D.1.2 Administration of State-Supplied Free Vaccine with Evaluation and Management (E/M) Visit D.1.3 Administration of a Provider Purchased

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1 Table of Contents 1. Section Modifications CMS 1500 Form Instructions for Completing the CMS Helpful Tips for Filling out the Paper Claim Form CMS 1500 Form Descriptions... 4 Appendix A. Adult Residential Care A.1.1 Adult Residential Living Facility- RALF A.1.2 Certified Family Home (CFH) Appendix B. Agency Institutional B.1 Home Health B.2 Hospice Appendix C. Agency - Professional C.1.1 Behavior Consultation/Crisis Management (BC/CM) C.1.2 Children s Service Coordination C.1.3 Chore Services Skilled C.1.4 Developmental Disability Agency Codes C.1.5 DD Service Coordinator C.1.6 Developmental Therapy (DT) and Intensive Behavioral Intervention (IBI) C.1.7 Developmental Therapy (DT) and Occupational Therapy (OT) C.1.8 Intensive Behavioral Intervention (IBI) C.1.9 Medical Equipment and Supplies C.1.10 Mental Health Service Coordination C.1.11 Nursing Agency-PDN C.1.12 Nursing Services C.1.13 Personal Care Services (PCS) C.1.14 Personal Care Services (PCS) Case Management C.1.15 Physical Therapy (PT) C.1.16 Physical Therapy (PT) and Occupational Therapy (OT) Services C.1.17 Psychosocial Rehabilitation Services (PSR) C.1.18 Psychotherapy C.1.19 Psychotherapy Treatment C.1.20 Registered Nurse Services Agency DD Waiver C.1.21 Residential Habilitation-Agency C.1.22 Respite Care C.1.23 School Based Services C.1.24 Specialized Services to Nursing Facility Participants C.1.25 Speech-Language Pathology Services C.1.26 Supported Employment Services C.1.27 Supportive Counseling C.1.28 Supports Brokerage - FEA C.1.29 Transportation Appendix D. Allopathic and Osteopathic D.1 Allergy and Immunology-Clinical and Laboratory Immunology D.1.1 State-Supplied Free Vaccines June 2010 Page i

2 D.1.2 Administration of State-Supplied Free Vaccine with Evaluation and Management (E/M) Visit D.1.3 Administration of a Provider Purchased Childhood Vaccine With or Without an Evaluation and Management (E/M) Visit D.1.4 Administration of a Provider Purchased Adult Vaccine With or Without an Evaluation and Management (E/M) Visit D.2 Anesthesiology D.3 Billing Presumptive Eligibility (PE) Determinations D.4 Diabetes Education D.5 Obstetrics and Gynecology D.5.1 Incomplete Antepartum Care D.5.2 Postpartum Care D.6 Oral and Maxillofacial Surgery D.7 Physician Service Policy D.8 Telemedicine Appendix E. Ambulatory Health Care Facility E.1.1 Adult Day Care E.1.2 Clinic/Center -Federally Qualified Health Center (FQHC) E.1.3 Clinic/Center Rehabilitation, Substance Use Disorder E.1.4 Clinic/Center -Rural Health Clinics E.1.5 Diagnosis and Evaluation E.1.6 Indian Health Center (IHC) E.1.7 Individual and Group Psychotherapy E.1.8 Mental Health Clinic E.1.9 Pregnant Women Clinic E.1.10 Rehab Mental Health Services Appendix F. Behavioral Health and Social Service Providers Appendix G. Chiropractor Appendix H. Dietary and Nutritional Service Providers Appendix I. Eye and Vision Services Provider Appendix J. Non-Emergent Transportation Providers Appendix K. Nursing and Custodial Care Appendix L. Nursing Services Providers Appendix M. Physician Assistants and Advanced Practice Nursing Providers Appendix N. Respiratory, Developmental, Rehab, and Restorative Services Appendix O. Speech, Language, and Hearing Service Providers O.1 Audiology Services O.2 Speech Therapy Appendix P. Suppliers P.1 Aged and Disabled (A&D) Waiver P.2 Developmentally Disabled (DD) Waiver P.3 Preventive Health Assistance (PHA) Appendix Q. Transportation Services August 2010 Page ii

3 1. Section Modifications Section/Column Update Date SME Appendix Q Updated with information for non-emergent 8/18/2010 M Wimmer medical transportation All Replaced member with participant 8/18/2010 C Stickney Appendix P Separated into specialty sections 8/17/2010 C Stickney All Appendix Alphabetized Appendices for ease of use. 8/14/10 T Kinzler All Appendix Alphabetized sections within each appendix for 8/14/2010 T Kinzler ease of use. Appendix P Added entries for Nicotine Lozenges, Nicotine 8/14/2010 C Brock Inhaler, and Nicotine Nasal Spray Appendix P Initial Installation fee needs to be called Personal 8/14/2010 P Grooms Emergency Response System Initial Installation Appendix P Monthly Service Fee/DD Waiver needs to be called Personal 8/14/2010 P Grooms Emergency Response System Monthly Service Fee B.1.5 Added codes H2014, H2021, H2032, and 8/14/2010 P Grooms with modifier HQ to reflect group therapy. Q.2 Added Home Health 7/30/2010 M Meints Q.1 Added Hospice 7/30/2010 M Meints N.1 Added multiple codes 7/30/2010 M Meints M. Added These codes plus other codes for state 7/30/2010 M Meints approved therapies and modalities. D.1.10 Updated 1 unit = 15 minutes 7/30/2010 M Meints D.1.4 Added Mental Health Clinic 7/30/2010 M Meints D.1.3 Updated to Rehab Mental Health Services, added 7/30/2010 M Meints multiple codes D.1.2 Removed 8296A 7/30/2010 M Meints B.1.31 Added DDA B.1.30 Added PHA 7/30/2010 C Taylor B.1.29 Added Supports Brokerage FEA 7/30/2010 D Baker B.1.28 Added H2011 7/30/2010 M Meints B.1.26 Added multiple codes 7/30/2010 M Meints B.1.26 Added multiple codes 7/30/2010 M Meints B.1.24 Added H2011 7/30/2010 M Meints B.1.23 Added multiple codes 7/30/2010 M Meints B.1.21 Added multiple codes 7/30/2010 M Meints B.1.20 Added multiple codes 7/30/2010 M Meints B.1.15 Added multiple codes 7/30/2010 M Meints B.1.10 Added multiple codes 7/26/2010 M Meints CFH- Removed 7/26/2010 C Taylor Independent Affiliation Fee CFH-Agency Removed 7/26/2010 C Taylor Affiliation Fee All Removed modifiers U2 U8 7/26/2010 C Taylor B and H2032 Added HQ modifier Added OT Assessment 7/26/2010 M Meints August 2010 Page 1 of 73

