Fund Codes FMCD FPAC FDUL (2) SDUL (2) FPRT (6) FTBI (6

Fund Codes FMCD FPAC FDUL (2) SDUL (2) FPRT (6) FTBI (6

Mapset
MD4
MDA
HSCRC
Partial Hospitalization
0912
S0201
S0201
52
Intensive Outpatient
S9480
0905
0949
Other Professional Services for IOP, PHP, CRS
90791
HE
90792
HE
HE
HE
HE
HE
HE
HE
HE
HE
HE
HE
MD6
Courtesy Reviews
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Claim
Form
Pre-Authorization Required
Uninsured
MD5
TBI
MDC
Federally FundedMedicare/Medicaid
Claim Place of
Type Service
21, 51, 56, 99
Primary Adult Care -PAC
Medicaid
Modifier 2
Service Description
Institutes for Mental Disease (IMDs)
Residential Treatment
0100
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
MD3
PRTF
MDE
Send Auth
Request to:
Yes
No
Yes
Yes
No
No
Yes***
Yes
Yes N/C No
N/C N/C N/C Yes ValueOptions X
Yes*
No
No
No
No
No
Yes***
Yes
Yes N/C No
N/C N/C N/C Yes ValueOptions X
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
Inpatient Services
0113, 0114, 0118,
0123, 0124, 0133,
0134, 0143, 0153,
0154, 0169, 0203,
0204
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
Residential Treatment Center
Regional Institute for Children and
Adolescents (RICA)
21, 51, 56, 57
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes*
Yes
Yes
Yes N/C No
Yes N/C No
N/C N/C N/C Yes ValueOptions X
N/C N/C Yes Yes ValueOptions X
Partial Hospitalization - Full Day
Partial Program - Non-Hospital Based
Partial Program - Non-Hospital Based
11, 21, 22, 52,
53, 99
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes N/C No
Yes N/C No
Yes N/C No
N/C N/C N/C Yes ValueOptions X
N/C N/C N/C Yes ValueOptions
N/C N/C N/C Yes ValueOptions
X
X
Intensive Outpatient Psych Services, Per Diem
(Clinic Model)
Intensive Outpatient Services - Psychiatric
11, 22, 53, 99
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes Yes Yes
N/C N/C N/C Yes ValueOptions
X
Yes
No
Yes
Yes
No
No
No
Yes
Yes N/C Yes
N/C N/C N/C Yes ValueOptions X
IOP - Partial Hospital Model or Partial Program
- Non Regulated Space
21, 22, 52, 53,
99
Yes
No
Yes
Yes
No
No
No
Yes
Yes N/C Yes
N/C N/C N/C Yes ValueOptions X
Psychiatric Diagnostic Interview
Psychiatric Diagnostic Interview--medical
services
Evaluation and Management
11, 12, 21, 22,
23
Yes
No
Yes
Yes
No
No
Yes
No
No N/C No
N/C N/C No
N/C Not Required
X
11, 12, 21, 22
Yes
No
Yes
Yes
No
No
Yes
No
No N/C No
N/C N/C No
N/C Not Required
X
Non HSCRC
space only
Mapset
MD4
MDA
MD6
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No N/C No
No N/C No
N/C N/C No
N/C N/C No
Send Auth
Request to:
N/C Not Required
N/C Not Required
X
X
Yes
No
Yes
Yes
No
No
Yes***
No
No N/C No
N/C N/C N/C N/A Not required
X
Initial Hospital Care - Attending Physician Only
Yes
No
Yes
Yes
No
No
Yes***
No
No N/C No
N/C N/C N/C N/A Not required
X
99223
Initial Hospital Care - Attending Physician Only
Yes
No
Yes
Yes
No
No
Yes***
No
No N/C No
N/C N/C N/C N/A Not required
X
99231
Yes
No
Yes
Yes
No
No
Yes***
No
No N/C No
N/C N/C N/C N/A Not required
X
Yes
No
Yes
Yes
No
No
Yes***
No
No N/C No
N/C N/C N/C N/A Not required
X
Yes
No
Yes
Yes
No
No
Yes***
No
No N/C No
N/C N/C N/C N/A Not required
X
99238
Subsequent Hospital Care - Attending
Physician Only
Subsequent Hospital Care - Attending
Physician Only
Subsequent Hospital Care - Attending
Physician Only
Discharge Day Management - MD Only
Yes
No
Yes
Yes
No
No
Yes***
No
No N/C No
N/C N/C N/C N/A Not required
X
99239
99251
Discharge Day Management - MD Only
Initial Inpatient Consultation - Physician Only
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes***
Yes***
No
No
No N/C No
No N/C No
N/C N/C N/C N/A Not required
N/C N/C N/C N/A Not required
X
X
99252
Initial Inpatient Consultation - Physician Only
Yes
No
Yes
Yes
No
No
Yes***
No
No N/C No
N/C N/C N/C N/A Not required
X
99253
Initial Inpatient Consultation - Physician Only
Yes
No
Yes
Yes
No
No
Yes***
No
No N/C No
N/C N/C N/C N/A Not required
X
99254
Initial Inpatient Consultation - Physician Only
Yes
No
Yes
Yes
No
No
Yes***
No
No N/C No
N/C N/C N/C N/A Not required
X
99255
Initial Inpatient Consultation - Physician Only
Yes
No
Yes
Yes
No
No
Yes***
No
No N/C No
N/C N/C N/C N/A Not required
X
Telehealth Originating Site
Q3014
Teleheath Origination Site
11, 12, 21, 22,
23, 24, 53
Yes
Yes
Yes
Yes
No
No
Yes
No
No N/C No
N/C N/C Yes
N/C Not required
X
Non HSCRC
space only
Psychiatric Diagnostic Interview
Psychiatric Diagnostic Interview--medical
services
11, 12, 13, 21,
22, 32, 33, 34,
53, 62, 71, 72
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Non HSCRC
space only
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes N/C No
N/C N/C Yes
N/C ValueOptions
X
99233
Outpatient Therapy Services
90791
90792
90791
90792
GT
GT
Psychiatric Diagnostic Interview- Telehealth
Psychiatric Daignostic Interview medical
services-telehealth
21, 51, 52, 61
Primary Adult Care -PAC
Claim Place of
Type Service
99222
99232
Initial Hospital Care - Attending Physician Only
Medicaid
Modifier 2
Service Description
Individual Therapy (30 Minutes) MD Only
Individual Therapy (45 Minutes) MD Only
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MD5
Uninsured
MDC
TBI
MD3
PRTF
MDE
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
2013 Add on
Code
Code
90832
HE
90834
HE
Inpatient Professional Billing Codes
99221
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
21, 61
21, 31, 32, 51,
52
Mapset
MD4
MDA
22
22
90832
90832
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
90834
90834
GT
90833
90836
90838
GT
GT
GT
GT
GT
GT
GT
GT
GT
GT
GT
90833
90836
90838
MD5
MD6
GT
GT
GT
Medicaid
Courtesy Reviews
Uninsured
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Medicaid
Yes
Yes
No
No
No
No
N/C Yes No
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Individual Psychotherapy (30 Minutes) Telehealth
