Covered Professional Services & Authorization Guidelines
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1 Covered Professional Services & orization Guidelines Please note that the listing below does not fully comprise all Cenpatico Mississippi covered services. Please refer to your Provider Agreement with Cenpatico to identify additional services you are contracted and eligible to provide. Facility Behavioral Health Services Service Description ECT Hospital 901/90870 Observation Hospital 760, 761, 762/G0378, G0379 Service Description Professional Behavioral Health Services Psychiatric diagnostic (no medical services) Psychiatrist(MD/DO),, Master s Level Professional (LCSW, LPC, LMFT), (PhD/ PsyD) , 11, 12, 20, 21, 22, 23, 51, 52, 53, 55, 71, 72, 99 Interactive psychiatric diagnostic with medical services Psychiatrist (MD/DO), Nurse Practitioner (ARNP, NP), Mental Health (MHNP), Clinical Nurse Specialist (CNS) , 11, 12, 20, 21, 22, 23, 51, 52, 53, 55, 71, 72, 99
2 Individual Psychiatrist 90832, 59 04, 11, 20, psychotherapy 90834, 21, 22, 51, (MD/DO), Nurse , 99 Practitioner (ARNP, NP), Mental Health (MHNP), Clinical Nurse Specialist (CNS), Individual 90833, 04, 11, 20, psychotherapy with 90836, 21, 22, 51, medication , 99 management Interactive complexity add-on code, , 11, 20, 21, 22, 51, 53, 99
3 Psychoanalysis, , 22, 51, 53, 72 Family psychotherapy without patient, , 11, 20, 21, 22, 23, 51, 52, 53, 55, 71, 72, 99 Family psychotherapy with patient, , 11, 20, 21, 22, 23, 51, 52, 53, 55, 71, 72, 99
4 Group Psychotherapy 90849, 59 04, 11, 20, , 22, 23, 51, 52, 53, 55, 71, 72, 99,, Electroconvulsive therapy 90870, , 51, 22 Medication Management M , 31, 32, 53, 99 Psychological testing (PhD/PsyD) , 11, 12, 21, 22, 51, 99 Developmental testing 96110, 03, 11, 12, , 99 (PhD/PsyD)
5 Neuropsychological testing (PhD) , 11, 12, 21, 22, 51, 99 Office Visits , , , HI 11, 22 Initial Hospital Care HI 21, 51 Subsequent Hospital Care HI 21, 51 Hospital Discharge Management 99238, HI 21, 51
6 Initial Observation Care HI 22, 23 Home visits HI 12 Community Mental Health Center (CMHC) Services Service Description Billable Provider Psychiatric diagnostic interview CMHC HW 53 Individual psychotherapy CMHC 90832, 90834, HW, Individual psychotherapy with medication management CMHC 90833, 90836, HW 53
7 Billable Provider Family psychotherapy without patient CMHC HW, Family psychotherapy with patient CMHC HW, Group Psychotherapy CMHC HW, Psychological testing CMHC HW 53 Neuropsychological testing CMHC 96110, 96111, HW 53 Assessment CMHC H0031 HW 53 Treatment Plan Review CMHC H0032 HW, HT 53 Mental health partial hospitalization, treatment, less than 24 hours CMHC H0035 HW 53 Community Support Services CMHC H0036 HW 53 Peer Support CMHC H0038 HW 53 Assertive Community Treatment (ACT) Restorative partial hospitalization, per half day CMHC H0039 HW 53 CMHC H2012 HW 53 Day Support CMHC H2017 HW 53 Wraparound Facilitation CMHC H2021 HW 53
8 Billable Provider Psychosocial Rehab CMHC H2030 HW, HB, HC 53 Intensive Outpatient Psychiatric CMHC S9480 HW 53 Crisis Services CMHC H2011 HW 53 Nursing Assessment CMHC T1002 HW 53 Case Management CMHC T1017 HW, HB, HA 53 Injectable Medication CMHC T1502 HW 53 Crisis Residential CMHC T2048 HW 53 Early Periodic Screening, Diagnostic, and Testing (EPSDT) Services Service Description Adolescent Counseling Clinic EP
9 Injectable Medications and Covered Drugs Service Description Trade Name Injectable Medication T1502 HW 53 Injectable Medication 90471, , 11, 12, Ziprasidone Mesylate Geodon J , 11, 12, Olanzapine Pamoate Zyprexa J , 11, 12, (Relprevv Paliperidone Palmitati Risperidone Invega Sustenna Risperdal Consta (long acting) J , 11, 12, J , 11, 12, Aripiprazole Abilify J , 11, 12, Aripiprazole Abilify J , 11, 12, Maintena Chlorpromazine HCL Thorazine J , 11, 12, Fluphenazine Decanoate Prolixin J , 11, 12, Prochlorperazine Edisylate Compazine J , 11, 12, Haloperidol Lactate Haldol J , 11, 12, Haloperidol Decanoate Haldol D J , 11, 12, Lorazepam Ativan J , 11, 12, Diazepam Valium J , 11, 12,
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