4 Section/Column Update Date SME B.1.3 Changed to 1 unit = 1 visit 7/26/2010 C Taylor B.1.1 Removed 03 School from place of service 7/26/2010 C Taylor A.1.1 Removed PA number must be billed on claim 7/26/2010 D Baker 3.2 Changed adjustment to replacement 7/26/2010 M Wood Field Enter all dates using the month, day, and year 7/26/2010 D Decreval (MM/DD/YY) format. 2.0 Updated for clarity 6/14/2010 E Charles 2.0 Updated for clarity 6/14/2010 E Charles Field 22 Updated for clarity 6/14/2010 E Charles Field 23 Updated for clarity 6/14/2010 E Charles Added Field 24D 24D (shaded top modifier section) NCD Unit Price Required if NDC code is present in 24A Enter unit price corresponding to NDC code. 6/14/2010 E Charles Field 33a Removed note that NPI numbers, sent on paper 6/14/2010 E Charles claims are optional and will not be used for claims processing Removed Interpretation, Bilingual Translation; 8296A; Interpretation for bilingual translation 1 Unit = 1 Hour 6/14/2010 M Meints B.1.20 DD Service Coordinator B.1.21 Children s Service Coordination B.1.21 Children s Service Coordination B.1.22 Mental Health Case Management D1.2. Individual and Group Psychotherapy Removed 1 unit = 1 month initial service coordination Changed Children s Service Coordinator to Children s Service Coordination Removed G9001 Added the following EPSDT G9012 Children s Plan Development Children s Plan Development, PA is required. 1Unit = 15 minutes Mental Health Service Coordination Crisis Updated for clarity All Services were updated for clarity with: The UA Modifier is required when provided by physician 6/14/2010 M Meints 6/14/2010 M Meints 6/14/2010 M Meints 6/14/2010 M Meints 6/14/2010 M Meints O. Suppliers Added Non-Physician Weight Management and 6/14/2010 C Taylor Non-Prescription Tobacco Cessation Multiple Updated diagnosis code V604 to V60.4 6/14/2010 C Taylor August 2010 Page 2 of 73

5 2. CMS 1500 Form August 2010 Page 3 of 73

6 3. Instructions for Completing the CMS Helpful Tips for Filling out the Paper Claim Form A maximum of six line items per claim can be accepted. If the number of services performed exceeds six lines, prepare a new claim form and complete all the required elements. Total each claim separately. Enter all dates except the Patient s Birth Date using the 2-digit month, day, and year (MM/DD/YY) format. You can bill with a date span (From and To Dates of Service) only if the service was provided every consecutive day within the span. Do not enter any data or documentation on the claim form that is not listed as required below. Consult the Use column to determine if information in any particular field is required. Only fields that are required for billing the Idaho Medicaid program are shown on the following table. There is no need to complete any other fields. Claims will be rejected when required information is not entered into a required field. The following numbered items correspond to the CMS-1500 (08/05) claim form CMS 1500 Form Descriptions Box No. Field Name Use Notes 1A Insured s ID Required Enter the Participant s Idaho Medicaid ID number exactly as it appears on their plastic ID card 2 Patient s Name Required Enter the participant s name exactly as it appears on the Participant s Idaho Medicaid ID card. Enter as last name, first name, middle initial. 3 Patient s Birth Date Required Enter the patient s date of birth. Formatted as MMDDCCYY 3 Sex Required Check the appropriate box indicating the patient s gender. M Male F - Female 5 Patient s Address Required Enter Patient s Street Address August 2010 Page 4 of 73

7 Box No. Field Name Use Notes 5 City Required Enter the patient s city 5 State Required Enter the patient s 2 character state code. 5 Zip Required Enter patient s 5 or 9 digit zip code. Is condition related to: 10a. Employment? Not Required If any are yes, then required. Indicate yes or no if this condition is related to the client s employment 10b. Auto Accident? Not Required Indicate yes or no if this condition is related to an auto accident. 10b. Place (State) Required if auto accident Enter 2 digit state abbreviation of the state where auto accident occurred. 10c Other Accident? Not Required Indicate yes or no if this condition is related to an accident other than an auto accident. 14 Date of Current: Illness, Injury or Pregnancy 17 Name of Referring Provider Required if any related cause in box 10 is marked. Required, if applicable Enter Date of Accident or the date the illness or injury first occurred, or the date of the last menstrual period (LMP) for pregnancy. Formatted MMDDYY Enter the referring physician s name formatted: Last Name, First Name, Middle Initial 17a Referring Physician Other ID Required, if applicable Enter the referring physician s Idaho Medicaid ID if the referring physician is not registered with an NPI. 17b Referring Physician NPI Required, if applicable Enter the referring physician s 10-digit NPI. August 2010 Page 5 of 73

