UnitedHealth Premium Physician Designation Program s and Medications Demonstrating Compliance with Nationally Endorsed Quality Measures Introduction This document is a reference for use during the online UnitedHealth Premium designation program s reconsideration process to determine if a patient met the clinical standards for measures indicated as non-compliant. This document is specifically referenced within the Reconsideration Quality Worksheet and the online Quality tab screen for nationally endorsed quality measures. Refer to this document for codes and medications that demonstrate compliance with these measures. The document is organized alphabetically by condition and then by measure. Each measure includes a list and description of billing codes and/or medications that satisfy the compliance criteria. The list for each measure may include medications and the following code types as applicable: ICD-9 HCPCS LOINC RVNU POS Definition Current Procedural Terminology () is coding used to describe medical services and procedures. A three to five digit number code describing a diagnosis or medical procedure. The Healthcare Common Procedure Coding System (HCPCS) is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (). Logical Observation Identifiers Names and s (LOINC) are a database and universal standard for identifying medical laboratory observations. s used to identify specific accommodations, ancillary services and billing calculations used by facilities as determined by the National Uniform Billing Committee. Place of Service (POS) s are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. Additional helpful definitions: Measure Source ID Symmetry EBM Connect Case ID or Symmetry Procedure Episode Group (PEG ) anchor category ID Rule ID Reference number for Symmetry EBM Connect rules. Note: You may also want to refer to the Evidence-Based Medicine (EBM) Synopses (Pathway: UnitedHealthcareOnline.com > UnitedHealth Premium > Premium Reconsideration > Reconsideration Resources.)
Table of Contents Acute Myocardial Infarction (AMI)...3 ADHD...4 Alcohol and Other Drug Dependence Treatment...15 Antidepressant Medical Management...29 Asthma...30 Avoidance of Antibiotic Treatment in adults with Acute Bronchitis...34 Breast Cancer Screening...35 Cardiovascular Disease...36 Cervical Cancer Screening...37 Chlamydia Screening.............................................40 Congestive Heart Failure...42 Coronary Artery Disease...47 Diabetes...50 Diabetes Mellitus...52 Diabetic Retinopathy (NS)...53 Glaucoma Screening...54 Medication Safety Monitoring...57 Migraine Headache...64 Osteoporosis Management...65 Pharyngitis...67 Pregnancy Management...68 Rheumatoid Arthritis...69 Upper Respiratory Infection (Pediatric)...70 Use of Appropriate Imaging for Back Pain...71 Table of Contents 2
Acute Myocardial Infarction (AMI) Measure Source (Case) ID: 203100 Measure: Medication Patient(s) hospitalized with an acute myocardial infarction (AMI) persistently taking a betablocker for six months after discharge. (Rule ID: 9000001) Acebutolol hydrochloride Atenolol Bendroflumethiazide-nadolol Betapace Betapace AF Betaxolol Blocadren Bystolic Cartrol Carvedilol Coreg Corgard Corzide Hydrochlorothiazide-metoprolol Hydrochlorothiazide-propranolol Inderal Inderide InnoPran XL Kerlone Levatol Lopressor Metoprolol succinate ER Metoprolol tartrate Nadolol Normodyne Pindolol Propranolol hydrochloride Sectral Sorine Sotalol hydrochloride Tenoretic Tenormin Timolide 10-25 Timolol maleate Toprol-XL Trandate Zebeta Ziac Acute Myocardial Infarction (AMI) 3
ADHD Measure Source (Case) ID: 200100 Measure: Measure: Patients who have an outpatient, intensive outpatient, or partial hospitalization follow-up visit with a prescribing provider within 30 days after the initial ADHD prescription. (Rule ID: 9000001) Patients who have an outpatient, intensive outpatient, or partial hospitalization follow-up visit with a prescribing provider within 30 days after the initial ADHD prescription AND two followup visits during the 31 days through 300 days after the initial. (Rule ID: 9000002) Description 90801 Psychiatric diagnostic interview examination 90802 Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication 90804 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; 90805 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services 90806 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; 90807 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services 90808 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; 90809 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services 90810 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; 90811 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services 90812 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; 90813 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services 90814 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; ADHD 4
Description 90815 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services 90816 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; 90817 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services 90818 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; 90819 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services 90821 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; 90822 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services 90823 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; 90824 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services 90826 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; 90827 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services 90828 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; 90829 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services 90845 Psychoanalysis 90847 Family psychotherapy (conjoint psychotherapy) (with patient present) 90849 Multiple-family group psychotherapy 90853 Group psychotherapy (other than of a multiple-family group) 90857 Interactive group psychotherapy ADHD 5
