Attachment K5 DWMHA Coding Manual

Transcription

Page 1 of 182
2013
Developed by Detroit-Wayne
Mental Health Authority
Coding Workgroup Team
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Authority Coding Workgroup Team Members
Mary Allix, Team Leader, Authority Quality Management Unit
David Pankotai, Executive Director, ConsumerLink
Bridgette Melton, Gateway Community Mental Health
David Taylor, Gateway Community Mental Health
Larry Cameron, Wayne County Jail
Darlene Owens, Southeast Michigan Community Alliance
Lynn Somenauer, Southeast Michigan Community Alliance
Andrea Goodwin, Community Living Services
Gail Parker, Consultant, Authority Quality Management Unit
Mark Ragg, Eastern Michigan University
Katherine Baessler, Graduate Assistant, Eastern Michigan University (formerly)
Robert Compton, Authority Clinical Services Unit
Donna Coulter, Wayne State Project Care
Katie Linehan, Wayne State Project Care
Gary Herman, Director of Information Technology, Authority IT Unit
Joyce Henderson, Consultant, Authority Quality Management Unit
Michael Anthony, Authority Quality Management Unit
Amy Neumeyer, The Guidance Center
Pam Cinpak, The Guidance Center
Jennifer Miller, Authority Evidence Based Practices/Utilization Management Unit
Denise Norman, Behavioral Health Professional, Inc.
Michelle Milligan, Deputy Court Administrator, 3rd Circuit Court
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Detroit-Wayne Mental Health Authority
Provider Coding Manual
Introduction
Detroit-Wayne Mental Health Authority (D-WMHA) is providing this manual as a guide for coding
services and supports. Our goal is to develop, administer, and operate a care delivery system that ensures
all services and supports are captured, coded and reported appropriately.
This manual is for use for those services covered under the Medicaid State Plan, Habilitation Supports
Waiver, Additional Mental Health (b)(3) Services, Adult Benefit Waiver, MiChild and General Fund.
The manual contains information relative to specific codes according to the Prepaid Inpatient Health
Plans (PIHP)/Community Health Services Programs (CMHSP) Encounter Reporting HCPCS and
Revenue Code list. The latest version, dated September 23, 2013, is effective April 2013. This list is
included with this manual as Attachment A.
According to the Medicaid Provider Manual, certain programs and sites require approval prior to service
delivery by the Michigan Department of Community Health in order to use Medicaid funds. These
programs are: Assertive Community Treatment, Clubhouse/Psychosocial Rehabilitation Programs,
Crisis Residential Programs, Day Program Sites, Drop-in Programs, Crisis Observation Care, Homebased Services, Intensive Crisis Stabilization, and Wraparound. Providers cannot report these services
as a covered Medicaid service without prior approval.
This Coding Manual incorporates into one document information from several different sources, in an
effort to provide a convenient guide for users. However, it is not possible to incorporate into this one
Manual all relevant laws, regulations, policies and procedures. For one example, section 17 of the
Mental Health Chapter of the Medicaid Provider Manual addresses “additional mental health services
(B3s).” Those include, for example, assistive technology, community living supports, enhanced
pharmacy, environmental modifications, etc. While each service is separately addressed in the Medicaid
Provider Manual, there are several common foundational criteria required for all such services – these
are listed in section 17.2 and include the beneficiary’s eligibility, proper documentation in the person
centered plan, medical necessity, etc.
This coding manual incorporates by reference all requirements in the Medicaid Provider Manual, and in
all other relevant state and federal laws, regulations, policies and procedures. All such laws, regulations,
policies and procedures must be met for any billings to be submitted, approved or paid. All providers
and payors in the Detroit Wayne Mental Health Authority (DWMHA) network, including Managers of
Comprehensive Provider Networks (MCPNs), Direct Contractors, Coordinating Agencies and providers,
must ensure that all applicable laws, regulations, policies and procedures are met before any claim is
submitted, approved or paid, regardless of whether the requirement expressly appears in this Manual.
DWMHA staff will endeavor to update this coding manual as changes are made at the federal, state or
local levels. However, as stated above, it is the responsibility of all providers and payors to comply with
all applicable state and federal laws, regulations, policies and procedures.
If you have any questions or require further information, please contact Detroit-Wayne Mental Health
Authority.
http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf
http://www.michigan.gov/mdch/0,4612,7-132-2941_38765---,00.html
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Table of Contents
Activity Therapy…………………………………………………………………………………………6
Assertive Community Treatment (ACT) ................................................................................................ 9
Assessments - Health Assessment .......................................................................................................... 11
Assessments – Other Assessments ......................................................................................................... 13
Assessments – Psychiatric Evaluation................................................................................................... 15
Assessments - Psychological Testing ..................................................................................................... 17
Assessments – Other Assessments, Tests .............................................................................................. 19
Assessments – Psychosocial/Intake........................................................................................................ 21
Assessments - Brief Screening................................................................................................................ 23
Assessments - Inpatient Screening ........................................................................................................ 25
Behavior Treatment Plan Review.......................................................................................................... 26
Chore Services ......................................................................................................................................... 28
Clubhouse Psychosocial Rehabilitation Programs .............................................................................. 29
Community Psychiatric Inpatient Hospital .......................................................................................... 31
Community Living Supports - Licensed Settings ................................................................................ 33
Community Living Supports - Unlicensed Settings ............................................................................. 36
Crisis Intervention .................................................................................................................................. 39
Crisis Residential Services ..................................................................................................................... 41
Electroconvulsive Therapy – ECT ........................................................................................................ 42
Enhanced Medical Equipment & Supplies (Assistive Technology) ................................................... 44
Enhanced Pharmacy ............................................................................................................................... 47
Environmental Modifications/Accessibility Adaptation-Community Transition (SED Waiver) ... 49
Family Training ...................................................................................................................................... 51
Fiscal Intermediary Services .................................................................................................................. 54
Goods and Services ................................................................................................................................. 56
Health Services ........................................................................................................................................ 57
Home Based Services .............................................................................................................................. 59
Housing Assistance.................................................................................................................................. 61
Intensive Crisis Stabilization Services .................................................................................................. 63
Medication Administration .................................................................................................................... 65
Medication Review .................................................................................................................................. 67
Occupational Therapy ............................................................................................................................ 71
Out of Home Non-Vocational Habilitation ........................................................................................... 73
Out of Home Prevocational Habilitation .............................................................................................. 75
Partial Hospitalization (Outpatient) ..................................................................................................... 77
Peer Delivered or Operated Support Services ..................................................................................... 78
Peer-Delivered or Operated Support Services (Certified Peer Support Specialist) ......................... 80
Peer-Delivered or Operated Support Services (DD Peer Mentor) ..................................................... 82
Recovery Supports (with/without Peer Recovery Coaches)................................................................ 84
Personal Care – Licensed Setting .......................................................................................................... 86
Personal Emergency Response System (PERS) ................................................................................... 87
Physical Therapy..................................................................................................................................... 88
Physician Services Related to Mental Health ....................................................................................... 90
Prevention Services - (Direct Model) .................................................................................................... 92
Private Duty Nursing .............................................................................................................................. 94
Respite Care ............................................................................................................................................ 98
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Respite Care (Per Diem)....................................................................................................................... 100
Skill Building Assistance ...................................................................................................................... 102
Speech & Language Therapy ............................................................................................................... 104
State Inpatient Psychiatric Hospital.................................................................................................... 105
Supported (Integrated) Employment Services ................................................................................... 107
Supports Coordination ......................................................................................................................... 109
Targeted Case Management ................................................................................................................ 112
Therapy - Family................................................................................................................................... 114
Therapy - Group ................................................................................................................................... 115
Therapy - Individual ............................................................................................................................. 116
Transportation ...................................................................................................................................... 118
Treatment Planning .............................................................................................................................. 120
Wraparound Services ........................................................................................................................... 122
Autism Benefit Services Section……………………………………………………………………...123
Physician Services ................................................................................................................................. 125
Assessments – Psychiatric Evaluation................................................................................................. 130
Assessments – Psychosocial/Intake...................................................................................................... 132
Assessments - Psychological Testing ................................................................................................... 134
Home Care Training – Applied Behavior Analysis (ABA) ............................................................... 137
Therapeutic Behavioral Services ......................................................................................................... 141
Substance Use Disorders Section ......................................................................................................... 144
Acupuncture .......................................................................................................................................... 145
Brief Intervention.................................................................................................................................. 146
Buprenorphine/Suboxone..................................................................................................................... 147
Case Management (Substance Abuse) ................................................................................................ 148
Day Treatment ...................................................................................................................................... 150
Drug Screens.......................................................................................................................................... 151
Early Intervention Services .................................................................................................................. 153
Family / Group Health (Didactic Group) ........................................................................................... 154
Group Therapy...................................................................................................................................... 155
In Home Therapy .................................................................................................................................. 156
Individual Therapy ............................................................................................................................... 157
Initial / Individual Assessments ........................................................................................................... 158
Intensive Outpatient ............................................................................................................................. 159
Intensive Outpatient with Domicile..................................................................................................... 160
Intensive Wraparound Services........................................................................................................... 162
Less Intensive Residential .................................................................................................................... 164
Medication Assisted Treatment ........................................................................................................... 165
Medication Management ...................................................................................................................... 166
Physician Services Related to Substance Abuse – Methadone Medication Monitoring ................ 167
Prevention Services ............................................................................................................................... 170
Psychiatric Evaluation .......................................................................................................................... 172
Recovery Homes .................................................................................................................................... 173
Recovery Supports (with/without Peer Recovery Coaches).............................................................. 174
Residential (short & long term) ........................................................................................................... 176
Room & Board ...................................................................................................................................... 178
Screening................................................................................................................................................ 179
Special Family Therapy........................................................................................................................ 180
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Sub-Acute Detoxification...................................................................................................................... 181
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Activity Therapy
Procedure Code/Description:
G0176 – Activity therapy (music, recreation or art) per session, 45 minutes or more – for Children’s
Waiver and Children’s SED Waiver ONLY
Program Element Definition:
A therapeutic activity is an alternative service that can be used in lieu of, or in combination with,
traditional professional services. The focus of therapeutic activities is to interact with the child to
accomplish the goals identified in the IPOS. The IPOS ensures the child's health, safety and skill
development and maintains the child in the community. Services must be directly related to an
identified goal in the IPOS. Providers are identified through the wraparound planning process and
participate in the development of a IPOS based on strengths, needs, and preferences of the child and
family. Therapeutic activities may include the following: child and family training, coaching and
supervision, monitoring of progress related to goals and objectives, and recommending changes to the
IPOS. Services provided under Therapeutic Activities include music therapy, recreation therapy, and art
therapy.
Clarifying Points:
The training, coaching, supervision and monitoring activities provided under this service are specific to
music, art, and recreation therapy and must be provided by providers with the qualifications listed
below.
Level of Care Table
Description
Code Type (HCPCS, HCPCS
CPT, State, etc.)
Population
Children’s Waiver and SED Waiver only
Coverage
State Plan
Unit Description
45 minute increment based on the recipients’ perspective = 1 unit
Unit Minimum
1 unit per session
Unit Maximum
4 sessions per month per type of specialty services
Other Rules
Training, coaching, supervision and monitoring activities are specific to music, art
and recreation therapy.
837 Type
Professional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
Replaces the Following
Codes
None
Member Age Check
Child/Adolescent
Provider Service
Array/Credential Check
Recreation Therapy must be provided by a Certified Therapeutic Recreation
Specialist credentialed by the National Council for Therapeutic Recreation
Certification (NCTRC).
Music Therapy Must be provided by a Music Therapist - Board Certified (MT-BC)
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or by a music therapist listed on the National Music Therapy Registry (NMTR).
Art Therapy Must be provided by a Registered Art Therapist - Board Certified
(ATR-BC).
Can be used in
conjunction with other
codes?
No
Authorization Required?
No
Place of Service/Type of No restrictions
Facility
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Assertive Community Treatment (ACT)
H0039 – ACT - Face to Face
H0039HE - (HE Modifier) Services included or delivered by a Certified Peer Support Specialist
H0039AM – (AM Modifier) Family Psycho-education (FPE) as part of the ACT activities
Assertive Community Treatment (ACT) is a set of intensive clinical, medical and psychosocial services
provided by a mobile multi-disciplinary treatment team. The team also provides basic services and
supports essential to maintaining the beneficiary's ability to function in community settings, including
assistance with accessing basic needs through available community resources, such as food, housing,
and medical care and supports to allow beneficiaries to function in social, educational, and vocational
settings.
ACT services are based on the principles of recovery and person-centered practice and are individually
tailored to meet the needs of the beneficiary. Services are provided in the beneficiary's residence or other
community locations by all members of the ACT team.
All team staff must have a basic knowledge of ACT programs and principles acquired through ACT
specific training.
Clarifying Points:
•
•
•
ACT services is only unbundled for psychiatric services when consumer has Medicare. See
detailed categories.
When peers are part of an ACT Team and provide an “ACT” service they are to report a modifier
of HE in addition to indicate the service was provided by a peer.
Minimum staffing: Physician (MD or DO) to provide psychiatric coverage, registered nurse who
provides direct services within scope of practice, team leader who is a mental health professional
(but not the registered nurse above), and other qualified mental health professionals (QMHPs).
Up to one full-time equivalent (FTE) Certified Peer Support Specialist may be substituted for
one FTE QMHP.
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Assertive Community Treatment (ACT)
Level of Care Table
Description
Code Type (HCPCS, CPT, State, etc.)
HCPCS
Population
MIA identified with the ACT program
Coverage
State Plan
Unit Description
15 minute increment based on the recipients’ perspective = 1 unit
Unit Minimum
1 unit per service line
Unit Maximum
48 units per day
Other Rules
An ACT encounter should not cross dates of service. All services
contained in the encounter should have the identical date of service.
837 Type
Professional
Modifier(s)
HE = Peer delivered
AM = Family Psycho-Education as part of the ACT activities
Start Date
October 1, 2013
End Date
None at this time
Replaces the Following Codes
None
Member Age Check
Adults only
Provider Service Array/Credential
Provider must be an approved ACT team by MDCH.
Check
Can be used in conjunction with other
No
codes?
No
Place of Service/Type of Facility
No restrictions
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Assessments - Health Assessment
Health Assessments for Nursing or Nutrition (T1001, 97802, 97803)
T1001 – Nursing Assessment/Evaluation
T1001QJ – (QJ Modifier - Nursing Assessment/Evaluation of a beneficiary while incarcerated)
97802 – Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with
patient.
97802QJ - (QJ Modifier – Medical nutrition therapy; initial assessment and intervention, individual,
face-to-face with a beneficiary while incarcerated)
97803 – Medical nutrition reassessment and intervention, individual, face-to-face with the patient.
97803QJ - (QJ Modifier – Medical nutrition reassessment and intervention, individual, face-to-face with
a beneficiary while incarcerated)
Health assessment includes activities provided by a registered nurse, physician assistant, nurse
practitioner, or dietitian to determine the beneficiary’s need for medical services and to recommend a
course of treatment within the scope of practice of the nurse or dietician.
Health Services are provided for purposes of improving the beneficiary’s overall health and ability to
care for health-related needs. This includes nursing services (on a per-visit basis, not on-going hourly
care), dietary/nutritional services, maintenance of health and hygiene, teaching self-administration of
medication, care of minor injuries or first aid, recognizing early symptoms of illness and teaching the
beneficiary to seek assistance in case of emergencies. Health assessments are covered under
Assessments Subsection. A registered nurse, nurse practitioner, physician’s assistant, or dietician must
provide these services, according to their scope of practice. Health services must be carefully
coordinated with the beneficiary’s health care plan so that PIHP/IPN does not provide services that are
the responsibility of the MHP.
Clarifying Points:
•
Registered nurse, licensed physician’s assistant, nurse practitioner, licensed dietician or licensed
nutritionist (operating within scope of practice).
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Assessments - Health Assessment
Level of Care Table
Description
CPT, HCPCS
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Unit Minimum
Unit Maximum
T1001/1 unit = 1 assessment a day
97802/1 unit = 15 minutes
97803/1 unit = 15 minutes
T1001 – 1 unit per day
97802 – 1 unit per day
97803 – 1 unit per day
DT – Duplicate threshold
T1001 = 1 unit per day
97802 = 40 units per day
97803 = 40 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
QJ = Beneficiary received a service while incarcerated.
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Check
codes?
Registered nurse, licensed physician’s assistant, nurse practitioner,
licensed dietician or licensed nutritionist (operating within scope of
practice)
No
No restrictions, however place of service code must be reported with
encounters.
No
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Assessments – Other Assessments
Physician Consultations (99241 - 99255)
Office Consultation
99241 – Office consultation for new or established patient – requires 3 key components: problem
focused history, problem focused examination, and straightforward medical decision making; typically
15 minutes
99242 – Office consultation for new or established patient – requires 3 key components: expanded
problem focused history, expanded problem focused examination, and straightforward medical decision
making; typically 30 minutes
99243 – Office consultation for new or established patient – requires 3 key components: detailed history,
detailed examination, and medical decision making of low complexity; typically 40 minutes
99244 – Office consultation for new or established patient – requires 3 key components: comprehensive
history, comprehensive examination, and medical decision making of moderate complexity: typically 60
minutes
99245 – Office consultation for new or established patient – requires 3 key components: comprehensive
history, comprehensive examination, and medical decision making of high complexity; typically 80
minutes
Inpatient Physical Health Consultation (New or Established patient)
99252 – Initial hospital consultation for physical health and male and is exhibiting signs of a potential
substance use disorder
99254 – Initial hospital consultation for physical health and female with multiple substance use disorder
history and prior treatment for a personality disorder; or female without previous psychiatric history but
is now having confusion and hallucinations
99255 – Initial hospital consultation for adolescent with attempt to elope from hospital
Generally accepted professional assessments or tests, other than psychological tests, that are conducted
by a mental health professional within their scope of practice for the purpose of determining eligibility
for specialty services and supports, and the treatment needs of the beneficiary. Professional services are
those face to face services rendered by physicians and other qualified health care professionals who may
report evaluation and management services reported by specific CPT codes.
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Assessments – Other Assessments
Level of Care Table
Description
CPT
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Refer to Code descriptions above
Unit Minimum
Unit = Encounter
Unit Maximum
Refer to Code Descriptions above for Significance of Time as a
Factor in the selection of an Evaluation and Management Code
Other Rules
Key Component Selection – meet 3 of 3
837 Type
Professional
Modifier(s)
Not Applicable
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
State of Michigan Licensed Psychiatrist (MD/DO)
Check
Can be used in conjunction with other No
codes?
No
encounters. Office or in an outpatient or other ambulatory facility,
including hospital observation services, home services, domiciliary,
rest home, or emergency department.
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Assessments – Psychiatric Evaluation
Procedure Code:
Psychiatric Diagnostic Evaluation (90791, 90792)
Psychotherapy with evaluation and management (90833, 90836, 90838)
90791 - Psychiatric diagnostic evaluations (no medical services)
90791QJ - (QJ Modifier – Psychiatric diagnostic evaluations (no medical services) when a beneficiary
received services while incarcerated)
90791GT - (GT Modifier - Telemedicine was provided via video-conferencing face to face with the
beneficiary)
90791U5 - (U5 Modifier – Autism Benefit – children ages 18 months to 5 years only)
90792 - Psychiatric diagnostic evaluations (with medical services)
90792QJ - (QJ Modifier – Psychiatric diagnostic evaluations (with medical services) when a beneficiary
received services while incarcerated)
90792GT - (GT Modifier - Telemedicine was provided via video-conferencing face to face with the
beneficiary)
90833, 90836, 90838 – Psychotherapy with evaluation and management
90833 – Psychotherapy with evaluation and management (30 minutes)
+90785 Interactive – add on codes only for complexity
Add-on-Codes: Procedures commonly carried out in the addition to the primary procedure performed.
Designated by the + symbol. Applies only to procedures or services performed by the same physician.
Add on codes are always performed in addition to the primary service or procedure and must never be
reported as a stand-alone code.
A comprehensive evaluation, performed face-to-face by a fully licensed psychiatrist that investigates a
beneficiary’s clinical status, including the presenting problem; the history of the present illness; previous
psychiatric, physical, and medication history; relevant personal and family history; personal strengths
and assets; and a mental status examination.
This examination concludes with a written summary based on a recovery model of positive findings, a
biopsychosocial formulation and diagnostic statement, an estimate of risk factors, initial treatment
recommendations, estimate of length of stay when indicated, and criteria for discharge.
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Level of Care Table
Description
CPT
Population
MIA, DDA, DDC, SED
Coverage
State Plan
Unit Description
Encounter
Unit Minimum
1 Encounter per day
Unit Maximum
90791 = 2 Encounters per day
90792 = 2 Encounters per day – (Moved to Medication Review
Section)
Other Rules
None
837 Type
Professional
Modifier(s)
QJ = Beneficiary received a service while incarcerated;
GT = Telemedicine was provided via video-conferencing face to
face with the beneficiary with 90791, 90792
U5 = Beneficiary is receiving Autism Spectrum Disorder Waiver
Benefits
Start Date
October 1, 2013
End Date
None at this time
90801/90802
Member Age Check
None
Check
Can be used in conjunction with other See other rules above for interactive complexity
codes?
No
encounters.
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Assessments - Psychological Testing
Psychological Testing (96101, 96102, 96103)
Neurobehavioral, Neuropsychological Testing (96116, 96118, 96119, 96120)
Psychological Testing
96101 - Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual
abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the
psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test
results and preparing the report.
96101U5 – (U5 Modifier – Autism Benefit) – for cognitive assessment tools only
abilities, personality and psychopathology, e.g., MMPI and WAIS), with qualified health care
professional interpretation and report, administered by technician, per hour of technician time, face-toface.
96102U5 – (U5 Modifier – Autism Benefit) – for psychological testing
abilities, personality and psychopathology, e.g. MMPI), administered by a computer, with qualified
health care professional interpretation and report.
Neurobehavioral, Neuropsychological Testing
96116 - Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g.
acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial
abilities), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and
time interpreting test results and preparing the report.
96118 - Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler
Memory Scales and Wisconsin Card Sorting Test) per hour of the psychologist’s or physician’s time,
both face-to-face time with the patient and time interpreting test results and preparing the report.
96119 - Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler
Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation
and report, administered by technician, per hour of technician time, face-to-face
96120 - Neuropsychological testing (e.g., Wisconsin Card Sorting Test), administered by a computer,
with qualified health care professional interpretation and report.
Includes the evaluation and the treatment as provided by a qualified health care professional and
prescribed by a physician. Standardized psychological tests and measures rendered by full, limitedlicense, or temporary-limited-licensed psychologists. The beneficiary’s clinical record must indicate the
name of the person who administered the test, the results of the test, the actual tests administered and
any recommendations. The protocols for testing must be available for review.
Page 18 of 182
Clarifying Points:
96101U5 – (U5 Modifier – Autism Benefit) – for cognitive assessment tools only. Psychologist who
has one year working with children with ASD.
96102 and 96103 – Mental Health Professional; or licensed bachelor’s social worker or limited-licensed
bachelor’s or master’s social worker acting within their scope of practice under the supervision of a
mental health professional who is a fully licensed master’s social worker.
96101, 96116, 96118, 96119, 96120 - Psychologist
Level of Care Table
Description
CPT
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Unit = 1 hour
Unit Minimum
One unit per hour
Unit Maximum
One unit per hour
Other Rules
None
837 Type
Professional
Modifier(s)
Not Applicable
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Check
96102 and 96103: Mental Health Professional; or licensed bachelor’s
social worker or limited-licensed bachelor’s or master’s social
worker acting within their scope of practice under the supervision of
a mental health professional who is a fully licensed master’s social
worker.
96101, 96116, 96118, 96119, and 96120; Psychologist
96101U5 = Modifier is mandatory for ASD Benefit
No
codes?
No
encounters.
Page 19 of 182
Assessments – Other Assessments, Tests
Other Assessments (96105, 96110, 96111, 90887)
96105 - 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.
96105TS – (TS Modifier for Re-certification of In-Patient Hospitalization)
96110 - Developmental testing; limited (e.g., Developmental screening Test II, Early Language
Milestone Screen), with interpretation and report.
96110TS - (TS Modifier for Re-certification of In-Patient Hospitalization)
96111 - Developmental testing; extended (includes assessment of motor, language, social, adaptive
and/or cognitive functioning by standardized developmental instruments) with interpretation and report
96111TS – (TS Modifier for Re-certification of In-Patient Hospitalization
90887 - Interpretation or explanation of results of psychiatric, other medical examinations and
procedures, or other accumulated data to family or other responsible persons, or advising them how to
assist patient.
