Assessment/Intake Codes: 90791-90792 (GT); (DJ); (TK) 4 visits per year per consumer. 1 unit per episode. Prior authorization is required beyond 4 visits per year. Visits do not count against unmanaged limits. LOCUS/CALOCUS: >1 ASAM: >.05 N/A +90875 (Interactive complexity Add-On code) Diagnostic Assessment: T1023 T1023 (GT) 4 visits per year per consumer. Prior authorization is required beyond 4 visits per year. Visits do not count against unmanaged limits. LOCUS/CALOCUS: >1 ASAM: >.05 N/A E/M Assessment Codes: 99201-99205 (GT) E/M Codes have unlimited benefits. No prior approval or authorization is required. LOCUS/CALOCUS: >1 ASAM: >.05 N/A E/M Established Patient Codes: 99211-99215 (GT) E/M Codes have unlimited benefits. No prior approval or authorization is required. LOCUS/CALOCUS: >1 ASAM: >.05 N/A 1
Electroconvulsive Therapy (ECT): 90870 Six (6) unmanaged ECT sessions per episode of care. Prior authorization required before (7 th ) and subsequent sessions per episode of care. N/A Electroconvulsive Therapy (ECT) Checklist Eye Movement Desensitization and Reprocessing (EMDR) Therapy 90837 (EM) Prior authorization requested. Initial: 13 units per 90 days. Concurrent: 13 units per 90 days. LOCUS/CALOCUS: >1 ASAM: >.05 Initial: Tx Plan and Service Order (valid for 1 year). Concurrent: Clinical information needs to speak to trauma symptoms; new Tx Plan/PCP annually. Family Therapy Codes: 90846-90847 Twenty-six (26) unmanaged outpatient visits per year. Visits can be individual, family, or a combination of both. Authorization required once 26 unmanaged visits are exhausted. Concurrent: Request cannot exceed 13 visits every 90 days. Crisis add-on codes are limited to 2 per year (no authorization required). LOCUS/CALOCUS: 1 ASAM: 1 Initial: Tx Plan/ PCP and service order (valid for 1 year). Concurrent: Clinical information to justify medical necessity; new TX Plan /PCP annually. 2
Group Therapy Codes: 90849; 90853 Twenty-six (26) unmanaged outpatient visits per year. Authorization is required once unmanaged visits are exhausted. LOCUS/CALOCUS: 1 ASAM: 1 Concurrent: Group therapy requests (after the unmanaged visits) will be no more than 20 visits per 90 days. Initial: Tx Plan/ PCP and service order (valid for 1 year). Concurrent: Clinical information to justify medical necessity; new Tx Plan/ PCP annually. Outpatient Consultation Codes: Limit of 4 visits per year. Does not count against unmanaged visits. LOCUS/CALOCUS: 1 ASAM: 1 N/A 99241-99245 Outpatient Individual Therapy: 90832-90834 (GT); 90837 (SR); 90845 90839-90840 are add-on codes for an additional 30- minute crisis intervention. 90833; 90836 and 90838 allow add-on codes when EM code occurs Simultaneously. Twenty-six (26) unmanaged outpatient visits per year. Visits can be individual/family or a combination of both. Authorization required once 26 unmanaged visits are exhausted. Each 90-day request cannot exceed 13 visits. Crisis add-on codes are limited to 2 per year (no authorization required). LOCUS/CALOCUS: 1 ASAM: 1 Initial: Tx Plan/ PCP and service order (valid for 1 year). Concurrent: Clinical information to justify medical necessity; new Tx Plan/ PCP annually. 3
Effective 1/1/19: 96110, 96112, +96113 Medicaid Adult MH/SU Services Benefit Plan Developmental Testing: One (1) episode of testing/year. Eight (8) hour limit for all codes/year. NA Psychological Testing Request serves as Service Order Ends 12/31/2018: 96111 Count as part of unmanaged visits/year. Psychological Testing: Ends 12/31/2018: 96101 Effective 1/1/19: 96136, +96137, 96130, +96131, 96125, 96138, +96139, 96146 One (1) episode of testing/year. Eight (8) hour limit for all codes/year. Count as part of unmanaged visits/year. NA Psychological Testing Request serves as Service Order. 4
Neuropsychological Testing: One (1) episode of testing/year. Eight (8) hour limit for all codes/year. Count as part of unmanaged visits/year. NA Psychological Testing Request serves as Service Order. Ends 12/31/2018: 96118 Effective 1/1/19: 96136, +96137, 96138, +96139, 96132, +96133, 96116, +96121, 96146 Trauma Focused-CBT: 90837 (ZI) 90846 (ZI) 90847 (ZI) Prior authorization required. Initial: 13 units per 90 days Concurrent: 13 units per 90 days LOCUS/CALOCUS: 1 ASAM:.05 * Initial: Tx Plan/ PCP and service order (valid for 1 year). Concurrent: Clinical information to justify medical necessity; new Tx Plan/ PCP annually. Trauma Intensive Comprehensive Clinical Assessment (TICCA): 90791 (TI) Prior authorization required. Up to 10 hours of assessment for a 3-month duration by Specialty Contract only. Does not count against unmanaged visits. LOCUS/CALOCUS: 1 ASAM:.05 * Clinical information to justify medical necessity. 5