Description 90862 Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy 90875 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately 20-30 minutes 90876 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately 45-50 minutes 96150 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment 96151 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment 96152 Health and behavior intervention, each 15 minutes, face-to-face; individual 96153 Health and behavior intervention, each 15 minutes, face-to-face; group (two or more patients) 96154 Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present) 98960 Education and training for patient self-management by a qualified, non physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; individual patient 98961 Education and training for patient self-management by a qualified, non physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; two to four patients 98962 Education and training for patient self-management by a qualified, non physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; five to eight patients 99078 Physician educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions) 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. 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 presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. 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 presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making 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 presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. ADHD 6
Description 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; 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. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; 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 presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes faceto-face with the patient and/or family. 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. 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 presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and 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 presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; 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. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive history; A comprehensive examination; 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 presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. 99217 Observation care discharge day management (This code is to be utilized by the physician to report all services provided to a patient on discharge from "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]) ADHD 7
Description 99218 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. 99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A 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. Usually, the problem(s) requiring admission to "observation status" are of moderate severity. 99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A 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. 99221 Initial hospital 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 are of low severity. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit. 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A 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. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit. 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: A comprehensive history; A 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 are of high severity. Physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit. 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A problem focused interval history; A problem focused examination; 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 patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit. 99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; 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. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit. ADHD 8
Description 99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A detailed interval history; A detailed examination; 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 patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit. 99238 Hospital discharge day management; 30 minutes or less 99239 Hospital discharge day management; more than 30 minutes 99241 Office consultation for a new or established patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. 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 presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family. 99242 Office consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. 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 presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. 99243 Office consultation for a new or established patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making 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 presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. 99244 Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A 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. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-toface with the patient and/or family. 99245 Office consultation for a new or established patient, which requires these three key components: A comprehensive history; A 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 presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family. 99251 Inpatient consultation for a new or established patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. 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 presenting problem(s) are self limited or minor. Physicians typically spend 20 minutes at the bedside and on the patient's hospital floor or unit. 99252 Inpatient consultation for a new or established patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. 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 presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient's hospital floor or unit. ADHD 9