90887TS - (TS Modifier for Re-certification of In-Patient Hospitalization)
prescribed by a physician. Standardized psychological tests and measures rendered by full, limitedlicense, or temporary-limited-licensed psychologists. The beneficiary’s clinical record must indicate the
Page 20 of 182
Assessments – Other Assessments, Tests
Level of Care Table
Description
CPT
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Encounter (Refer to CPT code book descriptions – some are per hour
and some per encounter)
Unit Minimum
1 Encounter per day
Unit Maximum
DT = duplicate threshold
96105 = 1 Encounter per day
Other Rules
None
837 Type
Professional
Modifier(s)
Use modifier TS for recertification
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Mental Health Professional; or licensed bachelor’s social worker or
limited-licensed bachelor’s or master’s social worker acting within
the scope of practice under the supervision of a mental health
professional who is a fully licensed master’s social worker.
Check
Assessments of children with SED are done by a child mental health
professional. Assessments of children aged 7-17 with SED must be
provided by a child mental health professional trained in CAFAS.
Assessments of children with DD are done by a QIDP.
codes?
No
encounters.
Page 21 of 182
Assessments – Psychosocial/Intake
H0031 – Intake Assessment or Psychosocial Assessment by a non-physician or for on-site, face-to-face
assessment by Center for Positive Living Supports (CPLS)
H0031ST – (ST Modifier when trauma assessment is performed as part of trauma-focused CPT)
Intake Assessment or Psychosocial Assessment by a non-physician
H0031QJ – (QJ Modifier when beneficiary received a service while incarcerated) Intake Assessment or
Psychosocial Assessment by a non-physician
H0031U5 - (U5 Modifier when beneficiary is receiving Autism Benefit – face/face with child or parent.
This includes interpretation of results to the family)
Assessments by a non-physician that may be used by a variety of disciplines and which provides more
flexibility.
Clarifying Points:
•
•
•
H0031U5 – Autism Benefit: for reporting ADOS and ADI-R only completed by a Qualified
Child Mental Health Professional (CMHP) that have a minimum of a master’s degree in a mental
health related field, have at least one year of experience in the examination and treatment of
children with ASD and are able to diagnose within their scope of practice including:
a. Psychologist
b. LMSW or LLMSW
c. LPC or LLPC
d. Registered Nurses who are also CMHP
H0031U5 – Autism Benefit: for reporting ABLLS-R and VB-MAPP by:
a. Board Certified Behavior Analyst (BCBA)
b. LP, LLP
c. CMHP
Use H0031 without modifier for BCBA completing Functional Behavioral Assessment
Page 22 of 182
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC,
Coverage
State Plan;
Unit Description
Per Encounter
Unit Minimum
1 Encounter per day
Unit Maximum
H0031 = 3 Encounters per day
Other Rules
None
837 Type
Professional
Modifier(s)
ST = when trauma assessment is performed as part of traumafocused CPT;
QJ = Beneficiary received a service while incarcerated
U5 = Beneficiary received ASD Benefit
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Mental Health Professional, QMHP, or QIDP if within their
licensure scope of practice
Check
codes?
No
No restrictions, however place of service code must be reported
with encounters.
Page 23 of 182
Assessments - Brief Screening
H0002 - Brief Screening to non-inpatient mental health programs.
(H0002) **This code is used exclusively under IPN providers for Intake Assessments for new
members.
A brief screening conducted by a clinical person to determine whether or not the consumer meets criteria
to receive services at a provider; or, a Behavioral Health screening by a non-physician to determine
eligibility for admission to a non-inpatient treatment program. This contact has to be face-to-face to be
reported.
Clarifying Points:
•
•
This code is to be used ONCE per individual, per episode of treatment.
Screenings done by non-clinical staff are not reportable to MDCH.
Page 24 of 182
Assessments - Brief Screening
Level of Care Table
Description
HCPCS
Population
DDA, DDC
Coverage
State Plan
Unit Description
Per Encounter
Unit Minimum
1 Encounter per day
Unit Maximum
H0002 = 1 Encounter per day
Other Rules
None
837 Type
Professional
Modifier(s)
Not Applicable
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Check
Mental Health Professional; or licensed bachelor’s social worker
or limited-licensed bachelor’s or master’s social worker under the
supervision of a fully licensed master’s social worker; unit
supervised by registered professional nurse or other mental health
professional possessing at least a master’s degree.
Assessments of children with SED are done by a child mental
health professional; for children aged 7-17 with SED, a child
mental health professional must be trained in CAFAS.
Assessments of children with DD are done by a QIDP.
codes?
No
with encounters.
Page 25 of 182
Assessments - Inpatient Screening
T1023 - Screening for Inpatient Program
T1023 – Pre-screening for Inpatient program
Screening to determine the appropriateness of consideration of an individual for participation in a
specified program, project, or treatment protocol. Screening for an inpatient program.
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Encounter
Unit Minimum
1 Encounter per day
Unit Maximum
1 Encounter per day
Other Rules
None
837 Type
Professional
Modifier(s)
Not Applicable
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Check
Mental Health Professional; or licensed bachelor’s social worker or
limited-licensed bachelor’s or master’s social worker under the
supervision of a fully licensed master’s social worker; unit
supervised by registered professional nurse or other mental health
professional possessing at least a master’s degree.
Assessments of children with SED are done by a child mental health
professional; for children aged 7-17 with SED, a child mental health
professional must be trained in CAFAS.
Assessments with children with DD are done by a QIDP.
codes?
No
encounters.
Page 26 of 182
Behavior Treatment Plan Review
Procedure Code Description:
H2000 – Behavior Treatment Plan Review
H2000TS – (TS Modifier for monitoring activities associated with a behavior treatment plan)
Comprehensive multidisciplinary evaluation
A behavior treatment plan, where needed, is developed through the person-centered planning process
that involves the beneficiary. The person-centered planning process determines whether a
comprehensive assessment should be done in order to rule out any physical or environmental cause for
the behavior.
Any behavior treatment plan that proposes aversive, restrictive, intrusive techniques, or psycho-active
medications for behavior control purposes and where the target behavior is not due to an active
substantiated psychotic process, must be reviewed and approved by a specially constituted body
comprised of at least three individuals, one of whom shall be a fully- or limited-licensed psychologist
and one of whom shall be a licensed physician/psychiatrist. The psychologist or physician must be
present during the review and approval process. At least one of the committee members shall not be the
developer or implementer of the behavior treatment plan.
The approved behavioral plan shall be based on a comprehensive assessment of the behavioral needs of
the beneficiary. Review and approval (or disapproval) of such treatment plans shall be done in light of
current research and prevailing standards of practice as found in current peer-reviewed psychological/
psychiatric literature. Any proposed aversive or restrictive technique not supported in current peerreviewed psychological/psychiatric literature must be reviewed and approved by MDCH prior to
implementing. Acceptable behavioral treatment plans are designed to reduce maladaptive behaviors, to
maximize behavioral self-control, or to restore normalized psychological functioning, reality orientation,
and emotional adjustment, thus enabling the beneficiary to function more appropriately in interpersonal
and social relationships. Such reviews shall be completed prior to the beneficiary’s signing and
implementation of the plan and as expeditiously as possible.
Staff implementing the individual’s behavior treatment plan must be trained in how to implement the
plan. This coverage includes the monitoring of the behavior treatment plan by the committee or a
designee of the committee which shall occur as indicated in the individual plan of service.
Clarifying points:
•
•
Use TS Modifier when a committee member or their designee monitors the activities of the
behavior plan
Minimum staffing – three individuals that include psychologist and physician or psychiatrist. In
order to report, at least two of the three must be present.
Page 27 of 182
Behavior Treatment Plan Review
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Encounter
Unit Minimum
None
Unit Maximum
2 Encounters per day
Other Rules
At least two of the three staff required by the Medicaid Manual must
be present in order to report. Report one encounter per person per
day regardless of the number of staff present. Staff who are present
through video-conferencing may be counted.
837 Type
Professional
Modifier(s)
TS = for monitoring activities associated with a behavior treatment
plan
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
See Provider service Array
Check
codes?
No
No restrictions
Page 28 of 182
Chore Services
Procedure Code:
S5120 – Service code for Habilitation Supports Waiver beneficiary only
Services to maintain the home in a clean, sanitary, and safe environment include:
• Heavy household chores such as washing walls, floors and exterior windows;
• Tacking down loose rugs and tiles;
• Moving heavy snow to provide safe access to, and egress from, the home.
These services should be provided by persons not routinely providing other direct waiver supports and
services and only in cases where neither the beneficiary, nor anyone else in the household, is capable of
performing or financially providing for them. In the case of rental property, the responsibility of the
landlord, pursuant to the rental or lease agreement, must be examined prior to authorization of the
service. This service may not be provided to beneficiaries who live in licensed settings because the
activities are the responsibility of the home’s licensee.
Level of Care Table
Description
HCPCS
Population
DDA, DDC – Habilitation Supports (HAB) Waiver only
Coverage
Habilitation Supports Waiver
Unit Description
Unit = 15 minutes
Unit Minimum
15 Minute Interval (4 per hour)
Unit Maximum
96 Units per day
Other Rules
None
837 Type
Professional
Modifier(s)
Not Applicable
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
No
Yes
Check
codes?
Yes
Home of consumer; non-licensed setting
Page 29 of 182
Clubhouse Psychosocial Rehabilitation Programs
H2030-Mental Health Clubhouse Services
Program Definition:
A clubhouse program is a community-based psychosocial rehabilitation program in which the
beneficiary (also called clubhouse “member”), with staff assistance, is engaged in operating all aspects
of the clubhouse, including food service, clerical, reception, janitorial and other member supports and
services such as employment, housing and education. In addition, members with staff assistance,
participate in the day-to-day decision making and governance of the program and plan community
projects and social activities to engage members in the community. Through the activities of the
ordered day, clubhouse decision-making opportunities and social activities, individual members achieve
or regain the confidence and skills necessary to lead vocationally productive and socially satisfying
lives.
Clarifying Points:
•
•
•
•
One full-time on-site clubhouse manager who has a minimum of a bachelor's degree in a human
services field and two years' experience with adults with serious mental illness, or a master's
degree in a human services field with one year's experience with adults with serious mental
illness and has appropriate licensure.
Social Recreational Time, services, and costs are reportable as long as it is detailed in the
“individual plan of service”.
When reporting units for this service, be aware of not duplicating activities. If case management
or other clinical work is done in the Day Program/Clubhouse setting, then you need to back-out
that reported time and do not out the time/units twice. This is the same time in two or more
different activities, and you cannot report that time twice.
When counting units of case management or other clinical work taking place in the Day program
or Clubhouse setting, the amount of time used for those additional services is backed out,
otherwise one is reporting the same time in different activities, which is not permitted.
Page 30 of 182
Clubhouse Psychosocial Rehabilitation Programs
Level of Care Table
Code Type (HCPCS, CPT, HCPCS
State, etc.)
Description
Population
MIA, DDA
Coverage
State Plan
Unit Description
1 Unit = 15-minute increment based on the Individuals perspective
The number of 15-minute increments that an individual participates in a
clubhouse program in a day. Does not include the time for consuming
meals. Back out any Clubhouse time for any other services provided
simultaneously. Implement a unit only after a 15-minute increment has
passed. No rounding up.
Unit Minimum
1 unit per day
Unit Maximum
48 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
Not Applicable
Start Date
October 1, 2013
End Date
None at this time
Replaces the Following
Codes
None
Member Age Check
Adults only
Provider Service
The State and County must approve a PSR program
Array/Credential Check
Can be used in conjunction No
with other codes?
No
Place of Service/Type of
Facility
Approved Clubhouse sites only
Page 31 of 182
Community Psychiatric Inpatient Hospital
Procedure Code/ Description:
0100 – IMD – Institutions of Mental Disease – All inclusive room and board plus ancillaries
0101 – All Inclusive room and board
0114 – Room & Board – Private
0124 – Room & Board – Semi-Private 2 Beds
0134 – Room & Board – Semi-Private 3-4 Beds
0144 – Room & Board – Private (Deluxe) 31
0154 – Room & Board – Ward
99221-99233-Physician Services provided in inpatient hospital care
Inpatient Consultation
99251 – Inpatient consultation for new or established patient – requires 3 key components: problem
focused history, problem focused examination, and straightforward medical decision making; typically
20 minutes
99252 – Inpatient consultation for new or established patient – requires 3 key components: expanded
problem focused history, expanded problem focused examination, and straightforward medical decision
making: typically 40 minutes
99253 – Inpatient consultation for new or established patient – requires 3 key components: detailed
history, detailed examination, and medical decision making of low complexity: typically 55 minutes
99254 – Inpatient consultation for new or established patient – requires 3 key components:
comprehensive history, comprehensive examination, and medical decision making of moderate
complexity: typically 80 minutes
99255 – Inpatient consultation for new or established patient – requires 3 key components:
comprehensive history, comprehensive examination, and medical decision making of high complexity:
typically 110 minutes
Community hospitals/non-state inpatient services in licensed psychiatric hospitals and licensed
psychiatric units of general hospitals are included in this element.
Clarifying Points:
•
•
•
•
•
•
•
•
Individual is in hospital as of 11:59 P.M.
No authorization for day of discharge
Valid COB (coordination of benefits) and Medicare responsibility, where appropriate
Hospitals are required to ensure Coordination of Benefits
Includes Discharge Medications
Includes Court Hearing Costs and Transportation Costs
Community Psychiatric Hospitalization - Must use provider type 73 followed by the 7-digit
Medicaid Provider ID number.
Institution for Mental Disease Inpatient Psychiatric Services – Must use provider type 68
followed by the 7-digit Medicaid Provider ID number
Page 32 of 182
Community Psychiatric Inpatient Hospital
Level of Care Table
Description
Revenue Codes
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Encounter per Day
Unit Minimum
1 Encounter per day
Unit Maximum
1 Encounter per day
Other Rules
None
837 Type
Institutional
Modifier(s)
Not Applicable
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Check
codes?
Yes, These code(s) can only be billed by a Community
Hospital. See providers service array
Place of Service/Type of Facility Code
1 – Hospital
Yes
Yes
Page 33 of 182
Community Living Supports - Licensed Settings
H2016 – Community Living Supports
H2016HE - (HE Modifier) to be used with any CLS provided by a Certified Peer Support Specialist
H2016HK – (HK Modifier) for Habilitation Supports Waiver beneficiary
H2016TF - (TF Modifier) for the per diem moderate
H2016TG - (TG Modifier) for the per diem intensive
T2036 – Therapeutic Overnight Camp, waiver each session (one night = one session)
T2037 – Therapeutic Day Camp, waiver each session (one day/partial day = one session)
S5140 – Foster Care, adult, per diem
S5145 – Foster Care, children in Child Caring Institution (SED Waiver ONLY)
Community Living Supports (CLS) are used to increase or maintain personal self-sufficiency, facilitate
an individual’s achievement of his/her goals of community inclusion and participation, independence or
productivity. The supports can be provided in the participant’s residence or in community settings
(including, but not limited to, libraries, city pools, camps).
Coverage includes:
• Assisting (that exceeds state plan for adults), prompting, reminding, cueing, observing, guiding
and/or training in the following areas:
o
Meal preparation
o
Laundry
o
Routine, Seasonal, and heavy household care and maintenance
o
Activities of daily living (eg. Bathing, eating, dressing, personal hygiene)
o
Shopping for food and other necessities of daily living
• Staff assistance, support and/or training the individual with activities such as:
• Money management
• Reminding, observing and/or monitoring of medications;
• Non-medical care (not requiring nurse or physician intervention)
• Socialization and relationship building;
• Transportation*;
• Participation in regular community activities and recreation opportunities (e.g. attending classes,
movies, concerts and events in the park; volunteering; voting)
• Acquiring or procuring goods, other than those listed under shopping, and non-medical services
• Staff assistance with preserving the health and safety of the individual in order that he/she may
reside or be supported in the most integrated, independent community setting
• Leisure choice and participation in regular community activities; and
o Attendance at medical appointments
The CLS do not include the costs associated with room and board. Payment for CLS does not include
payments made, directly or indirectly, to responsible relatives (i.e., spouses or parents of minor
children).
The HSW services cannot supplant Medicaid services. The beneficiary must use the DHS Home Help
or Enhanced Home Help services for assistance with meal preparation, laundry, routine household care
and maintenance, activities of daily living (bathing, eating, dressing, personal hygiene), and shopping.
Page 34 of 182
Transportation to medical appointments is covered by Medicaid through DHS or the Medicaid Health
Plan.
Refer to the Medicaid Manual for further information regarding the use of CLS.
Clarifying Points:
• H2016 procedure code is to be used for individuals in Specialized Residential ONLY or children
with SED in a foster care setting that is not a CCI or children with DD in either foster care or
CCI.
• T2036 & T2037 are to be used for Therapeutic Camp. Non-Therapeutic Camp is reported under
Respite Care H0045.
• Between CLS (H2016) and Personal Care (T1020) in Specialized Residential
• For H2016 in specialized residential assume:
o Less intensive staff involvement than personal care
o Staff provide one-on-one training to teach the consumer to eventually perform one or
more ADL task(s) independently; OR
o One staff to more than one consumer provides training along with prompting and or
guiding the consumers to perform the ADL tasks independently; OR
o One staff to more than one consumer prompting, cueing, reminding and/or observing the
consumers to perform one or more ADL tasks independently; OR
o One staff to one or more consumers supervising while consumers are sleeping.
Boundaries:
• Between CLS and supported employment (SE):
o Report SE if the individual has a job coach who is also providing assistance with ADLs
• Between CLS and Respite:
o Use CLS when providing such assistance as after-school care, or day care when caregiver
is normally working and there are specific CLS goals in the IPOS.
o Use Respite when providing relief to the caregiver who is usually caring for the
beneficiary during that time
• Between CLS and Skill-building (SK):
o Report SK when there is a vocational or productivity goal in the IPOS and the individual
is being taught the skills he/she will need to be a worker (paid or unpaid)
o Report CLS when an individual is being taught skills in the home that will enable him/her
to live more independently
Page 35 of 182
Community Living Supports - Licensed Settings
Level of Care Table
Description
HCPCS
Population
MIA, DDA
Coverage
Habilitation Supports Waiver & Additional, 1915(b((3) services and
EPSDT
Unit Description
Unit = day
Unit Minimum
1 unit per day
Unit Maximum
31 units per month
H2016 = 1unit per day
T2036 = 1unit per day
T2037 = 1unit per day
Other Rules
None
837 Type
Professional
Modifier(s)
HE = provided by a Certified Peer Support Specialist
HK = Specialized mental health programs for high-risk populations
HK must be reported for Habilitation Supports Waiver beneficiaries.
No modifier is reported for B3 services.
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Adult
Yes
Check
codes?
Licensed Settings only for Community Living Supports
Page 36 of 182
Community Living Supports - Unlicensed Settings
H2015 – Community Living Supports – comprehensive Community Support Services
H0043 – Community Living Supports provided in unlicensed independent living setting or own home
(per diem)
H0043TT – (TT Modifier to be used when multiple consumers are served simultaneously in nonlicensed settings)
Community Living Supports (CLS) are used to increase or maintain personal self-sufficiency, facilitate
an individual’s achievement of his/her goals of community inclusion and participation, independence or
productivity. The supports can be provided in the participant’s residence or in community settings
(including, but not limited to, libraries, city pools, camps.
Coverage includes:
• Assisting (that exceeds state plan for adults), prompting, reminding, cueing, observing, guiding
and/or training in the following areas:
o Meal preparation
o Laundry
o Routine, Seasonal, and heavy household care and maintenance
o Activities of daily living (eg. Bathing, eating, dressing, personal hygiene)
o Shopping for food and other necessities of daily living
• Staff assistance, support and/or training the individual with activities such as:
o Money management;
o Reminding, observing and/or monitoring of medications;
o Non-medical care (not requiring nurse or physician intervention);
o Socialization and relationship building;
o Transportation*;
o Participation in regular community activities and recreation opportunities (e.g.
attending classes, movies, concerts and events in the park; volunteering; voting)
o Acquiring or procuring goods, other than those listed under shopping, and nonmedical services
o Staff assistance with preserving the health and safety of the individual in order that
he/she may reside or be supported in the most integrated, independent community
setting
o Leisure choice and participation in regular community activities; and
o Attendance at medical appointments
The CLS do not include the costs associated with room and board. Payment for CLS does not include
payments made, directly or indirectly, to responsible relatives (i.e., spouses or parents of minor
children).
The HSW services cannot supplant Medicaid services. The beneficiary must use the DHS Home Help
or Enhanced Home Help services for assistance with meal preparation, laundry, routine household care
and maintenance, activities of daily living (bathing, eating, dressing, personal hygiene), and shopping.
Transportation to medical appointments is covered by Medicaid through DHS or the Medicaid Health
Plan.
Refer to the Medicaid Manual for further information regarding the use of CLS
Page 37 of 182
Clarifying Points:
•
•
This code may be used while other services are being performed, i.e. club house, vocational, etc.
This code is NOT to be used for any type of camp. Therapeutic Camp is to be reported under
Community Living Supports – Licensed Setting (T2036 & T2037) services. Non-Therapeutic
Camp is to be reported under Respite Care – Per Diem (H0045).
Questions/Answers:
Q. For Children's Waiver there is a rule against a paid supports staff taking the individual to his/her
home. We believe this rule is based on the fact that the waiver is specific to the family home. Was
wondering if the same rule applied to community living support staff outside of the waiver?
A. There was a recent Child waiver hearing on where supports were provided -- it was more
complicated than just where the service was provided. The law judge basically said that what the person
was getting in that location did not meet the CLS requirements about community integration -- it could
have been an integrated experience, but in this case the judge said they did not think so (it was more for
the parent/provider convenience). As such, yes it would apply to all CLS, not just Children’s Waiver. So
the documentation would need to support what integrative experience the person was getting
Q. Can Community Living Supports/staffing supports be provided in the individual's home when the
individual's name is not on the lease agreement in an unlicensed setting? What about if they don't require
24/7 care? For instance, a room and board facility - the consumer chooses to live there, pay rent and
needs minimal amounts of community living supports. Can we pay for staffing in this type of
environment with Medicaid funds?
A. Yes -- CLS is a service -- has nothing to do with how other expenses are covered (e.g. rent) – except
that Medicaid of course does not pay for room/board. So use H2015 to capture staff time/expense in
providing these supports. The who pays the lease issue comes up in the performance indicator arena
driven by demographic info – and DCH interest in having more folks manage the lease on where they
live (rather than having CMH do it).
Page 38 of 182
Community Living Supports - Unlicensed Settings
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC
Unit Description
Habilitation Supports Waiver & Additional, 1915(b((3) services and
EPSDT
H2015 = 15 minutes
H0043 = Per Diem
Unit Minimum
1 unit per day
Unit Maximum
H0043 = 1 unit per day
H2015 = 96 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
HK = Specialized mental health programs for high-risk populations;
HK must be reported for Habilitation Supports Waiver beneficiaries.
No modifier is reported for B3 services.
TT = when multiple consumers are served simultaneously in nonlicensed settings
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Coverage
Check
Medicaid Provider Qualifications – Respite/CLS providers must, in
addition to the specific training, supervision and standards for each
support/service, be:
• A responsible adult at least 18 years of age;
• Free from communicable diseases;
• Able to read and follow written plans of service/supports as
well as beneficiary-specific emergency procedures;
• Able to write legible progress and/or status notes;
• In “good standing” with the law (i.e., not a fugitive from
justice, a convicted felon or illegal alien);
• Able to perform basic first aid and emergency procedures;
• Have successfully completed Recipient Rights Training
• Cannot be the parent and/or guardian of consumer
If the provider does not meet all of these qualifications, Medicaid
funds cannot be used for the service, thus H2015 or H0043 cannot be
reported.
codes?
H0043 cannot be used in a licensed Adult Foster Care
Page 39 of 182
Crisis Intervention
H0030 – Michigan Center for Positive Living Supports Crisis Line (not face-face with beneficiary)
H2011 - Crisis Intervention Services – (face-face)
H2020 – Michigan Center for Positive Living Supports Crisis/Training Transition Home (face-face)
T2034 – Michigan Center for Positive Living Supports Mobile Crisis/Training Team (face-face)
90839 – Psychotherapy for Crisis, 1st 60 minutes
90840 – Psychotherapy for Crisis, each additional 30 minutes (Add-on code ONLY)
These are unscheduled activities for the purpose of resolving an emergency or an urgent situation
requiring immediate attention. Activities include crisis response, crisis line, assessment, referral, and
direct therapy. The standard for whether or not a crisis exists is a “prudent layperson” standard. That
means a prudent layperson would be able to determine from the beneficiary’s symptoms that crisis
services are necessary. Crisis situation means a situation in which an individual is experiencing serious
mental illness or a developmental disability, or a child is experiencing a serious emotional disturbance,
and one the following applies:
• The individual can reasonably be expected within the near future to physically injure himself or
another individual, either intentionally or unintentionally.
• The individual is unable to provide himself food, clothing, or shelter, or to attend to basic
physical activities such as eating, toileting, bathing, grooming, dressing, or ambulating, and this
inability may lead in the near future to harm to the individual or another individual.
• The individual’s judgment is so impaired that he is unable to understand the need for treatment
and, in the opinion of the mental health professional, his continued behavior as a result of the
mental illness, developmental disability, or emotional disturbance can reasonably be expected in
the near future to result in physical harm to the individual or to another individual.
