OptumHealth New Mexico NM Statewide Behavioral Health Program Practitioner Reimbursement Schedule

Transcription

1 for None Interactive complexity. Add-on Code. $3.50 $3.50 $3.50 $3.50 GT or None diagnostic evaluation. $ $87.30 $97.97 GT or None diagnostic evaluation with medical services. $ GT or None Psychotherapy, 30 minutes with patient and/or family member. $59.22 $46.68 $44.52 $43.07 Psychotherapy, 30 minutes with patient and/or family member when None performed with an evaluation and management services. Add-on Code. GT or None Psychotherapy, 45 minutes with patient and/or family member. $93.66 $75.54 $67.61 $66.93 None Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service. Add-on Code. GT or None Psychotherapy, 60 minutes with patient and/or family member. $ $77.18 $70.96 $66.93 None Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management services. Add-on Code. GT or None None Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services. Add-on Code. $63.05 $63.05 Family Psychotherapy (family without the patient) directed toward an individual and family to address emotional, behavioral or cognitive problems, which may be causative/exacerbating of the primary mental disorder or have been triggered by the stress related to coping with mental and physical illness, alcohol and drug abuse, and psychosocial dysfunction. Personal trauma, family conflicts, family dysfunction, self-concept responses to medication, and other life adjustments reflect a few of the many issues that may be addressed. $95.26 $67.90 $66.93 $66.93 Rev 07/13 <CC> Group/Practitioner Fee Schedule 1 of 6

2 for GT, or None None Family Psychotherapy (family with the patient) directed toward an individual and family to address emotional, behavioral or cognitive problems, which may be causative/exacerbating of the primary mental disorder or have been triggered by the stress related to coping with mental and physical illness, alcohol and drug abuse, and psychosocial dysfunction. Personal trauma, family conflicts, family dysfunction, self-concept responses to medication, and other life adjustments reflect a few of the many issues that may be addressed. $ $82.45 $77.60 $77.60 Multiple Family Group Psychotherapy sessions for multiple families when similar dynamics are occurring due to a commonality of problems. Each family is treated as a unit and all services are billed under one admitted individual. $30.50 $24.25 $24.25 $24.25 None Group psychotherapy (other than of a multiple-family group) $29.10 $24.25 $24.25 $24.25 None Preparation of report patient's psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other physicians, agencies, or insurance carriers. units $42.80 $42.82 $35.58 $35.58 None Psychological Testing, (including pyscho-diagnostic assessment of personality, psychopathology, emotionality, intellectual abilities, e.g., WAIS-R, Rorschach, MMPI) with interpretation and report, per hour. Per Hour $87.30 $87.30 None None Psychological Testing - Technician Psychological Testing - Computer Per Hour $38.80 Per Hour $72.75 None Assessment of aphasia with interpretation and report, per hour. Per Hour $58.84 None Developmental testing; limited, with interpretation and report, per utes. units $12.05 None Developmental testing; extended, with interpretation and report, per hour. Per Hour $60.52 $60.52 None Neurobehavioral status exam with interpretation and report, per hour. Per Hour $60.52 $60.52 None Neuropsychological testing battery with interpretation and report, per hour. Per Hour $97.00 $97.00 Rev 07/13 <CC> Group/Practitioner Fee Schedule 2 of 6

3 for None None Neuropsychological testing with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face Per Hour $38.80 Neuropsychological testing, administered by a computer, with qualified health care professional interpretation and report Per Hour $72.75 None Health and behavior assessment, each utes face-to-face with the patient; initial assessment units $22.79 None Re-assessment units $22.79 GT or None patient, approximately 10 minutes face-to-face with patient. $31.30 GT or None GT or None GT or None GT or None GT or None GT or None GT or None GT or None GT or None None None patient, approximately 20 minutes face-to-face with patient. $62.55 patient, approximately 30 minutes face-to-face with patient. $93.52 patient, approximately 45 minutes face-to-face with patient. $ patient, approximately 60 minutes face-to-face with patient. $ established patient, approximately 5 minutes. $20.25 $20.25 established patient, approximately 10 minutes. $36.89 established patient, approximately utes. $50.52 established patient, approximately 25 minutes. $79.45 established patient, approximately 40 minutes. $ Initial Hospital care, per day, for the evaluation and management of patient, approximately 30 minutes. $61.11 Initial Hospital care, per day, for the evaluation and management of patient, approximately 50 minutes. $ Rev 07/13 <CC> Group/Practitioner Fee Schedule 3 of 6

