Medicaid School-Based Services Reimbursement Rates Effective 8/1/15

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1 Speech Therapy (Provider Type 457 or 458) Evaluation of Speech Fluency (eg., stuttering, cluttering) 1 evaluation $ No Evaluation of Speech Sound Production (eg., articulation, phonological process, 1 evaluation $89.75 No 1 apraxia, dysarthria) Evaluation of Speech Sound Production; with Evaluation of Language Comprehension and Expression (eg., receptive and expressive language) 1 evaluation $ No Behavioral and Qualitative Analysis of Voice and Resonance 1 evaluation $93.66 No Treatment of Speech, Language, Voice, Communication, and/or Auditory 1 hour $60.14 Yes Processing Disorder, Individual Treatment of Speech, Language, Voice, Communication, and/or Auditory 1 hour $45.12 Yes 2, U Processing Disorder, Group of 2 Treatment of Speech, Language, Voice, Communication, and/or Auditory 1 hour $35.08 Yes 2, U Processing Disorder, Group of 3 Treatment of Speech, Language, Voice, Communication, and/or Auditory 1 hour $30.07 Yes 2, U , U1 Processing Disorder, Group of 4 Treatment of Speech, Language, Voice, Communication, and/or Auditory Processing Disorder, Home Visit 1 hour $77.60 Yes 1 1

2 Audiology (Provider Type 331) Pure Tone Audiometry (threshold), Air Only Pure Tone Audiometry (threshold), Air & Bone Speech Audiometry Threshold Comprehensive Audiometry Threshold Eval and Speech Recognition Tympanometry (Impedance Testing) Distortion Evoked Otoacoustic Emission, Limited Evaluation (3-6 frequencies) or Transient Evoked Otoacoustic Emissions, with Interpretation and Report Distortion Evoked Otoacoustic Emission, Comprehensive Evaluation (min 12 frequencies) with Interpretation and Report Auditory Rehabilitation; Pre-lingual hearing loss, U Auditory Rehabilitation; Pre-lingual hearing loss, Group of 2, U Auditory Rehabilitation; Pre-lingual hearing loss, Group of 3, U Auditory Rehabilitation; Pre-lingual hearing loss, Group of 4, U Auditory Rehabilitation; Post-lingual hearing loss, U Auditory Rehabilitation; Post-lingual hearing loss, Group of 2, U Auditory Rehabilitation; Post-lingual hearing loss, Group of 3, U Auditory Rehabilitation; Post-lingual hearing loss, Group of 4, U4 V5010 Audiology assessment and hearing aid check 1 evaluation $16.45 No 1 1 evaluation $24.67 No 1 1 evaluation $14.39 No 1 1 evaluation $44.88 No 1 1 evaluation $19.88 No 1 1 evaluation $56.07 No 1 1 evaluation $74.53 No 1 1 hour $60.14 Yes 8 1 hour $45.12 Yes 8 1 hour $35.08 Yes 8 1 hour $30.07 Yes 8 1 hour $60.14 Yes 8 1 hour $45.12 Yes 8 1 hour $35.08 Yes 8 1 hour $30.07 Yes 8 1 visit $12.18 No 1 2

3 Occupational Therapy (Provider Type 451 or 452) Occupational Therapy Evaluation Occupational Therapy Re-Evaluation Therapeutic Procedure, One or More Areas, Each 15 minutes, Individual, GO, GO, U2 Group of 2, GO, U3 Group of 3, GO, U4 Group of Therapeutic Procedure, One or More Areas, Each 15 minutes,, GO, U1 Home Visit Physical Therapy (Provider Type 453 or 454) Physical Therapy Evaluation , GP, GP, U2 Group of 2, GP, U3 Group of 3, GP, U4 Group of , GP, U1 Physical Therapy Re-Evaluation Therapeutic Procedure, One or More Areas, Each 15 minutes, Individual Therapeutic Procedure, One or More Areas, Each 15 minutes, Home Visit 1 evaluation $78.51 No 1 1 re-evaluation $46.79 No 1 15 min $11.16 No 6 1 visit $19.73 No 8 1 visit $17.38 No 8 1 visit $16.12 No 8 15 min $19.40 No 6 1 evaluation $73.72 No 1 1 re-evaluation $38.92 No 1 15 min $11.16 No 6 1 visit $19.73 No 8 1 visit $17.38 No 8 1 visit $16.12 No 8 15 min $19.40 No 6 3

4 Nursing (Billing under District #) T1001 Nursing Assessment/Evaluation 1 hour $43.60 Yes 4 T1002 RN Services, Each 15 minutes 15 min $10.90 No None T1003 LPN Services, Each 15 minutes 15 min $7.37 No None T1502 Medication administered by an RN or LPN U1 = 1 dose $12.00 No None U2 = 2 doses $15.00 (see units for addt'l U3 = 3 doses $18.00 modifier) U4 = 4+ doses $21.00 T1002, U1 RN Services, Each 15 minutes, home visit 15 min $26.51 No None Nutritional Counseling (Billing under District #) Medical nutrition therapy; initial assessment and intervention, individual, face-toface with the patient, Each 15 minutes Medical nutrition therapy; re-assessment and intervention, individual, face-toface with the patient, Each 15 minutes 15 min $11.64 No 4 15 min $2.91 No 4 Transportation (Billing under District #) Unit Rate Partial Units Maximum A0110 IEP School Bus Transportation Per one-way trip Varies by district and year No None (Contact the Medicaid SHO for 4