If the beneficiary developed a crisis plan, the plan is followed with permission from the beneficiary.
Clarifying points:
Reserved for reporting purchase of Crisis Intervention services from the Michigan Center for Positive
Living Supports:
•
•
H0030 – Qualified Intellectual Disability Professional (QIDP)
H2020 and T2034 – QIDP and trained aides; or trained aides supervised by a QIDP
Codes specific:
• 90839 and 90840 – Psychologist
Page 40 of 182
Crisis Intervention
Level of Care Table
Description
HCPCS
Population
All, Michigan Center for Independent Living Supports (DD Only)
Coverage
State Plan
Unit Description
Unit = 15 minutes
Unit Minimum
1 unit per day
Other Rules
H2011 = 96 units per day
90840 (add-on code) = per service
Direct contacts with individuals. Do not use this code for contacts
with others, family, advocates, hospital, etc.
837 Type
Professional
Modifier(s)
Not Applicable
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Unit Maximum
See provider service array
Check
codes?
No
No restrictions
Page 41 of 182
Crisis Residential Services
H0018 - Behavioral health; short-term residential (Non-hosp resident treatment program) without room
and board per diem - Use for both child & adult services.
Crisis residential services are intended to provide a short-term alternative to inpatient psychiatric
services for beneficiaries experiencing an acute psychiatric crisis when clinically indicated. Services
may only be used to avert an inpatient psychiatric admission, or to shorten the length of an inpatient
stay.
Clarifying Points:
•
•
•
•
First day counts when consumer is “in” as of 11:59PM.
Bundled per-diem, includes: staff, operational costs, lease, and physician services
Determine method for handling SSI. SSI funds must be deducted from amount billed.
In and out on the same day not reportable as crisis residential.
Level of Care Table
Description
HCPCS
Coverage
State Plan
Population
MIA, SED, DDA, DDC
Unit Description
Unit = 1 day
Unit Minimum
1 unit per day
Unit Maximum
1 unit per day
Other Rules
None
837 Type
Professional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Provider must be enrolled and approved by MDCH
Check
codes?
Yes
Approved, enrolled ICR Program only
Page 42 of 182
Electroconvulsive Therapy – ECT
Procedure Code/ Description:
0370 – Anesthesia
00104 – Anesthesia Charge
0701 – Recovery Room
0901 – ECT Facility Charge
90870 – Attending Physician Charge
Anesthesia services related to electro-convulsive therapy are covered by the Medicaid Health Plan
(MHP). The attending physician must obtain authorization from the MHP. Payment is made by the
MHP that authorized the service.
Questions/Answers:
Q. When a consumer is in a State facility, can the networks pay for ECT on an outpatient basis? We
had a State facility that was requesting ECT for a consumer. They wanted her to stay admitted to the
facility but be transported to another community hospital for the ECT and have the networks pay for
this. We actually came to a final decision to transport the consumer to a State facility that had ECT
services. But, it would be nice to know this if it comes up in the future.
A. Yes -- but it would be a GF expense not a Medicaid even if the person has Medicaid (as residing in a
state facility IMD excludes them from FFS Medicaid). However I am not clear as to why you are asked
to pay -- the state facility is supposed to take care of them, including medical needs that might be
handled through a community hospital.
Page 43 of 182
Electroconvulsive Therapy – ECT
Level of Care Table
Description
Revenue and CPT codes
0901, 0701, 0730 = revenue code
90870, 00104 = CPT codes
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Per Encounter
Unit Minimum
Unit Maximum
As authorized
Other Rules
None
837 Type
0901 = Institutional
90870 = Professional
00104 = Professional
Modifier(s)
Not Applicable
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
No
None
Check
codes?
Authorization Required
Yes
Hospital (Non-IMD)
Page 44 of 182
Enhanced Medical Equipment & Supplies
(Assistive Technology)
T2028 – Specialized Supply, NOS, Waiver
T2029 – Specialized Medical Equipment, NOS, Waiver
S5199 – Personal Care Item, NOS
E1399 – DME, Miscellaneous
T2039 – Van Lifts and Wheelchair Tie Down System
Assistive technology i.e. enhanced medical equipment and supplies is an item or set of items that enable
the individual to increase his ability to perform activities of daily living with a greater degree of
independence than without them; to perceive, control , or communicate with the environment in which
he lives. These are items that are not available under regular Medicaid coverage or through other
insurances (Refer to the Medical Supplier Chapter of the Medicaid Provider Manual for more a list of
non-covered equipment and supplies). All enhanced medical equipment and supplies must be specified
in the plan of service.
Items that are not of direct medical or remedial benefit, or that are considered to be experimental to the
beneficiary, are excluded from coverage.
•
•
“Direct medical or remedial” benefit is a prescribed specialized treatment and its associated
equipment or environmental accessibility adaptation that are essential to the implementation of
the individual plan of service.
“Experimental” means that the validity of the use of the item has not been supported in one or
more studies in a refereed professional journal.
The plan must document that, as a result of the treatment and its associated equipment or adaptation,
institutionalization of the beneficiary will be prevented. There must be documented evidence that the
item is the most cost-effective alternative to meet the beneficiary’s need. All items must be ordered on a
prescription or Certificate of Medical Necessity (CMN) as defined in the General Information Section of
the Medicaid Provider Manual. An order is valid one year from the date it was signed.
Coverage includes:
• Adaptations to vehicles (T2039)
• Items necessary for independent living (e.g. Lifeline, sensory integration equipment)
• Communication devices
• Special personal care items that accommodate the person’s disability (e.g., reachers, fullspectrum lamp)
• Prostheses necessary to ameliorate negative visual impact of serious facial disfigurements and/or
skill conditions
• Ancillary supplies and equipment necessary for proper functioning of assistive technology items
• Repairs to covered assistive technology that are not covered benefits through other insurances
• Assessments and specialized training needed in conjunction with the use of such equipment, as
well as warranted upkeep and repair, shall be considered as part of the cost of the services.
Coverage Excludes:
• Furnishings (e.g., furniture, appliances, bedding) and other non-custom items (e.g., wall and
floor coverings, and decorative items) that are routinely found in a home are not included.
Page 45 of 182
•
•
•
Items that are considered family recreational choices are not covered.
The purchase or lease of a vehicle, as well as any repairs or routine maintenance to the vehicle, is
not covered.
Educational equipment and supplies are expected to be provided by the school and are not
covered.
Covered items must meet applicable standards of manufacture, design, and installation. There must be
documentation that the best value in warranty coverage was obtained for the item at the time of
purchase.
Repairs to enhanced medical equipment that are not covered benefits through other insurances may be
covered. There must be documentation in the individual plan of services that the enhanced medical
equipment continues to be of direct medical or remedial benefit. All applicable warranty and insurance
coverage must be sought and denied before paying for repairs. Providers must document the repair is
the most cost-effective solution when compared with replacement or purchase of a new item. If the
equipment requires repairs due to misuse or abuse, there must be evidence of training in the use of the
equipment to prevent future incidents.
Clarifying Points:
•
•
•
•
Must have a supporting assessment
Must have a physician order
Must have 2 or more quotes for Enhanced Medical Services
Prior authorization required
Page 46 of 182
Enhanced Medical Equipment & Supplies (Assistive
Technology)
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC
Coverage
Habilitation Supports Waiver & (b)(3) services
Unit Description
1 unit = 1 item
Unit Minimum
1unit per day
Unit Maximum
1,000 units per day
837 Type
Professional
Modifier(s)
HK for HAB Waiver
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
No
NA
Check
codes?
No restrictions
Page 47 of 182
Enhanced Pharmacy
T1999 Enhanced Pharmacy
T1999HK – (Modifier HK for Habilitation Supports Waiver beneficiary)
Physician-ordered, nonprescription “medicine chest” items as specified in the individual’s plan of
service. There must be documented evidence that the item is not available through Medicaid or other
insurances, and is the most cost-effective alternative to meet the beneficiary’s need. Items that are not
direct medical or remedial benefit to the beneficiary are not allowed. Only the following items are
allowable:
The following items are allowable for non-HSW adult Medicaid beneficiaries living in independent
settings and HSW participants:
• Cough, cold, pain, headache, allergy, and/or gastrointestinal distress remedies;
• First aid supplies (e.g., Band-Aids, iodine, rubbing alcohol, cotton swabs, gauze, antiseptic
cleansing pads);
The following items are allowable for non-HSW Medicaid beneficiaries living in independent or
licensed settings and HSW participants:
• Vitamins and minerals;
• Special dietary juices and foods that augment, but do not replace a regular diet;
• Thickening agents for safe swallowing when the beneficiary has a diagnosis of dysphagia and
either a history of aspiration pneumonia or documentation that the beneficiary is at risk of
insertion of a feeding tube without the thickening agents for safe swallowing;
• Special oral care products to treat specific oral conditions beyond routine mouth care (e.g.,
special toothpaste, toothbrushes, anti-plaque rinses, antiseptic mouthwashes);
• Special items (i.e., accommodating common disabilities – longer, wider handles), tweezers and
nail clippers.
Routine cosmetic products (e.g., make-up base, aftershave, etc.) are not covered.
HSW funds cannot be used to pay for co-pays for other prescription plans the beneficiary may have.
Refer to Medicaid Provider Manual for more specific further information.
Page 48 of 182
Enhanced Pharmacy
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC
Coverage
Habilitation Supports Waiver & Additional “b3” services
Unit Description
1 unit = 1 Item
Unit Minimum
1 unit per day
Unit Maximum
1,000 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
HK for Habilitation Supports Waiver
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
See Provider Service Array
Check
No
codes?
No restrictions
Clarifying Points:
•
•
•
The product purchased must be reported in the “remarks” section of the 837 record.
General fund vs. Medicaid coverage
Maximum units, 1,000/day
Page 49 of 182
Environmental Modifications/Accessibility Adaptation
Community Transition (Waiver for Children with SED only)
S5165 Environmental Modifications
T2031 – Community Transition, Waiver for Children with SED only
Physical adaptations to the beneficiary’s home and/or workplace required by the beneficiary’s support
plan that are necessary to ensure the health, safety, and welfare of the beneficiary, or enable him to
function with greater independence within the environment(s) and without which the beneficiary would
require institutionalization. There must be documented evidence that the modification is the most costeffective alternative to meet the beneficiary’s need/goal based on the results of a review of all options,
including a change in the use of rooms within the home or alternative housing, or in the case of a vehicle
modification, alternative transportation.
Adaptations may include (refer to Medicaid Manual for further guidance):
• The installation of ramps and grab bars;
• Widening of doorways;
• Modification of bathroom facilities; and
• Installation of specialized electric and plumbing systems which are necessary to accommodate
the medical equipment and supplies necessary for the welfare of the beneficiary.
Excluded are those adaptations or improvements to the home that are of general utility, are considered to
be standard housing obligations or the beneficiary, and are not of direct medical or remedial benefit.
Examples of exclusions include, but are not limited to, carpeting, roof repair, sidewalks, driveways,
heating, central air conditioning (except under exceptions noted in the service definition), garages, raised
garage doors, storage and organizers, hot tubs, whirlpool tubs, swimming pools, landscaping and general
home repairs. Construction costs in a new home and additions to a home are not covered.
Clarifying points
•
•
•
1,000 units per day
T2031 – Community Transition, Waiver for Children with SED only
Licensed builder or utility company; requirements specified in the IPOS
See Medicaid Provider Manual for Children’s Waiver, HAB Waiver, and Additional Mental
Health Services (b)(3) for specific program requirements and code usage.
Page 50 of 182
Environmental Modifications/Accessibility Adaptation
Community Transition (Waiver for Children with SED only
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC
Coverage
Habilitation Supports Waiver & Additional or b3 services
Community Transition (Waiver for Children with SED only)
Unit Description
Unit = per service
Unit Minimum
1 unit per day
Unit Maximum
1,000 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
HK for Habilitation Supports Waiver
Start Date
October 1 2013
End Date
None at this time
None
None
Member Age Check
No
Check
codes?
Modifications can only be made to family home if they own or are
purchasing
Page 51 of 182
Family Training
S5110 - Family Psycho-Education skills workshop (Evidence-based practice)
S5111 – Home care training, family per session
S5111HA – (HA Modifier) for Parent Management Training Oregon model
S5111HK – (HK Modifier) Specialized mental health programs for high-risk populations must be
reported for Habilitation Supports Waiver beneficiaries. No modifier is reported for Additional or “b3”
Services.
S5111HM – (HM Modifier) Parent-to-parent support provided by a trained parent using the MDCHendorsed curriculum
S5111HS – (HS Modifier) when beneficiary is not present
S5111ST – (ST Modifier) Resource Parent Training by Trauma Initiative
S5111TT – (TT Modifier) when multiple consumers are served simultaneously
G0177 - Family Psycho-education family educational groups (either single or multi-family)
G0177HS – (HS Modifier) Family Psycho-education when beneficiary is not present during the activity
with the family (Evidence-based practice)
T1015 – Family Psycho-Education joining Note: Please use these codes only when implementing this
Evidence Based Practice
T1015HS – (HS Modifier) Family Psycho-education: joining when beneficiary is not present during the
activity with the family
Family-focused services provided to family (natural or adoptive parents, spouse, children, siblings,
relatives, foster family, in-laws, and other unpaid caregivers) of persons with serious mental illness,
serious emotional disturbance or developmental disability for the purpose of assisting the family in
relating to and caring for a relative with one of these disabilities. The services target the family
members who are caring for and/or living with an individual receiving mental health services. The
service is to be used in cases where the beneficiary is hindered or at risk of being hindered in his ability
to achieve goals of:
•
•
•
performing activities of daily living;
perceiving, controlling, or communicating with the environment in which he lives; or
Improving his inclusion and participation in the community or productive activity, or
opportunities for independent living.
The training and counseling goals, content, frequency and duration of the training must be identified in
the beneficiary’s individual plan of service, along with the beneficiary’s goal(s) that are being facilitated
by this service.
Coverage includes:
• Education and training, including instructions about treatment regimens, and use of assistive
technology and/or medical equipment needed to safely maintain the person at home as
specified in the individual plan of service.
• Counseling and peer support provided one-on-one or in group for assistance with identifying
coping strategies for successfully caring for or living with a person with disabilities.
• G0177 – Use this code only when implementing this Evidenced Based Practice. Use modifier
“HS” when consumer is not present during the activity with the family.
Page 52 of 182
Clarifying Points:
•
•
•
•
•
•
•
•
•
When working with multiple families simultaneously, do not split the total time by the number of
consumers involved. Report each consumer as one encounter.
Consumer need not be present to use this code.
There are no minimum credentials specified for procedure.
T1015 - encounter
S5110 – 15 minutes
This code cannot be used for training of a non-paid, non-family member. Use Community
Living Supports service code (H2015 per 15 minutes).
Note regarding using FPE codes: One group leader must have an LMSW, as required by the
licensing laws. In order to report using the FPE codes, a site must have the qualified staff as well
as have the training by McFarlane or his designee.
Children’s Waiver: Family training must be done by a psychologist, LMSW or a
QIDP
Services can be provided by Board Certified Behavior Analyst (BCBA)
Questions/Answers:
Q. Can this code be used for training of a non-paid, non-family member?
A. No, use Community Living Supports – H2015 (15 minutes) for this.
Q. In response to my question about the use of FPE codes, Judy Webb, MDCH, and Jeff Capobianco,
FPE State Subcommittee, reported the following:
A1. Jeff: "One group leader must have an LMSW, as required by the licensing laws."
A2. Judy Webb, Director of Division of Quality Management & Planning Bureau of Community Mental
Health Services: "It was my understanding that in order to report using FPE codes, a site not only has
to have the qualified staff, but they also must have been trained by McFarlane or his designee."
Page 53 of 182
Family Training
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC
Coverage
Habilitation Supports Waiver & Additional “b3” service
Unit Description
Encounter
Unit Minimum
1 Encounter per day
Unit Maximum
S5111 = 2 Encounters per day
G0177 = 1 Encounter per day (session at least 45
minutes)
T1015 = 2 Encounters per day
S5110 = 2 Encounters per day (15 minutes each
encounter)
Other Rules
None
837 Type
Professional
Modifier(s)
HS = When beneficiary is not present
HA = for Parent Management Training Oregon Model
HK = (Specialized mental health programs for high-risk
populations) must be reported for Habilitation Supports
Waiver beneficiaries.
TT = When multiple consumers are served
simultaneously.
Start Date
October 1, 2013
End Date
None at this time
Member Age Check
None
Check
Must meet training requirements to provide the EBP
services
Children’s Waiver: Family training must be done by a
psychologist, LMSW or a QIDP
BCBA can provide services
codes?
No
No restrictions
Page 54 of 182
Fiscal Intermediary Services
T2025 – Fiscal Intermediary Services (self-directed, waiver)
CMS approved coverage of fiscal intermediary services for beneficiaries who prefer more control over
their services and service budgets. The coverage definition and parameters of this new service are
detailed below.
Fiscal Intermediary Services is defined as services that assist the adult beneficiary, or a representative
identified in the beneficiary’s plan, to meet the beneficiary’s goals of community participation and
integration, independence or productivity while controlling his/her individual budget, and choosing staff
who will provide the services and supports identified in the individual plan of service and authorized by
IPN. The fiscal intermediary helps the beneficiary manage and distribute funds contained in the
individual budget. Fiscal intermediary services include, but are not limited to:
•
•
•
•
facilitation of the employment of service workers by the beneficiary, including federal, state and
local tax withholding/payments, unemployment compensation fees, wage settlements, fiscal
accounting;
Tracking and monitoring participant-directed budget expenditures and identifying potential overand under-expenditures;
Assuring adherence to federal and state laws and regulations; and
Ensuring compliance with documentation requirements related to management of public funds.
The fiscal intermediary may also perform other supportive functions that enable the beneficiary to selfdirect needed services and supports. These functions may include selecting, contracting with or
employing and directing providers of services, verification of provider qualifications, including
reference and background checks, and assisting the beneficiary to understand billing and documentation
requirements.
Fiscal intermediary services may not be authorized for use by a beneficiary’s representative where that
representative is not conducting tasks in ways that fit the beneficiary’s preferences, and/or do not
promote achievement of the goals contained in the beneficiary’s plan of service so as to promote
independence and inclusive community living for the beneficiary, or when they are acting in a manner
that is in conflict with the interests of the beneficiary.
Fiscal intermediary services must be performed by entities with demonstrated competence in managing
budgets and performing other functions and responsibilities of a fiscal intermediary. Neither providers
of other covered services to the beneficiary, family members, or guardians of the beneficiary may
provide fiscal intermediary services to the beneficiary.
Open Issues:
•
MDCH has issued new guidelines and requirements in this area. Need to ensure contracts are
current with these new requirements.
Page 55 of 182
Fiscal Intermediary Services
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC
Coverage
Additional “b3” Service
Unit Description
Per Month
Unit Minimum
1 per month
Unit Maximum
1 per month
837 Type
Professional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Check
Fiscal intermediary services must be performed by entities with
demonstrated competence in managing budgets and performing
other functions and responsibilities of a fiscal intermediary. Neither
providers of other covered services to the beneficiary, family
members, or guardians of the beneficiary may provide fiscal
intermediary services to the beneficiary.
codes?
Yes
No restrictions
Page 56 of 182
Goods and Services
T5999 – Waiver Service NOS – Must use HK Modifier: beneficiary is enrolled in Habilitation Supports
Waiver
Items or services that promote individual control over, and flexible use of, the individual budget by the
Beneficiary using arrangements that support self-determination to accomplish the goals identified in the
IPOS. Goods and Services must increase independence, facilitate productivity, or promote community
inclusion and substitute for human assistance (such as Personal Care, CLS, and other one-to-one support
to the extent that individual budget expenditures would otherwise be made for the human assistance.
Purchase of a warranty may be included when it is available for the item and is financially reasonable.
Level of Care Table
Description
HCPCS
Population
DD
Coverage
HSW
Unit Description
Item
Unit Minimum
Individually determined
Unit Maximum
Individually determined
Other Rules
Must be in a self-determined arrangement and budget must be
lodged with a fiscal intermediary
837 Type
Professional
Modifier(s)
HK
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
None
Check
codes?
No
Must not be used in a licensed facility
Page 57 of 182
Health Services
H0034 – Medication training and support
S9445 – Patient education NOC non-physician
S9446 – Patient education NOC non-physician group, per session
S9470 – Nutritional counseling dietician visit
T1002 – RN services up to 15 minutes
97802, 97803, 97804 - Medical nutrition therapy (initial assessment / re-assessment / group)
H0034 – Medication training and support ONLY, per 15 minutes
S9445 – Patient education, not otherwise classified, non-physician provider, individual, per encounter.
Examples: Any health related training including personal hygiene, first aid, care of minor injuries, how
to seek assistance in case of emergencies, understanding diseases such as diabetes, etc.
S9446 – Patient education, not otherwise classified, non-physician provider, group, per encounter.
Examples: Any medication or health related training or support, including personal hygiene, first aid,
care of minor injuries, how to seek assistance in case of emergencies, understanding diseases such as
diabetes, etc.
S9470 – Nutritional counseling, dietician visit
T1002 – Hands on treatment by an RN such as taking temperature, blood pressure, weight, drug screen,
breathalyzer, etc. up to 15 minutes
97802 – Medical nutrition therapy, initial assessment and intervention, individual, face-to-face with
patient, each 15 minutes
97803 – Medical nutritional therapy, re-assessment and intervention, individual, face-to-face with the
patient, each 15 minutes
97804 – Medical nutritional therapy, group (2 or more individuals), each 30 minutes
Health Services are provided for purposes of improving the beneficiary’s overall health and ability to
care for health-related needs. This includes nursing services (on a per-visit basis, not on-going hourly
care), dietary/nutritional services, maintenance of health and hygiene, teaching self-administration of
medication, care of minor injuries or first aid, recognizing early symptoms of illness and teaching the
beneficiary to seek assistance in case of emergencies. Health assessments are covered under
Assessments Subsection. A registered nurse, nurse practitioner, physician assistant, or dietician must
provide these services, according to their scope of practice. Health services must be carefully
coordinated with the beneficiary’s health care plan so that PIHP/IPN does not provide services that are
the responsibility of the MHP.
Page 58 of 182
Health Services
Level of Care Table
Description
HCPCS, CPT
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Some are 15 minutes, some per encounter
DT: duplicate threshold
Unit Description
97802 –unit = per 15 minutes
97803 – unit= per 15 minutes
97804 – unit = per 30 minutes
H0034 – unit= per 15 minutes
S9445 – per encounter
T1002 – unit = 15 minutes
Unit Minimum
1 15 minute/unit or 1 encounter
Unit Maximum
97802= 40 units per day
H0034= 40 units per day
S9445= 1 encounter per day
T1002= 40 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
None
Start Date
October 1,2013
End Date
None at this time
None
Member Age Check
None
Registered nurse, nurse practitioner, registered dietician, or licensed
physician’s assistant according to their scope of practice
Check
codes?
Yes
encounters.
Page 59 of 182
Home Based Services
H0036 – Home Based Services – Community psychiatric supportive treatment (face-face with child or
family, per 15 minutes)
H0036/HA – Parent Management Training-Oregon (PMTO)
H0036/HA & TT – PMTO delivered to multiple families
H0036/HS – Services are delivered when beneficiary is not present
H0036/ST - Trauma-focused Cognitive Behavioral Therapy (TFCBT) when pre-approved by MDCH
H2033- Multi-Systemic therapy (MST) in home-based program for juveniles provided in home-based
program
Mental health home-based service programs are designed to provide intensive services to children (birth
through age 17) and their families with multiple service needs who require access to an array of mental
health services. The primary goals of these programs are to promote normal development, promote
healthy family functioning, support and preserve families, reunite families who have been separated, and
reduce the usage of, or shorten the length of stay in, psychiatric hospitals and other substitute care
settings. Treatment is based on the child’s need with the focus on the family unit. The service style must
support a strength-based approach, emphasizing assertive intervention, parent and professional
teamwork, and community involvement with other service providers.
One staff member or a team of staff may provide these services. Home-based services programs are
designed to provide intensive services to children and families in their home and community. The degree
of intensity will vary to meet the needs of families. The home-based services worker-to-family ratio
must be established to accommodate the levels of intensity that may vary from two to twenty hours per
week based on individual family needs. The worker-to-family ratio should not exceed 1:12 for a fulltime equivalent position, yet can be adjusted to 1:15 to accommodate families transitioning out of homebased services (12 active/3 transitioning).
Medicaid providers seeking to become providers of home-based services must request approval from
MDCH. (Refer to the Directory Appendix for contact information.)
Service includes Home-Based Crisis, Family Collateral, Service Coordination and Therapy. MDCH
approved services provided to the entire family unit and are individual tailored to the unique needs of
each family. The family unit is the focus of treatment. Services may be provided by one staff or a team
of staff. Services include individual therapy, family therapy, group therapy, crisis intervention, service
coordination, family collateral contacts, as well as models such as Infant Mental Health Services. The
activities range from assisting recipients in meeting basic needs, such as food, housing, and medical
care, to more therapeutic interventions such as family therapy or individual therapy.