4 for None None None None None None None Initial Hospital care, per day, for the evaluation and management of patient, approximately 70 minutes. $ Subsequent Hospital care, per day, for the evaluation and management of patient, approximately utes. $31.04 Subsequent Hospital care, per day, for the evaluation and management of patient, approximately 25 minutes. $50.44 Subsequent Hospital care, per day, for the evaluation and management of patient, approximately 35 minutes. $70.81 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, low severity problem. $ Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, moderate severity problem. $ Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, high severity problem. $ None Hospital discharge day management, 30 minutes or less $63.05 None Hospital discharge day management, more than 30 minutes $86.33 Office consultation for a new or established patient, approximately 15 $31.53 $31.53 $31.53 None minutes. $45.99 Office consultation for a new or established patient, approximately 30 $56.99 $56.99 $56.99 None minutes. $80.51 None Office consultation for a new or established patient, approximately 40 minutes. $ $75.42 $75.42 $75.42 None Office consultation for a new or established patient, approximately 60 minutes. $ $ $ $ None Office consultation for a new or established patient, approximately 80 minutes. $ $ $ $ Rev 07/13 <CC> Group/Practitioner Fee Schedule 4 of 6

5 for None None None None None None Initial inpatient consultation for a new or established patient, approximately 20 minutes. $33.68 $23.98 Initial inpatient consultation for a new or established patient, approximately 40 minutes. $65.45 $55.75 Initial inpatient consultation for a new or established patient, approximately 55 minutes. $88.27 $78.21 Initial inpatient consultation for a new or established patient, approximately 80 minutes. $ $ Initial inpatient consultation for a new or established patient, approximately 110 minutes. $ $ Prolonged physician service in the office or other outpatient setting requiring direct patient contact beyond the usual service Per Hour $97.45 None Prolonged physician service in the office or other outpatient setting requiring direct patient contact beyond the usual service, each additional 30 minutes 30 min units $96.41 None Tobacco Cessation Treatment Services Intermediate Session, greater than 3 minutes up to 10 minutes. $13.19 $13.19 $13.19 $13.19 None Tobacco Cessation Treatment Services Intense Session, greater than 10 minutes $25.83 $25.83 $25.83 $25.83 GT or None H2010 Medication Monitoring Retro effective 01/01/13 units $50.52 $50.52 $ ) Applies to all New Mexico Medicaid providers rendering services to Medicaid eligible members regardless of program or location unless otherwise specified. These reimbursement rates are to be used for all Native Americans receiving services outside a Tribal 638 or an IHS facility and that are eligible for New Mexico Medicaid. Procedure codes may require a modifier in order to receive payment. The codes can be billed independently only when a modifier is not required as specified by "None". 2) Providers may only submit claims/encounters for services indicated on this fee schedule. All other services not reflected on this fee schedule are considered non-contracted and will not be reimbursed without an accompanying accommodation. Rev 07/13 <CC> Group/Practitioner Fee Schedule 5 of 6

6 for 3) The following treatment modalities and ancillaries are included in the above-referenced reimbursement rates, as applicable: Aftercare, Anesthesiology, Discharge Planning, Emergency Room, ECT, EEG, EKG, Family Therapy, Group Therapy, Individual Therapy, Initial Evaluation/Assessment, Laboratory/Pathology, Medical and Surgical Supplies, Medical History & Physical, Medications, Nursing, Neuropsychological Testing, fees, Primary Therapist (non-md), Radiology, Recreational/Occupational Therapy, Room & Board Charges, and Team Meetings. 4) Proper Billing Forms: CMS 1500 for professional services billing and/or UB04 for facility billing 5) For FFS consumers, NMAC regulation for staffing requirements must be strictly adhered to. Unless approved by OHNM through Supervisory Protocol application process, Non- professionals are prohibited from rendering services to Managed Medicaid consumers. If approved by OHNM, the codes that are allowable are: 90832, 90834, 90837, 90846, 90847, 90849, All other codes not identified are not reimbursable if rendered by a non-independent professional. 6) H RN's who do not have psychiatric certification and who were individually contracted with Optum prior to 1/1/13, shall be grandfathered in to provide H2010 services at the rate reflected above. Provider Agencies will be responsible for maintaining records for those employees that have been grandfathered in to render this service. 7) Time Calculations for Billing Purposes : 0-8 min. =.1hr min. =.6hr 9-14 min. =.2hr min. =.7hr min. =.3hr min. =.4hr min. =.5hr 8) s GT U min. =.8hr min. = 1.0hr Standard Description of s y (Note: FOR THE ORIGITING SITE, USE THE CODE THAT BEST DESCRIBES THE SERVICE RENDERED AT THE ORIGITING SITE WHICH MAY BE DIFFERENT THAN THE SERVICE PROVIDED BY THE DISTANT SITE. DO NOT USE A GT MODIFIER WITH THE CODE IF IT IS THE SERVICE PROVIDED AT THE ORIGITING SITE. FOR THE DISTANCE SITE USE CODE THAT BEST DESCRIBES THE SERVICE RENDERED BY THE DISTANT SITE. USE THE GT MODIFIER WITH THE CODE IF THE SERVICE IS PROVIDED BY THE DISTANT SITE. Psychosocial Rehabilitation (PSR) Program for those 18 years or older licensed by DOH/Division of Health Improvement (DHI) or contracted Rev 07/13 <CC> Group/Practitioner Fee Schedule 6 of 6