Description 99253 Inpatient consultation for a new or established patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making 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 presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient's hospital floor or unit. 99254 Inpatient consultation for a new or established patient, which requires these three key components: A comprehensive history; A 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. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes at the bedside and on the patient's hospital floor or unit. 99255 Inpatient consultation for a new or established patient, which requires these three key components: A comprehensive history; A 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 presenting problem(s) are of moderate to high severity. Physicians typically spend 110 minutes at the bedside and on the patient's hospital floor or unit. 99261 Follow-up inpatient consult 99262 Follow-up inpatient consult 99263 Follow-up inpatient consult 99341 Home visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. 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 presenting problem(s) are of low severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. 99342 Home visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making 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 presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. 99343 Home visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed 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. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-toface with the patient and/or family. 99344 Home visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A 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. Usually, the presenting problem(s) are of high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. ADHD 10
Description 99345 Home visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A 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 patient is unstable or has developed a significant new problem requiring immediate physician attention. Physicians typically spend 75 minutes face-to-face with the patient and/or family. 99347 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. 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 presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family. 99348 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making 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 presenting problem(s) are of low to moderate severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. 99349 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed interval history; A detailed examination; 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. Usually, the presenting problem(s) are moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. 99350 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to 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 presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 60 minutes face-to-face with the patient and/or family. 99383 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) 99384 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) 99393 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) 99394 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) 99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes ADHD 11
Description 99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes 99403 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes 99404 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes 99411 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes 99412 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 60 minutes 99510 Home visit for individual, family, or marriage counseling HCPCS G0155 G0176 G0177 H0002 H0004 H0031 H0034 H0035 H0036 H0037 H0039 H0040 H2000 H2001 H2010 H2011 H2012 H2013 H2014 H2015 H2016 H2017 H2018 H2019 ADHD Description Services of clinical social worker in home health setting, each 15 minutes Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more) Training and educational services related to the care and treatment of patient's disabling mental health problems per session (45 minutes or more) Behavioral health screening to determine eligibility for admission to treatment program Behavioral health counseling and therapy, per 15 minutes Mental health assessment, by non-physician Medication training and support, per 15 minutes Mental health partial hospitalization, treatment, less than 24 hours Community psychiatric supportive treatment, face-to-face, per 15 minutes Community psychiatric supportive treatment program, per diem Assertive community treatment, face-to-face, per 15 minutes Assertive community treatment program, per diem Comprehensive multidisciplinary evaluation Rehabilitation program, per 1/2 day Comprehensive medication services, per 15 minutes Crisis intervention service, per 15 minutes Behavioral health day treatment, per hour Psychiatric health facility service, per diem Skills training and development, per 15 minutes Comprehensive community support services, per 15 minutes Comprehensive community support services, per diem Psychosocial rehabilitation services, per 15 minutes Psychosocial rehabilitation services, per diem Therapeutic behavioral services, per 15 minutes 12
