V.17.2 Code Table Listing -- SSIS.MOD Sort = MOD_ID MOD_ID CD 1 2 3 4 UTC Desc 11 T2028 U2 09 CDCS - Treatment and training 10/01/2004 22 T2028 U3 09 CDCS - Environmental modifications and provisions 10/01/2004 33 T2028 U4 09 CDCS - Self direction support activities 10/01/2004 44 T1019 TT UC 16 Extended shared personal care services 1:2 11/01/2004 55 T1019 HQ UC 16 Extended shared personal care services 1:3 11/01/2004 66 S5135 U9 16 Behavioral programming by aide 11/01/2004 04/30/2013 77 S5135 UA 16 BI night supervision 11/01/2004 88 S5135 UB 16 24-hour emergency assistance (15 minutes) 11/01/2004 12/31/2013 99 S5136 UB 08 24-hour emergency assistance (day) 11/01/2004 12/31/2013 100 S5100 TF 16 Adult day care bath 11/01/2004 110 T1002 TT UC 16 RN, regular, extended 1:2 11/01/2004 111 T1003 TT UC 16 LPN, regular, extended 1:2 11/01/2004 112 S9131 TF UC 29 Extended physical therapy assistant 11/01/2004 113 S9129 TF UC 29 Extended occupational therapy assistant 11/01/2004 114 T1002 TG UC 16 RN, complex, extended 11/01/2004 115 T1003 TG UC 16 LPN, complex, extended 11/01/2004 116 T1002 TT 16 RN, regular 1:2 11/01/2004 117 T1002 UC 16 RN, regular, extended 1:1 11/01/2004 118 T1002 TG 16 RN, complex 11/01/2004 V.17.2 -- SSIS.MOD Page 1 of 14
MOD_ID CD 1 2 3 4 UTC Desc 119 T1003 UC 16 LPN, regular, extended 1:1 11/01/2004 120 T1003 TT 16 LPN, regular 1:2 11/01/2004 121 T1003 TG 16 LPN, complex 11/01/2004 122 T1019 TT 16 Personal care services (PCA) 1:2 11/01/2004 123 T1019 16 Personal care services (PCA) 1:1 11/01/2004 124 T1019 HQ 16 Personal care services (PCA) 1:3 11/01/2004 125 T2023 HA HE 18 MH-TCM, child, face-to-face 126 T2023 HE U4 18 MH-TCM, adult, telephone 127 T2023 HE HW 18 MH-TCM, adult, face-to-face by state staff 12/31/2007 128 T2023 HE HW U4 18 MH-TCM, adult, telephone by state staff 12/31/2007 129 T2023 U3 18 CW-TCM, face-to-face 130 T2023 U3 U4 18 CW-TCM, telephone 131 T2023 U1 18 VA/DD-TCM, face-to-face 132 T2023 U1 U4 18 VA/DD-TCM, telephone 135 T1005 TG 16 Crisis respite, specialized 11/01/2004 140 S5126 TG 08 DD, in home family support (day) 11/01/2004 12/31/2013 141 H0040 HW 08 Assertive Community Treatment (ACT) by state staff 07/01/2004 12/31/2007 142 H0019 08 Children's residential treatment 07/01/2004 143 H0019 HW 08 Intensive Residential Rehab. Treatment (IRT) by state staff 07/01/2004 12/31/2007 145 S9484 HM 11 Crisis assessment, intervention and stabilization, non-residential, ind. by rehab. worker V.17.2 -- SSIS.MOD Page 2 of 14
MOD_ID CD 1 2 3 4 UTC Desc 146 S9484 HQ 11 Crisis assessment, intervention and stabilization, non-residential, group 91155306 X5265 28 Transportation 01/01/1999 09/30/2006 91155312 X5291 18 Residential care services 01/01/1999 09/30/2006 91155315 X5294 28 Extended transportation 01/01/1999 09/30/2006 91155324 X5363 18 Foster care, corporate 01/01/2000 09/30/2006 91155325 X5400 26 DD county screening, MA elig 01/01/1999 09/30/2006 91155326 X5410 17 Day program, supported employment 01/01/1999 09/30/2006 91155327 X5411 22 Day program, supported employment 01/01/1999 09/30/2006 91155328 X5412 08 Day