test | 84703 | |
| 43 | Male Fertility Test | 89310 | |
| 44 | Stool Guaiac | 82270 | |
| 45 | Limited Follow-up Exam. Established Patient | 99213 | |
| 46 | Detailed Follow-up Exam. Established Patient | 99214 | |
| 47 | Quantitative Fit Testing | N/A | |
| 48 | Hepatitis B Vaccine | 90746 | |
| 49 | HIV Test | 86701 | |
| 50 | HIV Blood Draw | 36415 | |
| 51 | Bloodborne Pathogen Assessment | 99214 | |
| 52 | TB Symptom Interview without TST | N/A | |
| 53 | CDPH compliant/PHB accepted risk assessment questionnaire (Ordered by PHB) | N/A | |
| 54 | TB skin testing (new employee) | 86480 x2 | |
| 55 | Laboratory Services (As Requested) | N/A | |
| 56 | Hepatitis B Surface Antigen | 87340 | |
| 57 | Hepatitis B Surface Antibody Titer | 86317 | |
| 58 | Hepatitis C Antibody | 86803 | |
| 59 | Hepatitis B Antigen Test | 87340 | |
| 60 | Mumps Immunity Screening | 86735 | |
| 61 | Rubella immunity Screening | 86762 | |
| 62 | Hepatitis B Core Antibody Test | 86705 | |
| 63 | Truvada (Single Pill-Blister Pack)-Medication | N/A | |
| 64 | Raltegravir (25 mg)-Medication | N/A | |
| 65 | Oseltamivir (75 mg)-Medication | N/A | |
| 66 | Isoniazid (300 mg)-Medication | N/A | |
| 67 | Rifapentine (150 mg)- Medication | N/A | |
| 68 | Pyridoxine (50 mg)-Medication | N/A | |
| 69 | Post Exposure Follow Up Consultation | N/A | |
| 70 | Reporting Contact Investigation (Exhibit A-3(a) Summary Report of Case Contact Investigation) | N/A | |
| C. ADDITIONAL SERVICES (ITEMS 71-75) | CPT | RATE | |
| 71 | Physician Consultation (hourly rate) | N/A | |
| 72 | Medical Examination Team - Site Mobilization (per individual) | N/A | |
| 73 | TB Screening and Training (per individual, per test rate) | N/A |
This is the start of the file's text. The full file is on GovTribe.
File details come from the government source that posted it. Updated .