8 Box No. Field Name Use Notes 21 (1-4) Diagnosis or Nature of Illness or Injury 22 Medicaid Resubmission Code 22 Original REF. NO. At least one Required Required if claim is a resubmission Required if claim is a resubmission Enter the appropriate ICD-9-CM codes (up to 4). Enter the primary diagnosis in 21(1). If applicable, second, third, and fourth diagnosis in 21 (2-4). Always enter the entire diagnosis code including the decimal point. Enter 7 if claim is a replacement claim. Enter 8 if this claim voids a previously submitted claim. Only enter a value in this field if sending an replacement or void to a previously submitted claim, otherwise leave blank. Enter the claim ID number of the original claim to be voided or replaced. Only enter a value in this field if sending a replacement or void to a previously submitted claim, otherwise leave blank. 24A (unshaded) Date of Service - From/To Required Enter the from and to date(s) the service was provided, using the following format: MMDDYY 24 (shaded top) NDC code Required if appropriate Enter N4 followed by the 11 digit NDC code 24B (unshaded) Place of Service Required Enter the appropriate 2 digit numeric code 24B (shaded top) NDC Unit of measure Required if NDC code is present in 24A Enter appropriate 2 digit NDC unit of measure Valid values: F2 - International Unit GR - Gram ML - Milliliter UN - Unit 24C (unshaded) EMG Required, if applicable If the services performed are related to an emergency, mark this field with an X. August 2010 Page 6 of 73

9 Box No. Field Name Use Notes 24C-D (shaded top) NDC number of Units Required if NDC code is present in 24A Enter the actual metric decimal quantity (units) administered to the patient. If reporting a fraction of a unit, use the decimal point. Nine numbers may precede the decimal point and three numbers may follow the decimal. 24D (unshaded) Procedures, Services, or Supplies Required Enter the appropriate five-character HCPCS procedure code to identify the service provided. 24D (unshaded) Modifier Desired If applicable, add the appropriate HCPCS two digit modifier(s). Enter as many as four. Otherwise, leave this section blank. 24D (shaded top modifier section) NCD Unit Price Required if NDC code is present in 24A Enter unit price corresponding to NDC code. 24E (unshaded) Diagnosis Code Required if diagnosis code in block 21 is present Use the number of the subfield (1-4) for the diagnosis code entered in field 21. If the actual diagnosis code from block 21 is present, enter a 1. If the pointer is missing, leave the field blank. 24F (unshaded) 24G (unshaded) Charges Required Enter the usual and customary fee for each line item or service. Do not include tax. Days or Units Required Enter the quantity or number of units of the service provided. Maximum value of If there is a zero leading a value you need to remove it (IE. 01 will be 1). 24H (unshaded) EPSDT Family Plan Required if applicable Not required unless applicable. If the services performed constitute an EPSDT program screen, refer to the instructions for EPSDT claims in the provider handbook. August 2010 Page 7 of 73

10 Box No. Field Name Use Notes 24I (shaded) ID. Qualifier for service line rendering provider Required Enter Service line rendering provider id only if provider rendering the service is different than billing provider. Enter qualifier 1D followed by Idaho Medicaid provider number in 24J, only if Rendering Provider is not registered with an NPI. 24J (shaded top) Rendering Provider ID Number Required if billing with Idaho Medicaid ID. Enter Service line rendering provider id only if provider rendering the service is different than billing provider. Enter Rendering Provider Medicaid ID only if Rendering provider is not registered with an NPI. 24J (unshaded) Rendering Provider NPI Not Required Enter Service line rendering provider NPI only if provider rendering the service is different than billing provider. 25 Federal Tax ID Number Required Enter the Federal Tax ID. Must be 9 numeric characters. 26h Patient Account Number Required Enter patient account number. 28 Total Charge Required Enter total of all service line charges 32 Line 1 Service Facility Name 32 Line 2 Service Facility Address line 1 32 Line 3 Service Facility Address line 2 Required if Service Facility Location is present in 32a Required if Service Facility Location ID is present in 32a Not Required Enter name of service facility only if Service Location is different than Billing Provider name in box 33, otherwise leave box 32 blank. Enter Street Address of Service Facility, only if Service Location address is different than Billing Provider address in box 33, otherwise leave box 32 blank. Enter additional service facility address line if needed and service location if different than billing provider address in box 33, otherwise leave box 32 blank. August 2010 Page 8 of 73

11 Box No. Field Name Use Notes 32 Line 3 or 4 Service Facility City, State and Zip Code Required if Service Facility Location is present in 32a Enter Service Facility city, state, and zip code, only if Service Location address is different than Billing Provider address in box 33, otherwise leave box 32 blank. 32a Service Facility Location ID (NPI) Required, if applicable If you bill with an NPI, enter the 14-digit service location identifier only if the services were rendered at a location other than that of the billing provider in box 33. Do not enter any other value in box 32a. For example, b Service Facility Location ID (blank) Required, if applicable If you bill with an Idaho proprietary number (not an NPI) enter the 12-digit service location identifier only if rendered at a location other than that of the billing provider in box 33. Do not enter any other value in box 32b. For example, M or A Line 1 Billing Provider Name Required Enter billing provider name 33 Line 2 Billing Provider Address line 1 Required Enter street address of billing provider 33 Line 3 Billing Provider Address line 2 Not Required Enter additional billing provider address line, if needed 33 Line 3 or 4 Billing Provider city, state, and zip code Required Enter billing provider city, state, and zip code 33a NPI Number Required, if billing with an NPI Enter the 10-digit NPI number of the billing provider. 33b Billing Provider Medicaid ID Required if not billing with NPI in 33a Enter the qualifier 1D followed by the provider s 8-digit proprietary Idaho Medicaid provider number with no spaces in between. August 2010 Page 9 of 73

12 Appendix A. Adult Residential Care A.1.1 HCPCS S5140 T1001 S5100 T1019 Adult Residential Living Facility- RALF Description Foster Care, Adult 1 Unit = 1 day of service Nursing / Evaluation Adult Day Care 15mins Personal Care service per 15mins A.1.2 Certified Family Home (CFH) HCPCS Description S5140 T1019 S5100 H2011 Certified Family Home Daily one to two Participants Foster Care - Adult; per diem 1 Unit = 1 day Personal Care service per 15 minutes Adult Foster Care Crisis intervention per 15 minutes August 2010 Page 10 of 73