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes N/C No
N/C N/C Yes
N/C ValueOptions
X
Med Eval/Mgmt with Individual Psychotherapy
(Add on codes add 30 or 45 or 60 Minutes)
(90838 allowed for OMHCs only)
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Med Eval/Mgmt with Individual Psychotherapy
(Add on codes add 30 or 45 or 60 Minutes) telehealth
(90838 allowed for OMHCs only)
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes N/C No
N/C N/C Yes
N/C ValueOptions
X
Individual Psychotherapy (45 Minutes)
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Individual Psychotherapy (45 Minutes) Telehealth
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes N/C No
N/C N/C Yes
N/C ValueOptions
X
21,
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
13,
34,
72,
Yes
No
Yes
Yes
No
No
No
Yes
Yes N/C No
N/C N/C N/C Yes ValueOptions X
90846
Family Psychotherapy without Patient Present
Rev Codes
Outpatient Services
11, 12, 21, 22,
23, 24, 53
11,
22,
03,
22,
53,
99
12,
23,
11,
32,
62,
13,
53
12,
33,
71,
TBI
Yes
TBI
Modifier 2
No
Send Auth
Request to:
N/C N/C N/C N/C ValueOptions
Service Description
Psychiatric Diagnostic Interview
Psychiatric Diagnostic Interview--medical
services
Individual Psychotherapy (30 Minutes)
Claim Place of
Type Service
11, 12, 21, 22,
23, 53
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MDC
Uninsured
MD3
PRTF
MDE
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
90791
90792
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
X
Mapset
MD4
MDA
MD6
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Claim Place of
Type Service
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Medicaid
Modifier 2
Service Description
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MD5
Uninsured
MDC
TBI
MD3
PRTF
MDE
Send Auth
Request to:
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
0914,
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
0915, 0916,
0917,
0919, 0510,
0513
90847
Family Psychotherapy with Patient Present
90847
52
90849
90849
52
90853
90853
90875
90876
T1015
T1015
21
GT
99201
HH
99202
HH
99203
HH
99204
HH
99205
HH
99211
HH
99212
HH
99213
HH
99214
HH
99215
HH
Outpatient Therapy Services (for OMS Bundle)
90791
90792
90791
90792
GT
GT
Family Psychotherapy with Patient Present Abbreviated services
Multiple Family Group
Multiple Family Group - Abbreviated services
Group Psychotherapy
Group Psychotherapy - Extended
Individual psychotherapy w/ Biofeedback
Individual Psychotherapy w/ biofeedback
FQHC clinic visit/encounter (all inclusive)
FQHC clinic visit/encounter (all inclusive) Telehealth
Evaluation and Management - Nursing Home
Psychiatric Diagnostic Interview
Psychiatric Diagnostic Interview--medical
services
Psychiatric Diagnostic Interview- Telehealth
Pscyaitric Diagnostic Interview-medical
services-telehelath
11, 12, 13, 21,
22, 23, 53
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes*
Yes*
Yes
Yes
Yes Yes No
Yes Yes No
N/C N/C Yes
N/C N/C Yes
Yes ValueOptions
Yes ValueOptions
X
X
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes*
Yes*
Yes*
Yes*
Yes*
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
N/C
N/C
N/C
N/C
N/C
N/C
Yes
Yes
Yes
Yes
Yes
N/C
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
X
X
X
X
X
X
31, 32
Yes
Yes
Yes
Yes
No
No
Yes*
No
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
11, 12, 13, 21,
22, 32, 33, 34,
53, 62, 71, 72
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Non HSCRC
space only
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Non HSCRC
space only
11
Yes
Yes
Yes
Yes
Yes
N/C
No
No
No
No
No
Yes
N/C
N/C
N/C
N/C
N/C
N/C
Yes
Yes
Yes
Yes
Yes
Yes
Non HSCRC
space only
Mapset
MD4
MDA
22
22
90832
90832
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
90834
90834
90846
90837
GT
GT
90833
90836
90838
MD6
GT
GT
GT
Medicaid
Courtesy Reviews
Uninsured
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Medicaid
Yes
Yes
No
No
No
No
N/C Yes No
11, 12, 21, 22,
23, 24, 53
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
11, 12, 21, 22,
23, 24, 53
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Med Eval/Mgmt with Individual Psychotherapy
(Add on codes add 30 or 45 or 60 Minutes)
(90838 allowed for OMHCs only)
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Med Eval/Mgmt with Individual Psychotherapy
(Add on codes add 30 or 45 or 60 Minutes) telehealth
(90838 allowed for OMHCs only)
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Individual Psychotherapy (45 Minutes)
Individual Psychotherapy (45 Minutes) Telehealth
Family Psychotherapy without Patient Present
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes*
Yes*
Yes
Yes
Yes Yes No
Yes Yes No
N/C N/C Yes
N/C N/C Yes
Yes ValueOptions
Yes ValueOptions
X
X
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
11,
22,
11,
22,
12,
23,
12,
23,
13, 21,
53
13, 21,
53
TBI
Yes
TBI
Modifier 2
No
Psychotherapy, 60 Minutes with Patient and/or
family member (OMHC Only)
Claim Place of
Type Service
11, 12, 21, 22,
23, 53
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MD5
Uninsured
MDC
Send Auth
Request to:
N/C N/C N/C N/C ValueOptions
Service Description
Psychiatric Diagnostic Interview
Psychiatric Diagnostic Interview--medical
services
Individual Psychotherapy (30 Minutes)
Individual Psychotherapy (30 Minutes) Telehealth
90833
90836
90838
GT
GT
GT
GT
GT
GT
GT
GT
GT
GT
MD3
PRTF
MDE
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
90791
90792
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
X
90847
90847
52
90849
90849
52
90853
90875
90876
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
Rev Codes
HH
HH
HH
HH
HH
HH
HH
HH
HH
HH
Mapset
MD4
MDA
MD5
MD6
Medicaid
Courtesy Reviews
Uninsured
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Medicaid
