NM Behavioral Health Design Service List By HIPAA Code and Definition. Modifiers Service Definition Unit Comments

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1 CPT H9, TR, HA Psychiatric diagnostic interview examination Psychiatric diagnostic interview examination includes a history, mental status, and a disposition, and may include communication with family or other sources, ordering and medical interpretation of laboratory or other medical diagnostic studies. In certain circumstances other informants will be seen in lieu of the individual. Product/ Hourly Licensed Psychologist, Licensed or board-eligible Psychiatrist, Clinical Psychiatric Nurse Specialist, Licensed Independent Social Worker (LISW), Licensed Professional Clinical Mental Health Counselor (LPCC), Licensed Marriage & Family Therapist (LMFT). DOH will use this code for commitment-related evaluations only. CYFD will use this code only for a diagnostic exam. Use HA modifier. For HSD/Medicaid Psychosocial Rehabilitation Program (PSR), use H0031 for assessment. For school-based services, use modifier TR. For court-ordered exam, use modifier H9. For HSD/Medicaid, Practitioner Type will determine rate. Note: HSD/Medicaid pays based on practitioner and on an hourly rate; DOH and CYFD pay per product. Page 1 of 38 Revised 6/24/05

2 90802 H9, TR Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication. Licensed Psychologist, Licensed or board-eligible Psychiatrist, Clinical Psychiatric Nurse Specialist, LISW, LPCC, LMFT. Product/ Hourly For court-ordered, use modifier H9. For DOH school-based, use modifier TR TR, U8, HA Individual psychotherapy, office (90804 for min, for 45-50min, for min) Face-to-face interactive interventions are focused and time-limited. Interventions are designed to improve functioning and increase independence. Interventions are relevant to the needs of the recipient and relate directly to the individualized goals and objectives specified in the recipient s treatment plan. This service includes individual (child or adult), family, and group counseling. Individual psychotherapy, office with medical evaluation and management services (E/M), for min, for min, for min) Psychotherapy is the treatment for mental illness and behavioral disturbances in which the clinician establishes a professional contact with the individual and, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development Insight Oriented, Behavior Modifying and/or Supportive Psychotherapy refers to the development of insight or affective understanding, the CPT defined time For HSD/Medicaid, Practitioner Type will determine rate. Note: HSD/Medicaid pays based on practitioner and on an hourly rate. Authorized practitioners for even numbered services: Licensed Psychologist, Psychologist Associate licensed at the master s level, Licensed or board-eligible Psychiatrist, Clinical Psychiatric Nurse Specialist, LISW, LPCC, LMFT, Licensed Professional Art Therapist (LPAT), Licensed Alcohol & Drug Abuse Counselor (LADAC), Registered or Licensed Mental Health Counselor (RMHC/LMHC), Licensed Professional Mental Health Counselor (LPC), or Licensed Masters Social Worker (LMSW). Authorized practitioners for odd numbered services: Page 2 of 38 Revised 6/24/05

3 use of behavior modification techniques, the use of supportive interactions, the use of cognitive discussion of reality, or any combination of the above to provide therapeutic change. Individual psychotherapy is divided into two broad categories: 1) Insight Oriented, Behavior Modifying and/or Supportive Psychotherapy, and 2) Interactive Psychotherapy. Individual psychotherapy, interactive, office, (90810 for min, for min, for min) Individual psychotherapy, interactive, office with medical evaluation and management services (E/M), (90811 for min, for min, 908 for min) Licensed or board-eligible Psychiatrist. For HSD/Medicaid school-based services, use modifier TR. For HSD/Medicaid PSR Therapeutic Intervention service, use modifier U8. For CYFD, use HA modifier. Practitioner Type will determine rate. Interactive Psychotherapy ( ) is typically furnished to children. It involves the use of physical aids and non-verbal communication to overcome barriers to therapeutic interaction between the clinician and an individual who has not yet developed, or has lost, either the expressive language communication skills to explain his/her symptoms and response to treatment, or the receptive communication skills to understand the clinician if he/she were to use ordinary adult language for communications Individual psychotherapy, inpatient, (90816 for min, for min, for min) Individual psychotherapy, inpatient, with medical evaluation and management services (E/M), (90817 for min, for min, for min) Individual psychotherapy, interactive, inpatient, (90823 for min, for min, for min) Individual psychotherapy, interactive, inpatient, with medical evaluation and management services (E/M) (90824 for min, for min, for min) CPT defined time Authorized practitioners for 90816, 90818, 90821, 90823, & 90828: Licensed Psychologist, Licensed or board-eligible Psychiatrist. Authorized practitioners for 90817, & 90822, 90824, & 90829: Licensed or board-eligible Psychiatrist. For HSD/Medicaid, Practitioner Type will determine rate. Page 3 of 38 Revised 6/24/05