Clarifying Points:
•
•
•
Provider must be approved by MDCH to provide Home Based Services.
Per MDCH Costing Guidelines, indirect activities and collateral contacts made on behalf of the
consumer can be reported. The consumer does not need to be present for the service.
When the home-based staff is not doing therapy, but is meeting with the client, family, external
agency to monitor the success (or lack of success) of the plan and making appropriate changes in the
plan – this is a treatment planning meeting and should be reported as such.
Page 60 of 182
•
For DD: CMHP** must meet QIDP qualifications. Unless providing mental health therapy which
requires these qualifications: physician, psychologist, LMSW (or a LLMSW supervised by a
LMSW) or a licensed or limited-licensed professional counselor and one year of experience in
examination, evaluation and treatment of minors and their families.
Home Based Services
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA,DDC
Coverage
State Plan
Unit Description
Unit = 15 minutes
Unit Minimum
1unit per day
Unit Maximum
H0036= 96 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
HA for Parent Management Training Oregon model
HS when beneficiary is not present
ST when providing Trauma-focused Cognitive Behavioral
Therapy when pre-approved by MDCH
HA & TT when providing Parent Management Training
Oregon model to multiple families.
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
No
Provider must be approved and enrolled by MDCH to
provide Home Based Services.
Check
codes?
Yes = H0036ST must be pre-approved by MDCH
No restrictions
Page 61 of 182
Housing Assistance
T2038 – Community Transition, waiver, per service
Housing assistance is assistance with short-term, interim, or one-time-only expenses for beneficiaries
transitioning from restrictive settings into more independent, integrated living arrangements while in the
process of securing other benefits (e.g., SSI) or public programs (e.g., governmental rental assistance
and/or home ownership programs) that will become available to assume these obligations and provide
needed assistance.
Additional criteria for housing assistance:
• The beneficiary must have in his individual plan of services a goal of independent living, and
either live in a home/apartment that he/she owns, rents, or leases; or be in the process of
transition to such a setting; and
• Documentation of the beneficiary’s control (i.e., beneficiary-signed lease, rental agreement,
deed) of his living arrangement in the individual plan of service; and
• Documentation of efforts (e.g., the person is on a waiting list) under way to secure other benefits,
such as SSI or public programs (e.g., governmental rental assistance, community housing
initiatives and/or home ownership programs) so when these become available they will assume
these obligations and provide the needed assistance.
•
•
•
•
•
•
•
•
•
Coverage includes:
Assistance with utilities, insurance, and moving expenses where such expenses would pose a
barrier to a successful transition to owning or leasing/renting a dwelling.
Limited term or temporary assistance with living expenses for beneficiaries transitioning from
restrictive settings.
Interim assistance with utilities, insurance or living expenses when the beneficiary already living
in an independent setting experiences a temporary reduction or termination of his own or other
community resources.
Home maintenance when, without a repair to the home or replacement of a necessary appliance,
the individual would be unable to move there, or if already living there, would be forced to leave
for health and safety reasons.
Coverage Excludes:
Funding for on-going housing costs.
Costs for room and board that are not directly associated with transition arrangements while
securing other benefits.
Home maintenance that is of general utility or cosmetic value and is considered to be a standard
housing obligation of the beneficiary.
Replacement or repair of appliances should follow the general rules under assistive technology. Repairs
to the home must be in compliance with all local codes and be performed by the appropriate contractor
(refer to the general rules of the Environmental Modifications subsection of the chapter). Replacement
or repair of appliances, and repairs to the home or apartment do not need a prescription or order from a
physician.
Page 62 of 182
Clarifying Points Units and Definition:
•
•
•
•
•
If the exact date of the service cannot be determined, the date of the invoice will be used as the
date of services.
Date spans are NOT to be used.
This code is to be reported once a month per consumer per MDCH – but they will accept
multiples.
Payment cannot be made directly to the member – it must go through a contracted provider
agency.
Coverage excludes:
o Funding for on-going housing cost
o Costs for room and board that are not directly associated with transition arrangements
while securing other benefits
o Home maintenance that is of general utility or cosmetic value and is considered to be a
standard housing obligation of the beneficiary.
o PATH/Shelter Plus is NOT to be reported using this code
Housing Assistance
Level of Care Table
Description
HCPCS
Population
MIA, DDA
Coverage
Additional “b3” Services
Unit Description
Service
Unit Minimum
1 service per day
Unit Maximum
31 services per day
837 Type
Professional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Adults Only
No
Check
No
codes?
Yes
No restrictions
Page 63 of 182
Intensive Crisis Stabilization Services
S9484 – Crisis intervention mental health services, per hour. Use for the MDCH approved program
ONLY. Interaction must be face-face contact ONLY.
Structured treatment and support activities provided by a multidisciplinary team and designed to provide
short-term alternative to inpatient psychiatric services. Services may be used to avert psychiatric
admission or to shorten the length of an inpatient stay when clinically indicated. Approved by MDCH
crisis situation means a situation in which an individual is experiencing a serious mental illness or a
developmental disability, or a child is experiencing a serious emotional disturbance, and one of the
following applies:
• The individual can reasonably be expected within the near future to physically injure himself or
another individual, either intentionally or unintentionally.
• The individual is unable to provide himself clothing, or shelter, or to attend to basic physical
activities such as eating, toileting, bathing, grooming, dressing, or ambulating, and this inability
may lead in the near future to harm the individual or to another individual.
• The individual’s judgment is so impaired that he is unable to understand the need for treatment
and, in the opinion of the mental health professional, his continued behavior, as a result of the
mental illness, developmental disability, or emotional disturbance, can reasonably be expected in
the near future to result in physical harm to the individual or to another individual.
Intensive/crisis services are intensive treatment interventions delivered by an intensive/crisis
stabilization treatment team, under psychiatric supervision.
Component services include:
Intensive individual counseling/psychotherapy
Assessments
Family Therapy
Psychiatric Supervision
Therapeutic support services by trained paraprofessionals
Individual Plan of Service must contain:
Clearly stated goals and measurable objectives, derived from the assessment of immediate need, and
stated in terms of specific observable changes in behavior, skills, attitudes, or circumstances, structured
to resolve the crisis.
Identification of the services and activities designed to resolve the crisis and attain his goals and
objectives.
Plans for follow-up services (including other mental health services where indicated) after the crisis has
been resolved. The role of the case manager must be identified, where applicable.
For children’s intensive/crisis services, the treatment plan must address the child’s needs in context with
the family needs. Educational services must also be considered and the treatment plan must be
developed in consultation with the child’s school district staff.
Page 64 of 182
Intensive Crisis Stabilization Services
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Unit = Hour
Unit Minimum
1unit per day
Unit Maximum
24 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Provider must be enrolled and approved by MDCH
Check
codes?
No
Exceptions: Inpatient settings, Jails or other settings
where the beneficiary has been adjudicated or Crisis
residential settings.
Page 65 of 182
Medication Administration
96372 – Medication Administration
96372QJ – (QJ Modifier – jail/correction setting) Medication Administration
99605 - Medication Therapy management
96372 – Therapeutic, prophylactic, or diagnostic injection: subcutaneous or intramuscular
99605 – Medication Therapy management.
99211 – Office or other Outpatient visit for E/M established patient – may not require physician or other
health care professional – presenting problem usually minimal – Typically 5 minutes
90833 – (30 minutes with patient and/ or family member) add on code when performed with an
evaluation and management service
Medication Administration is the process of giving a physician-prescribed oral medication, injection,
intravenous (IV) or topical medication treatment to a beneficiary. This should not be used as a separate
coverage when other health services are utilized, such as Private Duty Nursing or Health Services,
which already include these activities. A physician, physician assistant, nurse practitioner, or registered
nurse may perform medication administration under the direct supervision of the physician; a licensed
practical nurse that is assisting the physician may perform medication administration as long as the
physician is on-site.
For injections administered through the CMHSP clinic, refer to the Inject able Drugs and Biological
subsection of the Practitioner Chapter of this manual.
Clarifying Points:
•
•
As medication administration is usually less than 15 minutes in length, the rounding rule is
waived. Report one 15 minute unit for each medication administration encounter that is less than
15 minutes.
For encounter reporting purposes, you may report both a Medication Review and Medication
Administration done on the same day if the Administration is done by someone other than the
professional who performed the Medication Review.
Page 66 of 182
Medication Administration
Level of Care Table
Description
CPT
Population
MIA, SED, DDA, DDC,
Coverage
State Plan,
Unit Description
Encounter
Unit Minimum
1 encounter per day
Unit Maximum
Generally no more than 4 encounters per day
Other Rules
Report procedure code only when provided as a separate service.
837 Type
Professional
Modifier(s)
QJ: Beneficiary received a service while incarcerated
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Physician, licensed physician’s assistant, nurse practitioner,
registered nurse, or a licensed practical nurse assisting a physician
Check
No
codes?
No
encounters.
Page 67 of 182
Medication Review
M0064 – Brief assessment (generally less than 10 minutes), medication monitoring and change
99201-99215 – Psychiatric evaluation and medication management
99324-99328, 99334-99337 – Domiciliary care, rest home, assisted living visits
99341-99350 – Home visits
H2010 – Comprehensive Medication Services (use ONLY with Evidence-based Practice – Medication
Algorithm)
M0064 - Brief assessment (generally less than 10 minutes), med monitoring by nurse; med monitoring
or change by nurse practitioner, or physician’s assistant, or physician; or PA or MD/DO plus a licensed
practical nurse.
NEW Patient (99201-99205)
99201 – Office or other outpatient visit: Evaluation and Management of a new patient requires 3 key
components: problem focused history, problem focused examination, and straightforward medical
decision making.
components: expanded problem focused history, expanded problem focused examination, and
straightforward medical decision making.
components: detailed history, detailed examination, and medical decision making of low complexity
components: a comprehensive history, comprehensive examination, and medical decision making of
moderate complexity
components: a comprehensive history, comprehensive examination, and a medical decision making of
high complexity
Established Patient (99211-99215)
99211 – Office or other outpatient visit: Evaluation and Management of an established patient that may
not require the presence of physician or other qualified health care professional: presenting problem
usually minimal: typically 5 minutes
99212 – Office or other outpatient visit: Evaluation and Management of an established patient requires 2
of 3 key components: problem focused history, problem focused examination, and straightforward
medical decision making: typically 10 minutes
of 3 key components: expanded problem focused history, expanded problem focused examination, and
medical decision making of low complexity: typically 15 minutes***Methadone Medication Monitoring
99214 – Office or other outpatient visit: Evaluation and Management of established patient requires 2 of
3 key components: detailed history, detailed examination, and medical decision making of moderate
complexity: typically 25 minutes ***Methadone Medication Monitoring
3 key components: comprehensive history, comprehensive examination, and medical decision making of
high complexity: typically 40 minutes ***Methadone Medication Monitoring
Page 68 of 182
H2010 Comprehensive Medication Services please use only with Evidence Based Practice – Medication
Algorithm.
Add on Codes
90833- Therapy (mental health) 30 minutes
90785- Interactive
Medication Review is evaluating and monitoring medications, their effects, and the need for continuing
or changing the medication regimen. A physician, physician assistant, nurse practitioner, registered
nurse, licensed pharmacist or licensed practical nurse assisting the physician may perform medication
reviews. Medication review includes the administration of screening tools for the presence of extra
pyramidal symptoms and tardive dyskinesia secondary to untoward effects of neuroactive medications.
EPS tardive dyskinesia testing is included in medication review services.
Clarifying Points:
•
•
If a Medication Review is provided to an ACT client who has Medicare and Medicaid, the
service is billed to Medicare as M0064. The service is also reported to DCH as an ACT
encounter (code H0039).
Only a MD or DO, or a licensed physician’s assistant or nurse practitioner under the supervision
of a physician (MCL 333.17076 (3)), may prescribe medications
Page 69 of 182
Medication Review
Level of Care Table
Description
CPT Codes 99201-99215. HCPCS for M0064 and H2010
Population
MIA, SED, DDA, DDC
Coverage
State Plan;
Unit Description
Encounter
Unit Minimum
1 Encounter per day
Unit Maximum
Other Rules
M0064= 2 encounters per day
99201-99215 – 2 encounters per day
New Patient; 99201-99205
Code: Presenting Problem
99201:Self limited or minor
99202: Low to moderate
99203:Moderate
99204: Moderate to High
Key Component Code Selection: Meet or exceed 3 of 3
99211: no key components are required at this coding level
99212: Self limited or minor
99214: Moderate to high
Key Component by Counseling Intraservice Time: Doctor time
doing the History, Exam, Clinical Decision Making, Counseling, and
Coordination of Care: When Counseling and/or coordination of care
represents 50% or more of the total E/M encounter, then time may
become the overriding factor for code selection.
Example:
E/M Beginning time 3:00 pm
Start Counseling
3:10 pm
E/M Ending Time 3:25 pm
Counseling/Total Time Ratio: 15/25 min
(15 minutes is more than 50%)
Time
40 min.
25 min
15 min
10 min
5 min
Code
99215
99214
99213
99212
99211
Add on Codes:
+90785 interactive complexity used with 90791 or 90792
psychiatric evaluation
837 Type
Professional
Modifier(s)
GT: telemedicine was provided via video-conferencing face – to –
face with the beneficiary;
Start Date
October 1, 2013
End Date
None at this time
90862
Member Age Check
None
Page 70 of 182
Check
Physician – 99201-99205
registered nurse, or a licensed practical nurse assisting a physician 99211-99215
codes?
No
encounters.
Page 71 of 182
Occupational Therapy
97003- Occupational Therapy Evaluation: Physician order required
97004 – Occupational Therapy Re-evaluation: Physician order required
Occupational Therapy – Individual:
97110, 97112, 97113, 97116, 97124, 97140, 97530, 97532, 97533, 97535, 97537, 97542, 97750, 97755,
97760, 97762, S8990 – per encounter
Occupational Therapy – Group, per session
97150
Includes both the evaluation as well as the treatment. Therapy is the application of occupation-oriented
or goal-oriented activity to achieve optimum functioning, to prevent dysfunction, and to promote health.
Services are prescribed by a physician and provided by a qualified occupational therapist licensed by the
State of Michigan to recommend a course of treatment. An occupational therapy assistant may not
complete evaluations.
•
•
•
OT and PT have the same codes
Services provided by a Certified Occupational Therapist Assistant must be signed off by the
supervising Occupational Therapist.
Physician order required for assessment and amount, scope, frequency and duration of
treatment must be listed.
Page 72 of 182
Occupational Therapy
Level of Care Table
Description
CPT, HCPCS
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Unit = 15 minutes (except for 97150, 97003, 97004 & S8990)
Unit Minimum
1 unit per day
Unit Maximum
15 minute units= 40 units per day
Hour units= 10 units per day
Encounters= 1 encounter per day
Other Rules
None
837 Type
Modifier(s)
Professional
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Check
Must be in provider’s service array. Provided by a qualified
occupational therapist licensed by the State of Michigan to
recommend a course of treatment. An occupational therapy assistant
may not complete evaluations.
codes?
No restrictions
Page 73 of 182
Out of Home Non-Vocational Habilitation
**See also Skill Building Assistance
H2014 - Out of Home Non-Vocational Habilitation - Skills training and development (Non-HSW
beneficiary)
H2014HK – (Modifier HK) for Habilitation Supports Waiver beneficiary
H2014TT – (Modifier TT) when multiple consumers are served simultaneously
Assistance with acquisition, retention, or improvement in self-help, socialization, and adaptive skills;
and the supports services, including transportation to and from, incidental to the provision of that
assistance that takes place in a non-residential setting, separate from the home or facility in which the
beneficiary resides.
Examples of incidental support include:
• Aides helping the beneficiary with his mobility, transferring, and personal hygiene functions at
the various sites where habilitation is provided in the community.
• When necessary, helping the person to engage in the habilitation activities (e.g., interpreting).
Services must be furnished four or more hours per day on a regularly scheduled basis for one or more
days per week unless provided as an adjunct to other day activities included in the beneficiary’s plan of
service.
These supports focus on enabling the person to attain or maintain his maximum functioning level, and
should be coordinated with any physical, occupational, or speech therapies listed in the plan of services.
Services may serve to reinforce skills or lessons taught in school, therapy, or other settings.
Clarifying Points:
•
Out of Home Non Vocational Habilitation is only reportable for HSW. If this service is
performed for a non-HSW individual, it is to be reported under Skill Building Assistance. It is
the same procedure code, but reported under a different line on the Cost Element Report. The
determination as to which line on the Cost Element Report is determined whether or not the HK
modifier is used.
Page 74 of 182
Out of Home Non-Vocational Habilitation
**See also Skill Building Assistance
Level of Care Table
Description
HCPCS
Population
DDA, DDC
Coverage
Unit Description
Unit = 15 minutes
Unit Minimum
1 unit per day
Unit Maximum
40 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
HK for HSW
TT when multiple individuals are served simultaneously
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Check
codes?
Yes
No restrictions
Page 75 of 182
Out of Home Prevocational Habilitation
T2015- Out of Home Prevocational Habilitation
T2015HK – (Modifier HK) specialized mental health programs for high-risk populations) must be
reported for Habilitation Supports Waiver beneficiaries
Services aimed at preparing a beneficiary for paid or unpaid employment, but that are not job taskoriented. They include teaching such concepts as compliance, attendance, task completion, problem
solving, and safety. Prevocational services are provided to people not expected to be able to join the
general workforce, or to participate in a transitional sheltered workshop within one year (excluding
supported employment programs). Transportation provided between the beneficiary’s place of residence
and the site of the prevocational services, or between habilitation sites, is included as part of the
prevocational and/or habilitation services.
Activities included in these services are primarily directed at reaching habilitative goals, such as
improving attention span and motor skills, not at teaching specific job skills. These services must be
reflected in the person’s individual plan of services and directed to habilitative objectives rather than
employment objectives. When compensated, beneficiaries are paid at less than 50 percent of the
minimum wage.
This service must not otherwise be available to the beneficiary through the Rehabilitation Act of 1973,
or Education of the Handicapped Act (P.L. 94-142).
Documentation must be maintained by the IPN provider that the beneficiary is not currently eligible for
work activity or supported employment services provided by Michigan Rehabilitation Services (MRS).
Information must be updated when MRS eligibility conditions change.
Clarifying Points:
•
Out of Home Prevocational Habilitation is only reportable for HSW.
Page 76 of 182
Out of Home Prevocational Habilitation
Level of Care Table
Description
HCPCS
Population
DDA, DDC
Coverage
Habilitation Supports Waiver only
Unit Description
Unit = Hour
Unit Minimum
1 unit per day
Unit Maximum
8 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
HK for HSW
Start Date
10/1/13
End Date
None at this time
None
Member Age Check
None
Check
codes?
Yes
No restrictions
Page 77 of 182
Partial Hospitalization (Outpatient)
0912-Partial Hospitalization-Less Intensive
0913-Partial Hospitalization-Intensive
(Licensed by Michigan Department of Consumer and Industry Services/MDCIS) Psychiatric partial
hospitalization services are short-term, intensive services provided through a licensed nonresidential
treatment program that provides psychiatric, psychological, social, occupational, nursing, music therapy,
and therapeutic recreational services (under the supervision of a physician) to adults diagnosed as having
serious mental illness or minors diagnosed as having serious emotional disturbance who do not require
24-hour continuous mental health care, and that is affiliated with a psychiatric hospital or psychiatric
unit to which clients may be transferred if they need inpatient psychiatric care.
Level of Care Table
Description
Revenue Code
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Unit = Day
Unit Minimum
1unit per day
Unit Maximum
1 unit per day
Other Rules
None
837 Type
Institutional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
See Provider array of service
Check
codes?
Approved programs only
Page 78 of 182
Peer Delivered or Operated Support Services
H0023 – Drop in Center attendance
H0038 – Mental Health Peer specialist services provided by a Certified Peer Specialist
H0038TT – (Modifier TT) when peer service is provided in a group
H0038 HF – Substance Abuse Recovery Coach
H0046 - Peer Mentor services provided by a DD Peer Mentor
H0046TT – (Modifier TT) when peer service is provided in a group
Drop-In Centers is one of two categories of Peer-delivered or Peer-operated support services. The
function of Drop-In Centers is to foster opportunities to learn and share coping skills and strategies, to
move into more active assistance and away from passive beneficiary roles and identities, and to build
and/or enhance self-esteem and self-confidence.
Some beneficiaries use drop-in centers anonymously and do not have a drop-in center listed as a service
in their IPOS. For those beneficiaries who do have drop-in specified in their IPOS, it must be
documented to be medically necessary and identify:
• Goals and how the program supports those goals; and
• The amount, scope and duration of the services to be delivered.
The individual clinical record provides evidence that the services were delivered consistent with the
plan.
Clarifying Points:
•
•
Drop-In Centers cannot be used as respite for caregivers (paid or non-paid) or residential
providers of individuals.
The staff and board of directors of the center must be 100% primary consumers. Staff are not
required to be certified peers.
Page 79 of 182
Peer Delivered or Operated Support Services
Level of Care Table
Population
Coverage
Unit Description
Unit Minimum
Unit Maximum
Other Rules
837 Type
Modifier(s)
Start Date
End Date
Member Age Check
Provider Service Array/Credential Check
Can be used in conjunction with other codes?
Description
HCPCS
MI-A
1915(b)(3) & EPSDT
Per Day/Encounter
1encounter per day
1encounter per day
• MDCH prior approval required
• Report as encounter when beneficiary signed
time-in/out log, other
Professional
N/A
October 1, 2013
None at this time
None
Adult
N/A
No
Approved programs only
Page 80 of 182
•
Peer-Delivered or Operated Support Services
(Certified Peer Support Specialist)
H0038 – Peer Specialist Services (Certified Peer Support Specialist)
H0038TT – (Modifier TT is used when peer service is provided in a group)
Peer Specialist Services is one of two categories of Peer-delivered or Peer-operated Support Services.
Certified Peer Support Specialists, individuals having lived experience with mental illness and MDCH
trained and certified to provide mental health services, and Certified Peer Mentors (MDCH trained and
certified to work with people who have a developmental disabilities) can provide billable services.
However, the scope of those services, procedure codes, and modifiers used for each differ:
H0038 is used when the Peer is a Certified Peer Support Specialist and provides one or a combination of
the services that follow:
Coverage includes:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Vocational assistance
Housing assistance
The person-centered planning process (reported as either treatment planning or supports
coordination*)
Developing and applying arrangements that support self-determination
Directly selecting, employing or directing support staff
Sharing stories of recovery and/or advocacy involvement and initiative for the
purpose of assisting recovery and self-advocacy
Accessing entitlements
Developing health and wellness plans
Developing advance directives
Learning about and pursuing alternatives to guardianship
Providing supportive services during crises
Developing, implementing and providing ongoing guidance for advocacy and support groups
Integration of physical and mental health care
Developing, implementing and providing health and wellness classes to address preventable risk
factors for medical conditions
Clarifying Points:
•
•
The HE modifier should not be used with the Peer Specialists Service code (H0038). The HE
modifier is only used when a Certified Peer Support Specialist provides or assists in the delivery
of a non-Peer-Delivered” covered service, e.g., Assertive Community Treatment (H0039),
Community Living Supports (H2015), and Treatment Planning (H0032), etc.
The HF modifier should be used with the H0038 Code when both: 1) the service is part of a
Substance Abuse Treatment or Program, 2) a Recovery Coach (peer services) provides the
service.
Page 81 of 182
•
Uncertified Peers may bill. Allowable billing codes include, but are not limited to Community
Living Supports (H2015 or H0043), Skill Building (H2014), and Treatment Planning (H0032),
etc.
(Certified Peer Support Specialist)
Level of Care Table
Population
Coverage
Unit Description
Unit Minimum
Unit Maximum
Other Rules
837 Type
Modifier(s)
Start Date
End Date
Member Age Check
Description
HCPCS
MI-A
1915(b)(3) & EPSDT
Unit = 15 minutes
1 unit per day
96 units per day
Peer service documented in scope, amount, and
duration in the Person-Centered Plan
Professional
TT- multiple people are face-to-face simultaneously
October 1, 2013
None at this time
None
Adult
MDCH Certified Peer Support Specialist
No
No restrictions apply
Page 82 of 182
(DD Peer Mentor)
H0046 - Peer Specialist Services (Certified Peer Mentor)
H0046TT - (Modifier TT is used when peer service is provided in a group)
Peer Specialist Services is one of two categories of Peer-delivered or –Peer-operated Support Services.
Certified Peer Support Specialists, individuals having lived experience with mental illness and MDCH
trained and certified to provide mental health services, and Certified Peer Mentors (MDCH trained and
certified to work with people who have a developmental disabilities) can provide billable services.