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Family Psychotherapy with Patient Present
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Family Psychotherapy with Patient Present abbreviated services
Multiple Family Group
Multiple Family Group - Abbreviated services
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes*
Yes*
Yes
Yes
Yes Yes No
Yes Yes No
N/C N/C Yes
N/C N/C Yes
Yes ValueOptions
Yes ValueOptions
X
X
Group Psychotherapy
Individual psychotherapy w/ Biofeedback
Individual Psychotherapy w/ biofeedback
Evaluation and Management - Nursing Home
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes*
Yes*
Yes*
Yes*
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
N/C
N/C
N/C
N/C
Yes
Yes
Yes
Yes
X
X
X
X
Yes
No
Yes
Yes
No
No
No
Yes
Yes N/C No
Outpatient Services
0914,
31, 32
03, 11, 12, 13,
22, 32, 33, 34,
53, 62, 71, 72,
99
Yes
Yes
Yes
Yes
No
No
No
No
TBI
Yes
Send Auth
Request to:
Yes ValueOptions
TBI
Modifier 2
Claim 11,
Place
12,of
13, 21,
Service Description
Type 22,
Service
23, 53
Psychotherapy, 60 Minutes with Patient and/or
family member - Telehealth (OMHC Only)
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MDC
Uninsured
MD3
PRTF
MDE
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
GT
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
90837
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
N/C
N/C
N/C
N/C
Yes
Yes
Yes
Yes
ValueOptions
ValueOptions
ValueOptions
ValueOptions
X
N/C N/C N/C Yes ValueOptions X
0915, 0916, 0917
0918,
No
N/C
0919, 0510,
0513
90889
Discharge
Rev Code 0929
Discharge
11,
22,
03,
22,
53,
12,
23,
11,
32,
62,
13,
53
12,
33,
71,
21,
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
13,
34,
72
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C N/C Yes ValueOptions X
X
Mapset
MD4
MDA
MD5
MD6
Medicaid
Courtesy Reviews
Uninsured
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes*
Yes*
Yes
Yes
Yes Yes No
Yes Yes No
N/C N/C Yes
N/C N/C Yes
Yes ValueOptions
Yes ValueOptions
X
X
TBI
Yes
Send Auth
Request to:
Yes ValueOptions
TBI
Claim Place of
Type Service
11, 12, 13, 21,
22, 23, 53
11
Medicaid
Modifier 2
Service Description
Family Psychotherapy w/o the identified
patient present
FQHC clinic visit/encounter (all inclusive)
FQHC clinic visit/encounter (all inclusive) Telehealth
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MDC
Uninsured
MD3
PRTF
MDE
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
90846
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
X
T1015
T1015
GT
BCARS
90791
90792
HA
HA
Psychiatric Diagnostic Interview
Psychiatric Diagnostic Interview--medical
services
11, 12, 13, 21,
22, 32, 33, 34,
53, 62, 71, 72
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
No
ValueOptions
X
90832
HA
Individual Psychotherapy (30 Minutes)
11, 12, 21, 22,
23, 24, 53
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
90834
HA
HA
HA
HA
HA
HA
HA
HA
HA
HA
HA
Med Eval/Mgmt with Individual Psychotherapy
(Add on codes add 30, 45 or 60 Minutes)
(90838 allowed for OMHCs only)
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
Individual Psychotherapy (45 Minutes)
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
90837
HA
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
90839
HA
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
90846
HA
Individual Psychotherapy (60 Minutes) OMHC
Only
Crisis Psychotherapy 60 Minutes (Add on Code
add 30 Minutes)
Family Psychotherapy without Patient Present
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
90847
HA
Family Psychotherapy with Patient Present
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
90847
HA 52
Family Psychotherapy with Patient Present
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
90849
HA
Multiple Family Group
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
90853
HA
Group Psychotherapy
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
90875
HA
Individual psychotherapy w/ Biofeedback
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
90876
HA
Individual Psychotherapy w/ biofeedback
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
90833
90836
90838
90840
HA
HA
HA
HA
11, 12, 13, 21,
22, 23, 24, 53
Non HSCRC
space only
Mapset
MD4
MDA
MD5
MD6
Yes
Yes
No
No
Yes*
Yes
No N/C No
N/C N/C No
11, 12, 13, 22,
32, 33, 34, 53,
62, 71, 72
Yes
No
Yes
Yes
No
No
Yes*
No
No N/C No
N/C N/C No
N/A Not Required
X
Respite Care Services - Not in home (per
diem)
Respite Care Services - In home
Residential Crisis Service
Treatment Foster Care
11, 52
Yes*
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C Yes
N/C N/C Yes
Yes ValueOptions
X
HA
HA
HA
15
11, 12, 15, 21,
51, 52, 56, 62,
99
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes*
Yes*
Yes*
Yes
Yes
Yes
Yes N/C No
Yes N/C Yes
Yes N/C Yes
N/C N/C Yes
N/C N/C Yes
N/C N/C Yes
Yes ValueOptions
Yes ValueOptions
Yes ValueOptions
X
X
X
96152
HA
Mental Health Service Plan
H0032
TBS BCARS
12
Yes
No
Yes
Yes
No
No
No
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
Mental Health Service Plan Development by
Non Physician
22,
53,
Yes
Yes
Yes
Yes
No
No
Yes*
No
No No
No
N/C N/C No
N/A Not Required
X
Non HSCRC
space only
0982
Interdisciplinary team tx planning w/ patient
present
11,
32,
62,
11,
32,
62,
22,
53,
Yes
Yes
Yes
Yes
No
No
Yes*
No
No No
No
N/C N/C No
N/A Not Required
X
Non HSCRC
space only
Crisis Psychotherapy 60 Minutes (Add on Code
add 30 Minutes)
11, 12, 21, 22,
23, 24, 53
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
99241
99242
Office Consult - MDs only
Office Consult - MDs only
11, 22
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes*
Yes*
Yes
Yes
Yes N/C No
Yes N/C No
N/C N/C N/C Yes ValueOptions
N/C N/C N/C Yes ValueOptions
X
X
99243
Office Consult - MDs only
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C N/C Yes ValueOptions
