V.15.4 Code Table Listing -- SSIS.HCPCS_MOD. Sort = HCPCS_MOD_ID
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1 V.5.4 Code Table Listing -- SSIS.MOD Sort = CD 4 UTC Desc T08 U 09 CDCS - Treatment and training 0/0/004 T08 U 09 CDCS - Environmental modifications and provisions 0/0/004 T08 U4 09 CDCS - Self direction support activities 0/0/ T09 TT UC 6 Extended shared personal care services : /0/ T09 HQ UC 6 Extended shared personal care services : /0/ S55 U9 6 Behavioral programming by aide /0/004 04/0/0 77 S55 UA 6 BI night supervision /0/ S55 UB 6 4-hour emergency assistance (5 minutes) /0/004 //0 99 S56 UB 08 4-hour emergency assistance (day) /0/004 //0 00 S500 TF 6 Adult day care bath /0/004 0 T00 TT UC 6 RN, regular, extended : /0/004 T00 TT UC 6 LPN, regular, extended : /0/004 S9 TF UC 9 Extended physical therapy assistant /0/004 S99 TF UC 9 Extended occupational therapy assistant /0/004 4 T00 TG UC 6 RN, complex, extended /0/004 5 T00 TG UC 6 LPN, complex, extended /0/004 6 T00 TT 6 RN, regular : /0/004 7 T00 UC 6 RN, regular, extended : /0/004 8 T00 TG 6 RN, complex /0/004 V SSIS.MOD December 4, 05 Page of
2 CD 4 UTC Desc 9 T00 UC 6 LPN, regular, extended : /0/004 0 T00 TT 6 LPN, regular : /0/004 T00 TG 6 LPN, complex /0/004 T09 TT 6 Personal care services (PCA) : /0/004 T09 6 Personal care services (PCA) : /0/004 4 T09 HQ 6 Personal care services (PCA) : /0/004 5 T0 HA HE 8 MH-TCM, child, face-to-face 6 T0 HE U4 8 MH-TCM, adult, telephone 7 T0 HE HW 8 MH-TCM, adult, face-to-face by state staff //007 8 T0 HE HW U4 8 MH-TCM, adult, telephone by state staff //007 9 T0 U 8 CW-TCM, face-to-face 0 T0 U U4 8 CW-TCM, telephone T0 U 8 VA/DD-TCM, face-to-face T0 U U4 8 VA/DD-TCM, telephone 5 T005 TG 6 Crisis respite, specialized /0/ S56 TG 08 DD, in home family support (day) /0/004 //0 4 H0040 HW 08 Assertive Community Treatment (ACT) by state staff 07/0/004 //007 4 H Children's residential treatment 07/0/004 4 H009 HW 08 Intensive Residential Rehab. Treatment (IRT) by state staff 07/0/004 // S9484 HM Crisis assessment, intervention and stabilization, non-residential, ind. by rehab. worker V SSIS.MOD December 4, 05 Page of
3 CD 4 UTC Desc 46 S9484 HQ Crisis assessment, intervention and stabilization, non-residential, group X565 8 Transportation 0/0/999 09/0/ X59 8 Residential care services 0/0/999 09/0/ X594 8 Extended transportation 0/0/999 09/0/ X56 8 Foster care, corporate 0/0/000 09/0/ X DD county screening, MA elig 0/0/999 09/0/ X540 7 Day program, supported employment 0/0/999 09/0/ X54 Day program, supported employment 0/0/999 09/0/ X54 08 Day program, supported employment 0/0/999 09/0/ X545 7 MR, adult supported living services 0/0/999 09/0/ X MR, adult supported living services 0/0/999 09/0/ X5467 Extended home health medical supplies/equipment 0/0/999 09/0/ X Case management 0/0/999 09/0/ X Respite care, out of home 0/0/999 09/0/ X549 6 Case management, paraprofessional 0/0/999 09/0/ X Consumer education and training 0/0/999 09/0/ X550 Consumer directed community support 0/0/999 06/0/ X Consumer directed community support 0/0/999 06/0/ X Independent Living Skills counseling 0/0/999 09/0/ X559 7 Independent Living Skills group therapy 0/0/999 09/0/006 V SSIS.MOD December 4, 05 Page of