However, the scope of those services, procedure codes, and modifiers used for each differ:
H0046 is used when the Peer is a Certified Peer Mentor and provides one or a combination of the
services that follow:
Coverage includes:
•
•
•
•
•
•
•
•
•
Benefits planning Support employment: supporting individuals obtain and maintain employment
Housing: assisting an individual to access safe and clean accessible housing
Transportation
Post-secondary Education
Moving toward independence
Recreation/community participation
Living well & knowing which way to turn
Person-Centered Planning
Independent Facilitation
Clarifying Points:
•
•
The HI modifier should not be used with the H0046 Code. HI modifier is only used when a
Certified Peer Mentor provides or assists with a non-Peer-Delivered covered service, e.g.,
Assertive Community Treatment (H0039), Community Living Supports (H2015), and Treatment
Planning (H0032), etc.
Uncertified Peers may bill. Allowable billing codes include, but are not limited to Community
Living Supports (H2015 or H0043), Skill Building (H2014), and Treatment Planning (H0032),
etc.
Page 83 of 182
(DD Peer Mentor)
Level of Care Table
Population
Coverage
Unit Description
Unit Minimum
Unit Maximum
Other Rules
837 Type
Modifier(s)
Start Date
End Date
Member Age Check
Description
HCPCS
DD-A
1915(b)(3) & EPSDT
Unit = 15 minutes
1 unit per day
96 units per day
None
Professional
TT- multiple people are face-to-face simultaneously
October 1, 2013
None at this time
None
Adult
MDCH Certified Peer Mentor
No
No restrictions apply
Page 84 of 182
Recovery Supports (with/without Peer Recovery Coaches)
T1012, H0038, G0409, H0023
T1012 - Alcohol and/or drug services; Recovery Support and Skills Development. Activities to develop
client community integration and recovery support
H0038 - Peer services, per 15 minutes
G0409 - Social work and psychological services
H0023 - Planned outreach service (Drop in Center attendance, Welcoming Center attendance)
Recovery/Peer support programs are designed to support and promote recovery and prevent relapse
through supportive services that result in the knowledge and skills necessary for an individual’s
recovery. Peer recovery programs are designed and delivered primarily by individuals in recovery and
offer social emotional and/or educational supportive services to help prevent relapse and promote
recovery.
Peer provided recovery support services make opportunities available to support, mentor and assist
individuals to achieve community inclusion, participation, independence, recovery, resiliency and/or
productivity. Peers are individuals who have a unique background and skill level from their experience
in utilizing services and supports to achieve their personal goals of community membership,
independence and productivity. Peers have a special ability to gain trust and respect of other individuals
based on shared experience and perspectives with disabilities and SUDs, and with planning and
negotiating human services systems.
Recovery community support center services (also called drop-in centers, welcoming centers,
engagement centers, recovery centers and sobering centers) provide an informal, supportive
environment to assist individuals with SUDs in the recovery process. These centers provide
opportunities to learn and share coping skills and strategies, to move into more active assistance and
away from passive individual roles and identities, and to build and/or enhance self-esteem and selfconfidence.
Page 85 of 182
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Block Grant, PA 2 & State Plan
Unit Description
Unit = 15 Minutes
Unit Minimum
Up to 1.25 hours per client
Unit Maximum
Up to 27 hours per client
Other Rules
837 Type
Professional
Modifier(s)
HA, HB, HC, HF, HG, HH
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Adolescents & Adults
Appropriately trained professional and/or non-professional staff
Check
codes?
Yes
(57) Non-residential substance abuse treatment facility
Page 86 of 182
Personal Care – Licensed Setting
T1020-Personal Care – Provided in specialized AFC home ONLY (no modifier for low need or low cost
cases)
T1020TF – Personal Care (moderate need or moderate need cases)
T1020TG – Personal Care (high need or high cost cases)
Personal care services are those services provided in accordance with an individual plan of service
(amount, duration and scope) to assist a beneficiary in performing his own personal daily activities.
Services may be provided only in a licensed foster care setting with a specialized residential program
certified by MDCIS. These personal care services are distinctly different from the state plan Home Help
program administered by DHS.
Personal care services are covered when authorized by a physician or other healthcare provider, in
accordance with an individual plan of services, and rendered by a qualified person. Supervision of
personal care services must be provided by a health care professional who meets the qualifications.
Level of Care Table
Description
HCPCS
Population
MIA/DDA (DDC with prior approval from DHS)
Coverage
State Plan
Unit Description
Encounter
Unit Minimum
1 encounter per day
Unit Maximum
31encounters per month depending on the number of days in a month
Other Rules
None
837 Type
Professional
Modifier(s)
No modifier = Low Level of Care
TF = Moderate Level of Care
TG = High Level of Care
Levels are specific to each Managed Care Provider Network
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Adult
No
Check
codes?
Licensed Specialized Residential Adult Foster Care Facilities Only
Page 87 of 182
Personal Emergency Response System (PERS)
Personal Emergency Response Systems (PERS)
S5160 – PERS installation
S5161 – PERS Service fee, per month
S5160HK – (Modifier HK is used for Habilitation Supports Waiver beneficiary)
Electronic devices that enable beneficiaries to secure help in the event of an emergency. The
beneficiary may also wear a portable “help” button to allow for mobility. The system is connected to
the person’s phone and programmed to signal a response center once the button is activated.
PERS coverage should be limited to beneficiaries living alone (or living with a roommate who does not
provide supports), or who are alone for significant parts of the day; who have no regular support or
service provider for those parts of the day; and who would otherwise require extensive routine support
and guidance.
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC
Coverage
Habilitation Supports Waiver & Additional “b3” Service
Unit Minimum
PERS Installation
PERS Service fee, per month
1 unit total for Installation
1 unit per month for Monthly Service Fee
Unit Maximum
Typically one per month
Other Rules
None
837 Type
Professional
Modifier(s)
HK
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Unit Description
Check
codes?
No
No restrictions
Page 88 of 182
Physical Therapy
97001 – PT Evaluation - Physician order required
97002 – PT Re-Evaluation - Physician order required
97110, 97112, 97113, 97116, 97124, 97140, 97530, 97532, 97533, 97535, 97537, 97542, 97750, 97760,
97762, S8990 – Physical Therapy – Individual
97150 - Physical Therapy – Group
Includes the evaluation and the treatment as provided by a qualified physical therapist/assistant and
prescribed by a physician. Physical therapy means the evaluation or treatment of an individual by the
employment of effective properties of physical measures and the use of therapeutic exercises and
rehabilitative procedures, with or without assistive devices, for the purpose of preventing, correcting, or
alleviating a physical or mental disability.
•
•
Physician order required or licensed physician assistant
Physician order required for assessment and amount, scope, frequency and duration of treatment
must be listed
Page 89 of 182
Physical Therapy
Level of Care Table
Description
CPT, HCPCS
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
15 minutes (except for 97150, 97001, 97002 & S8990)
Unit Minimum
1 unit per day
Unit Maximum
Other Rules
837 Type
15 minute units= 40 units per day
Hour units= 10 units per day
Encounters= 1encounter per day
None
Professional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Check
codes?
Provided by a qualified physical therapist/assistant and prescribed by
a physician
No restrictions
No
Page 90 of 182
Physician Services Related to Mental Health
90805 - Individual Psychotherapy with Medical Evaluation and Management Services
90887 - Interpretation of results of Psychiatric Examination
EVALUATION & MANAGEMENT--NEW PATIENT
99201 - Straightforward medical decision making--typically 10 minutes
99203 - Medical decision making of low complexity--typically 30 minutes
99204 - Medical decision making of moderate complexity--typically 45 minutes
99205 - Medical decision making of high complexity--typically 60 minutes
EVALUATION & MANAGEMENT--ESTABLISHED 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.
assist patient.
99201-99215 - Medicaid covers medically necessary evaluation and management (E/M) services
provided by a physician or other practitioner authorized by the State. Providers should refer to the CPT
explanations, coding conventions, and definitions for E/M services.
Most E/M services are covered once per day for the same beneficiary. In these cases, only one office or
outpatient visit is covered on a single day for the same beneficiary unless the visits were for unrelated
reasons and at different times of the day (e.g., office visit for blood pressure medication evaluation,
followed five hours later by a visit for evaluation of leg pain following an accident).
Coverage of an E/M service includes related activities such as coordination of care, telephone calls,
writing prescriptions, completing insurance forms, review and explanation of diagnostic test reports to
the beneficiary.
Clarifying Points:
•
Do not report the modifier for unusual procedural services with E/M services in order to request
individual consideration. This does not follow CPT coding guidelines and causes longer delays
in processing the claims for payment.
Page 91 of 182
Physician Services Related to Mental Health
Level of Care Table
Description
CPT
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Encounter
Unit Minimum
1 encounter per day
Unit Maximum
Normally 1 per day
Other Rules
None
837 Type
Professional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Check
codes?
No
No restrictions
Page 92 of 182
Prevention Services - (Direct Model)
H0025 -Prevention Services – Behavioral Health prevention education - Direct Model
H0025- School Success and Child Care Expulsion
H2027- Family Skills Training/ Group for children of adults with mental illness.
S9482- Infant Mental Health
T2024- Children of Adults with mental Illness\
T1027- Parent Education
Programs using both individual and group interventions designed to reduce the incidence of behavioral,
emotional or cognitive dysfunction, thus reducing the need for individuals becoming treatment
consumers of the mental health system. Models include Children of Adults with Disorders, Infant
Mental Health when not enrolled as a Home-Based Program, and Parent Education and School Success
programs.
Questions/Answers:
Q. How would you report prevention services to a non-enrolled member?
A. If you have no consumer ID number (i.e. not enrolled thru DWCCMHA) I am not sure you can.
Need to clarify this issue with DWCCMHA
Q. If prevention is provided to an enrolled member, wouldn't they already
be identified as needing mental health services?
A. On the Total Element report submitted by CMHSPs, there is a cell to report "indirect
prevention" costs -- that is where it would be reported in other places.....but if DWCCMHA does
not ask you about those costs, you cannot report them! If they are enrolled, you are right that
what they are getting is not usually prevention --- again elsewhere if a CMH sees a Medicaid
child who has a parent with SPMI then prevention is provided and reported (H0025). Your
barrier to reporting is the DW enrollment process.
Page 93 of 182
Prevention Services - (Direct Model)
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC
Coverage
Additional “b3” Services
Unit Description
H0025- Encounter
S948215- Minute unit
T2024- Encounter
T1027- 15 minute
H2027- 15 minute
Unit Minimum
Unknown
Unit Maximum
H0025= 1 encounter per day
S948215= 40 units per day
T2024- 1 encounter per day
T1027- 40 units per day
H2027- 96 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Must be approved by D-WCCMHA to provide this
service
Provider Service Array/Credential Check H0025- Qualified Children’s Mental Health
Professional
S9482- Infant Mental Health Level 2 Endorsement
T2024- Mental Illness Professional
codes?
No
No
No restrictions
Page 94 of 182
Private Duty Nursing
S9123 – Private Duty Nursing – 21 years and over ONLY – provided by Registered Nurse
S9124 – Private Duty Nursing – 21 years and over ONLY – provided by Licensed Practical Nurse
S9123HK, S9124HK – (Modifier HK – Habilitation Supports Waiver beneficiary age 21 years and older
ONLY) – individual nurse ONLY
S9123TT, S9124TT (Modifier TT – use for multiple beneficiaries in same setting)
T1000 – Private Duty/Independent Nursing Service(s), Licensed
T1000HK – Private Duty Nursing (Habilitation Supports Waiver)
T1000TD – Private Duty/Independent Nursing Service(s), Licensed provided by Registered Nurse
T1000TE - Private Duty/Independent Nursing Service(s), Licensed provided by Licensed practical nurse
or Visiting Nurse
Modifier HK – use for Habilitation Supports Waiver beneficiaries
Modifier TD – use for registered nurse
Modifier TE – use for licensed practical nurse or licensed visiting nurse
Modifier TT – use for multiple beneficiaries in same setting
Private Duty Nursing (PDN) services consist of nursing procedures to meet an individual’s health needs
that are directly related to his developmental disability. Private Duty Nursing is defined as nursing
services for beneficiaries who require more individual and continuous care, in contrast to part-time
intermittent care, than is available under the home health benefit. These services are provided by a
registered nurse (RN), or license practical nurse (LPN) under the supervision of an RN, and must be
ordered by the beneficiary’s physician. Beneficiaries requiring PDN must demonstrate a need for
continuous skilled nursing services, rather than a need for intermittent skill nursing, personal care,
and/or Home Help services.
The IPN provider must determine the extent to which the individual’s health needs, as described in I or
II below, require nursing procedures as described in III. The provider must find that the beneficiary
meets the Medical Criteria of I and III listed below, or meets Medical Criteria II and III listed below.
Regardless of whether the beneficiary meets Medical Criteria I or II, the beneficiary must also meet
Medical Criteria III. PDN services are necessary to prevent institutionalization.
Medical Criteria I – The beneficiary is dependent daily on technology-based medical equipment to
sustain life. “Dependent daily on technology-based medical equipment” means:
• Mechanical ventilation (four or more hours per day) or assisted respiration (Bi- PAP or CPAP);
or
• Oral or tracheostomy suctioning eight or more times in a 24-hour period; or
• Nasogastric tube feedings or medications when removal and insertion of the nasogastric tube is
required, associated with complex medical problems or medical fragility; or
• Total parenteral nutrition delivered via a central line, associated with complex medical
problems or medical fragility; or
• Continuous oxygen administration, in combination with a pulse oximeter and a documented need
for observations and adjustments in the rate of oxygen administration
Medical Criteria II – Frequent episodes of medical instability within the past three to six months,
requiring skilled nursing assessments, judgments or interventions (as described in III below) due to a
substantiated progressively debilitating physical disorder.
Definitions:
Page 95 of 182
•
•

•
•
•
“Frequent” means at least 12 episodes of medical instability related to the progressively
debilitating physical disorder within the past six months, or at least six episodes of medical
instability related to the progressively debilitating physical disorder within the past three months.
“Medical instability” means emergency medical treatment in a hospital emergency room or
inpatient hospitalization related to the underlying progressively debilitating physical disorder.
“Emergency medical treatment” means covered inpatient and outpatient services that are
furnished by a provider that is qualified to furnish such services and are needed to evaluate or
stabilize an emergency medical condition. “Emergency medical condition” means a medical
condition manifesting itself by acute symptoms of sufficient severity (including severe pain)
such that a prudent layperson who possesses an average knowledge of health and medicine could
reasonably expect the absence of immediate medical attention would result in placing the health
of the individual in serious jeopardy, serious impairment to bodily functions, or serious
dysfunction of any bodily organ or part.
“Progressively debilitating physical disorder” means an illness, diagnosis, or syndrome that
results in increasing loss of function due to a physical disease process, and that has progressed to
the point that continuous skilled nursing care (as defined in III below) is required.
“Substantiated” means documented in the clinical/medical record, including the nursing notes.
Note: For beneficiaries described in II above, the requirement for frequent episodes of medical
instability is applicable only to the initial determination for private duty nursing. A
determination of need for continued private duty nursing services is based on the continuous
skilled nursing care.
Medical Criteria III – The beneficiary requires continuous skilled nursing care on a daily basis during
the time when a licensed nurse is paid to provide services.
Definitions:
• “Continuous” means at least once every 3 hours throughout a 24-hour period, and/or when
delayed interventions may result in further deterioration of health status, in loss of function or
death, in acceleration of the chronic condition, or in a preventable acute episode.
• Equipment needs alone do not create the need for skilled nursing services.
• “Skilled nursing” means assessments, judgments, interventions, and evaluations of interventions
requiring the education, training, and experience of a licensed nurse. Skilled nursing care
includes, but is not limited to, performing assessments to determine the basis for acting or a need
for action monitoring fluid and electrolyte balance; suctioning of the airway; injections;
indwelling central venous catheter care; managing mechanical ventilation; oxygen administration
and evaluation; and tracheostomy are.
Licensed nurses provide the nursing treatments, observation, and/or teaching as ordered by a physician,
and that are consistent with the written individual plan of services.
These services should be provided to a beneficiary at home or in the community. A physician’s
prescription is required.
The IPN provider must assess and document the availability of all private health care coverage (e.g.,
private or commercial health insurance, Medicare, health maintenance organization, preferred provider
organization, Champus, Worker’s Compensation, an indemnity policy, automobile insurance) for private
duty nursing and will assist the beneficiary in selecting a private duty nursing provider in accordance
with available third-party coverage. This includes private health coverage held by, or on behalf of, a
beneficiary.
Note: Private Duty Nursing is a Medicaid coverage for beneficiaries under age 21 who meet the
medical criteria for eligibility and, therefore, private duty nursing services covered by this waiver are not
Page 96 of 182
available to that age group. Refer to the Private Duty Nursing Chapter of this manual for additional
information.
Questions/Answers:
Q. We were wondering what the differences are between the S9123 and S9124 Private Duty Nursing
versus the T1000 code (except that one is per hour and the other is per 15 minutes). Can you give some
clarification so we can use the codes appropriately?
A. There is no difference -- several PIHPs have decided to use the 15 minute code only as that allows
more precision in payment. DCH would like to take some codes off the list, but cannot dictate "billing"
practices -- especially when dealing with private agencies (such as PDN ones) -- but as the IPN you can
limit what codes are used.
Page 97 of 182
Private Duty Nursing
Level of Care Table
Description
HCPCS S9123 and S9124
Rev code 0582
Population
DDA, DDC
Coverage
Unit Description
S9123, S9124- Hour
0582- Hour
T1000- up to 15 minutes
Unit Minimum
1
Unit Maximum
S9123, S9124= 24 units per day
0582- none
T1000= 96 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
HK = Habilitation Supports Waiver
TD = Registered Nurse
TE = Licensed Practical Nurse or Licensed
Visiting Nurse
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
21 and over
21 and under is a state plan service billed directly
to the State
Have to be approved to bill Medicaid- Refer to
Medicaid Manual
codes?
No
No restrictions
Page 98 of 182
Respite Care
T1005 – Respite (15 Minutes) – Skilled or Unskilled – Medicaid Covered
This code is to be used when the provider of respite is skilled or unskilled respite providers as long as
the provider meets Medicaid qualifications (see below). Medicaid funds can be used for unskilled
respite providers as long as the payment mechanism meets Medicaid requirements (e.g., respite work is
under contract with a Network Provider or fiduciary). If the payment mechanism does NOT meet
Medicaid requirements, the General Fund procedure code S5150 (below) is to be reported.
T1005TD- (Modifier TD is for Registered Nurse ONLY)
T1005TE – (Modifier TE is for Licensed Practical Nurse ONLY)
T1005HK – (Modifier HK is for Habilitation Supports Waiver beneficiary)
H0045 – Respite care services, day in out-of-home setting
H0045HK – (Modifier HK for Habilitation Supports Waiver beneficiaries)
S5150 – Respite (15 minutes) – (Unskilled) General Fund ONLY
This code is used where respite provider does not meet Medicaid Qualifications (see below) and/or the
payment mechanism does not meet Medicaid requirements (e.g., respite worker is not under contract
with CMH or fiduciary)
S5151 – Respite (day – in-home)
S5151HK – (Modifier HK for specialized mental health programs for high-risk populations and
Habilitation Supports Waiver beneficiaries)
T2036 – Camping overnight (one night = one session)
T2037 – Day Camp (one day/partial day = one session)
Services provided to assist in maintaining a goal of living in a natural community home by temporarily
relieving the unpaid care giver. Decisions about the methods and amounts of respite should be decided
during person-centered planning. These services do not supplant or substitute for community living
support or other services of paid support/training staff.
Clarifying Points:
•
•
•
•
•
Respite care can be provided in the following locations: Beneficiary’s home or place of
residence; family friend’s home in the community; Licensed Foster Home or Licensed Group
Home. Respite Care may not be provided in: Day program settings; ICF/MR’s; nursing homes
or hospitals.
Respite Care may not be provided by: Parent of a minor beneficiary receiving the service;
spouse of the beneficiary served; beneficiary’s guardian or unpaid primary care giver.
Cost of room and board must not be included as part of the respite care unless furnished in a
facility approved by the State that is not a private residence.
Use CLS when providing such assistance as after-school care, or day care when caregiver is
normally working and there are specific CLS goals in the IPOS
Use Respite when providing relief to the caregiver.
Page 99 of 182
Respite Care
Level of Care Table
Description/Notes
HCPCS
Population
DDA, DDC, MIA and SED
Funding Source
Medicaid & General Fund
Unit Description
Unit = 15 minutes
Unit Minimum
1 unit per day
Unit Maximum
96 units per day
837 Type
Professional
Modifier(s)
T1005 -- MOD1 field
Blank = All service providers (except RN and LPN)
TD = RN
TE = LPN
T1005 – MOD2 field
Blank = Non HAB Waiver consumer
HK = HAB Waiver consumer
S5150 – MOD2
Blank = All Consumers
This is not a covered HAB Waiver service, so therefore HK cannot be
used if provided to a HAB Waiver consumer.
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Provider
Check
• Able to read and follow written plans of service/supports as well
as beneficiary-specific emergency procedures;
• In “good standing” with the law (i.e., not a fugitive from justice,
a convicted felon or illegal alien);
If the provider does not meet all of these qualifications, Medicaid funds
cannot be used for the service, thus T1005 cannot be reported. General
Funds can be used, however, and the service is to be reported as S5150.
Service
Array/Credential
codes?
Yes
See first bullet under clarifying points
Page 100 of 182
Respite Care (Per Diem)
H0045 – Respite Out of home
S5151 – Respite In home
S9125 – Respite In home – Children’s Waiver
S9125TD – (Modifier TD for RN only)
S9125TE – (Modifier TE for LPN only)
H0045 – Respite (Out of home - Per Diem) – Medicaid
This code is used when the service takes place OUT of the home and the provider meets Medicaid
qualifications (see below). Medicaid funds can be used for unskilled respite providers as long as the
payment mechanism meets Medicaid requirements (e.g., respite work is under contract with a network
provider or fiduciary). If the payment mechanism does NOT meet Medicaid requirements, the General
Fund – Respite (15 minutes) procedure code S5150 is to be reported.
S5151 – Respite (In home - Per Diem) – Medicaid
This code is used when service takes place IN the home and the provider meets Medicaid qualifications
(see below). Medicaid funds can be used for unskilled respite providers as long as the payment
mechanism meets Medicaid requirements (e.g., respite work is under contract with CMH or fiduciary).
If the payment mechanism does NOT meet Medicaid requirements, the General Fund – Respite (15
minutes) procedure code S5150 is to be reported.
Services provided to assist in maintaining a goal of living in a natural community home by temporarily
relieving the unpaid care giver. Decisions about the methods and amounts of respite should be decided
during person-centered planning. These services do not supplant or substitute for community living
support or other services of paid support/training staff.
Clarifying Points:
•
•
•
Respite care can be provided in the following locations: Beneficiary’s home or place of
residence; family friend’s home in the community; Licensed Foster Home or Licensed Group
Home. Respite Care may not be provided in: Day program settings; ICF/MR’s; nursing homes
or hospitals.
Respite Care may not be provided by: Parent of a minor beneficiary receiving the service;
spouse of the beneficiary served; beneficiary’s guardian or unpaid primary care giver.
Cost of room and board must not be included as part of the respite care unless furnished in a
facility approved by the State that is not a private residence.
Page 101 of 182
Respite Care (Per Diem)
Level of Care Table
Description/Notes
HCPCS Codes
Population
MIA, SED, DDA, DDC
Coverage
H0045 Habilitation /Supports Waiver and Additional “b3” Services
S5151 Additional “b3” Services
Unit Description
Unit = Day
Unit Minimum
1 unit per day
Unit Maximum
1 unit per day
837 Type
Professional
H0045 - MOD1 field
Blank = Non HAB Waiver consumer
HK = HAB Waiver consumer
Modifier(s)
S5151 – MOD1 field
Blank = All consumers
This is not a covered HAB Waiver service, so therefore HK cannot be used if
provided to a HAB Waiver consumer.
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Adult or Child
Check
• Able to read and follow written plans of service/supports as well as
beneficiary-specific emergency procedures;
• In “good standing” with the law (i.e., not a fugitive from justice, a
convicted felon or illegal alien);
If the provider does not meet all of these qualifications, Medicaid funds
cannot be used for the service, thus H0045 nor S5151 be reported.
General Funds can be used, however, and the service is to be reported
in 15 minute increments as a S5150.
codes?
Yes
See #2 below
Page 102 of 182
Skill Building Assistance
**See also Out of Home Non-Vocational Habilitation
H2014 – Skill Building Assistance, 15 minutes
H2014TT – (Modifier TT when multiple consumers are served simultaneously)
Consists of activities that assist an individual to achieve economic self-sufficiency and/or to engage in
meaningful activities such as school, work, and/or volunteering. The services provide knowledge and
specialized skill development and/or support. Skill-building assistance may be provided in the
beneficiary’s residence or in the community settings.
Coverage includes:
• Out-of-home adaptive skills training: Assistance with acquisition, retention, or improvement in
self-help, socialization, and adaptive skills; and supports services, including:
o Aides helping the beneficiary with his mobility, transferring, and personal hygiene
functions at the various sites where adaptive skills training is provided in the
community.
o When necessary, helping the person to engage in the adaptive skills training activities
(e.g., interpreting).