X
99244
Office Consult - MDs only
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C N/C Yes ValueOptions
X
99245
Office Consult - MDs only
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C N/C Yes ValueOptions
X
99354
Prolonged Service Requiring Face to Face
Patient Contact beyond the usual service
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
99355
Each Additional 30 minutes of a prolonged
Psych Service
Family Psycho-education (Evidence Based
Practice) With Consumer Present
Family Psycho-education - Without Consumer
Present
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Outpatient Psychotherapy Services-Consults
90839
90840
H2027
H1011
12,
33,
71,
12,
33,
71,
13,
34,
72
13,
34,
72
11, 12, 13, 22,
32, 33, 34, 53,
62, 71, 72
TBI
T1005
S9485 (1)
S5145 (1)
Medicaid
HA
Courtesy Reviews
H0045
Uninsured
No
TBI
Mental Health Service Plan Development by
Non Physician BCARS
PRTF
HA
State Funded Medicare/Medicaid
Yes
Send Auth
Request to:
N/A Not Required
Service Description
Behavioral Health Screening PRP Assessment
Claim Place of
Type Service
11, 15
Federally FundedMedicare/Medicaid
H0032
Primary Adult Care -PAC
HA
Medicaid
Modifier 2
2013 CPT/Rev
Code
H0002
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MDC
Uninsured
MD3
PRTF
MDE
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 Add on
Code
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
X
Mapset
MD4
MDA
MD6
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Claim Place of
Type Service
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Medicaid
Modifier 2
Service Description
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MD5
Uninsured
MDC
TBI
MD3
PRTF
MDE
Send Auth
Request to:
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
2013 Add on
Code
Code
Therapeutic Nursery Services
H0046
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
Therapeutic Nursery Services
11, 12, 13, 22,
32, 33, 34, 53,
62, 71, 72
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
Case Management Services
H0031
Case Management Assessment
11, 12, 15, 23,
49, 52
Yes
Yes % Yes
Yes
No
No
Yes
Yes
No No
N/C N/C No
N/A Not Required
X
T1016
Case Management - Daily
11, 12, 15, 22,
23, 49, 52, 53
Yes
Yes % Yes
Yes
No
No
Yes
Yes
Yes Yes Yes
N/C N/C Yes
Yes ValueOptions
X
Transitional Case Management
11, 12, 15, 21,
22, 23, 49, 51,
52, 53, 56, 99
Yes
Yes % Yes
Yes
No
No
Yes
Yes
Yes Yes Yes
N/C N/C Yes
Yes ValueOptions
X
Initial Assessment
Reassessment
TBS
12
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes N/C No
Yes N/C No
Yes N/C No
N/C N/C Yes
N/C N/C Yes
N/C N/C Yes
Yes ValueOptions
Yes ValueOptions
Yes ValueOptions
X
X
X
Occupational Therapy Evaluation
Therapeutic Activities, one on one patient
contact, each 15 minutes
Self Care/Home Management Training, each
15 min.
Community/Work Reintegration Training, each
15 min.
Development of Cognitive Skills, each 15
minutes
Therapeutic Procedure, group (2 or more
individuals)
Reevaluation (per 15 minutes)
21, 52
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Yes*
Yes*
No
No
No N/C No
No N/C No
N/C N/C No
N/C N/C No
No
No
Not Required
Not Required
X
X
Yes
No
Yes
Yes
No
No
Yes*
No
No N/C No
N/C N/C No
No
Not Required
X
Yes
No
Yes
Yes
No
No
Yes*
No
No N/C No
N/C N/C No
No
Not Required
X
Yes
No
Yes
Yes
No
No
Yes*
No
No N/C No
N/C N/C No
No
Not Required
X
Yes
No
Yes
Yes
No
No
Yes*
No
No N/C No
N/C N/C No
No
Not Required
X
Yes
No
Yes
Yes
No
No
Yes*
No
No N/C No
N/C N/C No
No
Not Required
X
Occupational Therapy Evaluation
Therapeutic Activities, one on one patient
contact, each 15 minutes
Self Care/Home Management Training, each
15 min.
11, 15
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes*
Yes*
Yes
Yes
Yes Yes Yes
Yes Yes Yes
N/C N/C Yes
N/C N/C Yes
Yes ValueOptions
Yes ValueOptions
X
X
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes ValueOptions
X
T1016
HW
TBS - Use DDA Dx and MH
96150
96151
96152
Occupational Therapy Services Inpatient
97003
97530
97535
97537
97532
97150
97004
Occupational Therapy Services Outpatient
97003
97530
97535
No
Non HSCRC
space only
Mapset
MD4
MDA
MD6
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Claim Place of
Type Service
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Service Description
Community/Work Reintegration Training, each
15 min.
Medicaid
Modifier 2
11, 15
Claim
Form
Pre-Authorization Required
Yes Yes Yes
N/C N/C Yes
Courtesy Reviews
MD5
Uninsured
MDC
TBI
MD3
PRTF
MDE
Send Auth
Request to:
Yes ValueOptions
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
97537
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
X
Mapset
MD4
MDA
Any Combination of On-Site or Off-Site
services for Community PRP client, not living
independently
On-Site services for community PRP Client,
not living independently (minimum 2
encounters)
Off-Site services for community PRP Client,
not living independently (minimum 2
encounters)
Any Combination of On or Off-Site services for
Supported Living Client, living independently
(Minimum 6 encounters)
Any Combination of On-Site services for
Supported Living Client, living independently
(Minimum 3 encounters)
Any Combination of Off-Site services for
Supported Living Client, living independently
(Minimum 5 encounters)
On-Site PRP services to Intensive Residential
Clients (Minimum 4 Encounters)
H2018
U2
H2018
U2
H2018
U3
H2018
U3
H2018
U3
H2018
U5
H2018
U4
H2018
U4
H2018
U5
03, 02 49
MD6
Claim
Form
Courtesy Reviews
Medicaid
Uninsured
Courtesy Reviews
Pre-Authorization Required
Uninsured
MD5
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Medicaid
Modifier 2
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes ValueOptions
X
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes ValueOptions
X
Yes
Yes
Yes
Yes*
No
No
Yes*
Yes
No No