4 CD 4 UTC Desc X560 8 Extended transportation 0/0/999 09/0/ X560 4 Extended transportation 0/0/999 09/0/ X Extended transportation - extra attendant 0/0/999 09/0/ X560 6 MR Preadmission screening - 5 min 0/0/999 09/0/ X56 6 MH preadmission screening 0/0/ X569 7 PASARR MH diag asses Masters 0/0/ X PASARR MH diag asses PhD 0/0/ X567 Assistive technology 0/0/999 09/0/ X5674 Specialist service 0/0/999 09/0/ X5679 DT&H, waiver, non-pilot 0/0/999 09/0/ Life/disability evaluation: Face-to-face LTCC assessment under age 65 07/0/00 0// X598 8 MR, adult supported living services 0/0/000 09/0/ T06 6 Relocation Service Coordination (RSC-TCM) 07/0/00 08// H Crisis stabilization, residential T0 HE 8 MH-TCM, adult, face-to-face S9484 Crisis assessment, intervention and stabilization, non-residential, ind. by professional H Partial hospitalization S565 Environmental accessibility adaptations, home modifications/install and expenses /0/ T08 U 09 CDCS - Personal assistance 0/0/ T040 6 CDCS - Background check 0/0/004 V SSIS.MOD December 4, 05 Page 4 of
5 CD 4 UTC Desc T04 6 CDCS - Mandatory case management 0/0/ S500 6 Day care services, adult (5 minutes) /0/ S50 08 Day care services, adult (day) /0/ S50 6 Family training /0/ S56 7 Caregiver training/education /0/004 06/0/ S50 6 Chore services /0/ S55 6 DD, in home family support (5 minutes) /0/ S56 08 Caregiver living expenses /0/ S50 6 Homemaker service - cleaning only (5 minutes) /0/ S5 08 Homemaker services (day) /0/ S Foster care, adult (day) /0/ S54 8 Foster care, adult (month) /0/004 // S Foster care, child (day) /0/ S546 8 Foster care, child (month) /0/004 // S550 6 Respite care, in home (5 minutes) /0/004 // S55 08 Respite care, in home (day) /0/ S570 Home delivered meals /0/ S95 08 Crisis respite (day) /0/ S98 UC 9 Extended speech therapy /0/ S99 UC 9 Extended occupational therapy /0/004 V SSIS.MOD December 4, 05 Page 5 of
6 CD 4 UTC Desc S9 UC 9 Extended physical therapy /0/ S Nutritional counseling, diet /0/ E99 Durable medical equipment /0/004 05// H Respite care services, not in home /0/ G054 6 Direct skilled nursing services - LPN or RN - home /0/ G056 6 Home health aide/extended home health aide /0/004 06/0/ T005 6 Crisis respite (5 minutes) /0/ T00 6 RN, regular /0/ T00 6 LPN, regular /0/ T09 UC 6 Extended personal care : /0/ T0 9 Home health aide visit /0/ T00 08 Personal care services /0/004 09/0/ T08 09 Transitional services /0/ S55 6 Companion care, adult/personal support /0/ S56 08 Personal support /0/004 // H Assertive Community Treatment (ACT) 07/0/ H07 HM UD 6 Transition to Community Living by a mental health rehabilitation worker 970 H07 HM HW UD 6 Psychosocial rehab., indiv., transitional by rehab worker/state employee // H07 HM HW 6 Psychosocial rehab., indiv. by rehab worker/state employee // H07 HW UD 6 Psychosocial rehab., indiv., transitional by state employee //007 V SSIS.MOD December 4, 05 Page 6 of
7 9707 CD H07 HQ HW 4 UTC 6 Desc Psychosocial rehab., group by state employee // T08 U8 09 CDCS - Flexible case management 0/0/ H07 6 Basic Living and Social Skills - individual; mental health professional or practitioner 9767 H07 HM 6 Basic Living and Social Skills - individual; mental health rehabilitation worker 9767 H07 HW 6 Psychosocial rehab., indiv. by state employee // H07 HQ 6 Basic Living and Social Skills - group; mental health professional or practitioner, or rehab. worker H07 UD 6 Transition to Community Living T06 U9 08 Supported living services, adult, corporate AFC (day) 0/0/ H07 HQ UD 6 Psychosocial rehab., group, transitional 9768 H07 HM HQ UD 6 Psychosocial rehab., group, transitional by rehab worker 9768 H07 HQ HW UD 6 Psychosocial rehab., group, transitional by state employee // H07 HM HQ HW UD 6 Psychosocial rehab., group, transitional by rehab worker/state employee // H07 HM HQ 6 Psychosocial