5 Behavioral Health (for most codes, rates vary by provider type) Individual Psychotherapy, 30 min, face-to-face, patient and/or family 301-Physician MD 1 visit $29.59 No 1 1 visit $23.28 No Lic visit $24.25 No Individual Psychotherapy, 45 min, face-to-face, 301-Physician MD 1 visit $59.17 No 1 patient and/or family 1 visit $46.56 No Lic visit $48.50 No 1 5

6 Individual Psychotherapy, 60 min, face-to-face, 301-Physician MD 1 visit $88.76 No 1 patient and/or family 1 visit $69.84 No Lic visit $72.75 No 1 Family Psychotherapy, without the patient present 301-Physician MD 1 hour $95.26 Yes 3 1 hour $66.93 Yes Lic hour $67.90 Yes 3 6

7 Family Psychotherapy, with the patient present 301-Physician MD 1 hour $ Yes 2 1 hour $77.60 Yes Lic hour $82.45 Yes 2 Multiple Family Group Psychotherapy 301-Physician MD 1 hour $30.50 Yes 2 1 hour $24.25 Yes Lic hour $24.25 Yes 2 7

8 90853, U , U3 Group Psychotherapy (other than multiple family), 301-Physician MD 1 hour $29.10 Yes 2 Group of 2 1 hour $34.92 Yes Lic hour $36.39 Yes 2 Group Psychotherapy (other than multiple family), 301-Physician MD 1 hour $29.10 Yes 2 Group of 3 1 hour $27.16 Yes Lic hour $28.29 Yes 2 8

9 90853, U Group Psychotherapy (other than multiple family), 301-Physician MD 1 hour $29.10 Yes 2 Group of 4 1 hour $23.28 Yes Lic hour $24.29 Yes 2 Psychiatric Diagnostic Evaluation 1 Evaluation $48.50 No 1 $87.30 No CNS $97.97 No $ No 1 Psychiatric Diagnostic Evaluation with Medical 301-Physician 1 Evaluation $ No 1 Services 316-Nurse CNP G0155 Services of Clinical Social Workers in Home Health Setting, Each 15 min. 15 min $19.40 No 12 Case Management (provider Type 462) T1017 Targeted Case Management, Each 15 min. (provider must be enrolled with Xerox as a case manager) 15 min $9.25 No 99 9

10 Medicaid School-Based Services Transportation Rates Per One-way Trip August 2015 District/REC Provider # Rate Alamogordo Public Schools Albuquerque Public Schools E Artesia Public Schools J Aztec Municipal Schools Belen Consolidated Schools P Bernalillo Public Schools H Bloomfield Schools Carlsbad Consolidated Schools K Central Consolidated Schools J Central Regional Education Cooperative # (Estancia, Jemez Valley, Magdalena, Mountainair, Quemado, Vaughn) Chama Valley Independent School District L Clovis Municipal Schools L Cobre Consolidated Schools L Cuba Independent Schools Dulce Independent Schools Espanola Public Schools Farmington Municipal Schools Gadsden Independent Schools J Gallup/McKinley Public Schools L Grants/Cibola Public Schools J High Plains Regional Educational Cooperative # (Cimarron, Clayton, Des Moines, Maxwell, Mosquero, Raton, Roy, Springer) Las Cruces Public Schools E Las Vegas City Schools R Los Lunas Public Schools E Lovington Schools P Mission Achievement & Success Charter Mora Independent Schools Moriarty-Edgewood School District J NW Regional Education Cooperative # (Chama, Cuba, Dulce, Jemez Mountain, Mesa Vista, Penasco, Questa) Pecos Independent Schools P Pecos Valley Regional Cooperative #8 J (Dexter, Hagerman, Lake Arthur, Loving) Penasco Independent Schools P Pojoaque Valley Schools K Questa Public Schools T Regional Educational Center #6 (Dora, Elida, Floyd, Ft. Sumner, Grady, House, Logan, Melrose, Portales, San Jon, Texico) E

11 Medicaid School-Based Services Transportation Rates Per One-way Trip August 2015 District/REC Provider # Rate Regional Educational Cooperative #7 J (Eunice, Hobbs, Jal, Tatum) Regional Cooperative Center #9 E (Capitan, Carrizozo, Cloudcroft, Corona, Hondo, Ruidoso, Tularosa) Rio Rancho Public Schools T Roswell Independent Schools Z Santa Fe Public Schools E Santa Rosa Consolidated Schools L Silver Consolidated Schools L Socorro Consolidated Schools L SW Regional Educational Cooperative #10 J (Animas, Deming, Hatch, Lordsburg, Reserve, T or C) Taos Municipal Schools Q Tucumcari Public Schools E West Las Vegas Schools H Zuni Public School District J

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