N/C N/C No
No
Not Required
X
Yes
Yes
Yes
Yes*
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes ValueOptions
X
No
TBI
Yes
Send Auth
Request to:
Yes ValueOptions
TBI
Modifier 1
Modifier 2
Modifier 1
U2
MDC
Public Mental Health Coverage
Claim Place of
Service Description
Type Service
Development of Cognitive Skills, each 15
minutes
97150
Therapeutic Procedure, group (2 or more
individuals)
97004
Reevaluation (per 15 minutes)
Rehabilitation Services - All Codes Must be Specifically Authorized Using the Appropriate Modifier (5) (6)
H0002
Behavioral Health Screening PRP Assessment
11, 15, 52
H2018
MD3
PRTF
MDE
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
11, 15
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
97532
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
X
02
52
Yes
Yes
Yes
Yes*
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes ValueOptions
X
02
15
Yes
Yes
Yes
Yes*
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes ValueOptions
X
06,05, 49
03,02
Yes
Yes
Yes
Yes*
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes ValueOptions
X
03,02 52
Yes
Yes
Yes
Yes*
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes ValueOptions
X
05,02 15
Yes
Yes
Yes
Yes*
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes ValueOptions
X
04,03, 52
02
Yes
Yes
Yes
Yes*
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes CSA
X
On-Site PRP services to General Residential
Clients (Minimum 4 Encounters)
04,03, 52
02
Yes
Yes
Yes
Yes*
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes CSA
X
Off-Site PRP Services to RRP General Clients
(Minimum 13 Encounters)
Off-Site PRP Services to RRP Intensive Clients
(Minimum 19 Encounters)
13,05, 15
02
19,13, 15
05,02
Yes
Yes
Yes
Yes*
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes CSA
X
Yes
Yes
Yes
Yes*
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes CSA
X
Mapset
MD4
MDA
MD5
MD6
Medicaid
Courtesy Reviews
Uninsured
PRTF
Yes
Yes
Yes
Yes*
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Send Auth
Request to:
Yes CSA
49
Yes
Yes
Yes
Yes*
No
No
Yes*
Yes
Yes Yes Yes
N/C N/C Yes
Yes CSA
X
Yes CSA
X
TBI
Place of
Service
49
TBI
Intensive Residential Combined (Minimum 23
State Funded Medicare/Medicaid
U7
Federally FundedMedicare/Medicaid
H2018
Claim
Type
17,13,
06,05,
04,03,
02
23,19,
17,13,
06,05,
04,03,
02
Primary Adult Care -PAC
U6
Service Description
General Residential Combined (Minimum 17
Encounters)
Medicaid
Modifier 2
2013 CPT/Rev
Code
H2018
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MDC
Uninsured
MD3
PRTF
MDE
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 Add on
Code
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
X
T1023
Transitional PRP. Any Combination of on/off
sitePRP services to adult or TAY consumer
transitioning to an RRP or IP Facility.
49 @
Yes*
No
Yes*
Yes*
No
No
Yes*
Yes
Yes N/C Yes
N/C N/C Yes
0911
Psychiatric Rehab - Johns Hopkins PRP
21, 22, 51, 56,
99
15, 52
15, 52
Yes
No
Yes
Yes*
No
No
No
Yes
Yes N/C Yes
N/C N/C N/C Yes ValueOptions
X
Yes
Yes
Yes
No
Yes
Yes
Yes*
Yes*
No
No
No
No
Yes*
Yes*
No
No
No No No
No N/C No
N/C N/C No
N/C N/C No
N/C Not Required
N/C Not Required
X
X
Yes*
No
Yes*
Yes*
No
No
Yes*
Yes
No N/C No
N/C N/C No
No
Not Required
X
Residential Room and Board
11, 12, 15, 21,
22, 49, 51, 52,
56, 62, 99
Yes*
No
Yes*
Yes*
No
No
Yes*
Yes
No N/C No
N/C N/C No
No
Not Required
X
Enhanced Support
12, 15
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C Yes
N/C N/C Yes
Yes CSA
X
11, 12, 15
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
(for Medicare Recipients
No
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
- ACT (Evidence Based
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
- ACT (for Medicare)
No
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
11, 52
Yes*
No
Yes
Yes
No
No
Yes
Yes
Yes N/C Yes
N/C N/C Yes
Yes ValueOptions
X
15
Yes
No
Yes
Yes
No
No
Yes
Yes
Yes N/C No
N/C N/C Yes
Yes ValueOptions
X
H2016
H2016
RRP Bed
H0019
U8
Encounter for PRP
Transitional PRP Encounter
Residential Bed Hold
T2048
Housing Services
S5150
Mobile Treatment
H0040
H0040
52
H0040
21
H0040
Respite Care
H0045
U9
T1005
Residential Crisis Services
Mobile Treatment
Based)
Mobile Treatment
Monthly)
Mobile Treatment
Practice)
Mobile Treatment
Monthly (Non-Evidence
Respite Care Services - Not in home (per
diem)
Respite Care Services - In home
Mapset
MD4
MDA
Treatment Foster Care
T2048
Residential Room and Board
H2024
Supported Employment per 15 minutes
(Intensive Job Coaching)
Supported Employment, Pre-Placement Phase
11, 12, 15, 99
MD6
Courtesy Reviews
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Claim
Form
Pre-Authorization Required
Uninsured
MD5
Send Auth
Request to:
Yes N/C Yes N/C N/C Yes Yes ValueOptions
**
Yes N/C Yes N/C N/C Yes Yes ValueOptions
**
N/C N/C N/C N/C N/C N/C N/C ValueOptions
**
TBI
MDC
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Claim Place of
Type Service
11, 12, 15, 21,
51, 52, 56, 62,
99
Medicaid
Modifier 2
Service Description
Residential Crisis Service
S5145 (1)
Supported Employment
H2023
MD3
PRTF
MDE
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
S9485 (1)
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
Yes
No
Yes
Yes
No
No
Yes*
Yes
X
Yes
No
Yes
Yes
No
No
Yes*
Yes
No
No
No
No
No
No
No
No
Yes*
No
Yes*
Yes*
No
No
Yes*
Yes
Yes N/C Yes
N/C N/C Yes
Yes CSA
X
Yes*
No
Yes*
Yes*
No
No
Yes*
Yes
Yes N/C Yes
N/C N/C Yes
Yes CSA
X
X
X
H2024
21
Supported Employment, Job Placement Phase
Yes*
No
Yes*
Yes*
No
No
Yes*
Yes
Yes N/C Yes
N/C N/C Yes
Yes CSA
X
H2026
H2026
21
Extended Support Services
Ongoing Support (Evidence Based Practice)
Yes*
Yes
No
No
Yes*
Yes
Yes*
Yes
No
No
No
No
Yes*
Yes*
Yes
Yes
Yes N/C Yes
Yes N/C Yes
N/C N/C Yes
N/C N/C Yes
Yes CSA
Yes CSA
X
X
S9445
52
