Effective 1/1/219 1 All inclusive room and board 11 All inclusive room and board 14 Anesthesia, ECT 114 Room and Board - private psychiatric 116 Room and Board - private room detoxification 118 Room and Board - private rehabilitation 12 Residential Treatment 124 Room and Board - semi private psychiatric 126 Room and Board - semi- private room detoxification 128 Room and Board - semi private rehabilitation 134 Room and Board - 3-4 bed psychiatric 136 Room and Board - 3-4 bed detoxification 138 Room and Board - 3-4 bed rehabilitation 144 Room and board private psychiatric 146 Room and board private - detoxification 154 Room and Board - ward psychiatric 156 Room and Board - detoxification ward 158 Room and Board - ward rehabilitation 18 Leave of absence from residential 183 Therapeutic home time 19 Sub Acute Inpatient 24 Intensive Care - psychiatric 24 Intensive Care - psychiatric 45 Emergency Room 451 Emergency Room 51 Clinic encounter all inclusive 513 Psych clinic 516 Urgent Care Clinic 519 Other clinic - med supervised withdrawal 52 Freestanding clinic 521 Rural Clinic 529 Other freestanding clinic ( = Additional ) PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
Effective 1/1/219 9 BH treatment services 91 ECT - electroshock treatment 95 Intensive Outpatient - providers should be instructed to use proper code with 915 96 Intensive Outpatient - providers should be instructed to use proper code with 915 91 BH treatment services 911 Substance abuse rehabilitation 914 Psychiatric/Psychological Services - Individual therapy 916 Psychiatric/Psychological Services - Family therapy 917 Biofeedback 918 Testing 919 Other BH treatment services 944 Drug Rehabilitation 945 Alcohol Rehabilitation 11 Behavioral Health Residential - psychiatric 12 Detox - Docimillary (DASA) 9785 Interactive complexity add-on code 9791 Psychiatric diagnostic evaluation (no medical Services) 9792 Psychiatric diagnostic evaluation with medical services 9832 Psychotherapy, 3 mins On At visit 21 3 min psychotherapy add on code when performed with E/M 9833 Service - (list separately) 9834 Psychotherapy, 45 mins On At visit 21 45 minute psychotherapy add on code when performed with E/M 9836 Service (list separately) 9837 Psychotherapy, 6 mins On At visit 21 6 min psychotherapy when performed with E/M service (list 9838 separately) ( = Additional ) PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
Effective 1/1/219 ( = Additional ) 9839 Psychotherapy for crisis, first 6 min. On At visit 21 984 Crisis code add on for each additional 3 min. 9845 Psychoanalysis 9846 Family Psychotherapy, without patient present On At visit 21 9847 Family Psychotherapy, 45 min On At visit 21 9849 Multiple-family group psychotherapy On At visit 21 9853 Group psychotherapy On At visit 21 9863 Pharmacologic management, add on code 9865 Narcosynthesis 9867 Therapeutic Repetitive Transcranial (TMS) 9868 Therapeutic Repetitive Transcranial (TMS) 9869 Therapeutic Repetitive Transcranial (TMS) 987 Electroconvulsive Therapy 9875 Ind psycho therapy incorporating bio feedback 3 min 9876 Ind psycho therapy incorporating bio feedback 45 min 988 Hypnotherapy 9882 Complex care management 9885 Psych eval of hospital records 9887 Interpretation or explan of results of psych exam and procedures Outpatient Collateral, 15 min. 9889 Prep of report of pt psych status 9899 Unlisted Psychiatric procedure 961 comp.comput.motion analysis 962 Functional brain mapping 9615 Assessment of Aphasia of speech/lang 9611 Developmental screening with interp PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
96112 Medicare Behavioral Health Authorization List Effective 1/1/219 Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour ( = Additional ) 96113 Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; each additional 3 minutes (List separately in addition to code for primary procedure) 96116 Neurobehavioral status exam w clin assess 96121 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; each additional hour (List separately in addition to code for primary procedure) 96125 Standardized cognitive perf testing 96127 Brief emotional needs assessment PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
9613 Medicare Behavioral Health Authorization List Effective 1/1/219 Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour ( = Additional ) 96131 Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure) 96132 Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
96133 Medicare Behavioral Health Authorization List Effective 1/1/219 Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure) ( = Additional ) 96136 Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 3 minutes 96137 Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; each additional 3 minutes (List separately in addition to code for primary procedure) 96138 96139 Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 3 minutes Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 3 minutes (List separately in addition to code for primary procedure) 96146 Psychological or neuropsychological test administration, with single automated, standardized instrument via electronic platform, with automated result only 9615 Nursing Assessment and Care-Initial PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
