G687

PDF page 25 / GP11

Payment for Diagnostic and Therapeutic Services Rendered at a Hospital
  The technical component of a diagnostic and therapeutic service listed below and rendered in a
  hospital is payable at 86.10% of the listed fee in the column headed “T”.
  G104A, G111A, G121A, G127A, G140A, G143A, G146A, G149A, G152A, G153A, G167A,
  G174A,G181A, G209A, G284A, G308A, G310A, G311A, G315A, G414A, G440A, G441A, G442A,
  G443A,G448A, G451A, G455A, G466A, G471A, G519A, G540A, G541A, G542A, G544A, G554A,
  G570A,G574A, G582A, G585A, G647A, G648A, G651A, G652A, G654A, G655A, G682A, G683A,
  G684A,G685A, G686A, G687A, G688A, G689A, G694A, G695A, G815A, G850A, G851A, G852A,
  G853A,G854A, G855A, G856A, G857A, G858A, J301B, J304B, J324B, J327B

PDF page 430 / J16

Level 2
                                    All other monitoring devices with fewer than three skin electrodes, or that record only portions
                                    of the monitoring period or do not provide trend analysis. Minimum 12 hours monitoring.
               G654                       - technical component - 12 to 35 hours recording ................    26.45
               G655                       - technical component - 12 to 35 hours scanning.................     18.10
               G653                       - professional component - 12 to 35 hours recording ...........                    34.10
               G686                       - technical component - 36 to 59 hours recording ................    52.95
               G687                       - technical component - 36 to 59 hours scanning.................     36.25
               G656                       - professional component - 36 to 59 hours recording ...........                    51.15
               G688                       - technical component - 60 hours to 13 days recording........        79.40
               G689                       - technical component - 60 hours to 13 days scanning ........        54.40
               G657                       - professional component - 60 hours to 13 days recording ..                        68.20
               G694 - technical component – 14 or more days recording ............ 124.30
               G695 - technical component – 14 or more days scanning .............  91.45
               G696 - professional component – 14 or more days recording .......          86.80
                  Note:
                  1.Maximum one professional component, one technical recording component and one
                    technical scanning component per patient, per recording.

Master, record 2338. Record Layout PDF, page 1.

G68720260401999999990000036250000000000000000000000000000000000000000000000

Auxiliary master fields are preserved as raw scaled values. The linked layout calls them zero-filled, but this edition contains non-zero values. They are not presented as final dollar fees or PDF units.