Services must be furnished on a regularly scheduled basis (several hours a day, one or more
days a week) as determined in the individual plan of services and should be coordinated
with any physical, occupational, or speech therapies listed in the plan of supports and
services. Services may serve to reinforce skills or lessons taught in school, therapy, or
other settings.
• Work preparatory services are aimed at preparing the beneficiary for paid or unpaid employment,
but are not job task-oriented. They include teaching such concepts as attendance, task
completion, problem solving, and safety. Work preparatory services are provided to people not
able to join the general workforce, or are unable to participate in a transitional sheltered
workshop within one year (excluding supported employment programs).
• Activities included in these services are directed primarily at reaching habilitative goals (e.g.,
improving attention span and motor skills), not at teaching specific job skills. These services
must be reflected in the beneficiary’s person-centered plan and directed to habilitative or
rehabilitative objectives rather than employment objectives.
• Transportation from the beneficiary’s place of residence to the skill building assistance training,
between skill training sites if applicable, and back to the beneficiary’s place of residence.
Clarifying Points:
•
•
Group Home transportation costs are not included in Skill Building.
Skill Building provided by peers need to be reported with HE modifier.
Boundaries between Skill-building and CLS:
• Report Skill-building when there is a vocational or productivity goal in the IPOS and the
individual is being taught the skills he/she will need to be a worker (paid or unpaid)
• Report CLS when an individual is being taught skills in the home that will enable him/her to live
more independently
Boundaries between Skill-building and Supported Employment:
Page 103 of 182
•
•
Report Skill-building when the individual has a vocational or productivity goal to learn how to be a
worker.
Report Supported Employment when the goal is to obtain a job (integrated, supported, enclave, etc.) and
assistance is being provided to obtain and retain the job.
Skill Building Assistance
**See also Out of Home Non-Vocational Habilitation
Level of Care Table
Description
HCPCS
Population
MIA, DDA
Coverage
Additional (b)(3) Services
EPSDT for individuals under 21
Unit Description
Unit = 15 minutes
Unit Minimum Rule
1 unit per day
Unit Maximum
40 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
HK = HSW
AC = ACT
HE = Peer
TT when multiple individuals are served simultaneously
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Adults
Check
Can be used in conjunction with other NA
codes?
Yes
No restrictions
Page 104 of 182
Speech & Language Therapy
92506 & 92610 - Speech & Language Evaluation
92507 & 92526 - Speech & Language Therapy, Individual, per session
92508 - Speech & Language Therapy, Group, per session
Includes activities provided by a speech-language pathologist or licensed audiologist to determine the
beneficiary’s need for services and to recommend a course of treatment. A speech-language pathology
assistant may not complete evaluations.
Level of Care Table
Description
CPT
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Encounter
Unit Minimum Rule
1 encounter per day
Unit Maximum
1 encounter day
Other Rules
Must have a doctor’s order on file prior to service initiation
837 Type
Professional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Check
codes?
No restrictions
Page 105 of 182
State Inpatient Psychiatric Hospital
Procedure Code Description
0100 – ICF/MR Only – All-Inclusive Room & Board plus Ancillary
0101 – ICF/MR Only – All-Inclusive Room & Board
0114 – Room & Board – Private
0124 – Room & Board – Semi-Private 2 Beds
0134 – Room & Board – Semi-Private 3-4 Beds
0154 – Room & Board - Ward
All encounters for State facilities are submitted to DWMHA who converts data to the 0100 code
for submission to the Michigan Department of Community Health.
Included are all inpatient services provided by state psychiatric hospitals for adults and children and
centers for persons with developmental disabilities. Services provided by the Forensic Center are not
included.
Clarifying Points:
•
•
•
•
Consumer is in hospital as of Midnight
Age exceptions can be made in certain circumstances
Bundled Per-Diem, not Room & Board
All State Hospitals are general fund
Page 106 of 182
State Inpatient Psychiatric Hospital
Level of Care Table
Description
Revenue Codes
Population
MIA, SED, DDA, DDC
Coverage
General Fund
Unit Description
Unit = Day
Unit Minimum
1unit per day
Unit Maximum
1 unit per day
Other Rules
None
837 Type
Institutional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Limited to a specific set of State Hospitals. See providers
service array
Check
codes?
Yes
8 – Hospital
Page 107 of 182
Supported (Integrated) Employment Services
H2023 - Supported Employment
H2023 HE – (Modifier HE - Supported Employment by Certified Peer Support Specialist)
H2023HI – (Modifier HI - Supported Employment by Peer Mentor)
H2023HK – (Modifier HK – Supported Employment for Habilitation Supports Waiver Beneficiaries)
H2023 TG – (Modifier TG - Supported Employment - Evidence Based Practice Model)
H2023 TT – (Modifier TT - Supported Employment, multiple people served simultaneously)
Provide job development, initial and ongoing support services to assist beneficiaries to obtain and
maintain paid employment that would otherwise be unachievable without such supports. Supports
services are provided continuously as needed throughout the period of employment. Capacity to
intervene to provide assistance to the individual and/or employer in episodic occurrences of need is
included in this service. Supported/integrated employment must be provided in integrated work settings
where the beneficiary works alongside people who do not have disabilities.
Coverage includes:
• Job development, job placement, job coaching, and long-term follow-along services required to
maintain employment.
• Individual-run businesses (e.g., vocational components of Fairweather Lodges, supported selfemployment, MicroEnterprises)
• Transportation provided from the beneficiary’s place of residence to the site of the supported
employment service, among the supported employment sites if applicable, and back to the
beneficiary’s place of residence.
Coverage excludes:
• Employment preparation
• Services otherwise available to the beneficiary under the Individuals with Disabilities Education
Act (IDEA)
Page 108 of 182
Supported (Integrated) Employment Services
Level of Care Table
Description
HCPCS
Population
MIA and DDA
Coverage
HAB & Additional (b)(3) Services
Unit Description
Unit = 15 Minutes
Unit Minimum
1 unit per day
Unit Maximum
40 units per day
Other Rules
None
837 Type
Professional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at time
None
Member Age Check
Must be 18 years or older
Provider Service Array/Credential Check See Provider Service Array
codes?
No
Yes
Individual’s place of work
Page 109 of 182
Supports Coordination
T1016 - Supports Coordination / Case Management – face-face ONLY
T1016HK – (Modifier HK – Habilitation Supports Waiver Beneficiaries)
Supports coordination involves working with the waiver beneficiary to assure all necessary supports and
services are provided to enable the beneficiary to achieve community inclusion and participation,
productivity, and independence in home-and community-based settings. Without the supports and
services the beneficiary would otherwise require the level of care services provided in and ICR/MR.
Supports coordination involves the waiver beneficiary, and others that are identified by the beneficiary
such as family member(s), in developing a written individual plan of services through the personcentered planning process. The waiver beneficiary may choose to work with a supports coordinator
through the provider agency, an independent supports coordinator, a supports coordinator assistant, or a
services and supports broker. Functions performed by a supports coordinator, supports coordinator
assistant, or services and supports broker include an assurance of the following:
• Assistance with access to entitlements and/or legal representation
• Brokering of provider services/supports
• Developing and IPOS using the person-centered planning process, including revisions to the
IPOS at the beneficiary’s request or as the beneficiary’s changing circumstances may warrant
• Linking to, coordinating with, follow up of, and advocacy with all supports and services,
including the Medicaid Health Plan, Medicaid fee for service or other healthcare providers.
Using person-centered process (including planning), support coordination assists in identifying and
implementing support strategies. Supports strategies will incorporate the principles of empowerment,
community inclusion, health and safety assurances, and the use of natural supports. Support
coordinators will work closely with the beneficiary to assure his ongoing satisfaction with the process
and outcomes of the supports, services, and available resources.
Supports coordination is reported only when there is a face-to-face contact with the beneficiary. Related
activities, such as telephone calls to schedule appointments or arrange supports, are functions that are
performed by a supports coordinator but not reported separately. Supports coordination functions must
assure:
• The desires and needs of the beneficiary are determined.
• The supports and services desired and needed by the beneficiary are identified and implemented.
• Housing and employment issues are addressed.
• Social networks are developed.
• Appointments and meetings are scheduled
• Person-centered planning is provided.
• Natural and community supports are used.
• The quality of the supports and services, as well as the health and safety of the beneficiary, is
monitored.
• Income/benefits are maximized.
• Activities are documented
• Plans of supports/services are reviewed at such intervals as are indicated during planning.
Additionally, the supports coordinator coordinates with the qualified mental retardation professional
(QIDP) on the process of initial waiver eligibility certification and annual re-certification
Page 110 of 182
Supports coordination does not include any activities defined as Out-of-Home Non-Vocational
Habilitation, Prevocational Services, Supported Employment, or CLS. While supports coordination as
part of the overall plan implementation and/or facilitation may include initiation of other coverages
and/or short-term provision of supports, it may not include direct delivery of ongoing day-to-day
supports and/or training, or provision of other Medicaid services.
The frequency and scope (face-to-face and telephone) of supports coordination contacts must reflect the
intensity of the beneficiary’s health and welfare needs identified in the individual plan of services.
Clarifying Points:
•
•
•
•
Reportable Supports Coordination must be face to face.
Supports Coordination Aides can be used to provide services.
Supports Coordination contacts are allowed in community and state inpatient facilities with the
proper Place of Contact code.
This code is NOT to be used for consumers on Children’s Waiver – See separate coding for this
program
Page 111 of 182
Supports Coordination
Level of Care Table
Population
Coverage
Unit Description
Unit Minimum Rule
Unit Maximum
Other Rules
837 Type
Modifier(s)
Start Date
End Date
Member Age Check
Check
codes?
Description
HCPCS
MIA, SED, DDA, DDC
Habilitation/Supports Waiver, 1915(b)(3) services and EPSDT
15 minutes
1 unit per day
48 units per day
None
Professional
HK = HAB
October 1, 2013
None at this time
None
None
QIDP
Can be used along with a Community Inpatient stay day and/or State
Hospital day
No restrictions
Page 112 of 182
Targeted Case Management
T1017 - Targeted Case Management (face-face ONLY)
T1017SE – (Modifier SE to be used for Nursing Facility Mental Health Monitoring ONLY)
Targeted case management is a covered service that assists beneficiaries to design and implement
strategies for obtaining services and supports that are goal-oriented and individualized. Services include
assessment, planning, linkage, advocacy, coordination and monitoring to assist beneficiaries in gaining
access to needed health and dental services, financial assistance, housing, employment, education, social
services, and other services and natural supports developed through the person-centered planning
process. Targeted case management is provided in a responsive, coordinated, effective and efficient
manner focusing on process and outcomes.
Targeted case management services must be available for all children with serious emotional
disturbance, adults with serious mental illness, persons with a developmental disability, and those with
co-occurring substance use disorders, who have multiple service needs, have a high level of
vulnerability, require access to a continuum of mental health services from the IPN, and/or are unable to
independently access and sustain involvement with needed services.
Beneficiaries must be provided choice of available, qualified case management staff upon initial
assignment and on an ongoing basis.
Clarifying Points:
•
•
•
•
Case Management contacts are allowed in community and state inpatient facilities with the
proper Place of Contact code.
This code is NOT to be used for consumers on Children’s Waiver – See separate coding for this
program.
Face to Face Services with consumer
Use SE Modifier when providing Case Management when monitoring consumers for mental
health in Nursing Facility
Questions/Answers:
Q: Staff attends court for a client for support, or may be called up by the judge to offer more
information regarding client’s treatment. Client is present in court. Would this be a case management
contact?
A: If the staff is the case manager, then yes, it is a CM contact as advocacy is part of the CM definition.
Page 113 of 182
Targeted Case Management
Level of Care Table
Description
Population
Coverage
Unit Description
HCPCS
Unit Minimum Rule
Unit Maximum
Other Rules
837 Type
Modifier(s)
Start Date
End Date
Member Age Check
Check
codes?
1 unit per day
MIA, SED, DDA, DDC
State Plan
Unit = 15 minutes
48 units per day
None
Professional
QJ for services provided in the Jail
October 1, 2013
None at this time
None
None
QIDP for DDA and DDC population
QMHP for MIA and SED population
No
No restrictions
Page 114 of 182
Therapy - Family
90846 – Family Therapy
90846HS – (Modifier HS when consumer not present during Family Psychotherapy)
90847 – Family Psychotherapy (consumer present)
90849 – Family Therapy, per session
90849HA – (Modifier HA – when reporting Parent Management Training Oregon Model (PTC Group)
Includes child therapy, family therapy, group therapy and individual therapy designed to reduce maladaptive
behaviors, to maximize behavioral self-control or to restore normalized functioning, reality orientation and
emotional adjustment, thus enabling improved functioning and more appropriate interpersonal and social
relationships.
Level of Care Table
Description
CPT
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Encounter
Unit Minimum
1encounter per day
Unit Maximum
1 encounter per day
837 Type
Professional
Modifier(s)
Use modifier HA with 90849 when reporting Parent Management
training Oregon Model (PTC Group),
Modifier HS: consumer was not present during activity with family.
Start Date
October 1,2013
End Date
None at this time
None
Member Age Check
None
No
Check
codes?
No
No restrictions
Page 115 of 182
Therapy - Group
90853 - Group psychotherapy, adult or child
90853HA – (Modifier HA – Parent Management Training Oregon Model – PTC Group)
H2019 TT – (Modifier TT - Therapeutic Behavioral Services – use for group skills training using
Dialectical Behavior Therapy (DBT) provided by staff trained and certified by MDCH.)
This treatment activity is designed to reduce maladaptive behaviors, maximize behavioral self-control,
or restore normalized psychological functioning, reality orientation, remotivation, and emotional
adjustment, thus enabling improved functioning and more appropriate interpersonal and social
relationships. Group therapy is facilitated by a mental health professional.
Level of Care Table
Description
CPT
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Encounter
Unit Minimum Rule
1encounter per day
Unit Maximum
1encounter per day
837 Type
Professional
Modifier(s)
Modifier HA: Parent Management Training Oregon Model
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
No
Check
No
codes?
No
No restrictions
Page 116 of 182
Therapy - Individual
90832 - Individual therapy, adult or child, 30 minutes
90833- (30 min) psychotherapy add-on codes only (2/day)
90836 - (45 min) psychotherapy add-on codes only (2/day)
90838 - (60 min) psychotherapy add-on codes only (2/day)
H2019 – Therapeutic Behavioral Services – use for individual Dialectical Behavior Therapy (DBT)
provided by staff trained and certified by MDCH.
Individual psychotherapy, adult or child, insight oriented, behavior modifying and/or supportive, in an
office or outpatient facility.
This treatment activity is designed to reduce maladaptive behaviors, maximize behavioral self-control,
or restore normalized psychological functioning, reality orientation, re-motivation, and emotional
adjustment, thus enabling improved functioning and more appropriate interpersonal and social
relationships. Individual therapy is performed by a mental health professional.
Clarifying Points:
•
Individual therapy codes are to be reported as a unit of 1 and do not follow the “15 minute”
reporting requirement.
Page 117 of 182
Therapy - Individual
Level of Care Table
Description
CPT
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Encounter
Unit Minimum
1 encounter per day
Unit Maximum
1
837 Type
Professional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
See provider’s service array
Check
No
codes?
No
No restrictions
Page 118 of 182
Transportation
•
•
•
•
•
•
•
•
•
•
•
•
A0080 Non-emergency transportation, per mile, vehicle provided by volunteer (individual or
organization) with no vested interest.
A0090 Non-emergency transportation, per mile – vehicle provided by individual (family
member, self, neighbor) with vested interest
A0100 Non-emergency transportation; taxi
A0110 Non-emergency transportation and bus, intro-r interstate carrier
A0120 Non-emergency transportation; mini-bus, mountain area transports, or other
transportation systems
A0130 Non-emergency transportation; wheelchair van
A0140 Non-emergency transportation and air travel (private or commercial), intra-or interstate
A0170 Transportation ancillary; parking fees, tolls, other
S0209 Wheelchair van, mileage, per mile
S0215 Non-emergency transportation; mileage, per mile (see also codes A0021-A0999)
T2001 Non-emergency transportation; patient attendant; escort
T2005 Non-emergency transportation; stretcher van
IPN providers are responsible for coordinating transportation to and from the beneficiary’s place of
residence when provided so a beneficiary may participate in a state plan, HSW or additional/B3 service
at an approved day program site or in a psychosocial rehabilitation program.
Medicaid Health Plans (MHPs) are responsible for assuring their enrollees’ transportation to the primary
health care services provided by the MHPs, and to (non-mental health) specialists and out-of-state
medical providers.
The DHS is responsible for assuring transportation to medical appointments for Medicaid beneficiaries
not enrolled in MHPs; and to dental, substance abuse, and mental health services (except those noted
above and in the HSW program described in the Habilitation/Supports Waiver for Persons with
Developmental Disabilities Section of this chapter) for all Medicaid beneficiaries. (Refer to the local
DHS or MHP for additional information, and to the Ambulance Chapter of this manual for information
on medical emergency transportation.)
IPN payment for transportation is only authorized after it is determined that it is not otherwise available
(e.g., DHS, MHP, volunteer, family member), and for the least expensive available means suitable to the
beneficiary’s need.
Clarifying Points:
•
•
•
DHS is the primary funder for transportation to/from a doctor’s office for Medicaid beneficiaries
Transportation to a hospital, including between hospital settings, should be covered directly by
the ambulance company billing Medicaid directly.
Residential providers are responsible for transportation to and from program
Questions/Answers:
Q. Code S0215, used for non-emergency transportation, has a per mile unit. However, we received a
'Units of Service Exceed Allowed Limit' error after submitting encounters for this code. Can you let us
know what the maximum units allowed or should this edit be turned off, since it is based on mileage?
Page 119 of 182
A. This code (S0215) had an undefined unit type at our end. It has been changed to a mileage unit type
(the max is 500 miles). Please resubmit and it shouldn't reject for excessive units. [From April 11,
2007]
Transportation
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC
Coverage
State Plan, Additional “b3” Services
A0425 and A0425 General fund services only
Unit Description
Refer to individual code descriptions
Unit Minimum
1 mile/ unit per day
Unit Maximum
Mile codes- 1,000 miles per day
Per diem codes- 1 unit per day
Other Rules
None
837 Type
Professional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
None
Check
codes?
Yes
No restrictions
Page 120 of 182
Treatment Planning
H0032 - Treatment Planning – Mental health service plan development by non-physician
H0032TS- (Modifier TS for clinician monitoring of treatment; or, can be used for on-site, face/face
monitoring of treatment by Center for Positive Living Supports (CPLS)
H0032QJ – (Modifier QJ for beneficiaries that are incarcerated)
H0032HE – (Modifier HE for Certified Peer Specialist present during treatment planning)
H0032U5 – Treatment Planning completed by BCBA
Activities associated with the development and periodic review of the plan of service, including all
aspects of the person-centered planning process, such as pre-meeting activities, and external facilitation
of person-centered planning. This includes writing goals, objectives, and outcomes; designing strategies
to achieve outcomes (identifying amount, scope, and duration) and ways to measure achievement
relative to the outcome methodologies; attending person-centered planning meetings per invitation; and
documentation.
Case managers and supports coordinators perform these functions as part of the case management and
supports coordination services; therefore, they should not report this activity as "Treatment Planning."
Other mental health and health professionals who attend the beneficiary’s person-centered planning
should report the activity as "Treatment Planning."
Clarifying Points:
•
•
•
•
This code is to be used by independent facilitators, non-case managers and all professional staff
participating in a person-centered planning/review session with the consumer.
Case Managers and Supports Coordinators are NOT to use this code to report their time in a
person-centered planning/review session. They are to report their time as Case Management or
Supports Coordination accordingly (with the “T” modifier for ) to indicate the session was
related to treatment/ person centered planning.
Only face-to-face contacts with the consumer are to be reported using this code.
This code can also be used by a Peer Advocate when the purpose of the session is
treatment/person centered planning. However, the HE modifier must be reported to indicate the
service was provided by a peer.
Page 121 of 182
Treatment Planning
Level of Care Table
Description
HCPCS
Population
MIA, SED, DDA, DDC
Coverage
State Plan
Unit Description
Encounter
Unit Minimum
1 encounter per day
Unit Maximum
1,000 encounters per day
Other Rules
None
837 Type
Professional
Modifier(s)
TS = Clinician monitoring of treatment or on-site, face-toface monitoring of treatment by CPLS
QJ = Beneficiary received service while incarcerated
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
None
Check
codes?
No
No restrictions
Page 122 of 182
Wraparound Services
H2021 – Specialized Wraparound Facilitation, 15 minute unit
H2022 – Community-based Wraparound Services – SED Waiver ONLY
T5999 – Supply not otherwise specified Community-based Wraparound Services, General Fund, per
Diem
Wraparound services for children and adolescents is a highly individualized planning process performed
by specialized case managers who coordinate the planning for, and delivery of, wraparound services and
incidental non-staff items that are medically necessary for the child beneficiary. The planning process
identifies strengths, needs, strategies (staffed services and non-staff items) and outcomes.
Wraparound utilizes a Child and Family Team with team members determined by the family, often
representing multiple agencies, and informal supports. The Child and Family Team creates a highly
individualized plan of service for the child beneficiary that consists of mental health specialty treatment,
services and supports covered by the Medicaid mental health state plan, waiver or B3 services.
The plan may also consist of other-non-mental health services that are secured from, and funded by,
other agencies in the community. The wraparound plan is the result of a collaborative team planning
process that focuses on the unique strengths, values and preferences of the child beneficiary and family,
and is developed in partnership with other community agencies. This planning process tends to work
more effectively with child beneficiaries who, due to safety and other risk factors, require services from
multiple systems and informal supports. The Community Team that consists of parents, agency
representatives, and other relevant community members oversees wraparound.
Clarifying Points:
•
•
•
Child beneficiaries served in wraparound shall meet two or more of the following:
o
children who are involved in multiple systems
o
children who are at risk of out-of-home placement or are currently in out-of-home
placement
o
children who have been served through other mental health services with minimal
improvement
o
the risk factors exceed capacity for traditional community-based options
o
Numerous providers are serving multiple children in a family, and the outcomes are
not being met.
Wraparound planning and service coordination is reported with procedure code H2021 and
services/products purchased with non-Medicaid funds are reported with procedure code T5999.
When working with multiple families simultaneously, do not split the total time by the number of
consumers involved. Report each consumer in 15 minute units using the H2022 code.
Page 123 of 182
Wraparound Services
Level of Care Table
Description
Code Type (HCPCS, CPT, State, etc.) HCPCS
Population
SED
Unit Description
H2021 = EPSDT
H2022 = SED Waiver
T5999 = General Fund
H2021 – 15 minutes
T5999 – Per Diem
Unit Minimum
1 unit per day
Unit Maximum
1unit per day for H2021
Other Rules
None
837 Type
Professional
Modifier(s)
None
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Child
Coverage
Provider Service Array/Credential See provider service array
Check
Can be used in conjunction with
No
other codes?
No
No restrictions
Page 124 of 182
AUTISM BENEFIT SECTION
Page 125 of 182
Autism Benefit Services
Physician Services
Procedure Code:
the beneficiary.
99201U5-99215U5 – Psychiatric evaluation and medication management
99324U5 – Domicilary Care, Rest Home, Assisted Living visits – New Patient (20 minutes)
99325U5 - Domicilary Care, Rest Home, Assisted Living visits – New Patient (30 minutes)
99334U5 - Domicilary Care, Rest Home, Assisted Living visits – Established Patient (15 minutes)
99341U5 – Home Visit – New Patient (20 minutes)
99343U5 - Home Visit – New Patient (45 minutes)
99347U5 – Home Visit – Established Patient (15 minutes)
NEW Patient (99201-99205)
components: problem focused history, problem focused examination, and straightforward medical
decision making.
Page 126 of 182
components: expanded problem focused history, expanded problem focused examination, and
straightforward medical decision making.
components: detailed history, detailed examination, and medical decision making of low complexity
components: a comprehensive history, comprehensive examination, and medical decision making of
moderate complexity
components: a comprehensive history, comprehensive examination, and a medical decision making of
high complexity
Established Patient (99211-99215)
99211 – Office or other outpatient visit: Evaluation and Management of an established patient that may
not require the presence of physician or other qualified health care professional: presenting problem
usually minimal: typically 5 minutes
of 3 key components: problem focused history, problem focused examination, and straightforward
medical decision making: typically 10 minutes
of 3 key components: expanded problem focused history, expanded problem focused examination, and
medical decision making of low complexity: typically 15 minutes
3 key components: detailed history, detailed examination, and medical decision making of moderate
complexity: typically 25 minutes
3 key components: comprehensive history, comprehensive examination, and medical decision making of
high complexity: typically 40 minutes
Page 127 of 182
Autism Benefit Services - Physician Services
Page 128 of 182
Level of Care Table
Description
CPT
Population
Autism – 18 mo to 5 years old
Coverage
State Plan;
Unit Description
Encounter
Unit Minimum
1 Encounter per day
Unit Maximum
99201-99215 – Encounter
99324-99328 - Encounter
99334-99337 - Encounter
99341-99350 - Encounter
99201:Self limited or minor (10 minutes)
99202: Low to moderate (20 minutes)
99203:Moderate (30 minutes)
99204: Moderate to High (45 minutes)
99205: Moderate to High (60 minutes)
99324: Domicilary Care; Rest Home, Assisted
minutes)
minutes)
minutes)
minutes)
minutes)
Other Rules
Living Visits (20
Living Visits (30
Living Visits (45
Living Visits (60
Living Visits (75
99341: Home Visit (20 minutes)
Established Patient: 99211-99215
99211: no key components are required at this coding level**only
use when provided as separate service
99212: Self limited or minor **office or other outpatient visit
99213: Low to moderate (15 minutes)
99214: Moderate to high (25 minutes)
99215: Moderate to high (40 minutes)
minutes)
minutes)
minutes)
minutes)
Living Visits (20
Living Visits (30
Living Visits (45
Living Visits (60
Page 129 of 182
Example:
Start Counseling
3:10 pm
Time
40 min.