13 Appendix B. Agency Institutional B.1 Home Health Revenue Code Modifier Description 270 Home Health Supplies 291 Rental Durable Medical Equipment 421 Home Health Physical Therapy Visit 431 Home Health Occupational Therapy Visit 441 Home Health Speech-Language Pathology Visit 551 Home Health Skilled Nurse Visit 571 Home Health Aide Visit 771 Drugs Requiring Special Coding B.2 Hospice Revenue Code Modifier Description 651 Routine Care 652 Continuous Care 655 Respite Care 656 General Inpatient Care August 2010 Page 11 of 73

14 Appendix C. Agency - Professional C.1.1 Behavior Consultation/Crisis Management (BC/CM) HCPCS Modifier Description Diagnosis Place of Service H2019 H2019 Therapeutic Behavioral Services 1 Unit = 15 minutes Therapeutic Behavioral Services 1 Unit = 15 minutes H2019 HM Therapeutic Behavioral Services Limited to 96 units per calendar month. 1 Unit = 15 minutes Enter V for the primary diagnosis 11 Office 12 Home 99 Other (Community) H2011 Community Crisis supports (1 unit = 15 minutes) C.1.2 Children s Service Coordination HCPCS Modifier Description Diagnosis G9002 Coordinated Care Fee, Maintenance Rate (Ongoing Children s Service Coordination) 1 Unit = 15 minutes G9002 HM DD Service Coordination Paraprofessional Use diagnosis code V60.4 as the primary diagnosis code for personal care case management. G9003 G9012 H2011 Coordinated Care Fee, Risk Adjusted High, Initial (Emergency service coordination). PA is required by Medicaid. 1 Unit = 15 minutes Children s Plan Development, PA is required. 1 Unit = 15 minutes Children s Crisis Assistance (1 unit = 15 min) H2011 HM Children s Crisis Assistance Paraprofessional (1 unit = 15 min) August 2010 Page 12 of 73

15 C.1.3 Chore Services Skilled HCPCS Description Diagnosis Place of Service S5121 Chore Services, per diem 1 Unit = 1 service Cost of service up to $1, or lowest of three bids. Not to exceed $8.00 per hour. Enter V60.4 for the primary diagnosis 12 Home C.1.4 Developmental Disability Agency Codes HCPCS Modifier Description T2025 Residential Care (NOS) Waiver; per diem rate (1 unit = 1 day) Psychiatric Diagnostic Interview and Exam (1 unit = 15 minutes) Family Medical Psychotherapy (1 unit = 15 minutes) Group Medical Psychotherapy (1 unit = 15 minutes) Pharmacological Management (1 unit = 1 visit) Collateral Contact (1 unit = 15 minutes) Speech Evaluation (1 unit = 1 evaluation/day) Individual Speech Therapy (1 unit = 15 minutes) Group Speech Therapy (1 unit = 15 minutes) Psychiatric Testing for Diagnosis/Evaluation Psychologist/Physician (1 unit = 1 hour) Psychiatric Testing for Diagnosis/Evaluation Technician (1 unit = 1 hour) Psychiatric Testing for Diagnosis/Evaluation (with computer and professional interpretation) (1 unit = 1 test) Physical Therapy Evaluation (1 unit = 1 evaluation/day) Occupational Therapy Evaluation (1 unit = 1 evaluation/day) Individual Physical Therapy (1 unit = 15 minutes) Group Physical Therapy (1 unit = 15 minutes) Individual Occupational Therapy (1 unit = 15 minutes) HQ Group Occupational Therapy (1 unit = 15 minutes) Home/Community Individual Developmental Therapy for Adults (1 unit = 15 minutes) HQ Home/Community Group Developmental Therapy for Adults (1 unit = 15 minutes) August 2010 Page 13 of 73

16 HCPCS Modifier Description E1399 U8 Specialized Medical Equipment (75% of vendor s retail price) H0004 Individual Medical Psychotherapy (1 unit = 15 minutes) H0004 HM Supportive Counseling (1 unit = 15 minutes) H0024 H2000 Intensive Behavioral Intervention Consultation (1 unit = 15 minutes) Developmental Therapy Evaluation (1 unit = 15 minutes) H2014 Individual Developmental Therapy Center for Children (1 unit = 15 minutes) H2014 HQ Group Developmental Therapy Center for Children (1 unit = 15 minutes) H2015 Individual Supported Living (1 unit = 15 minutes) H2015 HQ Group Supported Living (1 unit = 15 minutes) H2019 Intensive Behavioral Intervention Professional (1 unit = 15 minutes) H2019 U1 Behavioral Consultation by Psychiatrist (1 unit = 15 minutes) H2019 HM Intensive Behavioral Intervention Paraprofessional (1 unit = 15 minutes) H2021 Individual Developmental Therapy Home/Community for Children (1 unit = 15 minutes) H2021 HQ Group Developmental Therapy Home/Community for Children (1 unit = 15 minutes) H2032 Center Based Individual Developmental Therapy for Adults (1 unit = 15 minutes) H2032 HQ Center Based Group Developmental Therapy for Adults (1 unit = 15 minutes) S5100 T1028 T2024 Adult Day Care (1 unit = 15 minutes) Social History/Evaluation (1 unit = 15 minutes) Comprehensive Intensive Behavioral Intervention Assessment (1 unit = 15 minutes) August 2010 Page 14 of 73