4 90846 w/out patient w/ patient TR, HA Family psychotherapy (without the patient present) Psychotherapy 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 Family psychotherapy (conjoint psychotherapy) (with patient present) minutes Licensed Psychologist, Licensed or board-eligible Psychiatrist, Clinical Psychiatric Nurse Specialist, LISW, LPCC, LMFT, LPAT, LADAC, RMHC, LMHC, LPC, LMSW. For school-based services, use modifier TR. For CYFD, use modifier HA TR Multiple family group psychotherapy Therapy 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. minutes Practitioner Type will determine rate. Licensed Psychologist, Licensed or board-eligible Psychiatrist, Clinical Psychiatric Nurse Specialist, LISW, LPCC, LMFT, LPAT, LADAC, RMHC, LMHC, LPC, LMSW. For DOH school-based services, use modifier TR. Practitioner Type will determine rate. Page 4 of 38 Revised 6/24/05

5 90853 TR, U8, HA, UN, UP, UQ, Group psychotherapy (other than a multiple-family group) Psychotherapy administered in a group setting with a trained group leader in charge of individuals. Personal and group dynamics are discussed and explored in a therapeutic setting when similar dynamics are occurring due to a commonality of problems. minutes Licensed Psychologist, Psychologist Associate licensed at the masters level, Licensed or board-eligible Psychiatrist, Clinical Psychiatric Nurse Specialist, LISW, LPCC, LMFT, LPAT, LADAC, RMHC, LMHC, LPC, LMSW. For school-based services, use modifier TR. For HSD/Medicaid PSR, use U8. For CYFD, use modifier HA. Group size should be at least two or more, but no more than 9. For group of two, use modifier UN, for group of three, use modifier UP, for group of 4 or more, use modifier UQ. Note: More than one modifier may be used. Practitioner Type will determine rate. Page 5 of 38 Revised 6/24/05

6 90857 TR, U8, UN, UP, UQ Interactive group psychotherapy Interactive psychotherapy, using play equipment, physical devices, language interpretation or other mechanisms of communication, in a group setting with a trained group leader in charge of individuals. Personal and group dynamics are discussed and explored in a therapeutic setting when similar dynamics are occurring due to a commonality of problems. minutes Licensed Psychologist, Psychologist Associate licensed at the masters level, Licensed or board-eligible Psychiatrist, Clinical Psychiatric Nurse Specialist, LISW, LPCC, LMFT, LPAT, LADAC, RMHC, LMHC, LPC, LMSW. For school-based services, use modifier TR. For HSD/Medicaid PSR, use U8. Group size should be at least two or more, but no more than 9. For group of two, use modifier UN, for group of three, use modifier UP, for group of 4 or more, use modifier UQ. Note: More than one modifier may be used. Practitioner Type will determine rate TR, U8 Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy. Comprehensive medication services provided by a licensed professional with prescriptive authority to assess and evaluate the individual s presenting conditions and symptoms, medical status, medication needs and/or substance abuse status. Comprehensive medication services include medication assessment, medication administration, medication monitoring, and medication education. There is a focus on educating and teaching individuals and members of their support system as to the effects of medication and its impact on alcohol/drug minutes Licensed Psychologist with prescriptive authority, Licensed or board-eligible Psychiatrist, Physician Assistant, Nurse Practitioner or Clinical Psychiatric Nurse Specialist. For school-based services, use modifier TR. Page 6 of 38 Revised 6/24/05

