Speech Therapy (Provider Type 457 or 458) 92521 Evaluation of Speech Fluency (eg., stuttering, cluttering) 1 evaluation $110.28 No 1 92522 Evaluation of Speech Sound Production (eg., articulation, phonological process, 1 evaluation $89.75 No 1 apraxia, dysarthria) 92523 Evaluation of Speech Sound Production; with Evaluation of Language Comprehension and Expression (eg., receptive and expressive language) 1 evaluation $186.14 No 1 92524 Behavioral and Qualitative Analysis of Voice and Resonance 1 evaluation $93.66 No 1 92507 Treatment of Speech, Language, Voice, Communication, and/or Auditory 1 hour $60.14 Yes 1 92508 Processing Disorder, Individual Treatment of Speech, Language, Voice, Communication, and/or Auditory 1 hour $45.12 Yes 2, U2 92508 Processing Disorder, Group of 2 Treatment of Speech, Language, Voice, Communication, and/or Auditory 1 hour $35.08 Yes 2, U3 92508 Processing Disorder, Group of 3 Treatment of Speech, Language, Voice, Communication, and/or Auditory 1 hour $30.07 Yes 2, U4 92507, 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
Audiology (Provider Type 331) 92552 Pure Tone Audiometry (threshold), Air Only 92553 Pure Tone Audiometry (threshold), Air & Bone 92555 Speech Audiometry Threshold 92557 Comprehensive Audiometry Threshold Eval and Speech Recognition 92567 Tympanometry (Impedance Testing) 92587 Distortion Evoked Otoacoustic Emission, Limited Evaluation (3-6 frequencies) or Transient Evoked Otoacoustic Emissions, with Interpretation and Report 92588 Distortion Evoked Otoacoustic Emission, Comprehensive Evaluation (min 12 frequencies) with Interpretation and Report 92630 Auditory Rehabilitation; Pre-lingual hearing loss, U1 92630 Auditory Rehabilitation; Pre-lingual hearing loss, Group of 2, U2 92630 Auditory Rehabilitation; Pre-lingual hearing loss, Group of 3, U3 92630 Auditory Rehabilitation; Pre-lingual hearing loss, Group of 4, U4 92633 Auditory Rehabilitation; Post-lingual hearing loss, U1 92633 Auditory Rehabilitation; Post-lingual hearing loss, Group of 2, U2 92633 Auditory Rehabilitation; Post-lingual hearing loss, Group of 3, U3 92633 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
Occupational Therapy (Provider Type 451 or 452) 97003 Occupational Therapy Evaluation 97004 Occupational Therapy Re-Evaluation 97110 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 4 97110 Therapeutic Procedure, One or More Areas, Each 15 minutes,, GO, U1 Home Visit Physical Therapy (Provider Type 453 or 454) 97001 Physical Therapy Evaluation 97002 97110, GP, GP, U2 Group of 2, GP, U3 Group of 3, GP, U4 Group of 4 97110, 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
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 #) 97802 97803 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
Behavioral Health (for most codes, rates vary by provider type) 90832 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 1 439-Lic 431-1 visit $24.25 No 1 90834 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 1 439-Lic 431-1 visit $48.50 No 1 5
90837 90846 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 1 439-Lic 431-1 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 3 439-Lic 431-1 hour $67.90 Yes 3 6
90847 90849 Family Psychotherapy, with the patient present 301-Physician MD 1 hour $104.76 Yes 2 1 hour $77.60 Yes 2 439-Lic 431-1 hour $82.45 Yes 2 Multiple Family Group Psychotherapy 301-Physician MD 1 hour $30.50 Yes 2 1 hour $24.25 Yes 2 439-Lic 431-1 hour $24.25 Yes 2 7