Effective 1/1/219 96151 Nursing Assessment and Care-Re-Assessment 96152 H&B individual intervention 96153 H&B group intervention 96154 Health & Behavior Intervention with patient present 96155 Health & Behavior Intervention without patient present 9616 Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument Administration of caregiver-focused health risk assessment 96161 instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument 96372 Medication administration 97537 Community integration counseling 9951 Services rendered after hours 9958 Office Emergency Services 9921 New Patient Office Visit Level 1 9922 New Patient Office Visit Level 2 9923 New Patient Office Visit Level 3 9924 New Patient Office Visit Level 4 9925 New Patient Office Visit Level 5 99211 Est Patient Office Visit Level 1 99212 Est Patient Office Visit Level 2 99213 Est Patient Office Visit Level 3 99214 Est Patient Office Visit Level 4 99215 Est Patient Office Visit Level 5 99221 Initial Hospital Care - comprehensive; low complexity 99222 Initial Hospital Care - comprehensive; moderate complexity ( = Additional ) PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
99223 Medicare Behavioral Health Authorization List Initial Hospital Care - comprehensive; high complexity Effective 1/1/219 99224 Subsequent observation Care 99225 Subsequent observation Care 99226 Subsequent observation Care 99231 Subsequent Hospital Care - focused; low complexity 99232 Subsequent Hospital Care - focused; moderate complexity 99233 Subsequent Hospital Care - focused; high complexity 99234 Observation - comprehensive; low complexity 99235 Observation - comprehensive; moderate complexity 99236 Observation - comprehensive; high complexity 99238 Discharge Day Management - 3 min or less 99239 Discharge Day Management - more than 3 min 99241 Problem focused; straightforward -15 min 99242 Expanded; straightforward - 3 min 99243 Detailed; low complexity - 4 min 99244 Comprehensive; moderate complexity - 6 min 99245 Comprehensive; high complexity - 8 min 99251 Initial Consultation - focused, straightforward 99252 Initial Consultation - expanded, straightforward 99253 Initial Consultation - detailed, low complexity 99254 Initial Consultation - comprehensive, moderate complexity 99255 Initial Consultation - comprehensive, high complexity 99281 ER Consultation - focused, straightforward 99282 ER Consultation - expanded; low complexity 99283 ER Consultation - expanded; moderate complexity 99284 ER Consultation - detailed; moderate complexity 99285 ER Consultation - comprehensive; high complexity 9934 Nursing facility consultation, 25 min ( = Additional ) PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
Effective 1/1/219 9935 Nursing facility consultation, 35 min 9936 Nursing facility consultation, 45 min 9937 Evaluation Management nursing facility, 1 min 9938 Evaluation Management nursing facility, 15 min 9939 Evaluation Management nursing facility, 25 min 9931 Evaluation Management nursing facility, 35 min 99341 Home visit, new patient 99342 Home visit, new patient 99343 Home visit, new patient 99344 Home visit, new patient 99345 Home visit, new patient 99347 Home visit, est patient 99348 Home visit, est patient 99349 Home visit, est patient 9935 Home visit, est patient 99354 Prolonged evaluation and mgmt psycho therapy svs 99355 Prolonged evaluation and mgmt psycho therapy svs 99366 Medical team conference 99367 Medical team conference with family 99368 Medical team conference without family 9941 Preventive counseling, individual 9942 Preventive counseling, individual, 3 min 9943 Preventive counseling, individual, 45 min 9944 Preventive counseling, individual 9946 Smoking cessation 9947 Smoking cessation 9948 Alcohol substance abuse BH change intervention 9949 Alcohol and substance abuse screening and brief intervention 99411 Preventive counseling, individual, 6 min 99412 Preventive medicine group counseling, 6 min 9951 Home visit, single, family counseling ( = Additional ) PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
Effective 1/1/219 97, H212 Community behavioral program (day treatment) Partial Hospitalization 915 and G41, G411, or H35 915, H15 BH intensive outpatient substance abuse 915, S948 BH intensive outpatient psychiatric Recreation, related to the care and treatment of patients G176 disabling mental health problems; per session (45 minutes or more) Training and educational services related to the care and G177 treatment of patients disabling mental health problems per session (45 minutes or more) G396 Alcohol/subs interv 15-3min G397 Alcohol/subs interv >3 min G49 Social work and psychological services, directly relating to and/or furthering the patient s rehabilitation goals G41 Partial Hospitalization G411 BH intensive outpatient substance abuse G436 Tobacco-use counsel 3-1 min G437 Tobacco-use counsel>1min G442 Annual alcohol misuse screening 15 min G443 Alcohol mis use and screening -various markets; Iowa=face to face BH counseling, 15 min G444 Depression Screening G445 High intensity BH counseling, 3 min G446 Intensive BH therapy G447 Face to face behavioral counseling, 15 min G451 Developmental testing with I & R G463 Hospital outpatient clinic visit G473 Face to face behavioral counseling, 15 min ( = Additional ) PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