rehab., group by rehab worker H07 HM HQ HW 6 Psychosocial rehab., group by rehab worker/state employee // Community Intervention; mental health professional or practitioner 0/0/ UD 7 Transition to Community Intervention 0/0/ HM UD 7 Transition to Community Intervention by a mental health rehabilitation worker 0/0/ HW UD 6 Community intervention, indiv., transitional by state employee 0/0/00 // HM HW UD 6 Community intervention, indiv., transitional by rehab worker/state employee 0/0/00 // HM 7 Community Intervention mental health rehabilitation worker 0/0/00 V SSIS.MOD December 4, 05 Page 7 of
8 CD 4 UTC Desc HW 6 Community intervention, indiv. by state employee 0/0/00 // HM HW 6 Community intervention, indiv. by rehab worker/state employee 0/0/00 // T05 09 Consumer Support Grant (CSG) 06/0/ H005 6 Behaviorial Support, by analyst 0/0/ H005 TF 6 Behaviorial Support, by specialist 0/0/ H005 TG 6 Behaviorial Support, by professional 0/0/ H0 6 Independent living skills, maintenance 0/0/006 // H0 TG 6 Independent living skills, individual therapy 0/0/ H0 HQ 6 Independent living skills, group therapy 0/0/ T00 08 DT&H, non-pilot/structured day program 0/0/ T00 U5 DT&H, non-pilot 0/0/006 // T00 08 DT&H, non-pilot, transportation 0/0/006 // T0 TG 6 DT&H pilot, Rate A 0/0/006 // T0 TF 6 DT&H pilot, Rate B 0/0/006 // T0 UB 6 DT&H pilot, Rate C 0/0/006 // T0 6 DT&H pilot, Rate D/Structured day program 0/0/ T04 6 DD screening (screen) 0/0/006 05// T0 8 Residential care services (month) 0/0/006 // T0 U9 8 Supported living services, adult, corporate AFC (month) 0/0/006 // T0 HA 8 Supported living services, child (month) 0/0/006 //0 V SSIS.MOD December 4, 05 Page 8 of
9 CD 4 UTC Desc T08 U5 Supported employment (partial day) 0/0/006 // S05 UC 4 Transportation, mileage (commercial vehicle) 0/0/006 // T08 TF Housing access coordination 0/0/006 // T09 Assistive technology/supplies and equip., extended 0/0/ T0 Specialist service 0/0/ T07 HA 6 Supported living services, child (5 minutes) 0/0/ T06 HA 08 Supported living services, child (day) 0/0/ T07 6 Supported living services, adult (5 minutes) 0/0/ T07 U9 6 Supported living services, adult, corporate AFC (5 minutes) 0/0/ T06 08 Supported living services, adult (day) 0/0/ S509 7 Consumer training and education 0/0/ T06 UC 6 Waiver case management 0/0/ S54 HQ 8 Foster care, adult (month) 0/0/ T00 UC 8 Non-emergency transportation; encounter/trip (one way) 0/0/ T09 UA 6 Supervision of PCA 0/0/ T00 8 Non-emergency transportation; encounter/trip (one way) 0/0/ S50 TF 6 CAC Family training 0/0/006 04/0/ T00 8 Customized living services (monthly) 0/0/006 // T00 TG 8 4-hour customized living (monthly) 0/0/006 // T00 TG U9 8 4-hour customized living (corporate) 0/0/006 //0 V SSIS.MOD December 4, 05 Page 9 of
10 CD 4 UTC Desc T09 6 Supported employment (5 minutes) 0/0/ T08 08 Supported employment (day) 0/0/006 // T06 TF UC 6 Waiver case management by paraprofessional 0/0/ S550 UB 6 Respite care, out of home 0/0/ T05 Prevocational services (hour) 0/0/ T04 08 Prevocational services (day) 0/0/ H0 TF 6 Independent living skills, counseling 0/0/ T00 UC 0 Transportation, extra attendant 0/0/ T0 08 Customized living services (daily) 0/0/ T0 08 Residential care services (day) 0/0/ T06 6 AC Conversion 07/0/ T00 UC 5 Non-emergency transportation; round trip 0/0/006 09/0/ T0 4 Supported living services, adult (semi-monthly) 0/0/006 // S05 UC 4 Transportation, mileage 0/0/ T0 U9 4 Supported living services, adult, corporate AFC (semi-monthly) 0/0/006 // T0 HA 4 Supported living services, child (semi-monthly) 0/0/006 //0 98 T0 8 Supported living services, adult (month) 0/0/006 //0 986 X AC Discretionary service 07/0/ H Intensive Residential Rehab. Treatment (IRT) 07/0/ T05 UD 09 Family Support Grant (FSG) with CSG 06/0/006 07//0 V SSIS.MOD December 4, 05 Page 0 of