25 min
15 min
10 min
5 min
Code
99215
99214
99213
99212
99211
Add on Codes:
837 Type
Professional
Modifier(s)
U5 - Mandatory
Start Date
April 1, 2013
End Date
None at this time
90862
Member Age Check
None
Check
Physician – 99201-99205
99211-99215, 99324-99328, 99334-99337, and 99341-99350:
Physician (MD or DO), licensed physician’s assistant, nurse
practitioner, registered nurse, or a licensed practical nurse assisting a
physician
codes?
No
encounters.
Page 130 of 182
Procedure Code:
Psychiatric Diagnostic Evaluation (90791, 90792)
Psychotherapy with evaluation and management (90833, 90836, 90838)
90791 - Psychiatric diagnostic evaluations (no medical services)
90792 - Psychiatric diagnostic evaluations (with medical services)
90833, 90836, 90838 – Psychotherapy with evaluation and management
+90785 Interactive – add on codes only for complexity
Add-on-Codes: Procedures commonly carried out in the addition to the primary procedure performed.
Designated by the + symbol. Applies only to procedures or services performed by the same physician.
Add on codes are always performed in addition to the primary service or procedure and must never be
reported as a stand-alone code.
beneficiary’s clinical status, including the presenting problem; the history of the present illness; previous
Page 131 of 182
Level of Care Table
Description
CPT
Population
MIA, DDA, DDC, SED
Coverage
State Plan
Unit Description
Encounter
Unit Minimum
1 Encounter per day
Unit Maximum
90792 = 2 Encounters per day – (Moved to Medication Review
Section)
Other Rules
None
837 Type
Professional
Modifier(s)
QJ = Beneficiary received a service while incarcerated;
GT = Telemedicine was provided via video-conferencing face to
face with the beneficiary with 90791, 90792
U5 = Beneficiary is receiving Autism Spectrum Disorder Waiver
Benefits
Start Date
October 1, 2013
End Date
None at this time
90801/90802
Member Age Check
None
Check
Can be used in conjunction with other See other rules above for interactive complexity
codes?
No
encounters.
Page 132 of 182
H0031U5- Intake Assessment or psychosocial assessment by a non-physician (U5 Modifier for Autism
Benefit)
H0031U5TF- when assessment is for an intermediate level of care (AIBI)
H0031U5TG - when assessment is for a complex/high level of care (Early Intensive Behavioral
Intervention - EIBI)
H0031U5AH- (AH Modifier for Clinical Psychologist)
H0031U5AJ - (AJ Modifier for Clinical Social Worker)
H0031U5HO- (HO Modifier for Master’s Degree)
H0031U5HP- (HP Modifier for Doctoral Degree)
H0031U5TF- when assessment is for an intermediate level of care – AIBI
H0031U5TFAH- (AH Modifier for Clinical Psychologist)
H0031U5TFAJ- (AJ Modifier for Clinical Social Worker)
H0031U5TFHO- (HO Modifier for Master’s Degree)
H0031U5TFHP- (HP Modifier for Doctoral Degree)
H0031U5TG – (TG Modifier for a complex/high level of care - EIBI).
H0031U5TGAH- (AH Modifier for Clinical Psychologist)
H0031U5TGAJ- (AJ Modifier for Clinical Social Worker)
H0031U5TGHO- (HO Modifier for Master’s Degree)
H0031U5TGHP- (HP Modifier for Doctoral Degree)
Assessments by a non-physician that may be used by a variety of disciplines and which provides more
flexibility.
Clarifying Points:
•
•
•
H0031U5 – Autism Benefit: for reporting ADOS and ADI-R only completed by a Qualified
Child Mental Health Professional (CMHP) that have a minimum of a master’s degree in a mental
health related field, have at least one year of experience in the examination and treatment of
children with ASD and are able to diagnose within their scope of practice including:
a. Psychologist
b. LMSW or LLMSW
c. LPC or LLPC
d. Registered Nurses who are also CMHP
H0031U5 – Autism Benefit: for reporting ABLLS-R and VB-MAPP by:
a. Board Certified Behavior Analyst (BCBA)
b. LP, LLP
c. CMHP
Use H0031 without modifier for BCBA completing Functional Behavioral Assessment
Page 133 of 182
Level of Care Table
Description
HCPCS
Population
Autism 18 months to 5 years
Coverage
State Plan;
Unit Description
Per Encounter
Unit Minimum
1 Encounter per day
Unit Maximum
1 Encounter per day
Other Rules
Diagnosis/Determination of Eligibility:
• ADOS-2 Module
• ADI-R
Behavioral Outcome Measurement Tools:
• ABBLS-R
• VB-MAPP
837 Type
Professional
Modifier(s)
**Mandatory: U5
TF = when assessment is for an intermediate level of care (AIBI)
TG = when assessment is for a complex/high level of care (EIBI)
Start Date
April 1, 2013
End Date
None at this time
None
Member Age Check
18 months to 5 years
Check
** For Diagnosis/Determination of Eligibility: CMHP must have a
minimum of a Master’s degree in a mental health related field,
have at least one year of experience in the examination and
treatment of children with ASD and are able to diagnose within
their scope of practice and professional license.
**For Behavioral Outcome Measurement Tools: CMHP and,
• Board Certified Behavior Analyst (BCBA)
• Licensed or limited license psychologist (LP. LLP)
codes?
No
with encounters.
Page 134 of 182
96101U5, 96102U5- Psychological Testing (U5 Modifier for Autism Benefit)
96118U5, 96119U5 - Neuropsychological Testing (U5 Modifier for Autism Benefit)
Psychological Testing for Adaptive Behavior Assessment
96101U5 - Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual
abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS, Vineland Adaptive Scales –
Second Edition – VBAS-2), per hour of the psychologist’s time, both face-to-face time with the patient
and time interpreting test results and preparing the report.
96101U5AH- (AH Modifier for Clinical Psychologist)
96101U5AJ - (AJ Modifier for Clinical Social Worker)
96101U5HO- (HO Modifier for Master’s Degree)
96101U5HP- (HP Modifier for Doctoral Degree)
96102U5 - Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual
abilities, personality and psychopathology, e.g., Vineland Adaptive Scales – Second Edition – VBAS-2),
with qualified health care professional; or licensed bachelor’s social worker or limited-licensed
bachelor’s or master’s social worker acting within their scope of practice under the supervision of a
Mental Health Professional who is a fully licensed master’s social worker, per hour of time, face-to-face.
96102U5AJ - (AJ Modifier for Clinical Social Worker)
96102U5HN – (HN Modifier for Bachelor’s level)
96102U5HO- (HO Modifier for Master’s Degree)
96102U5HP- (HP Modifier for Doctoral Degree)
Neuropsychological Testing for Adaptive Behavior Assessment
96118U5 - Neuropsychological testing (e.g., Vineland Adaptive Scales – Second Edition – VBAS-2),
per hour of the psychologist’s time, both face-to-face time with the patient and time interpreting test
results and preparing the report.
96118U5HP- (HP Modifier for Psychologist Doctoral Degree)
96119U5 - Neuropsychological testing (e.g., Vineland Adaptive Scales – Second Edition – VBAS-2),
with psychologist, per hour of time, face-to-face
96119U5HP- (HP Modifier for Psychologist Doctoral Degree)
prescribed by a physician. Standardized psychological tests and measures rendered by full, limited-
Page 135 of 182
license, or temporary-limited-licensed psychologists. The beneficiary’s clinical record must indicate the
Page 136 of 182
Level of Care Table
Description
CPT
Population
Autism 18 mo – 5 years
Coverage
State Plan
Unit Description
Per hour
Unit Minimum
Per hour
Unit Maximum
Per hour
Other Rules
None
837 Type
Professional
Modifier(s)
**Mandatory: U5
Start Date
April 1, 2013
End Date
None at this time
None
Member Age Check
18 mo – 5 years
Check
96102: Mental Health Professional; or licensed bachelor’s social
worker or limited-licensed bachelor’s or master’s social worker
acting within their scope of practice under the supervision of a
mental health professional who is a fully licensed master’s social
worker.
96101, 96118 and 96119; Psychologist
codes?
No
encounters.
Page 137 of 182
Home Care Training – Applied Behavior Analysis (ABA)
Home Care Training to home care client (supervision of direct care provider)
S5108U5 – (U5 Modifier for Autism Benefit) - Supervision of H2019 Treatment
S5108U5AH - (AH Modifier for Clinical Psychologist)
S5108U5AJ- (AJ Modifier for Clinical Social Worker)
S5108U5HN – (HN Modifer for Bachelor’s Degree Provider)
S5108U5HO - (HO Modifier for Master’s Degree Provider)
S5108U5HP - (HP Modifier for Doctoral Degree Provider)
S5108U5TT - (TT Modifier to be used for supervision of more than one ABA provider at the same time)
S5108U5TTAH (AH Modifier for Clinical Psychologist providing supervision of more than one ABA
provider at the same time)
S5108U5TTHP (HP Modifier for Doctoral Degree Supervisor providing supervision of more than one
ABA provider at the same time)
S5108U5TTHO (HO Modifier for Master’s Degree supervisor providing supervision of more than one
ABA provider at the same time)
Clarifying Points:
•
•
•
•
•
•
•
•
•
•
Report only face/face contacts
Cannot report H2019 and S5108 at the same time
Report S5108 only for supervision of ABA services provided to children 18
months through age 5 receiving the Autism Benefit
The reporting cost includes staff, facility, equipment, staff travel, contract
services, supplies and materials
Under the supervision of a BCBA or other appropriately qualified (LP, LLP) or
master’s prepared CMHP working within the scope of their practice supervised by BCBA.
Additional provider qualifications regarding enrolling in BCBA training program and obtaining
BCBA status are found in the Medicaid Provider Manual (currently in policy 13-09).
H2019U5 (Autism Benefit) – BCaBA must have certification as a BCaBA
through the BACB and work under the supervision of a BCBA. The BCBA must provide one
hour of supervision for every 10 hours of direct treatment.
ABA Aide – The ABA Aide must work under the supervision of a BCBA, LP,
LLP, or CMHP overseeing the ABA plan and must provide one hour of supervision for every 10
hours of direct treatment
S5108U5 (Autism Benefit) – Under the supervision of a BCBA or other
appropriately qualified LP, LLP or master’s prepared CMHP working within the scope of their
practice supervised by BCBA. Additional provider qualifications regarding enrolling in BCBA
training program and obtaining BCBA status are found in the Medicaid Provider Manual
(currently in policy 13-09).
Use Modifier AH to identify clinical psychologist provider
Use Modifier AJ to identify clinical social worker provider
Page 138 of 182
•
•
•
Use Modifier HN to identify bachelor’s degree provider
Use Modifier HO to identify other master’s degree provider
Use Modifier HP for other doctoral degree provider
Page 139 of 182
Home Care Training – Applied Behavior Analysis (ABA)
Level of Care Table
Description
CPT
Population
Coverage
State Plan
Unit Description
15 minutes
Unit Minimum
15 minutes
Unit Maximum
15 minutes
Other Rules
U5 Modifier is Mandatory in reporting the service
837 Type
Modifier(s)
**Mandatory – U5
•
Use Modifier TG for Early Intensive
Behavioral Intervention (EIBI)
•
Use Modifier TT for services provided
to more than one child at the same time by the same provider
•
Use Modifier AH to identify clinical
psychologist provider
•
Use Modifier AJ to identify clinical
social worker provider
•
Use Modifier HN to identify
bachelor’s degree provider
•
Use Modifier HO to identify other
master’s degree supervisor
•
Use Modifier HP for other doctoral
degree supervisor
Start Date
April 1, 2013
End Date
None
None
Member Age Check
18 mo – 5 years
•
•
Under the supervision of a BCBA or
Other appropriately qualified licensed
or limited licensed psychologist (LP, LLP) or
•
Master’s prepared CMHP working
within the scope of their practice supervised by BCBA
•
Additional provider qualifications
regarding enrolling in BCBA training program and obtaining
BCBA status are found in the Medicaid Provider Manual
(currently in policy 13-09)
codes?
No
Page 140 of 182
with encounters
Page 141 of 182
Therapeutic Behavioral Services
H2019U5 – (U5 Modifier for Autism Benefit) Applied Behavior Analysis
H2019U5TF – (TF Modifier for intermediate level of care AIBI)
H2019U5TG – (TG Modifier for complex/high level of care – EIBI)
H2019U5TT - (TT Modifier for multiple children receiving services by the same provider at the same
time)
H2019U5- (U5 Modifier for Autism Benefit – no additional Modifier for No intensity modifier for
Applied Behavioral Intervention (AIBI)
H2019U5AH- (AH Modifier for Clinical Psychologist - No intensity modifier for Applied
Behavioral Intervention (AIBI)
H2019U5AJ- (AJ Modifier for Clinical Social Worker - No intensity modifier for Applied
H2019U5HN- (HN Modifier for Bachelor’s Degree Provider - No intensity modifier for Applied
H2019U5HO- (HO Modifier for Master’s Degree Provider - No intensity modifier for Applied
H2019U5HP- (HP Modifier for Doctoral Degree Provider - No intensity modifier for Applied
H2019U5TF – (TF Modifier for Intermediate level of care AIBI).
H2019U5TFAH- (AH Modifier for Clinical Psychologist)
H2019U5TFAJ- (AJ Modifier for Clinical Social Worker)
H2019U5TFHN- (HN Modifier for Bachelor’s Degree Provider)
H2019U5TFHO- (HO Modifier for Master’s Degree Supervisor)
H2019U5TFHP- (HP Modifier for Doctoral Degree Supervisor)
H2019U5TG – (TG Modifier for Early Intensive Behavioral Intervention (EIBI).
H2019U5TGAH- (AH Modifier for Clinical Psychologist)
H2019U5TGAJ- (AJ Modifier for Clinical Social Worker)
H2019U5TGHN- (HN Modifier for Bachelor’s Degree Provider)
H2019U5TGHO- (HO Modifier for Master’s Degree Supervisor)
H2019U5TGHP- (HP Modifier for Doctoral Degree Supervisor)
H2019U5TT - (TT Modifier to be used for services provided to more than one child at the same
time by the same provider)
H2019U5TTAH - (AH Modifier for Clinical Psychologist)
H2019U5TTAJ- (AJ Modifier for Clinical Social Worker)
H2019U5TTHO - (HO Modifier for Master’s Degree supervisor)
H2019U5TTHP - (HP Modifier for Doctoral Degree Supervisor)
Direct behavior analytic service provided to patient implementation of ABA based methodologies,
Page 142 of 182
treatment plan or protocol as designed by the supervising BCBA or BCBA-D. Records
behavioral data throughout each session
Clarifying Points:
•
AH for Clinical Psychologist provider of ABA service/supervision of ABA
service
•
AJ for Clinical Social Worker provider of ABA service/supervision of ABA
services
•
•
•
HN for Bachelor’s degree, BCaBA or other Bachelor’s level staff
HO for Master’s degree, BCBA, Licensed or Limited License Psychologist
HP for Doctoral degree, Licensed Psychologist, BCBA-D
Page 143 of 182
Therapeutic Behavioral Services
Level of Care Table
Description
CPT
Population
Coverage
State Plan
Unit Description
15 minutes
Unit Minimum
15 minutes
Unit Maximum
Other Rules
U5 Modifier is Mandatory in reporting the
service
837 Type
Modifier(s)
**Mandatory – U5
TF – Intermediate level of care
TG – Complex/high level of care (EIBI)
TT – Individualized service provided to
more than one patient in the same setting
Start Date
April 1, 2013
End Date
None
None
Member Age Check
18 mo – 5 years
Use:
HN modifier to report Bachelor’s degree
staff providing service, BCaBA or other
Bachelor’s level staff
HO modifier to report Master’s degree staff
providing services, BCBA; Licensed or
Limited License Psychologist that meets
coursework and experience requirements
specified in the Medicaid Provider Manual
(Policy Bulletin 13-09) or CMHP as
defined.
HP to report doctoral degree staff providing
service: Licensed Psychologist, BCBA-D
No
No
No restrictions, however place of service
code must be reported with encounters
Page 144 of 182
Substance Use Disorders Section
Only for use by providers contracted by the coordinating agencies.
Procedure Code Description
Acupuncture
Brief Intervention
Buprenorphine or Suboxone
Vivitrol, Antabuse, and Camprel,
Case Management
Day Treatment
Drug Screens
Early Intervention
Group Health 60/90 min (Didactic)**
Group Therapy 60/90 min
In Home Therapy
Individual Therapy
Initial Assessments
Intensive Wraparound
IOP I, IOP II, IOP III (Domicile)
Less Intensive Residential
Medication Assisted Treatment (Methadone Dosing)
Med Management (Co-occurring)
Medication Management
Code
97810, 97811
H0050
H0033
H0006
H0015, H2036
H0003, 80100
H0022
H0005
90853
90837
90832, 90834, 90837
H0001
H0006
H0015
H0018
H0020
M0064
H2010
Prevention
H0022, H0023,H0024, H0025, H0026,
H0027, H0028, H0029, H0049, H0050,
99406, 99407, G0396, G0397, G0436,
G0437, G8402
Psychiatric Evaluation
Recovery Homes
Recovery Support
Residential Long Term
Residential Short Term
Room & Board
Screening (Telephone)
Screening Face to Face
Special Family Therapy
Sub-Acute Detox
Sub-Acute Detox (Med Monitored), Level III.7
Sub-Acute Detox Level I.D
90791, 90792, H0001
S9976
T1012, H0038, G0409, H0023
H0019
H0018
S9976
H0049
H0002
90847
H0012
H0010
H0014
All encounters for Substance Use Disorders will be submitted to DWCMHA who converts data for submission to the
Michigan Department of Community Health.
Page 145 of 182
Acupuncture
97810 – Initial 15 minutes.
97811 – Each additional 15 minutes.
Is a therapy which was developed in China over 2500 years ago and has been used successfully to treat a
wide variety of illnesses. It is now used worldwide. Acupuncture works by stimulating designated points
on the body via the insertion of very fine needles. These points correspond with the functions of internal
organs and other bodily processes as defined by the principals of Chinese medicine.
Level of Care Table
Description
CPT Code
Population
SUD
Coverage
Block Grant & PA 2
Unit Description
Unit = 15 min
Unit Minimum
1 hour per week, per client
Unit Maximum
Other Rules
837 Type
Professional
Modifier(s)
HA, HB, HC, HD, HG, HH
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
ADS, CPC, CPS, SATS
Check
Can be used in conjunction with other Yes
codes?
Yes
Page 146 of 182
Brief Intervention
H0050 - Brief Intervention or care coordination, per 15 minutes
Brief Intervention for Substance Abuse Disorders
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
State Plan ; Block Grant
Unit Description
Unit = 15 min
Unit Minimum
1 Unit
Unit Maximum
100 Units
Other Rules
837 Type
Professional
Modifier(s)
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
ADS, CPC, CPS, SATS
Check
Yes
codes?
Yes
Page 147 of 182
Buprenorphine/Suboxone
H0033 - Includes Vivitrol, Antabuse and Camprel
Medication assisted treatment is a form of pharmacotherapy and refers to any treatment for a SUD that
includes a pharmacologic intervention as part of a comprehensive treatment plan with an ultimate goal
of recovery with full social function. This service uses medications, in combination with counseling and
behavioral therapies, to provide a patient-centered approach to the treatment of a SUD. This service
provides adjunct treatment for opioids, alcohol, and other addictions to support recovery.
Buprenorphine hydrochloride (Subutex) and buprenorphine hydrochloride/naloxone hydrochloride
(Suboxone) were approved by the Food and Drug Administration (FDA) on October 8, 2002, Vivitrol,
Antabuse, and Camprel (approved by SAMHSA), for the treatment of opioid addiction.
Level of Care Table
Description
HCPCS, CPT Codes
Population
SUD
Coverage
State Plan, Block Grant & PA 2
Unit Description
Unit Minimum
Unit
Unit Maximum
Up to 31 Days
1 unit per day
Other Rules
837 Type
Professional
Modifier(s)
HB, HC, *HG, HH
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Adults
Check
Clinical Services: LP, LLP, TLLP, LMSW, LLMSW, LCP, TLLPC, LBSW,
LLBSW, SATS, IC&RC, FAODP, FASC
Administration: MD, DO, PA, NP, RN, LPN
Pharmacist certified to dispense Buprenorphine/Suboxone
(*Mandatory*)
codes?
Yes
(57) Non-Residential and Residential substance abuse treatment facility
Page 148 of 182
Case Management (Substance Abuse)
H0006 – Case Management
Case management is a collaborative process which assesses, plans, implements, coordinates, monitors
and evaluates the options and services to meet an individual’s overall health and recovery needs, using
communication and available resources to promote quality, cost-effective outcomes. It is provided as a
stand-alone service or as an adjunct to another level of care based on need.
Services provided to clients who are identified as having a substance abuse problem ranging from
minimal to severe use, who are at risk of continued or increased use, who display treatment resistant
behavior.
Case management is a program designed to coordinate, plan, provide, evaluate and monitor services or
recovery utilizing a variety of resources on behalf of, and in collaboration with, a client who has a
substance use disorder. A substance use disorder case management program offers these services
through designated staff working in collaboration with the substance use disorder treatment team and as
guided by the individualized treatment planning process.
Case Management activities are as follows: assessment; reassessment; service plan; linking/coordinating
and monitoring.
Page 149 of 182
Case Management (Substance Abuse)
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Block Grant & PA 2
Unit Description
Unit
Unit Minimum
5 units per 30 Days
Unit Maximum
20 units per 30 Days
Other Rules
837 Type
Professional
Modifier(s)
HA, HB, HC, HD, HF, HG, HH, ( Must be reported with HF), QJ
Start Date
October 1, 2013
End Date
None at this time
H0006.001, H0006.002, H0006.003, H0006.004, H0006.005 (used
internally)
Member Age Check
Clinical Services: LP, LLP, TLLP, LMSW, LLMSW, LCP, TLLPC,
LBSW, LLBSW, SATS, IC&RC, FAODP, FASC
Check
codes?
Yes
Page 150 of 182
Day Treatment
H0015
H2036, Per Diem
Day treatment is defined as intensive substance abuse services available six days a week, six hours per
day. Day treatment is considered to be at a higher level of intensity than IOP, but less restrictive than
residential settings.
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Unit Description
Day
Unit Minimum
6 Hours per day, 6 Days a week, minimum of 1 Month of services
Unit Maximum
6 Hours per day, 6 Days a week, maximum of 3 Months of services
Other Rules
837 Type
Professional
Modifier(s)
HB ,HC, HH
Start Date
October 1, 2013
End Date
None at this time
90899.4
Member Age Check
Adults
LBSW, LLBSW, SATS, IC&RC, CADC, CAADC, FASC
Check
codes?
Yes
Page 151 of 182
Drug Screens
H0003: Lab analysis of specimens to detect presence of alcohol or drugs.
80100: Drug screen and/or alcohol
Drug screens for the purposes of monitoring the ongoing use of substances when required as part of an
individualized treatment and recovery plan or when deemed to be a need by a medical or treatment
professional. To establish practices and guidelines for urine drug screening assignments. Also, to
establish protocols for dirty urine/drug screens. The drug screen sampling will vary per level of care and
treatment provider as needed.
The scientific process of determining the un-metabolized level of a substance in the body of a person
through laboratory testing of bodily fluids, hair or nails.
Normally the following 12 panel urine drug screen is conducted on clients. The most common drugs to
be screened are the following:
6-Acetyl-morphine (Heroin), Amphetamines, Barbiturates, Benzodiazepines, Cocaine, Methadone
Metabolites, Methadone, Opiates, Oxycodone, Ecstasy, Propoxyphene (Darvon/Darvocet),
TetraHydraCanibonal (THC) and Alcohol
Page 152 of 182
Drug Screens
Level of Care Table
Description
HCPCS, CPT Codes
Population
SUD
Coverage
Block Grant & PA 2
State Plan
Unit Description
Unit
Unit Minimum
1 per Various Levels of Care
1 per Detox/Residential
2 per Intensive Outpatient & Outpatient
Unit Maximum
2 units per 30 Days
Other Rules
837 Type
Professional
Modifier(s)
N/A
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Check
codes?