Effective 1/1/219 Alcohol and/or substance (other than tobacco) abuse structured G211 assessment (e.g., audit, DAST), and brief intervention, 5-14 minutes H1 Alcohol and/or drug assessment H2 Behavioral Health Screen to determine eligibility for admission to treatment program H3 Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol or drugs H4 Behavioral health counseling and therapy; per 15 minutes H5 Alcohol and/or drug services; group counseling by a clinician H6 Alcohol and/or drug services; case management H7 Alcohol and/or drug services; crisis intervention (outpatient) H8 H9 H1 Alcohol and/or drug services; sub acute detoxification (outpatient) Alcohol and/or drug services; acute detoxification (hospital inpatient) Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) ( = Additional ) H11 H12 Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) Alcohol and/or drug services; sub-acute detoxification (residential addiction program outpatient) H13 H14 Alcohol and/or drug services; acute detoxification (residential addiction program outpatient) Alcohol and/or drug services; ambulatory detoxification PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
H15 Medicare Behavioral Health Authorization List Effective 1/1/219 Alcohol and/or drug services; intensive outpatient treatment (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan) including assessment, counseling, crisis intervention, and activity therapies or education ( = Additional ) H16 H17 Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory setting) Behavioral health; residential (hospital residential treatment program), without room and board; per diem H18 Behavioral health; short-term residential (non hospital residential treatment program), without room and board; per diem H19 Behavioral health; long term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 3 days), without room and board; per diem H2 Alcohol and/or drug services; methadone administration and/or service (provisions of the drug by a licensed program) H21 Alcohol and Drug training service for staff H22 Alcohol and/or drug intervention service (planned facilitation) H23 H24 Behavioral health outreach service (planned approach to reach a targeted population) Behavioral health prevention information dissemination service (one way direct or non-direct contact with service audiences to affect knowledge and attitude); 15 minutes auth requirement up to 2 units. Prior Authorization Request = ON after 2 Units Total of all HCPC Series Codes. PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
H25 H26 Medicare Behavioral Health Authorization List Effective 1/1/219 Behavioral health prevention education service (delivered services with target population to affect knowledge, attitude and/or behavior), 15 minutes Alcohol and/or drug intervention service (planned facilitation) H27 Alcohol and drug prevention service H28 Alcohol and/or drug prevention problem identification and referral service Alcohol and/or drug prevention alternatives service (services for H29 populations that exclude alcohol and other drug use, e.g. alcoholfree social events) H3 Behavioral health hotline service H31 Mental health assessment, by non-physician H32 Mental health service plan development by non-physician H33 Oral medication administration, direct observation H34 Medication training and support; per 15 minutes H35 Mental health partial hospitalization, treatment, less than 24 hours H36 Community psychiatric supportive treatment, face to face H37 Community psychiatric supportive treatment program; per diem H38 Self-help/peer services; per 15 minutes H39 Assertive Community Treatment; per 15 min H4 Assertive Community Treatment; per diem H41 Foster Care child, non therapeutic per diem H42 Foster Care child, non therapeutic per month H43 Supported housing; per diem H44 Supported housing; per month H45 Respite care services, not in the home; per diem H46 Mental Health Services NOS ( = Additional ) PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
Effective 1/1/219 H47 Alcohol and drug services not otherwise specified H48 Alcohol and/or other drug testing: collection and handling only, specimens other than blood H49 Alcohol and/or drug Screening H5 Alcohol and/or Drug Service, Brief Intervention; per 15 minutes H1 Prenatal care, at-risk assessment H11 Prenatal care, at-risk enhanced service; antepartum management H12 Prenatal care, at-risk enhanced service; care coordination H13 Prenatal care, at-risk enhanced service; education H14 Prenatal care, at-risk enhanced service; follow-up home visit H15 Prenatal care, at-risk enhanced service package (includes H11- H) H11 n-medical family planning education; per session H111 Family assessment by licensed behavioral health professional for state defined purposes H2 Comprehensive multidisciplinary evaluation H21 Rehab program 1/2 day H21 Comprehensive medication services; per 15 minutes H211 Crisis Intervention Services; per 15 Minutes H212 Behavioral health day treatment; per hour H213 Psychiatric health facility service; per diem H214 Skills training and development; per 15 minutes H215 Comprehensive community support services; per 15 minutes H216 Comprehensive community support services; per diem H217 Psychosocial rehabilitation services; per 15 minutes H218 Psychosocial rehabilitation services; per diem ( = Additional ) PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
