SCHOOL-BASED REHABILITATIVE AND RBHS SERVICE RATES (With Interim PRS Rates) Revised 4/16/15 Description Code Modifiers Reimbursement Rates AUDIOLOGY

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1 Description Code Modifiers Reimbursement Units Rates AUDIOLOGY Frequency AUDIOLOGICAL EVALUATION None $40.80 One evaluation 1/12 months (Comprehensive Audiometry Threshold) AUDIOLOGICAL RE-EVALUATION $20.40 One reevaluation 6/12 months (Comprehensive Audiometry Threshold) HEARING AID EXAMINATION AND None $42.19 One evaluation 6 /12 months SELECTION;MONAURAL FITTING/ORIENTATION/CHECKING V5011 None $45.44 One orientation 6 /12 months OF HEARING AID EAR IMPRESSION, EACH -(ONE-Bill V5275 None $31.35 One ear impression 6/ 12 months 1 unit) EAR IMPRESSION, EACH -(BOTH- V5275 None $31.35 One ear impression 6/ 12 months Bill 2 units) HEARING AID CHECK;MONAURAL None $17.91 One analysis 6/ 12 months HEARING AID RE $8.95 One analysis 6/ 12 months CHECK;MONAURAL (re-check) PURE TONE AUDIOMETRY( None $15.03 One test 6/ 12 months threshold);air TYMPANOMETRY (IMPEDANCE None $17.94 One test 6/ 12 months TESTING) EVALUATION OF AUDITORY None $73.09 First hour 10 /12 months REHABILITATION STATUS, FIRST HOUR ELECTROCOCHLEOGRAPHY None $84.45 One procedure One per implantation DISPENSING FEE; unspecified V5090 None $ One fee 6 /12 months hearing aid ACOUSTIC REFLEX TESTING; None $ test 2/12 months THRESHOLD NURSING REGISTERED NURSE (RN) T1002 None $ minutes 24 / LICENSED PRACTICAL NURSE (LPN) T1003 None $ minutes 24 / CLINICAL VISIT/ENCOUNTER, ALL INCLUSIVE (RN) CLINICAL VISIT/ENCOUNTER, ALL INCLUSIVE (LPN) ASSESSMENT REASSESSMENT-(Follow-up service) T1015 TD $6.16 < 15 minutes 4 / T1015 TE $4.22 < 15 minutes 4 / T1024 None $ minutes One Assessment (up to 8 units) T1024 TS $ minutes One assessment (up to 5 units 3 times per year.) 1

2 Description Code Modifiers Reimbursement Units Rates SERVICES Frequency T1024 TM $ minutes Up to 30 units /week OCCUPATIONAL AND PHYSICAL THERAPY OCCUPATIONAL THERAPY GO $63.95 One evaluation 2 /12 months EVALUATION INDIVIDUAL OCCUPATIONAL GO $ minutes 4/ THERAPY GROUP OCCUPATIONAL THERAPY GO $ minutes 4 / PHYSICAL THERAPY EVALUATION GP $60.01 One evaluation 2 /12 months INDIVIDUAL PHYSICAL THERAPY GP $ minutes 4 / GROUP PHYSICAL THERAPY GP $ minutes 4 / WRIST HAND FINGER ORTHOSIS (WHFO) FABRICATION OF ORTHOTIC; LOWER EXTREMITY ORTHOSIS,NOT OTHERWISE SPECIFIED FABRICATION OF ORTHOTIC; UPPER LIMB ORTHOSIS, NOT OTHERWISE SPECIFIED SPEECH LANGUAGE THERAPY L3808 None $51.03 One splint 4/12 months L2999 None $ One Orthotic 4 /12 months L3999 None $37.40 One Orthotic 4 /12 months *Initial Evaluation of speech None $70.80 One Evaluation 1 per lifetime fluency (e.g. stuttering, cluttering) *Initial Evaluation of speech None $57.67 One Evaluation 1 per lifetime sound production (e.g. articulation, phonological process, apraxia, dysarthria); *Initial Evaluation of speech None $ One Evaluation 1 per lifetime sound production (e.g. articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g. receptive and expressive language) *Initial Behavioral and qualitative None $59.05 One Evaluation 1 per lifetime analysis of voice and resonance Initial Evaluation of oral and None $52.96 One Evaluation 1 per lifetime pharyngeal swallowing function SPEECH THERAPY, RE- S9152 None $61.68 One re-evaluation 2 /12 months EVALUATION INDIVIDUAL SPEECH THERAPY None $ minutes 4 units GROUP SPEECH THERAPY None $ minutes 4 units *Note: The appropriate procedure code may be billed for an initial Speech evaluation on or after January 1,