Clinic Coordination (Evidence Based Practice)
Yes*
No
Yes*
Yes*
No
No
Yes*
Yes
Yes N/C Yes
N/C N/C Yes
Yes CSA
X
S9445
H2016
U1
Outpatient ECT
90870
00104
0901
Inpatient ECT Treatment
90870
00104
0901
Psych Testing
0918
On or Off-Site PRP Services for an Individual
in a Supported Employment Program
(Minimum 2 Encounters)
Encounter for Supported Employment
15, 49, 52
Yes
No
Yes
Yes
No
No
Yes*
Yes
Yes N/C Yes
N/C N/C Yes
Yes CSA
X
11, 15, 52, 99
Yes*
No
Yes*
Yes*
No
No
Yes*
No
No N/C No
N/C N/C No
No
X
ECT Single Seizure with Monitoring
Anesthesia for ECT
ECT Facility
11, 22, 53
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes N/C No
No (2)
N/C No
No (4)
N/C No
N/C N/C Yes Yes ValueOptions
N/C N/C No (2)Yes ValueOptions
N/C N/C N/C Yes ValueOptions X
X
X
ECT Single Seizure
Anesthesia for ECT
ECT Facility
21, 51, 52, 56
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes N/C No
No (4)
N/C No
No (4)
N/C No
N/C N/C N/C Yes ValueOptions
N/C N/C N/C Yes ValueOptions X
N/C N/C N/C Yes ValueOptions X
X
Psychological Testing
11, 21, 22, 51,
52, 53, 56, 99
Yes
No
Yes
Yes
No
No
No
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Not Required
96101
Psychological Testing
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
96102
Psychological Testing
Yes
Yes
Yes
Yes
No
No
Yes*
Yes
Yes Yes No
N/C N/C Yes
Yes ValueOptions
X
Non HSCRC
space only
FPR1 FTB1 UIN1
MCOU
MACR
Mapset
MD4
MDA
MD1
MDE
G9011
G9011
HE
Emergency Room Facility
0450, 0451, 0452
Emergency Room Physician
99281
99282
99283
99284
99285
90791
90792
90791
HA
90792
HA
MD5
MD6
11, 12, 15
Coordinated care fee, risk adjusted
maintenance, Level 4 - Chesapeake
Coordinated care fee, risk adjusted
maintenance, Level 4 - Chesapeake
Coordinated care fee, risk adjusted
maintenance, Level 5 - Creative Alternatives
11, 12, 22, 53
11, 12, 15, 50,
53, 72
Coordinated care fee, risk adjusted
maintenance, Level 5 - Creative Alternatives
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
No
No
No
No
No
No
No
No
N/C N/C N/C N/C N/C N/C N/A Not Required X
No
No
No
No
No
No
No
No
N/C N/C N/C N/C N/C N/C N/A Not Required X
No
No
No
No
No
No
No
No
N/C N/C N/C N/C N/C N/C N/A Not Required X
No
No
No
No
No
No
No
No
N/C N/C N/C N/C N/C N/C N/A Not Required X
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Uninsured
TBI
Send Auth
Request to:
UB04
No
No
No
No
No
No
No
No
No
No
Courtesy Reviews
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Uninsured
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
TBI
No
No
No
No
No
No
No
No
No
No
PRTF
No
No
No
No
No
No
No
No
No
No
Courtesy Reviews
No
No
No
No
No
No
No
No
No
No
PRTF
No
No
No
No
No
No
No
No
No
No
Claim Place of
Type Service
Residental habilitation Level 1 {per day}
Residental habilitation Level 2 {per day}
Residental habilitation Level 3 {per day}
Day habiliation Level 1 {per day}
Day habiliation Level 2 {per day}
Day habilitation Level 3 {per day}
Supported Employment Level 1 {per day}
Supported Employment Level 2 {per day}
Supported Employment Level 3 {per day}
Individual Support Services {ISS}
Primary Adult Care -PAC
No
No
No
No
No
No
No
No
No
No
Medicaid
Modifier 2
Service Description
Claim
Form
Pre-Authorization Required
Priamry Adult Care -PAC
HE
MDC
Medicaid
G9010
MD3
UINS
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
BMHS Capitation
G9010
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
2013 Add on
Code
Code
Tramatic Brain Injury - Dx Code = 310.9
W0037
W0038
W0039
W0054
W0055
W0056
W0057
W0058
W0059
W0060
SDUL
(2)
MHA
MHA
MHA
MHA
MHA
MHA
MHA
MHA
MHA
MHA
Emergency Room
21, 23
Yes
Yes~
Yes
Yes
No
No
No
No
No No
No
N/C N/C N/C N/C Not Required X
Emergency Department Visit
Emergency Department Visit
Emergency Department Visit
Emergency Department Visit
Emergency Department Visit
Psychiatric Diagnostic Interview
22, 23
23
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
N/C
Psychiatric Diagnostic Interview
23
Yes
No
Yes
Yes
No
No
No
No
No N/C No
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
No
N/C N/C No
N/A
N/A
N/A
N/A
N/A
N/A
HCFA 1500
FDUL
FMCD FPAC (2)
Medicare/Medicaid
Fund Codes
Not
Not
Not
Not
Not
Not
Required
Required
Required
Required
Required
Required
X
X
X
X
X
X
N/A Not Required
X
Mapset
MD4
MDA
MD6
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Claim Place of
Type Service
23
Medicaid
Modifier 2
Service Description
Office Consult - MDs only
Office Consult - MDs only
Office Consult - MDs only
Office Consult - MDs only
Office Consult - MDs only
Claim
Form
Pre-Authorization Required
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
Courtesy Reviews
MD5
Uninsured
MDC
TBI
MD3
PRTF
MDE
N/A
N/A
N/A
N/A
N/A
Send Auth
Request to:
Not Required
Not Required
Not Required
Not Required
Not Required
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
99241
99242
99243
99244
99245
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
X
X
X
X
X
W5008
W5002
W5003
W5004
W5014
W5015
W5012
W5013
W5010
W5011
W5020
W5021
W5016
W5017
W5018
W5019
W5000
W5001
Transport
A0362
A0380
A0080
A0170
Lab Services
36415
Mapset
MD4
MDA
MD6
Caregiver Peer to Peer Support
Youth Peer to Peer Support
Family and Youth Training Individual
Family and Youth Training Group
Crisis & Stabilization Service
Art Therapy Individual
Art Therapy Group
Dance Therapy Individual
Dance Therapy Group
Equine Assisted Therapy Individual
Equine Assisted Therapy Group
Horticultural Therapy Individual
Horticultural Therapy Group
Music Therapy Individual
Music Therapy Group
Drama Therapy Individual
Drama Therapy Group
Respite Care In Home
Respite Care Residential
Ambulance service, BLS, emergency transport,
mileage, and disposable supplies separately
billed
BLS Mileage {Per Mile}
Non-Emergency transportation; Per Mile
volunteer, with no vested or personal interest.