17 C.1.5 DD Service Coordinator HCPCS Modifier Description Diagnosis Place of Service G9001 Coordinated Care Fee, Initial Rate (Initial service coordination) Flat monthly rate for the first six calendar months. 1 Unit = 15 minutes Use diagnosis code V60.4 as the primary diagnosis code for personal care case management. 03 School 11 Office 12 Home 22 Outpatient hospital 23 Emergency Room: hospital 31 Skilled nursing facility 32 Nursing facility 33 Custodial care facility 53 Community mental health center 54 Intermediate care facility/mentally retarded (ICF/MR) 71 Public health clinic 99 Other unlisted facility G9002 Coordinated Care Fee, Maintenance Rate (Ongoing service coordination) Flat monthly rate for the calendar months after the initial six months. 1 Unit = 1 month ongoing service coordination G9002 HM DD Service Coordination Paraprofession al (1 unit = 15 min) August 2010 Page 15 of 73

18 HCPCS Modifier Description Diagnosis Place of Service G Unit = 15 minutes H2011 DD Crisis Assistance (1 unit = 15 min) H2011 HM DD Crisis Assistance Paraprofession al (1 unit = 15 min) C.1.6 HCPCS Developmental Therapy (DT) and Intensive Behavioral Intervention (IBI) Description Psychological testing per hour includes face-to-face time with the patient and time interpreting test results and preparing the report. 1 Unit = 1 Hour Psychological testing with qualified healthcare professional interpretation and report, administered by technician, per hour of technician time, face-to-face. 1 Unit = 1 Hour Psychological testing, administered by a computer, with qualified healthcare professional interpretation and report. 1 Unit = 1 Test Psychiatric diagnostic interview examination. T1028 Assessment of home, physical and family environment, to determine suitability to meet participant s medical needs. This service may be performed by licensed practical nurse (LPN) or registered nurse (RN) as well as other qualified staff. This code should be used as part of the initial intake only. It is not considered an ongoing service. Specify exact time 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 participant. This code cannot be used for staffing. Specify exact time. August 2010 Page 16 of 73

19 HCPCS H2011 Description Intervention for participant in crisis situations. (See IDAPA , Subsection for specific requirements). Service is limited to a maximum of 20 hours per crisis, for 5 consecutive days. Service may not exceed 20 hours per crisis. 1 Unit = 15 Minutes Pharmacologic management, including prescription use, and review of medication with no more than minimal medical psychotherapy. This service may be billed by: Physician, nurse practitioner, physician assistant, psychiatric nurse practitioner, or clinical nurse specialist-psychiatric. 1 Unit = 1 Visit. C.1.7 Developmental Therapy (DT) and Occupational Therapy (OT) HCPCS Modifier Description H2000 H2014 Comprehensive multidisciplinary evaluation. Specify exact time. 1 Unit = 15 Minutes. Skills training and development. Specify exact time. H2014 HQ Skills training and development, two or more individuals. Specify exact time. H2021 Community based wrap-around services, individual. Specify exact time. H2021 HQ Community based wrap-around services, two or more individuals. Specify exact time. H2032 Individual activity therapy. (PA required for adults in the DD care management process) H2032 HQ Group activity therapy. (PA required for adults in the DD care management process) August 2010 Page 17 of 73

20 HCPCS Modifier Description OT evaluation. Specify exact time. 1 Unit = 1 evaluation OT re-evaluation Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, individual. Specify exact time HQ Self-care/home management training (e.g., ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, two or more individuals. Specify exact time Home/community and/or work reintegration training, individual. (PA required for adults in the DD care management process) HQ Home/community and/or work reintegration training, two or more individuals. (PA required for adults in the DD care management process) C.1.8 Intensive Behavioral Intervention (IBI) HCPCS Modifier Description Requires PA H2019 Therapeutic behavioral services. Specify exact time. H2019 HM Therapeutic behavioral services. Specify exact time. August 2010 Page 18 of 73

21 HCPCS Modifier Description Requires PA H0024 T2024 Behavioral health prevention information dissemination service (one-way direct or non-direct contact with audiences to affect knowledge and attitude). Specify exact time. Service assessment. Specify exact time. C.1.9 Medical Equipment and Supplies HCPCS Description Requires PA E1399 DME, miscellaneous. 1 Item = 1 Unit. Note: All items require invoice or MSRP. C.1.10 Mental Health Service Coordination HCPCS Description Diagnosis H0031 T1017 H2011 Mental Health Assessment and Service Coordination Plan Includes annual assessment, interviewing and treatment plan building 1 Unit = 15 minutes Limited to 24 units for the initial assessment and plan. Targeted Service Coordination, each 15 minutes (ongoing service coordination). Limited to 5 hours of non-crisis ongoing service coordination monthly and 3 hours of crisis ongoing service coordination. Crisis service coordination services must be authorized by Medicaid. The participant must meet the criteria described in Section Crisis Assistance for Adults with Severe and Persistent Mental Illness. 1 Unit = 15 minutes Use diagnosis code V60.4 as the primary diagnosis code for personal care case management. C.1.11 Nursing Agency-PDN HCPCS Modifier Description Place of Service T1001 TD Nursing Assessment/Evaluation Professional licensed nurse, registered nurse or RN employed by an agency 12 Home 99 Other (unlisted August 2010 Page 19 of 73

22 HCPCS Modifier Description Place of Service 1 Unit = 15 minutes facility) T1000 T1000 T1000 T1001 T1002 Private duty/independent nursing service(s) licensed Agency LPN 1 Unit = 15 minutes Private duty/independent nursing service(s) licensed Individual RN 1 Unit = 15 minutes Private duty/independent nursing service(s) licensed Individual LPN 1 Unit = 15 minutes Nursing Assessment/Evaluation Professional licensed nurse oversight of a licensed practical nurse 1 Occurrence = 1 assessment/evaluation RN Services Ventilator care by licensed nurse RN or LPN 1 Unit = 15 minutes C.1.12 Nursing Services HCPCS Modifier Description T1003 LPN services. Specify exact time. T1002 TD RN services. Specify exact time. T1002 RN oversight. Specify exact time. C.1.13 Personal Care Services (PCS) HCPCS Description Supervisory RN G9001 T1001 G9002 Coordinated care fee, initial rate. Flat rate paid for 1 assessment, per year. Nursing assessment/evaluation. Flat rate paid for no more than 1 visit per month. Coordinated Care Fee Maintenance Rate (Agency) Supervisory QMRP August 2010 Page 20 of 73