Yes
Page 153 of 182
Early Intervention Services
H0022 – Early intervention services
Early intervention services explore and address any problems or risk factors that appear to be related to a
SUD and help the individual to recognize the presence of, or the need for, changing behavior patterns
that may lead to further health problems. Such individuals may not appear to meet the diagnostic
criteria for a SUD, but require education and further assessment.
Early Intervention is a specifically focused treatment program including stage-based intervention for
individuals with substance use disorders as identified through a screening or assessment process to
include individuals who may not meet the threshold of abuse or dependence.
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Block Grant & PA 2
Unit Description
Unit = 15 min
Unit Minimum
8 hours per client
Unit Maximum
Other Rules
837 Type
Professional
Modifier(s)
HA, HB, HC, HF, HG HH,
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Check
codes?
Yes
Page 154 of 182
Family / Group Health (Didactic Group)
H0005 - Family / Group Health
Educational small groups with interactive discussions. Handouts, writing assignments and videos may
support the educational sessions (60 or 90 minutes sessions, per level of care and authorization).
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Unit Description
Unit = 60/90 minute sessions
Unit Minimum
1 session
Unit Maximum
6 sessions per authorization
Other Rules
837 Type
Professional
Modifier(s)
HA, HB, HC, HD, HF, HG, HH
Start Date
October 1, 2013
End Date
None at this time
99078
Member Age Check
(Used Internally)
Check
codes?
Yes
Page 155 of 182
Group Therapy
H0005 – Alcohol and/or drug services; group counseling by a clinician
90853HF – (Modifier HF for Substance Abuse) – Group psychotherapy
Face-to-face counseling with three or more clients, and can include didactic lectures, therapeutic
discussions, and other group related activities (60 or 90 minutes sessions, per level of care and
authorization).
Level of Care Table
Description
CPT
Population
SUD
Coverage
Unit Description
Unit = 60/90 minute sessions
Unit Minimum
1 session
Unit Maximum
Other Rules
837 Type
Professional
Modifier(s)
Start Date
October 1, 2013
End Date
None at this time
90857
Member Age Check
Check
codes?
Yes
Page 156 of 182
In Home Therapy
90837HF – (Modifier HF for Substance Abuse) - 60 minutes of Psychotherapy
Home-based treatment is designed to provide services to child/adult and their families with multiple
service needs who require access to an array of SUD services. The primary goals of these programs are
to support families in meeting their developmental needs, to support and preserve families, to reunite
families who have been separated, and to provide effective treatment and community supports to address
risks that may increase the likelihood of a child being placed outside the home. Treatment is based on
the child/adult family member’s needs, with the focus on the family unit. The service style must support
a family-driven and/or youth-guided approach, emphasizing strength-based, culturally relevant
interventions, adult/youth and professional teamwork, and connection with community resources and
supports.
Level of Care Table
Description
CPT
Population
SUD
Coverage
Block Grant & PA 2
Unit Description
Unit =15 Minutes
Unit Minimum
4 units per Week
Unit Maximum
8 units per Week
Other Rules
837 Type
Professional
Modifier(s)
HB, HC, HG, HH
Start Date
October 1, 2013
End Date
None at this time
90806
Member Age Check
Adults
LBSW, LLBSW, SATS, IC&RC, FAODP, FASC, MAFE
Check
codes?
Yes
(57) Non-Residential substance abuse treatment facility
Page 157 of 182
Individual Therapy
90832HF – (Modifier HF for Substance Abuse) – 30 minutes of psychotherapy
90785 – Add-on ONLY
Face-to-face counseling services with client or the client’s significant other. If the significant other
receives on-going counseling services, (maximum six (6) sessions), per authorizations; 50 minutes/hour.
If significant other is receiving counseling, then Co-dependent must be marked on the admission as ‘yes’
with Other Factor for ‘Significant Other’.
Level of Care Table
Description
CPT
Population
SUD
Coverage
Unit Description
Unit = 50 Minute session
Unit Minimum
1 session
Unit Maximum
Other Rules
837 Type
Professional
Modifier(s)
Start Date
October 1, 2013
End Date
None at this time
90806
Member Age Check
Check
codes?
Yes
Page 158 of 182
Initial / Individual Assessments
H0001 – Alcohol and/or drug assessment (conducted by provider)
Alcohol and/ or Drug Assessment
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Unit Description
Unit
Unit Minimum
1 unit
Unit Maximum
2 units every 6 months
Other Rules
837 Type
Professional
Modifier(s)
Start Date
October 1, 2013
End Date
None at this time
90801
Member Age Check
Clinical Services:
Check
Yes
codes?
Yes
(55) Residential substance abuse treatment facility
Page 159 of 182
Intensive Outpatient
H0015 – Alcohol and/or Drug Services, Intensive Outpatient
0906 – Intensive Outpatient Services – Chemical Dependency
Supervised rehabilitative and therapeutic services provided in a structured outpatient setting for a partial
day of 3 or more hours. Services provides multiple days per week over a specified time period as
determined by program design and the client’s need and treatment plan. Individualized care is provided
appropriate to the client’s age development, and presenting problem. Didactic lectures, group and
individual therapies in combination with the individualized treatment needs of the clients are provided.
SEMCA has established three levels of IOP.
•
•
•
Level 1 Minimum 3 days a week at 3 hours
Level 2 Minimum 4 days a week at 4 hours
Level 3 Minimum 5 days a week at 4-5 hours
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Unit Description
Day
Unit Minimum
3 Hour Day per 3 Days for 3 Months
Unit Maximum
4 Hours Day per 4 Days for 3 Months
Other Rules
837 Type
Professional
Modifier(s)
HA, HB, HC, HH
Start Date
October 1, 2013
End Date
None at this time
90899.1, 90899.2
Member Age Check
Adults & Adolescents
Check
codes?
Yes
Page 160 of 182
Intensive Outpatient with Domicile
H0015 - Intensive Outpatient with Domicile
Intensive outpatient (IOP) services are "Supervised rehabilitative and therapeutic services provided in a
structured outpatient setting for a partial weekday of 4-5 or more hours."
Services are provided multiple days per week (Monday-Friday) over a specified time period as
determined by program design and the client's need and treatment plan. Individualized care is provided
appropriate to the client's age, development, and presenting problem. Didactic lectures, group and
individual therapy, in combination with the individualized treatment needs of the client are provided.
Aftercare planning and referral services are provided.
IOP providers may optionally provide room and board services if the following criteria are met: (a) the
provider must present evidence of an annual fire marshal inspection and approval of the room and board
facility; (b) the provider must provide assurances that the room and board facility complies with all
applicable Michigan and local laws and ordinances; (c) the room and board facility must be associated
with a licensed IOP substance abuse treatment program; (d) all residents of the room and board facility
must be admitted to and be current clients of the associated IOP provider; (e) the provider/room and
board facility shall maintain a daily census log to document use of the facility by eligible clients; (f) the
room and board facility must be located in a different building than the IOP substance abuse treatment
program; (g) the provider must document that clients’ Aid to Families with Dependent Children or foster
care payments do not cover room and board expenses.
IOPD consists of:
Page 161 of 182
Intensive Outpatient with Domicile
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Unit Description
Day
Unit Minimum
4-5 Hours Day, 5 Days a week, minimum 10 Days
Unit Maximum
4-5 Hours Day, 5 Days a week, maximum 1 Month
Other Rules
837 Type
Professional
Modifier(s)
HB, HC, HH
Start Date
October 1, 2013
End Date
None at this time
90899.3
Member Age Check
Adults
Check
Yes
codes?
Yes
Page 162 of 182
Intensive Wraparound Services
H0006
This program focuses primarily on, but is not limited to families in which the client experiences chronic
substance abuse. In addition to substance abuse, the families must be at risk of outplacement of children
into residential, foster care and/or psychiatric settings; demonstrate that other regular services have been
attempted and failed to meet family needs.
The Wraparound Program provides specific assistance to individuals within the family and are as
follows:
1. Childcare for difficult/troubled children
2. Employment Training, Educational & Placement services.
3. Transportation
4. Financial Counseling
5. Housing
6. Food
7. Medical assistance
Page 163 of 182
Intensive Wraparound Services
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
PA 2
Unit Description
Encounter
Unit Minimum
1 encounter weekly, up to $553.08 per family
Unit Maximum
20 encounters weekly, up to $2,500.00
Other Rules
837 Type
Professional
Modifier(s)
HB, HC, HF, HH (Must be reported with HF)
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
LBSW, LLBSW, SATS, IC&RC, FAODP
Check
Yes
codes?
Yes
Page 164 of 182
Less Intensive Residential
H0018 – Alcohol and/or Drug Services
Residential treatment occurs 24 hours a day, in a live-in setting that is either housed in or affiliated with
a permanent facility. While there are several types of residential programs of varying intensity, a
defining characteristic of all residential programs is that they serve “individuals who require safe and
stable living environments in order to develop their recovery skills.” The services provided are
organized and staffed by addiction and mental health personnel who provide a planned regimen of care,
and generally include medical and social services needed by the individuals being served.
Less Intensive Residential: Planned individual and/or group therapeutic and rehabilitative counseling
and didactics that are provided as an intense, organized, daily treatment regimen in a residential setting
which includes an overnight stay. These programs of care have trained treatment staff that is supervised
by a professional responsible for the overall quality of clinical care.
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Unit Description
Day
Unit Minimum
1 Day
Unit Maximum
Typically 29 Days / 14 days
Other Rules
837 Type
Professional
Modifier(s)
HA, HB, HC, *HF, HH (*Mandatory*)
Start Date
October 1, 2013
End Date
None at this time
20260
Member Age Check
Adolescents and Adults
Institutional - Clinical Services: LP, LLP, TLLP, LMSW, LLMSW,
LCP, TLLPC, LBSW, LLBSW, SATS, IC&RC, FAODP, FASC
codes?
Yes
Page 165 of 182
Medication Assisted Treatment
H0020 - Methadone Dosing
Medication assisted treatment is a form of pharmacotherapy and refers to any treatment for a SUD that
includes a pharmacologic intervention as part of a comprehensive treatment plan with an ultimate goal
of recovery with full social function. This service uses medications, in combination with counseling and
behavioral therapies, to provide a whole-patient approach to the treatment of a SUD. This service
provides adjunct treatment for opioids, alcohol, cocaine and other addictions to support recovery.
Methadone is an opioid medication used in the treatment and recovery of opioid dependence to prevent
withdrawal symptoms and opioid cravings, while blocking the euphoric effects of opioid drugs. In doing
so, methadone stabilizes the individual so that other components of the treatment and recovery
experience, such as counseling and case management, are maximized in order to enable the individual to
reacquire life skills and recovery. Methadone is not a medication for the treatment and recovery from
non-opioid drugs.
Level of Care Table
Population
Coverage
Unit Description
Unit Minimum
Unit Maximum
Other Rules
837 Type
Description
HCPCS
SUD
Unit
1 unit per Day
31 units per Month
Report each daily dosage per person
Professional
Modifier(s)
Must submit with HG modifier. Only licensed Methadone Programs
can use this modifier.
Start Date
October 1, 2013
End Date
None at this time
Member Age Check
Adolescents with approval & Adults
Check
codes?
Provision of the drug by a licensed program. Clinical Services: LP,
LLP, TLLP, LMSW, LLMSW, LCP, TLLPC, LBSW, LLBSW,
SATS, IC&RC, FAODP, FASC
None
Yes
Yes
Page 166 of 182
Medication Management
H2010 comprehensive medication services for 15 minutes
M0064 is used for a brief office visit for mental health drugs (M0064 is for co-occurring only and must
be submitted with HF modifier.)
A medication review is done by a licensed psychiatrist or physician to assess if the client needs
prescribed medication to assist in the client’s treatment; medication review is evaluating and monitoring
medications, their effects, and the need for continuing or changing the medication regimen. Medication
reviews includes the administration of screening tools for the presence of extra pyramidal symptoms and
tardive dyskinesia secondary to untoward effects of neuroactive medications.
An authorization MUST be obtained prior to the treatment. (Block Grant Clients only.)
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Block Grant & PA 2
Unit Description
Unit = 15 minutes
Unit Minimum
1 medication review every 60 days
Unit Maximum
6 medication reviews per every 12 months
Other Rules
None
837 Type
Professional
Modifier(s)
HA, HB, HC, HD, HF, HG, (HF must be used with M0064)
Start Date
October 1, 2013
End Date
None at this time
90862
Member Age Check
State of Michigan Licensed Psychiatrist
Check
codes?
Yes
Page 167 of 182
Physician Services Related to Substance Abuse
Methadone Medication Monitoring
EVALUATION & MANAGEMENT--NEW PATIENT
EVALUATION & MANAGEMENT--ESTABLISHED 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.
assist patient.
the beneficiary.
Page 168 of 182
Physician Services Related to Substance Abuse
Methadone Medication Monitoring
Level of Care Table
Description
CPT Codes 99203-99205; 99213-99215
Population
SUB
Coverage
State Plan;
Unit Description
Encounter
Unit Minimum
1 Encounter per day
Unit Maximum
Other Rules
99203:Moderate
Example:
Start Counseling
3:10 pm
Time
40 min.
25 min
15 min
10 min
5 min
Code
99215
99214
99213
99212
99211
Add on Codes:
837 Type
Professional
Modifier(s)
GT: telemedicine was provided via video-conferencing face – to –
face with the beneficiary;
Start Date
October 1, 2013
End Date
None at this time
90862
Member Age Check
None
Page 169 of 182
Check
Physician – 99201-99205
registered nurse, or a licensed practical nurse assisting a physician 99211-99215
codes?
No
encounters.
Page 170 of 182
Prevention Services
H0022, H0023,H0024, H0025, H0026, H0027, H0028, H0029, H0049, H0050, 99406, 99407, G0396,
G0397, G0436, G0437, G8402
Primary prevention activities are those directed at individuals who do not require treatment for substance
abuse. In implementing the comprehensive primary prevention program, the State shall use a variety of
strategies listed below.
H0022 - alcohol and/or drug intervention service (planned facilitation)
H0023 - behavioral health outreach service (planned approach to reach a targeted population)
H0024 - behavioral health prevention information dissemination service (one-way direct or non-direct
contact with service audiences to affect knowledge and attitude)
H0025 - behavioral health prevention education service (delivery of services with target population to
affect knowledge, attitude and/or behavior)
H0026 - alcohol and/or drug prevention process service, community-based (delivery of services to
develop skills of impactors)
H0027 - alcohol and/or drug prevention environmental service (broad range of external activities geared
toward modifying systems in order to mainstream prevention through policy and law)
H0028 - alcohol and/or drug prevention problem identification and referral service (e.g. student
assistance and employee assistance programs), does not include assessment
H0029 - alcohol and/or drug prevention alternatives service (services for populations that exclude
alcohol and other drug use e.g. alcohol free social events)
H0049 - alcohol and/or drug screening
H0050 - alcohol and/or drug services, brief intervention, per 15 minutes
99406 – Smoking and tobacco cessation counseling visit, intermediate, greater than 3 minutes up to 10
minutes.
99407 – Smoking and tobacco cessation counseling visit, greater than 10 minutes
G0396 – Alcohol and/or Substance (other than tobacco) Abuse structured assessment (e.g., Audit, Dast),
and Brief Intervention 15 – 30 minutes
G0397 - alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., Audit, Dast),
and intervention, greater than 30 minutes
G0436 - smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate,
greater than 3 minutes, up to 10 minutes
G0437 - smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater
than 10 minutes
G8402 - tobacco (smoke) use cessation intervention, counseling
Page 171 of 182
Prevention Services
Level of Care Table
Description
HCPCS, CPT
Population
SUD
Coverage
Block Grant & PA 2
Unit Description
Unit = 15 Minutes unless otherwise stated
Unit Minimum
Varies
Unit Maximum
Varies
Other Rules
837 Type
Professional
Modifier(s)
HA, HB, HC
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
CPC, CPS
Check
Yes
codes?
No
Page 172 of 182
Psychiatric Evaluation
90791
client’s clinical status, including the presenting problem; the history of the present illness; previous
An authorization MUST be obtained prior to the treatment. (Block Grant Clients only.)
Level of Care Table
Description
CPT, HCPCS
Population
SUD
Coverage
Block Grant & PA 2
Unit Description
Unit = 60 minute evaluation
Unit Minimum
1 evaluation per every 12 months
Unit Maximum
1 evaluation per every 12 months / as needed
Other Rules
837 Type
Professional
Modifier(s)
HA, HB, HC, HD, *HF, HG, HH (*Mandatory*)
Start Date
October 1, 2013
End Date
None at this time
90809
Member Age Check
State of Michigan Licensed Psychiatrist
Check
codes?
Yes
Page 173 of 182
Recovery Homes
S9976 – Recovery Homes – Room and Board ONLY
Transitional and Recovery housing provides a location where individuals, in early recovery from a SUD,
are given the time needed to rebuild their lives while developing the necessary skills to embark on a life
of recovery. This temporary living arrangement will provide the individual with a safe and secure
environment to begin the process of reintegration into society and to build the necessary recovery capital
to return to a more independent and functional life in the community. These residences provide varying
degrees of support and structure and participation is based on individual need and being able to follow
the requirements of the program.
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Block Grant & PA 2
Unit Description
Unit = Day
Unit Minimum
30 Days
Unit Maximum
Up to 60 Days / 180 days
Other Rules
837 Type
Professional
Modifier(s)
HB, HC, HG, HH
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Adults
Peer Run Service
Check
codes?
Yes
Page 174 of 182
T1012, H0038, G0409, H0023
T1012 - Alcohol and/or drug services; Recovery Support and Skills Development. Activities to develop
client community integration and recovery support.
H0038HF – (Modifier HF for Recovery Coaches) - Peer services, per 15 minutes
G0409 - Social work and psychological services
H0023 - Planned outreach service (Drop in Center attendance, Welcoming Center attendance)
Recovery/Peer support programs are designed to support and promote recovery and prevent relapse
through supportive services that result in the knowledge and skills necessary for an individual’s
recovery. Peer recovery programs are designed and delivered primarily by individuals in recovery and
offer social emotional and/or educational supportive services to help prevent relapse and promote
recovery.
Peer provided recovery support services make opportunities available to support, mentor and assist
individuals to achieve community inclusion, participation, independence, recovery, resiliency and/or
productivity. Peers are individuals who have a unique background and skill level from their experience
in utilizing services and supports to achieve their personal goals of community membership,
independence and productivity. Peers have a special ability to gain trust and respect of other individuals
based on shared experience and perspectives with disabilities and SUDs, and with planning and
negotiating human services systems.
Recovery community support center services (also called drop-in centers, welcoming centers,
engagement centers, recovery centers and sobering centers) provide an informal, supportive
environment to assist individuals with SUDs in the recovery process. These centers provide
opportunities to learn and share coping skills and strategies, to move into more active assistance and
away from passive individual roles and identities, and to build and/or enhance self-esteem and selfconfidence.
Page 175 of 182
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Block Grant, PA 2 & State Plan
Unit Description
Unit = 15 Minutes
Unit Minimum
Up to 1.25 hours per client
Unit Maximum
Other Rules
837 Type
Professional
Modifier(s)
HA, HB, HC, HF, HG, HH
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Appropriately trained professional and/or non-professional staff
Check
No
codes?
Yes
Page 176 of 182
Residential (short & long term)
H0018 – Short Term, Residential Stabilization – Alcohol and/or Drug Services
H0019 – Long Term, Residential – Alcohol and/or Drug Services
Residential treatment occurs 24 hours a day, in a live-in setting that is either housed in or affiliated with
a permanent facility. While there are several types of residential programs of varying intensity, a
defining characteristic of all residential programs is that they serve “individuals who require safe and
stable living environments in order to develop their recovery skills.” The services provided are
organized and staffed by addiction and mental health personnel who provide a planned regimen of care,
and generally include medical and social services needed by the individuals being served.
Short Term Residential:
Planned individual and/or group therapeutic and rehabilitative counseling and didactics that are provided
as an intense, organized, daily treatment regimen in a residential setting which includes an overnight
stay. These programs of care have a trained treatment staff that is supervised by a professional
responsible for the overall quality of clinical care. Treatment is authorized for 29 days or less.
Long Term Residential:
A professionally supervised program with supportive or confrontational peer therapy that is
supplemented with individual or group therapeutic counseling didactic and rehabilitative care in a
residential setting which includes an overnight stay. Individual and group counseling are built into daily
routines. Treatment is usually authorized 30 days or longer.
Page 177 of 182
Residential (short & long term)
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Unit Description
Unit = Day
Unit Minimum
1 Day
Unit Maximum
Typically 29 Days Short, 180 Days long
Other Rules
837 Type
Professional
Modifier(s)
HA, HB, HC, HF, HH (HF must be used with H0018)
Start Date
October 1, 2013
End Date
None at this time
20220, 20240
Member Age Check
Adolescents and Adults
Institutional - Clinical Services: LP, LLP, TLLP, LMSW, LLMSW,
LCP,
TLLPC, LBSW, LLBSW, SATS, IC&RC, FAODP, FASC
Check
codes?
Yes
Page 178 of 182
Room & Board
S9976 – Room and Board
Applies to programs where clients are in programs that involve overnight stay (Detoxification,
Residential and Intensive Outpatient with Domicile)
Lodging, per diem, not otherwise specified
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Block Grant & PA 2
Unit Description
Unit = Day
Unit Minimum
1 unit per day
Unit Maximum
180 units for 180 Days
Other Rules
837 Type
Professional
Modifier(s)
HA, HB, HC, HF, HH
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
N/A Lodging
Check
codes?
Yes
Page 179 of 182
Screening
H0002 (Face-to-Face),
H0049 (Telephone)
Screening is a formal, brief process that occurs as the individual requests or presents for services to
determine the likelihood of a SUD or other health condition. Included in the process are brief
interventions (using evidence based practices like motivational interviewing or specific screening
instruments) and facilitated referrals to treatment.
The brief screening process assures efficient and professional analysis, including triage needs of a client,
gathers data on the client’s eligibility and financials and directs the client to appropriate services as
reflected by the results of the screening.
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Unit Description
Unit
Unit Minimum
1 Unit per 180 Days
Unit Maximum
2 Units per 365 Days
Other Rules
837 Type
Professional
Modifier(s)
N/A
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Check
codes?
Yes
Page 180 of 182
Special Family Therapy
90846 HF – (Modifier HF for Substance Abuse) – Family Psychotherapy
90847HF – (Modifier HF for Substance Abuse) – Family Psychotherapy
90849 HF – (Modifier HF for Substance Abuse) – Family Psychotherapy
Face-to-face counseling with the client and his/her significant other and/or family members (60 minutes
sessions, per level of care and authorization). If significant other is receiving counseling, then Codependent must be marked on the admission as ‘yes’ with Other Factor for ‘Significant Other’.
Level of Care Table
Description
CPT
Population
SUD
Coverage
Unit Description
Unit = 60 minute session
Unit Minimum
1 session
Unit Maximum
Other Rules
837 Type
Professional
Modifier(s)
Start Date
October 1, 2013
End Date
None at this time
Stays the same
Member Age Check
Check
codes?
Yes
Page 181 of 182
Sub-Acute Detoxification
H0010 – Alcohol and/or drug services; sub-acute detoxification medically monitored. Level III.7
H0012 – Clinically managed residential detoxification; non-medical or social detoxification setting.
H0014 – Ambulatory detoxification w/o extended onsite monitoring. Level I.D
Detoxification services are defined as supervised care for the purpose of managing the effects of
withdrawal from alcohol and/or other drugs as part of a planned sequence of SUD treatment.
Detoxification is limited to the stabilization of the medical effects of the withdrawal and to the referral
to necessary ongoing treatment and/or support services. Sub-acute detoxification is part of a continuum
of care for SUDs and does not constitute the end goal in the treatment process. The detoxification
process consists of three essential components: evaluation, stabilization, and fostering client readiness
for, and entry into, treatment.
Medically supervised care provided in a sub-acute residential setting for the purpose of managing the
effects of withdrawal from alcohol and/or other drugs. Specifically, the reduction/elimination of the
amount of a drug in the body or the elimination of a drug from the body concomitant with supportive
treatment services. Usually authorized for 3-5 days.
Page 182 of 182
Sub-Acute Detoxification
Level of Care Table
Description
HCPCS
Population
SUD
Coverage
Unit Description
Unit = Day
Unit Minimum
3 Days
Unit Maximum
14 Days
Other Rules
Alcohol detoxification may be authorized up to 10 days. Methadone
detox may be authorized up to 14 days
837 Type
Professional
Modifier(s)
HB, HC, HD, HH
Start Date
October 1, 2013
End Date
None at this time
None
Member Age Check
Adults
LBSW, SATS, IC&RC, FAODP, FASC
Check
codes?
Yes

Attachment K5 DWMHA Coding Manual

Transcription

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