7 abuse/dependence and/or mental illness. Medication services are goal-directed interventions to administer and monitor pharmacological treatment. Oral, injectable, intravenous, or topical medications and treatments are administered and their positive and negative effects monitored. This includes antabuse and other medications, excluding methadone and buprenorphine medications, used to treat substance abuse or addiction. Counseling related to medication management and case coordination with other practitioners involved with the individual may be included. For administration only, use T02. For administration of methadone use H0020, and for the administration of buprenorphine use J Narcosynthesis for psychiatric diagnostic and therapeutic purposes (e.g. Sodium amobarbital [Amytal] interview) Preparation of report of patient s psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other physicians, agencies, or insurance carriers U8, TR Unlisted psychiatric service or procedure (Specialized Consultation) Specialized consultation is access to expertise, in order to assist the treatment team in the development of a comprehensive assessment and master treatment plan, and its on going monitoring and assessment. This service provides an opportunity to gather all relevant caregivers with specialized expertise so that they can coordinate the care provided, and assure that the customer s care is individualized and comprehensive. The specialized expertise includes the provision of tests, the interpretation of reports or other required skills and abilities to enhance the decisions related to the care and treatment of the individual. Session Product minutes For HSD/Medicaid PSR, use modifier U8. Practitioner Type will determine rate. Licensed or board-eligible Psychiatrist, Clinical Psychiatric Nurse Specialist, Licensed Psychologist, LPCC, LMFT, LISW. For CYFD & HSD/Medicaid use only. Licensed Psychologist, Licensed or board-eligible Psychiatrist, Clinical Psychiatric Nurse Specialist, LISW, LPCC, LMFT, LADAC. DOH & CYFD will use for Specialized Consultation. HSD/Medicaid will use for PSR only. Use modifier U8. For DOH school based services, use modifier TR. Practitioner Type will determine rate. Page 7 of 38 Revised 6/24/05

8 96100 H9, HA Psychological testing (includes psychodiagnostic assessment of personality, psychopathology, emotionality, intellectual abilities, e.g., WAIS-R, Rorschach, MMPI) with interpretation and report, per hour 1 Hour Licensed Psychologist, Licensed or Board-eligible Psychiatrist Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen) with interpretation and report Developmental testing; extended (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments, e.g. Bayley Scales of Infant Development) with interpretation and report, per hour 961 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, memory, visual spatial abilities, language functions, planning) with interpretation and report, per hour CYFD will use this code with both HA and H9 modifiers for Forensic evaluations. For Comprehensive Psychological Evaluations, Emergency Mental Health and Intellectual & Cognitive Evals, use only modifier HA. Note: For CYFD, bill a maximum of one unit. One unit = product. 1 Hour For HSD/Medicaid use only. Licensed Psychologist, Licensed or board-eligible Psychiatrist. min. HSD/Medicaid use only. Licensed Psychologist, Licensed or board-eligible Psychiatrist 1 Hour For HSD/Medicaid use only. Licensed Psychologist, Licensed or board-eligible Psychiatrist 1 Hour For HSD/Medicaid use only. Licensed Psychologist, Licensed or board-eligible Psychiatrist Page 8 of 38 Revised 6/24/05

9 96117 Neuropsychological testing battery (e.g., Halstead-Reitan, Luria, WAIS-R) with interpretation and report, per hour Office or other outpatient visit for the evaluation and management of a new patient, which requires three key components: Problem focused history, problem focused exam, straightforward medical decision making, typically 10 minutes face-to-face: Self limited or minor problems Expanded problem focused history, expanded problem focused exam, straightforward medical decision making, typically 20 minutes face-to-face: low to moderate severity problems Detailed history, detailed exam, low complexity medical decision making, typically 30 minutes face-to-face: moderate severity problems Comprehensive history, comprehensive exam, moderate complexity medical decision making, typically 45 minutes face-to-face: moderate to high severity problems Comprehensive history, comprehensive exam, high complexity medical decision making, typically 60 minutes face-to-face: moderate to high severity problems. The activities and components completed, more than the time, define which code to use. 1 Hour For HSD/Medicaid use only. Licensed Psychologist, Licensed or Board-eligible Psychiatrist CPT Defined Time For HSD/Medicaid use only. Licensed or board-eligible Psychiatrist. Page 9 of 38 Revised 6/24/05