Therapeutic Injection: Up to 52 units per year; does not require authorization. LOCUS/CALOCUS: 1 ASAM:.05 N/A 96372-96375 Assertive Community Treatment Team: H0040 (DJ) Initial: 24 units per 6 months. If consumer enters treatment with less than 14 days left in calendar month, authorize 4 units for partial month + 24 units for additional 6 months. LOCUS: 3-5 ASAM: 1-2.5-1 Initial: CCA, PCP and CCP, Service order. Concurrent: Updated PCP. Concurrent: 24 units per 6 months Community Support Team: H2015HT (DJ) Initial: Up to 128 units per 60 days Concurrent: Up to 128 units per 60 days LOCUS: 2-4 ASAM: 1-2.5 Initial: CCA, PCP and CCP and Service order. Concurrent: Updated PCP and Independent CCA if request exceeds 6 months per calendar year and new service order. 6
Critical Time Intervention (CTI): Pre-CTI: 12 units LOCUS: 1-4 ASAM: 1-2.5 * Pre-CTI: Notification SAR only. H0032U5 (DJ) Phase I: 155 units for three months. Phase II: 8 units weekly; 104 units per 3 months. Phase III: 4 units weekly; 52 units per 3 months. Each of the 3 phases lasts 3 months. Service is not to exceed 312 units for 9-month duration. Phase I: Phase Plan, Service order, and assessment. Phase II/III: Updated phase plan and authorization request. Mobile Crisis Management: 32 units (8hours) per 24-hours unmanaged N/A Crisis Plan after 32 units per 24-hour period. H2011 Partial Hospitalization: H0035 (DJ) 0912; 0913 (Inpatient Codes) Initial: 7-day Concurrent: 7 days LOCUS/CALOCUS: 4-5 ASAM: 1-2.5 Initial: SAR with justification on day of admission; PCP, CCP Service order w/in two business days of admission. Concurrent: Clinical updates w/progress notes. 7
Psychosocial Rehabilitation: LOCUS/CALOCUS: 2-5 ASAM: 1-2.5 H2017 No authorization required for consumers who receive 32 hours or less per week. For over 32 hours, initial and concurrent authorization is for up to one year. Initial: CCA, PCP, CCP, Service Order. Concurrent: Updated PCP 8
Medicaid Adult Substance Use (SU) Services ADACT: 0126-Acute 0218-Rehabilitation Initial: Up to 5 days Concurrent: Based on medical necessity; no more than 30 days total for both codes. CALOCUS: 5-6 ASAM: 3.7 Acute ASAM: 3.5 Non-Acute Initial: Prior approval by Regional Referral Form, Live Review, or Initial Inpatient Review Form. Concurrent: Inpatient Continuing Care Form. Ambulatory Detox: H0014 Initial: Pass-through of 3 days, 72 units, maximum. Concurrent: Up to 3 days, 24 units/day, for 10 days maximum per episode of care. LOCUS: 4 ASAM: Level I-WM Notification SAR is required for the pass-through. No clinical documentation required to be uploaded with the Notification SAR Concurrent: SAR with clinical information is required along with PCP and CCP, Service order (dated on or prior the first day the service was provided). 9
Medicaid Adult Substance Use (SU) Services Facility Based Crisis: S9484 Initial: Pass through of 7 days. One day equals 16 hours. Concurrent: Limited to 8 days (128) units. Annual limits is 30 days from first date of admission. LOCUS: 3-5 CALOCUS: 3-5 ASAM: 3.5-2 Initial: Pass-through- Service order on file. Concurrent: Service order and clinical information to support medical necessity. Non-Hospital Medical Detox: H0010 Initial: Pass-Through of 3 days Concurrent: Up to 7 days LOCUS: 5 ASAM: 3.7 WM Initial: Notification SAR is required for the passthrough. No clinical documentation required to be uploaded with the Notification SAR. Concurrent: SAR with clinical information is required along with PCP and CCP, Service order (dated on or prior the first day the service was provided). Outpatient Opioid Treatment: Initial: 60 days Concurrent: 90 days LOCUS: 2 ASAM: OTP Initial: Tx Plan, Service order. H0020 Concurrent: Updated TX Plan w/each request. 10
Medicaid Adult Substance Use (SU) Services Substance Abuse Comprehensive Outpatient Treatment Program (SACOT): H2035 Initial: Pass-through of 180 hours for 60 days; one per fiscal year. Concurrent: Additional units authorized per medical necessity, minimum is 4 hours, per day LOCUS: 3-5 ASAM: 2.5 Initial: PCP and CCP, Service order on file Concurrent: First request- submit above with updated PCP w/each additional request. Substance Abuse Intensive Outpatient (SAIOP): H0015 Initial: Pass-through of 13 units for 30 days once per fiscal year. Concurrent: Up to 26 units for 60 days. An additional 2 weeks can be authorized if medically necessary. LOCUS: 3-5 ASAM: 2.1 Initial: PCP and CCP, Service order on file. Concurrent: First request- submit above with updated PCP w/each additional request. Substance Abuse Medically Monitored Community Residential Treatment: Initial: Up to 10 days Concurrent: Up to 10 days; no more than 30 days per 12 months. LOCUS: 3-5 ASAM: 3.7 Initial: PCP, CCP, Service order. Concurrent: Updated PCP w/each request. H0013 11