23 HCPCS Description G9001 H2020 Coordinated Care Fee Initial (Agency) Therapeutic Behavioral Services (Agency) Personal Assistance Service Provider T1019 T1004 Personal Care Services of an aide. Specify exact time. Independent Provider s Home (no withholding): T1019 PCS Alternate Care Home Home and Community Based Services S5125 S5130 T1001 Attendant Care Services Homemaker Services Nursing Assessment/Evaluation (Agency) Other S5140 S5120 S5115 S5135 S5170 T1005 Adult Residential Care based on client need of services described under Home and Community based Services above Chore Services Consultation Home Companion Home Delivered Meals Respite C.1.14 Personal Care Services (PCS) Case Management HCPCS Modifier Description Requires PA G9001 G9002 Coordinated Care Fee, Initial Rate (Assessment and ICSP). This is a onetime rate. Coordinated Care Fee, Maintenance Rate Ongoing and emergency PCS service coordination. Indicate the total number of 15-minute units billed. Diagnosis Use diagnosis code V60.4 as the primary diagnosis code for personal care case management. August 2010 Page 21 of 73

24 HCPCS Modifier Description Requires PA G9002 HM PCS Service Coordination Paraprofessional (1 unit = 15 min) Diagnosis H2011 PCS Crisis Assistance (1 unit = 15 min) H2011 HM PCS Crisis Assistance Paraprofessional (1 unit = 15 min) C.1.15 Physical Therapy (PT) HCPCS Description PT evaluation. Specify exact time Therapeutic procedure, one or more areas, each 15 minutes, therapeutic exercises to develop strength and endurance, range of motion and flexibility, individual. Specify exact time Therapeutic procedure(s), two or more individuals. Specify exact time. 1 Unit = 15 Minutes. C.1.16 Physical Therapy (PT) and Occupational Therapy (OT) Services HCPCS Description Requires PA Place of Service Unlisted modality (specify type and time if constant attendance). 11 Office (DDA center or PSR Service agency) 12 Home (of participant) 99 Other (community) Unlisted therapeutic procedure (specify) Community/work reintegration training (e.g., shopping, transportation, money management, a vocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact by provider, each 15 minutes August 2010 Page 22 of 73

25 C.1.17 Psychosocial Rehabilitation Services (PSR) HCPCS Modifier Description H2017 PSR services. Professional only, individual. Specify exact time. H2017 HQ PSR services. Professional only, two or more individuals. Specify exact time. C.1.18 Psychotherapy HCPCS Description Unlisted psychiatric service. This code was previously, Individual Psychiatric Therapy. Note: This is an interim code to be used by schools to be able to bill for psychotherapy services. This code should be used instead of 90804, 90806, and Professional only. 1 Unit = 15 Minutes Group psychotherapy; Two or more students. Professional only. Specify exact time Family psychotherapy (conjoint psychotherapy) (with patient present). Professional only. Specify exact time Family psychotherapy without patient present. Must be face-to-face with at least one family participant present. The participant must be the focus of services. Professional only. Goals of treatment must be specified on the participants individualized treatment plan. C.1.19 Psychotherapy Treatment HCPCS Modifier Description H0004 Behavioral health counseling and therapy, individual. Specify exact time Psychotherapy; two or more individuals. Specify exact time Family psychotherapy; (with patient present). Specify exact time. August 2010 Page 23 of 73

26 C.1.20 Registered Nurse Services Agency DD Waiver HCPCS Description Place of Service T1001 T1001 T1000 T1000 T1000 T1001 Nursing Assessment/Evaluation 1 Occurrence = 1 assessment/evaluation Nursing Assessment /Evaluation 1 Occurrence = 1 assessment/evaluation Private Duty/Independent Nursing Services Licensed 1 Unit = 15 minutes Private Duty/Independent Nursing Services Licensed 1 Unit = 15 minutes Private Duty Nursing/Independent Nursing Services Licensed Minimum age is Unit = 15 minutes Nursing Assessment/Evaluation 1 Occurrence = 1 assessment/evaluation. 12 Home 99 Other (unlisted facility) August 2010 Page 24 of 73

27 C.1.21 Residential Habilitation-Agency HCPCS Modifier Description Diagnosis Place of Service H2011 Community Crisis Supports (1 unit = 15 min) H2015 Comprehensive Community Support Services; per 15 minutes (24-hour/day unavailable under hourly services) for participants who live in their own home or apartment or live with a nonpaid caregiver. This code requires PA. 1 Unit = 15 minutes H2015 HQ Comprehensive Community Support Services; per 15 minutes Supported living for two or three participants who live in their own home or apartment or live with a non-paid caregiver. This code requires PA. 1 Unit = 15 minutes 24 hour/day unavailable under hourly serviced. Enter V60.4 for the primary diagnosis 12 Home (CFH, participant s own home, or home of unpaid family) 99 Other (Community) This code should only be used when the participant receives hourly supported living to access the community. All other RES/HAB should be coded as, Home. H2022 Community Based Services, per diem 24 hours per day support and supervision. Provided through a blend of 1:1 and group staffing. August 2010 Page 25 of 73

28 HCPCS Modifier Description Diagnosis Place of Service H2016 Comprehensive Community Support Services, per diem 24 hours per day support and supervision. Typically requires 1:1 staffing but requests for blend of 1:1 and group staffing will be reviewed on a case-by-case basis. S5100 Day Care Services Adult; per 15 minutes S5140 Foster Care Adult; per diem T1019 Personal care services per 15 minutes T2025 Agency - Certified Family Home Affiliation Fee DD Waiver Agency - Certified Family Home Affiliation Fee PA number must be billed on claim for payment consideration Certified Family Home (CFH) - Agency Affiliation Fee C.1.22 Respite Care HCPCS Description Diagnosis Place of Service T1005 Respite Care Services, up to 15 minutes 1 Unit = 15 minutes. Enter V60.4 for the primary diagnosis 12 Home (CFH, participant s own home, or home of unpaid family) S9125 Maximum of six hours per day or 24 units. Respite Care, In the Home, per diem 1 Unit = 1 day 99 Other (Community) This code should only be used when the participant receives hourly supported living to access the community. All other RES/HAB should be coded as, Home. August 2010 Page 26 of 73