11 CD 4 UTC Desc 9874 S540 U9 08 Foster care, adult, corporate (day) /0/ S54 U9 8 Foster care, adult, corporate (month) /0/004 // T08 U 09 Transitional services, furniture /0/ T08 U 09 Transitional services, supplies /0/ T04 6 DD Screening (5 minutes) 06/0/ T00 9 Home health skilled nurse /0/ T00 GT 09 Home health telehomecare /0/ H09 UA 6 Therapeutic behavioral services, Level I MHBA 07/0/ H09 HM UA 6 Therapeutic behavioral services, Level II MHBA 07/0/ H09 HE UA 6 Therapeutic behavioral services, direction of MHBA 07/0/ S500 U7 6 Family adult day services (FADS) (5 minutes) 0/0/ S50 U7 08 Family adult day services (FADS) (day) 0/0/ T0 6 Life/disability evaluation: Face-to-face LTCC assessment under age 65 04/0/ T07 6 Relocation Service Coordination (RSC-TCM) 09/0/ T004 6 Home health aide/extended home health aide 07/0/ S565 U Environmental accessibility adaptations, square footage 08/0/ H000 6 Alcohol and/or drug assessment 07/0/ H000 6 Behavioral health eligibility screening 07/0/ S9484 HN Crisis assessment, intervention and stabilization, non-residential, ind. by practitioner 0/0/ HK 7 Community intervention, crisis response 0/0/00 V SSIS.MOD December 4, 05 Page of
12 CD 4 UTC Desc S56 TF Caregiver assessment 04/0/00 06/0/ S560 Emergency response system-installation and testing 05/0/ S56 Emergency response system-service fee, per month 05/0/ S56 Emergency response system-purchase 05/0/ H0040 U6 08 Assertive Community Treatment, MHM 06/0/ H05 U6 6 Comprehensive community support services, MHM 06/0/ T06 U6 6 Case management, MHM 06/0/ T08 U6 09 Transition plan development, MHM 06/0/ T08 UD U6 09 Transition coordination, MHM 06/0/ A080 U6 09 Non-emergency transportation: ancillary lodging, recipient, MHM 06/0/ A000 U6 09 Non-emergency transportation: lodging for caseworker, escort, parent, MHM 06/0/ S55 UA U6 6 Night supervision, MHM 06/0/ S560 U6 Emergency response system installation and testing, MHM 06/0/ S56 U6 Emergency response system service fee per month, MHM 06/0/ S56 U6 Emergency response system purchase, MHM 06/0/ S565 U6 Environmental accessibility adaptations, MHM 06/0/ S9970 U6 Health club membership, annual, MHM 06/0/0 07// T08 U6 Adaptations - home assessment, MHM 06/0/ T999 U6 Tools, clothing and equipment for employment, MHM 06/0/ T08 U U6 09 Transitional services, furniture, MHM 06/0/0 V SSIS.MOD December 4, 05 Page of
13 CD 4 UTC Desc T08 U U6 09 Transitional services, supplies, MHM 06/0/ T08 UA U6 09 Transitional services, housing deposit, MHM 06/0/ S55 6 Caregiver training/education 07/0/ S55 TF 6 Caregiver Coaching and Counseling/Caregiver Assessment 07/0/ T0 6 PASRR Level II Screening 09/0/ S550 6 Respite care, in home (5 minutes) 0/0/ T09 U6 Assistive technology/supplies and equip., extended, MHM /0/ S9970 U5 U6 8 Health club membership, monthly, MHM 08/0/ H05 6 Community Living Assistance Services, in person 0/0/ H06 08 Community Living Assistance Services, remote 0/0/ S55 TG 6 Family Caregiver Coaching and Counseling/Family Memory Care 07/0/ E99 NU Durable medical equipment, new 06/0/ E99 RB Durable medical equipment, repair 06/0/ E99 RR Durable medical equipment, rental 06/0/0 V SSIS.MOD December 4, 05 Page of
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