10 Office or other outpatient visit for the evaluation and management of an established patient, which requires three key components: May not require the presence of a physician, presenting problems minimal, typically 5 minutes spent performing services: presenting problems minimal Problem focused history, problem focused exam, straightforward medical decision making, typically 10 minutes face-to-face: self-limited or minor problems Expanded problem-focused history, expanded problem focused exam, low complexity medical decision making, typically minutes face-to-face: low to moderate problems Detailed history, detailed exam, moderate complexity medical decision making, typically 25 minutes face-to-face: moderate to high severity problems Comprehensive history, comprehensive exam, high complexity medical decision making, typically 40 minutes face-to-face: moderate to high severity problems. The activities and components completed, more than the time, define which code to use. Observation care discharge day management (This codes is to be utilized by the physician to report all services provided to a patient on discharge from observation status.) Initial observation care, per day, for the evaluation and management of a patient which requires these three key components: A detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the problem(s) requiring admission to observation status are of low severity A detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. CPT Defined Time CPT Defined Time For HSD/Medicaid use only. Licensed or board-eligible Psychiatrist. For HSD/Medicaid use only. Licensed or board-eligible Psychiatrist For HSD/Medicaid use only. Licensed or board-eligible Psychiatrist Page 10 of 38 Revised 6/24/05

11 Usually, the problem(s) requiring admission to observation status are of moderate severity A detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the problem(s) requiring admission to observation status are of high severity. Initial hospital care new or established patient Used to report the first hospital inpatient encounter with the patient by the admitting physician Initial hospital care, per day, for the evaluation and management of a patient, which requires three key components: Detailed or comprehensive history, detailed or comprehensive exam, straightforward or low complexity medical decision making, typically 30 minutes at the bedside and on the patient s hospital floor or unit: low severity problems Comprehensive history, comprehensive exam, moderate complexity medical decision making, typically 50 minutes at the bedside and on the patient s hospital floor or unit: moderate severity problems Comprehensive history, comprehensive exam, high complexity medical decision making, typically 70 minutes at the bedside and on the patient s hospital floor or unit: high severity problems. CPT Defined Time For HSD/Medicaid use only. Licensed or board-eligible Psychiatrist. Page 11 of 38 Revised 6/24/05

12 Subsequent hospital care all levels of subsequent hospital care including reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient s status. CPT Defined Time For HSD/Medicaid use only. Licensed or board-eligible Psychiatrist. Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: Problem focused interval history, problem focused exam, straightforward or low complexity medical decision making, typically minutes at the bedside and on patient s hospital floor or unit: Usually, patient is stable, recovering or improving Expanded problem focused interval history, expanded problem-focused exam, moderate complexity medical decision making, typically 25 minutes at the bedside and on the patient s hospital floor or unit. Usually, patient is responding inadequately to therapy or has developed a minor complication Detailed interval history, detailed exam, high complexity medical decision making, typically 35 minutes at the bedside and on the patient s hospital floor or unit: Usually, patient is unstable or has developed a significant complication or a significant new problem , Observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components: Detailed or comprehensive history, detailed or comprehensive exam, straightforward or low complexity medical decision making, low severity problems Comprehensive history, comprehensive exam, moderate complexity medical decision making, moderate severity problems Comprehensive history, comprehensive exam, high complexity medical decision making, high severity problems. Hospital discharge services - used to report total duration of time spent by a physician for final hospital discharge of a patient Hospital discharge day management; 30 minutes or less Hospital discharge day management; more than 30 minutes CPT Defined Time CPT Defined Time For HSD/Medicaid use only. Licensed or board-eligible Psychiatrist. For HSD/Medicaid use only. Licensed or board-eligible Psychiatrist. Page 12 of 38 Revised 6/24/05

13 HA Office or other outpatient consultations new or established patient, which requires three key components Problem focused history, problem focused exam, straightforward medical decision making, typically minutes face-to-face with patient and/or family: selflimited or minor problems Expanded problem focused history, expanded problem focused exam, straightforward medical decision making, typically 30 minutes face-to-face with patient and/or family: low severity problems Detailed history, detailed exam, low complexity medical decision making, typically 40 minutes face-to-face with patient and/or family: moderate severity problems Comprehensive history, comprehensive exam, moderate complexity medical decision making, typically 60 minutes face-to-face with patient and/or family: moderate to high severity problems Comprehensive history, comprehensive exam, high complexity medical decision making, typically 80 minutes face-to-face with patient and/or family: moderate to high severity problems. CPT Defined Time Licensed or board-eligible Psychiatrist, Clinical Psychiatric Nurse Specialist, Licensed Psychologist, LPCC, LMFT, LISW. For CYFD, use code 99241only. And include HA modifier. This code is used only when seeking consultations outside of the agency. Page 13 of 38 Revised 6/24/05