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Claim Place of
Type Service
Send Auth
Request to:
11, 15, 21, 22,
52
No
No
No
No
Yes
No
No
No
N/C N/C N/C Yes N/C N/C No
ValueOptions
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
ValueOptions
41, 42
No
No
No
No
No
No
No
No
N/C N/C N/C N/C N/C N/C No
Not required
X
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
N/C N/C N/C N/C N/C N/C No
N/C N/C N/C N/C N/C N/C No
Not required
Not required
X
X
No
No
No
No
No
No
No
No
N/C N/C N/C N/C N/C N/C No
Not required
X
Yes
Yes
Yes
Yes
No
No
Yes*
No
No No
Not Required
X
Non-Emergency transportation; ancillary,
parking fees, tolls other
Collection blood by Venipuncture
Medicaid
Modifier 2
Service Description
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MD5
Uninsured
MDC
TBI
MD3
PRTF
MDE
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
PRTF Waiver
W5009
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
11, 21, 22, 23,
53, 81
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C N/C No
No
Mapset
MD4
MDA
MD5
MD6
Medicaid
Courtesy Reviews
Uninsured
PRTF
State Funded Medicare/Medicaid
Yes
Yes
Yes
No
No
Yes*
No
No No
No
N/C N/C No
No
TBI
Yes
Send Auth
Request to:
Not Required
TBI
Claim Place of
Type Service
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Medicaid
Modifier 2
Service Description
Collection blood by Venipuncture
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MDC
Uninsured
MD3
PRTF
MDE
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
HW
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
36415
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
X
80002-89999
Lab Services
Yes
Yes
Yes
Yes
No
No
Yes*
No
No No
No
N/C N/C No
No
Not Required
X
96372
Therapeutic Injection
11
Yes
No
Yes
Yes
No
No
Yes*
No
No N/C No
N/C N/C No
N/C Not Required
X
Lab & EKG Services
22
Yes
Yes
Yes
Yes
No
No
No
No
No No
No
No
N/C N/C N/C Not Required X
0637
Self Administered Drugs
22
Yes
Yes
Yes
Yes
No
No
No
No
No No
No
No
N/C N/C N/C Not Required X
0940
Therapeutic Injection
11, 21, 22, 23,
53, 81
Yes
No
Yes
Yes
No
No
No
No
No N/C No
0300;
0304;
0307;
0311;
0301;
0305;
0309;
0312;
0302;
0306;
0310;
0730
N/C N/C N/C N/C Not Required X
Mapset
MD4
MDA
MD6
Special Charges - Admission Charge
Pharmacy - General Classification
Pharmacy - General Drugs
Pharmacy - Non Prescription Drugs
Pharmacy - IV Solutions
Pharmacy - Other Pharmacy
Equipment for and administration of Ivs
Medl/Surg Supplies and Devices General
Medl/Surg Supplies
Med/Surg Supplies and Devices - Sterile
Laboratory - General Classification
Laboratory - Chemistry
Laboratory - Immunology
Non-Routine Dialysis
Laboratory - Hematology
Laboratory - Bacteriology & Microbiology
Laboratory - Urology
Laboratory - Other
Laboratory Pathology - General
Laboratory Pathological - Cytology
Histology
Radiology-Diagnostic General Class
Angiocardiography
Radiology-Diagnostic Chest X-Ray
Radiation Therapy
Chemotherapy Administration - IV
Nuclear Medicine - Diagnostic Procedures
Nuclear Medicine - General
Nuclear Medicine - Other
CT Scan - General
CT Scan - Head
CT Scan - Body
Operating Room Services - General
Operating Room Services - Minor Surgery
Anesthesia - General
Blood - General
Blood - Administration (transfusion)
Ultrasound
21, 51, 56, 99
11, 12, 13, 32,
33, 34, 52, 53,
62, 71, 72
21, 51, 56, 99
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes***
Yes***
Yes***
Yes***
No
No
No
No
No
No
Yes***
Yes***
Yes***
No
Yes***
Yes***
Yes***
Yes***
No
No
No
Yes***
No
Yes***
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes***
Yes***
Yes***
Yes***
No
No
No
No
No
No
Yes***
Yes***
Yes***
No
Yes***
Yes***
Yes***
Yes***
No
No
No
Yes***
No
Yes***
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Claim Place of
Type Service
11, 12, 13, 22,
32, 33, 34, 52,
53, 62, 71, 72
Primary Adult Care -PAC
Medicaid
Modifier 2
Service Description
Claim
Form
Pre-Authorization Required
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
Courtesy Reviews
MD5
Uninsured
MDC
TBI
MD3
PRTF
MDE
Send Auth
Request to:
N/C Not Required X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
N/C
X
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
2013 Add on
Code
Code
Ancillary Services {Benefit Code ANS}
0221
0250
0251
0257
0258
0259
0260
0270
0271
0272
0300
0301
0302
0304
0305
0306
0307
0309
0310
0311
0312
0320
0321
0324
0333
0335
0340
0341
0349
0350
0351
0352
0360
0361
0370
0390
0391
0402
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
Mapset
MD4
MDA
MD6
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Claim Place of
Type Service
Same as LB2
above
Primary Adult Care -PAC
Medicaid
Modifier 2
Service Description
Positron Emission Tomography (PET)
Respiratory Services - General
Respiratory Services - Inhalation
Physical Therapy - General
Physical Therapy - Eval/Re-Eval
Occupational Therapy - General
Occupational Therapy - Group
Occupational Therapy - Eval
Speech/Language Pathology - General
Speech/Language Path - Eval/Re-Eval
Pulmonary Function - General
Cardiology - General
Cardiology - Stress
Diagnostic Services
MRI
MRI - Spinal Cord
MRA - Head & Neck
Drugs Requiring Detail Coding
Self Administable Drugs
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MD5
Uninsured
MDC
TBI
MD3
PRTF
MDE
Send Auth
Request to:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes***
Yes***
Yes***
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes***
Yes***
Yes***
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes***
No
No
No
No
No
No
No
No
No
No
No
Yes***
No
No
No
No
No
No
No
No
N/C
N/C
N/C
N/C
No
No
No
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
X
X
X
X
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
0710
0720
0729
0730
Recovery Room - General
Labor Room - General
Other Labor Room
EKG/ECG
0731
0740
0761
0762
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
X
X
X
X
0771
0900
Holter Monitor
EEG
23 Hour Crisis Stabilization
Treatment or Observation Room - Observation
Room
Vaccine Administration
Psychiatric/Psychological Treatment-General
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes*** No
No
No
No
Yes***
No
No
No N/C No
No N/C No
No
No
N/C N/C N/C
N/C N/C N/C
X
X
0902
0904
0906
0921
0925
Milieu Therapy
BH Treatments-Act Therapy
Intensive Outpatient Svc-Chemical
Peripheral Vascular Lab
Pregnancy Test
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes***
No
No
No
No
No
No
No
No
No
Yes***
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
X
X
X
X
X
Same as LB2
above
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
0404
0410
0412
0420
0424
0430
0433
0434
0440
0444
0460
0480
0482
0610
0611
0612
0615
0636
0637
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
FPR1 FTB1 UIN1
MCOU
MACR
Mapset
MD4
MDA
MD1
MDE
MDC
MD5
MD6
12, 13, 32,
34, 62, 71,
13, 32, 33,
62, 71, 99
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
N/C
No
No
No
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Yes
No
Yes
No
No
No
No
No
No N/C No
No
N/C N/C N/C
X
NOTE: PRP Payment levels for case rates are affected by the HCPCS code level used, modifier, place of service code and billed
charges. There must be an exact match between the authorization and the claim. Code H2016 is an encounter data code only and
should be billed for zero dollars and must pay 0 on an EOB to be considered valid for meeting minimums for H2018, the billable code.