HCPCS H2020 M0064 S0201 S9480 S9484 S9485 Description Therapeutic behavioral services, per diem Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders Partial hospitalization services, less than 24 hours, per diem Intensive outpatient psychiatric services, per diem Crisis intervention mental health services, per hour Crisis intervention mental health services, per diem Description RVNU 0510 Clinic-General 0513 Clinic-Psychiatric Clinic 0515 Clinic-Pediatric Clinic 0516 Clinic-Urgent Care Clinic 0517 Clinic-Family Practice Clinic 0519 Clinic-Other Clinic 0520 Freestanding Clinic-General 0521 Freestanding Clinic-Clinic visit by member to RHC/FQHC 0522 Freestanding Clinic-Home visit by RHC/FQHC Practitioner 0523 Freestanding Clinic-Family Practice Clinic 0526 Freestanding Clinic-Urgent Care Clinic 0527 Freestanding Clinic-Visiting Nurse Service (s) to a Member's Home When in a Home Health Shortage Area 0528 Freestanding Clinic-Visit by RHC/FQHC Practitioner to Other Non-RHC/FQHC Site (e.g. Scene of Accident) 0529 Freestanding Clinic-Other Freestanding Clinic 0770 Preventive Care Services-General 0771 Preventive Care Services-Vaccine Administration 0779 Preventive Care Services-Other Preventive Care Services 0900 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-General 0902 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Milieu Therapy 0903 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Play Therapy 0904 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Activity Therapy 0905 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Intensive Outpatient Services-Psychiatric 0907 Behavioral Health Treatments/Services (also see 091X, an extension of 090X)-Community Behavioral Health Program (Day Treatment) 0911 Behavioral Health Treatments/Services-Extension of 090X-Rehabilitation 0912 Behavioral Health Treatments/Services-Extension of 090X-Partial Hospitalization-Less Intensive ADHD 13
RVNU Description 0913 Behavioral Health Treatments/Services-Extension of 090X-Partial Hospitalization-Intensive 0914 Behavioral Health Treatments/Services-Extension of 090X-Individual Therapy 0915 Behavioral Health Treatments/Services-Extension of 090X-Group Therapy 0916 Behavioral Health Treatments/Services-Extension of 090X-Family Therapy 0917 Behavioral Health Treatments/Services-Extension of 090X-Bio Feedback 0919 Behavioral Health Treatments/Services-Extension of 090X-Other Behavioral Health Treatments/ Services 0982 Professional Fees (Extension of 096X and 097X)-Outpatient Services 0983 Professional Fees (Extension of 096X and 097X)-Clinic Description POS 03 Education Facility 05 Indian Health Service Free-Standing Facility 07 Tribal 638 Free-Standing Facility 09 Unassigned 11 Office 12 Home 13 Assisted Living Facility 14 Group Home 15 Mobile Unit 20 Urgent Care Facility 22 Outpatient Hospital 33 Custodial Care Facility 49 Independent Clinic 50 Federally Qualified Health Center 52 Psychiatric Facility Partial Hospitalization 53 Community Mental Health Center 71 State or Local Public Health Clinic 72 Rural Health Clinic ADHD 14
Alcohol and Other Drug Dependence Treatment Measure Source (Case) ID: 202700 Measure: Patients between the ages of 13 and 17 who initiated AOD treatment. (Rule ID: 9000002) Measure: Patient(s) between the ages of 13 and 17 who engaged in AOD treatment. (Rule ID: 9000008) Measure: Patient(s) age 18 years or older who initiated AOD treatment. (Rule ID: 9000013) Measure: Patient(s) age 18 years or older who engaged in AOD treatment. (Rule ID: 9000014) Description ICD-9 291 Alcohol-induced mental disorders 291.0 Alcohol withdrawal delirium 291.1 Alcohol-induced persisting amnestic disorder 291.2 Alcohol-induced persisting dementia 291.3 Alcohol-induced psychot disorder w/hallucination 291.4 Idiosyncratic alcohol intoxication 291.5 Alcohol-induced psychotic disorder w/delusions 291.8 Other specified alcohol-induced mental disorders 291.81 Alcohol withdrawal 291.82 Alcohol induced sleep disorders 291.89 Other specified alcohol-induced mental disorders 291.9 Unspecified alcohol-induced mental disorders 292 Drug-induced mental disorders 292.0 Drug withdrawal 292.1 Paranoid & or hallucinatory states induced drugs 292.11 Drug-induced psychotic disorder with delusions 292.12 Drug-induced psychotic disorder w/hallucinations 292.2 Pathological drug intoxication 292.8 Other specified drug-induced mental disorders 292.81 Drug-induced delirium 292.82 Drug-induced persisting dementia 292.83 Drug-induced persisting amnestic disorder 292.84 Drug-induced mood disorder 292.85 Drug induced sleep disorders 292.89 Other specified drug-induced mental disorder 292.9 Unspecified drug-induced mental disorder 303.00 Acute alcoholic intoxication unspec drunkenness 303.01 Acute alcoholic intoxication cont drunkenness Alcohol and Other Drug Dependence Treatment 15
Description ICD-9 303.02 Acut alcoholic intoxication episodic drunkenness 303.90 Oth & unspec alcohol dependence unspec drunkenness 303.91 Other & unspec alcohol dependence cont drunkenness 303.92 Oth & unspec alcohol depend episodic drunkenness 304.00 Opioid type dependence unspecified abuse 304.01 Opioid type dependence continuous abuse 304.02 Opioid type dependence episodic abuse 304.10 Sedative hypnotic/anxiolytic dependence unspec 304.11 Sedative hypnotic/anxiolytic dependence cont 304.12 Sedative hypnotic/anxiolytic dependence episodic 304.20 Cocaine dependence unspecified abuse 304.21 Cocaine dependence continuous abuse 304.22 Cocaine dependence, episodic abuse 304.30 Cannabis dependence unspecified abuse 304.31 Cannabis dependence continuous abuse 304.32 Cannabis dependence, episodic abuse 304.40 Amphet & oth psychostimulant dependence unspec abs 304.41 Amphet & oth psychostimulant dependence cont abs 304.42 Amphet & oth psychostimulant depend episodic abs 304.50 Hallucinogen dependence unspecified abuse 304.51 Hallucinogen dependence continuous abuse 304.52 Hallucinogen dependence episodic abuse 304.60 Other spec drug dependence unspec abuse 304.61 Other specified drug dependence continuous abuse 304.62 Other specified drug dependence episodic abuse 304.70 Comb opioid rx w/any oth rx depend unspec abs 304.71 Comb opioid drug w/any oth drug depend cont abs 304.72 Comb opioid rx w/any oth rx depend episodic abs 304.80 Comb drug depend excld opioid drug unspec abs 304.81 Comb drug depend excluding opioid drug cont abs 304.82 Comb drug depend excld opioid drug episodic abs 304.90 Unspecified drug dependence unspecified abuse 304.91 Unspecified drug dependence continuous abuse 304.92 Unspecified drug dependence episodic abuse 305.00 Nondependent alcohol abuse unspec drunkenness 305.01 Nondependent alcohol abuse cont drunkenness 305.02 Nondependent alcohol abuse episodic drunkenness Alcohol and Other Drug Dependence Treatment 16