14 Initial inpatient consultations new or established patient, which requires these three key components Problem focused history, problem focused exam, straightforward medical decision making, typically 20 minutes at the bedside and on the patient s hospital floor or unit: self-limited or minor problems Expanded problem focused history, expanded problem focused exam, straightforward medical decision making, typically 40 minutes at the bedside and on the patient s hospital floor or unit: low severity problems Detailed history, detailed exam, low complexity medical decision making, typically 55 minutes at the bedside and on the patient s hospital floor or unit: moderate severity problems Comprehensive history, comprehensive exam, moderate complexity medical decision making, typically 80 minutes at the bedside and on the patient s hospital floor or unit: moderate to high severity problems Comprehensive history, comprehensive exam, high complexity medical decision making, typically 110 minutes at the bedside and on the patient s hospital floor or unit: moderate to high severity problems. CPT Defined Time For HSD/Medicaid use only. Licensed or board-eligible Psychiatrist, Licensed Psychologist Follow-up inpatient consultations established patient, which requires at least two of three key components Problem focused interval history, problem focused exam, straightforward or low complexity medical decision making, typically 10 minutes at the bedside and on patient s hospital floor or unit: Usually, patient is stable, recovering or improving Expanded problem focused interval history, expanded problem-focused exam, moderate complexity medical decision making, typically 20 minutes at the bedside and on the patient s hospital floor or unit. Usually, patient is responding inadequately to therapy or has developed a minor complication Detailed interval history, detailed exam, high complexity medical decision making, typically 30 minutes at the bedside and on the patient s hospital floor or unit: Usually, patient is unstable or has developed a significant complication or a significant new problem. CPT Defined Time For HSD/Medicaid use only. Licensed or board-eligible Psychiatrist, Licensed Psychologist Page 14 of 38 Revised 6/24/05

15 Prolonged physician service with direct (face-to-face) patient contact Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (e.g. Prolonged care and treatment of an acute asthmatic patient in an a=outpatient setting); first hour (list separately in addition to code for office or other outpatient Evaluation and Management service). Note that is an add-on code and must be used in conjunction with , , and each additional 30 minutes (list separately in addition to code for prolonged physician service). Note that is an add-on code and must be used in conjunction with Prolonged physician service in the inpatient setting, requiring direct (faceto-face) patient contact beyond the usual service, first hour, (list separately in addition to code for inpatient Evaluation and Management service). Note that is an add-on code and must be used in conjunction with , , and each additional 30 minutes (list separately in addition to code for prolonged physician service). Note that is an add-on code and must be used in conjunction with CPT Defined Time For HSD/Medicaid use only. Licensed or board-eligible Psychiatrist HCPCS A0090 Non-emergency transportation, per mile vehicle provided by individual (family member, self, neighbor) with vested interest Non-emergency transportation is provided when necessary to secure a necessary, covered behavioral health service in or out of the individual s home community. Transportation is provided by self, a family member, or neighbor, and is reimbursed only if an individual does not have access to transportation services which are available free of charge. A0100 Non-emergency transportation; taxi Non-emergency transportation is provided when necessary to secure a necessary, covered behavioral health service in or out of the individual s home community. Currently not paid by DOH or CYFD. Note: The HSD/Salud! Managed Care Organizations will be responsible for Medicaid client transportation. Currently not paid by DOH or CYFD. Note: The HSD/Salud! Managed Care Page of 38 Revised 6/24/05