29 C.1.23 School Based Services HCPCS Modifier Description Consultation or treatment direction about the student to a significant other in the student s life may be face-to-face or by telephone contact. Specify exact time. Note: This code cannot be used for general staff training, regularly scheduled parent-teacher conferences, general parent education or for parent support groups or for treatment team meetings, even when the parent is present. Collateral contact cannot be provided by paraprofessionals Individual Psychotherapy by School district (1 unit = 15 minutes) H2000 Comprehensive multidisciplinary evaluation. Specify exact time. 1 Unit = 15 Minutes HO Therapeutic procedure(s) with two or more individuals. Specify exact time Therapeutic procedure(s) with two or more individuals. Specify exact time HO Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation), two or more individuals. Specify exact time Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation), two or more individuals. Specify exact time. V5008 Hearing screening. Specify exact time HO Therapeutic procedure, in one or more areas. Therapeutic exercises to develop strength and endurance range of motion and flexibility, individual. Specify exact time Therapeutic procedure, one or more areas. Therapeutic exercises to develop strength and endurance range of motion and flexibility, individual. Specify exact time HO Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation), individual. Specify exact time. August 2010 Page 27 of 73

30 HCPCS Modifier Description HM Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation), individual. Specify exact time OT evaluation. Specify exact time. 1 Unit = 1 evaluation Psychiatric diagnostic interview examination. Specify exact time Family Psychotherapy by School District (1 unit = 15 minutes) Psychological testing (including psycho diagnostic assessment of personality, psychopathology, emotionality, intellectual abilities, e.g., WAIS, Rorschach, MMPI), 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. Specify exact time. 1 Unit = 1 Hour Psychological testing (including psycho diagnostic assessment of personality, psychopathology, emotionality, and intellectual abilities, e.g., WAIS, MMPI), with qualified healthcare professional interpretation and report, administered by technician, per hour of technician time, face-to-face. 1 Unit = 1 Hour Psychological testing (includes psycho diagnostic assessment of emotionality, intellectual abilities, personality, and psychopathology, e.g., MMPI), administered by a computer, with qualified healthcare professional interpretation and report. 1 Unit = 1 Test. H0031 Mental health (MH) assessment, by non-physician. Specify exact time PT evaluation. Specify exact time. 1 Unit = 1 evaluation T1023 Evaluation to determine appropriateness of consideration of an individual for participation in a specified program, project, or treatment protocol, per encounter Evaluation of speech, language, voice, communication, and/or auditory processing and/or aural rehabilitation status. Specify exact time. 1 Unit = 1 evaluation HO Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), individual. Specify exact time. August 2010 Page 28 of 73

31 HCPCS Modifier Description HO/HQ Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), two or more individuals. Specify exact time HM/HQ Therapeutic activities, (direct one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), individual. Specify exact time. H2014 Skills training and development, individual. Specify exact time. H2014 HQ Skills training and development, two or more individuals. Specify exact time. E1399 G9001 H0024 H2017 Medical Equipment and Supplies by School Personal Care Services RN Assessment by School (1 unit = 1 plan) Intensive Behavioral Intervention Consultation - Professional (1 unit = 15 minutes) Individual Skill Training by School District (1 unit = 15 minutes) H2017 HQ Group Skill Training by School District (1 unit = 15 minutes) H2019 Intensive Behavioral Intervention Professional (1 unit = 15 minutes) H2019 HM Intensive Behavioral Intervention Paraprofessional (1 unit = 15 minutes) H0036 T1001 Community Reintegration By School District (1 unit = 15mins) Personal Care Services - Supervising RN Visit (Per Visit) T1002 Nursing Services RN Oversight of LPN by School District (1 unit = 15 minutes) T1002 TD Nursing Services by School RN, Skilled (1 unit = 15 minutes) T1003 Nursing Services by School LPN, Skilled (1 unit = 15 minutes) T1004 Personal Care Services by qualified nursing aide for School District (1 unit = 15 minutes) T2001 T1028 A0080 Non-Emergency Transportation: Patient Attendant/Escort (1 unit= 15 minutes) Medical/Social History (1 unit = 15 minutes) Transportation by School (1 unit = 1 mile) August 2010 Page 29 of 73

32 C.1.24 Specialized Services to Nursing Facility Participants HCPCS Modifier Description H2000 Comprehensive multidisciplinary evaluation. Skills training and development, individual. Specify exact time. H2014 HQ Skills training and development, two or more individuals. Specify exact time. H0004 Physicians use U1 modifier. Individual psychotherapy. Must be provided at therapist s office and be conducted face-to-face. Specify exact time Physicians use U1 modifier Group psychotherapy, two or more individuals. Must be provided at therapist s office and be conducted face-to-face. Specify exact time Family psychotherapy (with patient present). Must be provided at therapist s office and be conducted face-to-face. Physicians use U1 modifier. Specify exact time. C.1.25 Speech-Language Pathology Services HCPCS Description Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status. 1 Unit = 1 visit Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation), individual. 1 Unit = 1 visit Treatment of speech, language, voice, communication and/or auditory processing disorder (includes aural rehabilitation), two or more individuals. 1 Unit = 1 visit. C.1.26 Supported Employment Services HCPCS Description Diagnosis Place of Service H2011 Community Crisis Supports (1 unit = 15 minutes) H2023 Supported Employment, per 15 minutes The maximum allowable units per week are Unit = 15 minutes Enter V60.4 for the primary diagnosis 99 Other (Community) August 2010 Page 30 of 73