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
N/C
Uninsured
TBI
Send Auth
Request to:
UB04
No
No
Yes***
No
No
No
Yes***
Yes***
Yes***
Yes***
Yes***
Yes***
Yes***
Yes***
No
Courtesy Reviews
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Uninsured
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
TBI
No
No
Yes***
No
No
No
Yes***
Yes***
Yes***
Yes***
Yes***
Yes***
Yes***
Yes***
No
PRTF
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Courtesy Reviews
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
PRTF
Priamry Adult Care -PAC
ECT Facility
11,
33,
99
12,
34,
Claim
Form
Pre-Authorization Required
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Claim Place of
Type Service
21, 51, 56, 99
Primary Adult Care -PAC
Service Description
Other Therapeutic Services - Drug Rehab
Professional Fees - ER
Professional Fees - EKG
Ambulatory Surgery Care - General
Chronic Pain Center
Clinic - General
Psychiatric Clinic
Psychiatric/Psychological Services - Indiv
Psychiatric/Psychological Services - Group
Psychiatric/Psychological Services - Family
Biofeedback
Psychiatric/Psychological Services
Psychiatric/Psychological Services - Other
Other Diagnstic Services
Other Therapeutic Services
Medicaid
Modifier 2
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
MD3
UINS
Medicaid
0901
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
0942
0981
0985
0490
0511
0510
0513
0914
0915
0916
0917
0918
0919
0929
0949
SDUL
(2)
HCFA 1500
FDUL
FMCD FPAC (2)
Medicare/Medicaid
Fund Codes
Mapset
MD4
MDA
MD6
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Claim Place of
Type Service
Medicaid
Modifier 2
Service Description
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MD5
Uninsured
MDC
TBI
MD3
PRTF
MDE
Send Auth
Request to:
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
Place of Service
11
15
21
22
23
52
49
Modifiers
52
21
U1
U2
U3
U4
U5
U6
U7
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
Mapset
MD4
MDA
MD6
(2) Medicare/Medicaid Dual Eligibles - Claims will only be paid for LPC's and when Medicare is exhausted; Authorization is required for PRP, Case Management, IOP and crisis bed.
(4) One unit of anesthesia will be automatically granted per unit of ECT services (90807 or 90871).
(5) PRP Services - Medicaid or Medicaid-PAC services are authorized by ValueOptions, except when receiving RRP, then services are authorized by CSA.
(6) TBI and PRTF waiver eligibile consumers are also eligible for other services as long as they are not duplicative and are medically necessary.
State Funded Services
Non HSCRC space only
Under the Covered Services:
Yes = Covered
No = Not Covered
Under Auth Requirements:
N/C = Not Covered
Yes = Auth Required
No = No Auth Required
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Claim Place of
Type Service
Medicaid
Modifier 2
2013 CPT/Rev
2013 Add on
Code
Code
Service Description
^ Covered for Outpatient only.
# Benefit for Uninsured Consumers Only
* State general funds as available
**First 10 days authorized by VO, all concurrents authorized by CSA.
***IP Facility/Professional can be covered for Uninsured and PAC under Purchase of Care Only
****Services covered only when provided by non-regulated hospital clinics.
~ Coverage effective 1/1/2010
(1) Auth for Residential Crisis Service and Treatment Foster Care requires a T2048 auth as well.
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MD5
Uninsured
MDC
TBI
MD3
PRTF
MDE
Send Auth
Request to:
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
Modifier 1
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
Mapset
MD4
MDA
MD6
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Claim Place of
Type Service
Medicaid
Modifier 2
Service Description
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MD5
Uninsured
MDC
TBI
MD3
PRTF
MDE
Send Auth
Request to:
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes
Mapset
MD4
MDA
MD6
Medicaid
Courtesy Reviews
Uninsured
TBI
PRTF
State Funded Medicare/Medicaid
Federally FundedMedicare/Medicaid
Primary Adult Care -PAC
Claim Place of
Type Service
Medicaid
Modifier 2
Service Description
Claim
Form
Pre-Authorization Required
Courtesy Reviews
MD5
Uninsured
MDC
TBI
MD3
PRTF
MDE
Send Auth
Request to:
HCFA 1500
MCOU
MACR
MD1
UINS
UB04
FPR1 FTB1 UIN1
Public Mental Health Coverage
Modifier 1
Modifier 2
Modifier 1
2013 Add on
Code
FPRT FTBI
(6)
(6)
Benefit Package FMC1 FPA1 FDU1 SDU1
MARYLAND SERVICE MATRIX 02/07/13
2013 CPT/Rev
Code
SDUL
(2)
Medicare/Medicaid
FDUL
FMCD FPAC (2)
Priamry Adult Care -PAC
Fund Codes