16 Services are provided by a taxicab, taxi van or van certified by the NM Public Regulation Commission within those geographic regions of the state specifically authorized by the NM Public Regulation Commission. Transportation is reimbursed only if this is the least costly transportation available for required service. A0110 Non-emergency transportation and bus, intra-or interstate carrier Non-emergency transportation is provided when necessary to secure a necessary, covered behavioral health service in or out of the individual s home community. Services are provided by certain bus services certified by the NM Public Regulation Commission within those geographic regions of the state specifically authorized by the NM Public Regulation Commission. Transportation is reimbursed only if this is the least costly transportation available for the service required. A0140 Non-emergency transportation per mile, Air, intra- or interstate carrier, private or commercial Non-emergency transportation is provided when necessary to secure a necessary, covered behavioral health service. Air transportation is reimbursed only if this is the least costly transportation available for the service required. A0160 HA Non-emergency transportation: per mile case worker or social worker Non-Emergency Transportation is provided by a Caseworker or Social Worker and compensates for vehicle use while providing necessary, covered transportation to designated target populations. Eligible staff include, but are not limited to, Caseworker or Social worker, Community Support Worker, Clinician, and other appropriate agency staff. A0180 Non-emergency transportation, Lodging, recipient Lodging is reimbursed if an individual is required to travel to receive a covered behavioral health service more than four hours one-way from the individual s home community, and an overnight stay is required due to medical necessity or cost considerations. Per Mile Organizations will be responsible for Medicaid client transportation. Currently not paid by DOH or CYFD. Note: The HSD/Salud! Managed Care Organizations will be responsible for Medicaid client transportation. Currently not paid by DOH or CYFD. Note: The HSD/Salud! Managed Care Organizations will be responsible for Medicaid client transportation. For CYFD and DOH use only. For CYFD use modifier HA. This service will be reimbursed at a flat rate. Currently not paid by DOH or CYFD. Note: The HSD/Salud! Managed Care Organizations will be responsible for Medicaid client transportation. Page 16 of 38 Revised 6/24/05

17 A0190 Non-emergency transportation, Meals, recipient Meals are reimbursed if an individual is required to travel for eight hours or more to receive a covered behavioral health service. A0200 Non-emergency transportation, Lodging, Escort Lodging for an escort is reimbursed if (a) an individual is required to travel to receive a necessary, covered behavioral health service more than four hours oneway from the individual s home community, and an overnight stay is required due to medical necessity or cost considerations; and (b) the medical necessity for the presence of an escort is certified in writing by the individual s behavioral health provider; or if the individual who is receiving covered behavioral health services is under 18 years of age. The escort for a child under 18 years of age should be the parent or legal guardian. A0210 Non-emergency transportation, Meals, Escort H0002 HE, HF, HH, TR, HA, H9 Meals for an escort are reimbursed if (a) an individual is required to travel for eight hours or more to receive a covered behavioral health service; and (b) the medical necessity for the presence of an escort is certified in writing by the individual s behavioral health provider; or if the individual who is receiving covered behavioral health services is under 18 years of age. The escort for a child under 18 years of age should be the parent or legal guardian. Behavioral Health Screening Behavioral Health Screening is provided to determine eligibility for admission to behavioral health treatment services, and may include the following: Integrated mental health and substance use disorders screening, mental health screening, alcohol screening and drug abuse screening. The behavioral health screen is a preliminary procedure limited in nature and intended to merely indicate whether there is a probability that a mental health problem and/or drug/alcohol abuse or dependence problem is present. This screen Product Currently not paid by DOH or CYFD. Note: The HSD/Salud! Managed Care Organizations will be responsible for Medicaid client transportation. Currently not paid by DOH or CYFD. Note: The HSD/Salud! Managed Care Organizations will be responsible for Medicaid client transportation. Currently not paid by DOH or CYFD. Note: The HSD/Salud! Managed Care Organizations will be responsible for Medicaid client transportation. Bachelor s degree in human services related field and a combination of relevant education, training and experience totaling four years; or LADAC; or Masters Degree in human services related field. Page 17 of 38 Revised 6/24/05

18 may be accomplished using any one of a collection of nationally accepted standardized screening tools that are appropriately designed for the individuals being screened. NOTE: Completed screening must be signed and dated by staff completing the screening and as appropriate, a masters level supervisor. For supervision requirements, see specific service requirement staffing guideline. H0003 H9, TR Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol and/or drugs Alcohol and/or drug screening is provided for the laboratory analysis of specimens for the presence of alcohol and/or drugs (illicit or licit). Product For DOH school based, use modifier TR. For CYFD, use modifier HA. Also use modifier H9 if court-ordered. For mental health screening, use modifier HE. For substance abuse screening, use modifier HF When both a mental health and substance abuse screen are conducted, use modifier HH. For NMCD or DOH use only. Note: Analysis conducted by a certified clinical laboratory. For DOH school based, use modifier TR. For court-ordered services, use modifier H9. Page 18 of 38 Revised 6/24/05