90853, U2 90853, U3 Group Psychotherapy (other than multiple family), 301-Physician MD 1 hour $29.10 Yes 2 Group of 2 1 hour $34.92 Yes 2 439-Lic 431-1 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 2 439-Lic 431-1 hour $28.29 Yes 2 8
90853, U4 90791 90792 Group Psychotherapy (other than multiple family), 301-Physician MD 1 hour $29.10 Yes 2 Group of 4 1 hour $23.28 Yes 2 439-Lic 431-1 hour $24.29 Yes 2 Psychiatric Diagnostic Evaluation 1 Evaluation $48.50 No 1 $87.30 No 1 443-CNS $97.97 No 1 431- $107.67 No 1 Psychiatric Diagnostic Evaluation with Medical 301-Physician 1 Evaluation $136.77 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
Medicaid School-Based Services Transportation Rates Per One-way Trip August 2015 District/REC Provider # Rate Alamogordo Public Schools 76131 15.11 Albuquerque Public Schools E7599 14.62 Artesia Public Schools J0994 22.95 Aztec Municipal Schools 73126837 10.90 Belen Consolidated Schools P4423 13.35 Bernalillo Public Schools H8226 12.82 Bloomfield Schools 64434826 17.04 Carlsbad Consolidated Schools K3057 14.79 Central Consolidated Schools J7695 12.70 Central Regional Education Cooperative #5 99472279 18.82 (Estancia, Jemez Valley, Magdalena, Mountainair, Quemado, Vaughn) Chama Valley Independent School District L9498 22.49 Clovis Municipal Schools L1859 17.12 Cobre Consolidated Schools L1871 17.61 Cuba Independent Schools 47458 17.52 Dulce Independent Schools 21700281 17.53 Espanola Public Schools 34659714 14.90 Farmington Municipal Schools 72381 14.31 Gadsden Independent Schools J3682 17.51 Gallup/McKinley Public Schools L5895 14.94 Grants/Cibola Public Schools J7683 11.81 High Plains Regional Educational Cooperative #3 47125 23.80 (Cimarron, Clayton, Des Moines, Maxwell, Mosquero, Raton, Roy, Springer) Las Cruces Public Schools E7687 13.91 Las Vegas City Schools R5896 12.67 Los Lunas Public Schools E7706 12.40 Lovington Schools P6705 19.93 Mission Achievement & Success Charter 50182561 14.84 Mora Independent Schools 47265 16.56 Moriarty-Edgewood School District J6984 13.18 NW Regional Education Cooperative #2 09802827 16.54 (Chama, Cuba, Dulce, Jemez Mountain, Mesa Vista, Penasco, Questa) Pecos Independent Schools P2767 20.05 Pecos Valley Regional Cooperative #8 J0907 18.78 (Dexter, Hagerman, Lake Arthur, Loving) Penasco Independent Schools P6722 15.74 Pojoaque Valley Schools K3063 18.60 Questa Public Schools T6536 20.05 Regional Educational Center #6 (Dora, Elida, Floyd, Ft. Sumner, Grady, House, Logan, Melrose, Portales, San Jon, Texico) E7641 16.47
Medicaid School-Based Services Transportation Rates Per One-way Trip August 2015 District/REC Provider # Rate Regional Educational Cooperative #7 J2193 19.15 (Eunice, Hobbs, Jal, Tatum) Regional Cooperative Center #9 E7676 17.41 (Capitan, Carrizozo, Cloudcroft, Corona, Hondo, Ruidoso, Tularosa) Rio Rancho Public Schools T6823 15.20 Roswell Independent Schools Z7697 13.97 Santa Fe Public Schools E7606 15.43 Santa Rosa Consolidated Schools L5223 17.13 Silver Consolidated Schools L1865 16.01 Socorro Consolidated Schools L5902 18.16 SW Regional Educational Cooperative #10 J6978 16.78 (Animas, Deming, Hatch, Lordsburg, Reserve, T or C) Taos Municipal Schools Q1853 19.33 Tucumcari Public Schools E7582 34.29 West Las Vegas Schools H8215 12.80 Zuni Public School District J3004 18.99