3 RBHS - LEA RATES SCHOOL-BASED REHABILITATIVE AND RBHS SERVICE RATES Service Psychological Testing and Evaluation (Note: School provides the service) Psychological Testing and Evaluation (Note: referral to a private provider) Comprehensive Diagnostic Assessment- Initial Child and Adolescent Level of Care Utilization System (CALOCUS) Assessment Child and Adolescent Level of Care Utilization System (CALOCUS) Assessment Mental Health Comprehensive Assessment - Follow-up Procedure Code No Modifier Staff Rates FREQUENCY DAILY FREQUENCY LIMITS 3 Certified School (I, II, III) and Licensed Psychoeducational Specialist AH Licensed $ unit =60 minutes $ unit =60 minutes 10 units and 20 units per year 10 units and 20 units per year AH Licensed $ Encounter 1 per every 6 months HO Master's Level $ Encounter 1 per every 6 months H2000 AH Licensed Encounter Once a -2 times as needed H2000 HO Master's Level Encounter Once a -2 times per month as needed H0031 AH Licensed Behavioral Health Screening H0002 AH Licensed Service Plan Development by Non-physician $ Encounter 12 per year HO Master's Level $76.97 Encounter 12 per year $ minutes 2 units per HO Master's Level $ minutes 2 units per HN Bachelor's Level $ minutes 2 units per H0032 AH Licensed $ minutes 10 units HO Master's Level $ minutes 10 units HN Bachelor's Level $ minutes 10 units

4 Service Plan Development with Client/Family Service Plan Development without Client/Family Face-to-Face for 30 minutes SCHOOL-BASED REHABILITATIVE AND RBHS SERVICE RATES No No Service Plan Development Team Service Plan Development Team AH Licensed $39.54 Encounter 6 per 12 months $39.54 Encounter 6 per 12 months $ minutes HO Master's Level $ minutes Face-to-Face 45 minutes per session AH Licensed $ minutes Face-to-Face - 60 minutes Group Psychotherapy- Hour session Multiple Family Group Psychotherapy Hour session Family Psychotherapy without Client - Hour session Family Psychotherapy with Client - Hour session HO Master's Level $ minutes AH Licensed $ minutes HO Master's Level $ minutes AH Licensed $24.30 Encounter 8 sessions HO Master's Level $16.65 Encounter 8 sessions AH Licensed $24.30 Encounter 8 sessions HO Master's Level $16.65 Encounter 8 sessions AH Licensed $ Encounter, HO Master's Level $ Encounter, AH Licensed $ Encounter, 4

5 HO Master's Level $ Encounter, Crisis Management H2011 AH Licensed $ minutes 16 HO Master's Level $ minutes 16 Behavioral Modification H2014 AH Licensed HN Bachelor's Level $ minutes 16 $ minutes 32 units HO Master's Level $ minutes 32 units HN Bachelor's Level $ minutes 32 units TD Registered $ minutes 32 units Psychosocial Service Rehabilitative- Individual Psychosocial Service Rehabilitative -Group H2017 U1 Licensed $ minutes 24 units U2 Master's Level $ minutes 24 units U3 Bachelor's Level $ minutes 24 units U4 Registered H2017 U6 Licensed $ minutes 24 units $ minutes 24 units U7 Master's Level $ minutes 24 units U8 Bachelor's Level $ minutes 24 units U9 Registered $ minutes 24 units Family Support Services S9482 AH Licensed $ minutes 32 units HO Master's Level $ minutes 32 units TD Registered $ minutes 32 units HN Bachelor's level $ minutes 32 units 5