33 C.1.27 Supportive Counseling HCPCS Modifier Description H0004 HM Modifier Required Behavioral health counseling delivered by a LSW, individual Specify exact time. C.1.28 Supports Brokerage - FEA HCPCS Description Notes T2040 Financial management selfdirected waiver per 15 minutes Monthly amount based on UCR fee schedule T2025 Waiver services not otherwise specified Pay as billed C.1.29 Transportation HCPCS Description T2001 A0080 Non emergency transportation, patient attendant/escort. Specify exact time. Non-emergency transportation, per mile, vehicle provided by volunteer (individual or organization), with no vested interest. Specify number of miles from pick-up to delivery. August 2010 Page 31 of 73

34 Appendix D. Allopathic and Osteopathic D.1 Allergy and Immunology-Clinical and Laboratory Immunology D.1.1 State-Supplied Free Vaccines Service HCPCS Modifier Billed Amount State- Supplied Free Vaccines to SL $0.00 For E/M visits use modifier 25. D.1.2 Administration of State-Supplied Free Vaccine with Evaluation and Management (E/M) Visit Service HCPCS Modifier Billed Amount Administration of State- Supplied Free Vaccine with Evaluation and Management (E/M) Visit to SL $0.00 For E/M visits use modifier 25. D.1.3 Administration of a Provider Purchased Childhood Vaccine With or Without an Evaluation and Management (E/M) Visit Service HCPCS Modifier Administration of a Provider Purchased Childhood Vaccine With or Without an Evaluation and Management (E/M) Visit to If there is a significant, separately identifiable service, performed, at the time of the vaccine administration, an appropriate E/M code may also be billed with modifier 25. August 2010 Page 32 of 73

35 D.1.4 Administration of a Provider Purchased Adult Vaccine With or Without an Evaluation and Management (E/M) Visit Service HCPCS Modifier Administration of a Provider Purchased Adult Vaccine With or Without an Evaluation and Management (E/M) Visit to If applicable, the appropriate CPT code for the E/M visit with modifier 25. D.2 Anesthesiology HCPCS Modifier Diagnosis Unit of Service To bill for the epidural injections use the appropriate CPT procedure codes A repeat anesthesia procedure on the same day which is billed with the CPT modifier 76 or 77 will be paid at $0.00. AA AD Anesthesia services personally performed by an anesthesiologist. The AA modifier is used for all basic procedures Medical supervision by a physician, more than four concurrent anesthesia procedures. Diagnosis code V25.2 must be used for sterilizations. Enter total units (minutes) for time P1 P2 P3 P4 P5 QS Normal healthy patient. Patient with mild systemic disease Patient with severe systemic disease Patient with severe systemic disease that is a constant threat to life Moribund patient who is not expected to survive without the operation. Monitored anesthesia care service (can be billed by CRNA or a physician). Modifier QS (Monitored Anesthesia Care) is for informational purposes. Please report actual monitoring time on the claim form. This modifier must be billed with another modifier to show that the service was personally performed or medically directed. August 2010 Page 33 of 73

36 HCPCS Modifier Diagnosis Unit of Service QX QY QZ CRNA service, with medical direction by a physician. Medical direction of one 1 CRNA by an anesthesiologist. CRNA service, without medical direction by a physician. D.3 Billing Presumptive Eligibility (PE) Determinations Service Billing Presumptive Eligibility (PE) Determinations HCPCS T1023 to bill for PE determination. D.4 Diabetes Education Service HCPCS Group Counseling G0109 Individual Counseling G0108 D.5 Obstetrics and Gynecology D.5.1 Incomplete Antepartum Care Service Billing for Incomplete Antepartum Care HCPCS When billing for four to six prenatal visits, When billing for seven or more prenatal visits with or without an initial visit D.5.2 Postpartum Care Service HCPCS Modifier Billing for Twin Deliveries For Second baby: 59409, 59514, 59612, or August 2010 Page 34 of 73

37 D.6 Oral and Maxillofacial Surgery Service Oral and Maxillofacial Surgery HCPCS Do not use CPT procedure code 41899, as this is an unspecified code and will cause delay in payment for services. D.7 Physician Service Policy Service Locum Tenens and Reciprocal Billing Modifier Q5 - Service furnished by a substitute physician under a reciprocal billing arrangement. Q6 - Service furnished by a locum tenens physician D.8 Telemedicine HCPCS Description Modifier Pharmacological Management Including prescription, use and review of medication with no more than minimal medical psychotherapy Psychotherapy minute session with medical evaluation and management services Psychiatric diagnostic interview examination. 1 Unit = 15 minutes GT GT GT Q3014 T1014 Telehealth Originating Site Transmission 1 Unit + 1 Originating Site Transmission Telehealth Distant Site Transmission 1 Unit + 1 Distant Site Transmission August 2010 Page 35 of 73

38 Appendix E. Ambulatory Health Care Facility E.1.1 Adult Day Care HCPCS Description Modifier Place of Service S5100 Day Care Services, Adult 1 Unit = 15 minutes U2 modifier is no longer required when billing this service code. 12 Home 99 Other (Community) E.1.2 Clinic/Center -Federally Qualified Health Center (FQHC) Service HCPCS Diagnosis Description Clinic/Center -FQHC T1015 All rural health clinics must use procedure code T1015 for medical services. T Mental health encounters Child Wellness Exams T1015 Report with diagnosis ICD-9 code. V20.1 Other healthy infant or child receiving care. V20.2 Routine infant or child health check, to show that the encounter is a well baby or child examination and to satisfy federal reporting requirements. Family Planning T1015 V25.01 Prescription of oral contraceptive. V25.02 Initiation of other contraceptive measure (fitting of diaphragm, prescription of foams, creams, other agents). V25.09 Family planning advice (other). V25.1 Insertion of intrauterine contraceptive device. V25.2 Sterilization (admission). August 2010 Page 36 of 73