19 H0010 H9, TG Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) Residential inpatient detoxification Residential detoxification (sometimes referred to as social setting detoxification ) services include 24-hour supervision, observation, and support for individuals who are intoxicated or experiencing withdrawal. Residential detoxification is delivered by appropriately trained staff, is characterized by its emphasis on peer and social support, and provides care to individuals whose intoxication/withdrawal signs and symptoms are sufficiently severe to require 24-hour structure and support. All programs at this level rely on established clinical protocols to identify individuals who are in need of medical services beyond the capacity of the facility and to transfer such individuals to more appropriate levels of care. This service is delivered under a defined set of physician-approved policies and procedures or clinical protocols. Sub-intensive Medically Monitored Detoxification This service, equivalent to the American Society of Addiction Medicine (ASAM) Level III.7D, medical monitored inpatient detoxification, is an organized service, delivered by medical and nursing professionals, that provides 24-hour medically supervised evaluation and withdrawal management in a permanent facility with inpatient beds. This service provides care for individuals whose intoxication and/or withdrawal signs and symptoms are sufficiently severe to require 24-hour structure and support. All programs at this level rely on established clinical protocols to identify individuals who are in need of medical services beyond the capacity of the facility and to transfer such individuals to more appropriate levels of care. This service is delivered under a defined set of physician-approved policies and procedures or clinical protocols. 24 hours Authorized Staff: Staff must receive relevant training, to include but not limited to safety, basic first aid, CPR, and emergency protocols. Staff must be trained in the defined set of physician-approved policies and procedures or clinical protocols for residential detox. Staff must successfully pass a criminal background check. The program must be under the supervision of a licensed behavioral health professional or licensed medical professional. For court-ordered service, use modifier H9. For medically monitored detoxification service, use modifier TG. NOTE: For medically monitored detox, the above requirements must be met. In addition, a nurse must be on staff for all shifts and a physician must be accessible 24/7. Page 19 of 38 Revised 6/24/05

20 H00 SE, H9, HH Alcohol and/or drug services; intensive outpatient treatment (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling, crisis intervention, and activity therapies or education. An Intensive Outpatient Treatment Program provides a time-limited, multi-faceted approach to treatment service for individuals who require structure and support to achieve and sustain recovery. Intensive outpatient treatment programs generally provide a minimum of 9 treatment hours per week delivered during the day, evenings and/or weekends. A multi-disciplinary team must provide this service. The treatment program consists of, but is not limited to, individual, group and family counseling; relapse prevention and education; withdrawal management; and drug refusal skills. The amount of weekly services per individual is directly related to the goals and objectives specified in the individual s treatment plan; however, a minimum of 3 hours per day, 3 days a week is required. Per diem = min. 3 hours per day Authorized Staff: Intensive Outpatient Treatment can only be provided by a Licensed BH Professional (excluding licensed substance abuse interns). For supervision requirements, see specific service requirement staffing guideline. For HSD TANF, use modifier SE. For court-ordered services, use modifier H9. For co-occurring services, use modifier HH. Use BHSD s billing instructions. H0018 HD, HE, HF, HH, HI, H9 Behavioral health; short-term residential (non-hospital residential treatment program), without room and board, per diem A short-term residential treatment program offering 24-hour intensive residential treatment, habilitative, and rehabilitative services for up to 30 days in a highly structured, community-oriented environment. This type of program is appropriate for individuals who need concentrated therapeutic services prior to community residence. The focus of services is to stabilize the individual and provide a safe and supportive living environment during detox and/or recovery from addictions. Per diem Authorized Staff: Staff must receive relevant training, to include but not limited to safety, basic first aid, CPR, emergency protocols. Staff must be trained in the defined set of physician-approved policies and procedures or clinical protocols for residential services. Staff must successfully pass a criminal background check. The program must be under the supervision of a licensed behavioral health professional or licensed medical professional. Refer to modifier list for appropriate use of modifiers. Page 20 of 38 Revised 6/24/05

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