Effective 1/1/219 H219 Therapeutic behavioral services; per 15 minutes H22 Therapeutic behavioral services; per diem In NE Therapeutic group home H221 Community-based wrap-around services; per 15 min H222 Community-based wrap-around services; per diem (intensive inhome services) H223 Supported employment; per 15 minutes H224 Supported employment; per diem H225 Ongoing support to maintain employment; per 15 minutes ( = Additional ) H226 Ongoing support to maintain employment; per diem H227 See tes - per 15 minutes H228 Sexual offender treatment service, per 15 minutes H229 Sex Offend Tx Svc, Per Diem Clubhouse services ; per 15 min auth requirement up to 2 units. Prior H23 Authorization Request = ON after 2 Units Total of all HCPC Series Codes. Clubhouse services; per diem auth requirement up to 2 units. Prior H231 Authorization Request = ON after 2 Units Total of all HCPC Series Codes. H232 Activity Therapy H233 Multi-systemic therapy for juveniles; per 15 minutes H234 Alcohol and/or drug abuse halfway house services; per diem H235 Alcohol and/or drug treatment program; per hour H236 Alcohol and/or other drug treatment program; per diem H237 Developmental delay prevention activities, dependent child of client, per 15 minutes PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
M64 Medicare Behavioral Health Authorization List Effective 1/1/219 Brief Office Visit for the Sole Purpose of Monitoring or Changing Drug Prescriptions Used in the Treatment of Mental Psychoneurotic and Personality Disorders ( = Additional ) Q314 Telehealth original site facility S19 Methadone, oral, 5mg S21 Alcohol and/or drug treatment program; per hour S518 Home care training to home care client, per 15 minutes S511 Home care training, family; per 15 minutes S5145 Behavioral health specialized foster care S515 Unskilled respite care, not hospice; per 15 minutes S911 In-home telemonitoring S9123 In-home psychiatric nursing S9475 Ambulatory setting substance abuse treatment or detoxification services; per diem S948 Intensive outpatient psychiatric services; per diem; in IL use 913 in combination with this code S9482 Family stabilization services; per 15 minutes S9484 Crisis intervention mental health services; per hour S9485 Crisis intervention mental health services; per diem T11 Nursing Assessment/Evaluation T12 RN services up to 15 minutes T13 LPN/ LVN services up to 15 minutes T15 Respite care services, up to 15 minutes T16 Alcohol and/or substance abuse services, family/couple counseling T17 Alcohol and/or substance abuse services, treatment plan development and/or modification T112 Alcohol and/or substance abuse services, skills development PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
T113 Medicare Behavioral Health Authorization List Sign language or oral interpretive services; per 15 minutes Effective 1/1/219 T114 Telehealth telemedicine T115 Clinic encounter all inclusive T116 Case management, each 15 minutes T117 Targeted case management, each 15 minutes T119 Personal care services; per 15 minutes T12 Personal care services; per diem T123 Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol; per encounter T124 Team evaluation & management T127 Family training & counseling T152 Psychotropic Medication Administration T21 n emergency transportation; patient attendant/escort T22 n-emergency transportation; per diem T23 n-emergency transportation; encounter/trip T24 n-emergency transport; commercial carrier, multi-pass T25 n-emergency transportation; stretch van T21 Preadmission screening and resident review (pasrr) level 1 identification screening; per screen T211 Preadmission screening and resident review level II evaluation; per evaluation T212 Children s Day Treatment T214 Pre-vocational Services - per diem T215 Pre-vocational Services - per hour T217 Community integration counseling T218 Supported Employment Job Development T219 Supported Employment ( = Additional ) PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_
Effective 1/1/219 T22 Day Habiliitation T221 Preadmission PASSR assessment T222 Other specified case management service not elsewhere classified T223 Targeted Case Management- per month T224 Service Assessment Plan of Care Dev T225 Waiver Services; t Otherwise Specified (NOS) T227 Specialized childcare, waiver; per 15 minutes T233 Psychiatric residential treatment facility - per diem T236 Therapeutic camping, overnight, waiver; each session T237 Therapeutic camping, day, waiver; each session T248 Behavioral health; long-term care residential (non-acute care in a residential treatment program community-based per diem) ( = Additional ) PRO_28999E Internal Approved 17219 WellCare 219 NA9PROGDE28999E_