Medicaid Adult Substance Use (SU) Services Substance Abuse Non- Medically Monitored Community Residential Treatment: H0012 Initial: Up to 10 days. Concurrent: Up to 10 days; no more than 30 days per 12 months. LOCUS: 5 ASAM: 3.7 WM Initial: PCP and CCP, Service order. Concurrent: Updated PCP w/each request. 12
NOTES * Indicates Partners In Lieu of Service Definition or Alternative Payment Agreement + Indicates an add-on code. Add-on codes cannot be billed separately and should be billed as an addition to a primary procedure code when applicable. Please consult the American Medical Association s CPT Code Book for complete details. Services requiring a PCP include the service order. A separate service order is indicated for those services for which a treatment plan and service order is required. Individual outpatient and family therapy services are not to exceed an average frequency of once weekly. Evaluation/Management services may be delivered by an MD, PA or NP. Evaluation/Management services for adult and children are not limited and do not require authorization. Interactive Complexity Code (90785) is used for individual psychophysiological therapy that incorporates biofeedback training by any modality that occurs face to face. 13
Modifier Interpretation AD Used to indicate that the service is for adolescent: Substance Abuse Intensive Outpatient: H0015AD Distinguishes Diversion & Assessment Program (DAP) PRTF, 911AD DJ Department of Justice for Transition to Community Living Program specific service codes EM Added to outpatient codes to designate Eye Movement Desensitization and Reprocessing (EMDR) EP Added to outpatient codes to designate smoking and tobacco use cessation GT Designates use of interaction telecommunication HE Designates use of Evidence Based Practice Family Centered Treatment H2022HE (Core Phase) versus (Engagement and Transition Phases) and Intensive In-Home Service H2022 HT Indicates Intensive Alternative Family Treatment (IAFT) Therapeutic Foster Care Code (S5145HT-TFC) M1-M5 Used with Multi-Systemic services to indicate the month of service H2033 (1-5) PB Added to Multi-Systemic Therapy (MST), H2033M to designate Problem Sexualized Behavior MST rate RR Indicates Rapid Response when attached to Therapeutic Foster Care code (S5145RR) SR Added to Outpatient Codes to designate In-Home Setting TF Added to Outpatient Codes and Residential Codes to indicate use of Trauma Focused Cognitive Behavioral Therapy delivered by a rostered provider who has a specialty contract with Partners. TI Designates the Trauma Intensive Comprehensive Clinical Assessment (TICCA) 907941TI TK Attached to Alternative Codes to designate Transportation YA346TK; YA341TK TL Attached to an Outpatient Code and refers to Treatment Alternative for Sexualized Kids (TASK) 90791TK U4 Therapeutic Leave U5 Designates B-3 services ZI In-Lieu of Service Definition 14
Medicaid Benefit Plan Revision Information Date of Service and Section Revised Actual Change Change 7/7/17 Ambulatory Detox Added a pass-through period 7/27/17 Non-Hospital Detox Added a pass-through period 8/1/17 Psychological Testing Replaced codes that were deleted from the grid in error 8/2/17 B3 Supported Employment (MH) Replaced pass-through that was deleted from the grid in error 8/14/17 B3 Supported Employment (MH) Extended authorization limit to 6 months 8/30/17 Ambulatory Detox Corrected pass-through information 9/6/17 B3 Individual Supports Clarified notification SAR requirement 11/13/17 TICCA Clarified hourly unit 2/2/18 Peer Support Clarified benefit limit 2/15/18 Residential Level III Shortened continued stay auth limit to 60 days 2/15/18 FCT Clarified option to group codes on one SAR 2/15/18 Facility Based Crisis for Children Added Service 3/23/18 Peer Support Removed notification SAR requirement 7/1/18 Update in Formatting Separated by Age and Disability 11/9/18 Electroconvulsive Therapy (ECT) Added information re: unmanaged visits. 11/26/18 Eye Movement Desensitization and Reprocessing Added Service 1/1/19 Developmental, Psychological, Neuropsychological Testing, FCT Updated Code Changes 15