Description ICD-9 305.20 Nondependent cannabis abuse unspecified 305.21 Nondependent cannabis abuse continuous 305.22 Nondependent cannabis abuse episodic 305.30 Nondependent hallucinogen abuse unspecified 305.31 Nondependent hallucinogen abuse continuous 305.32 Nondependent hallucinogen abuse episodic 305.40 Nondepend sedative hypnot/anxiolytic abs unspec 305.41 Nondepend sedative hypnotic/anxiolytic abs cont 305.42 Nondepend sedat hypnot/anxiolytic abs episodic 305.50 Nondependent opioid abuse unspecified 305.51 Nondependent opioid abuse continuous 305.52 Nondependent opioid abuse, episodic 305.60 Nondependent cocaine abuse unspecified 305.61 Nondependent cocaine abuse continuous 305.62 Nondependent cocaine abuse episodic 305.70 Nondepend amphet/rel act sympathomimet abs uns 305.71 Nondepend amphet/rel act sympathomimet abs cont 305.72 Amphetamine/related drug abuse-episodic 305.80 Nondependent antidepressant type abuse unspec 305.81 Nondependent antidepressant type abuse cont 305.82 Nondependent antidepressant type abuse episodic 305.90 Oth mixed/unspec nondependent drug abuse unspec 305.91 Other mixed/unspec nondependent drug abuse cont 305.92 Oth mixed/unspec nondependent drug abs episodic 535.3 Alcoholic gastritis 535.30 Alcoholic gastritis without mention hemorrhage 535.31 Alcoholic gastritis with hemorrhage 571.1 Acute alcoholic hepatitis Description 90801 Psychiatric diagnostic interview examination 90802 Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication 90804 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; 90805 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services Alcohol and Other Drug Dependence Treatment 17
Description 90806 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; 90807 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services 90808 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; 90809 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services 90810 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; 90811 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services 90812 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; 90813 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services 90814 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; 90815 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services 90816 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; 90817 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services 90818 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; 90819 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services 90821 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; 90822 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services Alcohol and Other Drug Dependence Treatment 18
Description 90823 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; 90824 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services 90826 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; 90827 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services 90828 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; 90829 Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services 90845 Psychoanalysis 90847 Family psychotherapy (conjoint psychotherapy) (with patient present) 90849 Multiple-family group psychotherapy 90853 Group psychotherapy (other than of a multiple-family group) 90857 Interactive group psychotherapy 90862 Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy 90875 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately 20-30 minutes 90876 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-toface with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); approximately 45-50 minutes 98960 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; individual patient 98961 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; 2-4 patients 98962 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/ family) each 30 minutes; 5-8 patients 99078 Physician educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions) Alcohol and Other Drug Dependence Treatment 19
Description 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. 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 presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. 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 presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; Medical decision making 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 presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; 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. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; 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 presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. 99211 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services. 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. 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 presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and 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 presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; 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. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. Alcohol and Other Drug Dependence Treatment 20