program, supported employment 01/01/1999 09/30/2006 91155331 X5415 17 MR, adult supported living services 01/01/1999 09/30/2006 91155332 X5416 08 MR, adult supported living services 01/01/1999 09/30/2006 91155352 X5467 12 Extended home health medical supplies/equipment 01/01/1999 09/30/2006 91155353 X5476 16 Case management 01/01/1999 09/30/2006 91155358 X5484 17 Respite care, out of home 01/01/1999 09/30/2006 91155362 X5491 16 Case management, paraprofessional 01/01/1999 09/30/2006 91155364 X5502 06 Consumer education and training 01/01/1999 09/30/2006 91155365 X5503 11 Consumer directed community support 01/01/1999 06/30/2005 91155366 X5504 08 Consumer directed community support 01/01/1999 06/30/2005 91155378 X5590 17 Independent Living Skills counseling 01/01/1999 09/30/2006 91155381 X5593 17 Independent Living Skills group therapy 01/01/1999 09/30/2006 V.17.2 -- SSIS.MOD Page 3 of 14
MOD_ID CD 1 2 3 4 UTC Desc 91155386 X5601 28 Extended transportation 01/01/1999 09/30/2006 91155387 X5602 14 Extended transportation 01/01/1999 09/30/2006 91155388 X5603 09 Extended transportation - extra attendant 01/01/1999 09/30/2006 91155396 X5630 16 MR Preadmission screening - 15 min 01/01/1999 09/30/2006 91155398 X5632 16 MH preadmission screening 01/01/1999 91155400 X5639 17 PASARR MH diag asses Masters 01/01/1999 91155401 X5640 17 PASARR MH diag asses PhD 01/01/1999 91155419 X5671 12 Assistive technology 01/01/1999 09/30/2006 91155422 X5674 11 Specialist service 01/01/1999 09/30/2006 91155425 X5679 22 DT&H, waiver, non-pilot 01/01/1999 09/30/2006 91155438 99450 16 Life/disability evaluation: Face-to-face LTCC assessment under age 65 07/01/2001 03/31/2008 91155439 X5398 18 MR, adult supported living services 02/01/2000 09/30/2006 91155440 T1016 16 Relocation Service Coordination (RSC-TCM) 07/01/2001 08/31/2008 91155443 H0018 08 Crisis stabilization, residential 91155445 T2023 HE 18 MH-TCM, adult, face-to-face 91155446 S9484 11 Crisis assessment, intervention and stabilization, non-residential, ind. by professional 91155447 H0035 08 Partial hospitalization 91155448 S5165 12 Environmental accessibility adaptations, home modifications/install and expenses 11/01/2004 91155449 T2028 U1 09 CDCS - Personal assistance 10/01/2004 91155450 T2040 16 CDCS - Background check 10/01/2004 V.17.2 -- SSIS.MOD Page 4 of 14
MOD_ID CD 1 2 3 4 UTC Desc 91155451 T2041 16 CDCS - Mandatory case management 10/01/2004 91155452 S5100 16 Day care services, adult (15 minutes) 11/01/2004 91155453 S5102 08 Day care services, adult (day) 11/01/2004 91155454 S5110 16 Family training 11/01/2004 91155455 S5116 27 Caregiver training/education 11/01/2004 06/30/2013 91155456 S5120 16 Chore services 11/01/2004 91155457 S5125 16 DD, in home family support (15 minutes) 11/01/2004 91155458 S5126 08 Caregiver living expenses 11/01/2004 91155459 S5130 16 Homemaker service - cleaning only (15 minutes) 11/01/2004 91155460 S5131 08 Homemaker services (day) 11/01/2004 91155461 S5140 08 Foster care, adult (day) 11/01/2004 91155462 S5141 18 Foster care, adult (month) 11/01/2004 12/31/2013 91155463 S5145 08 Foster care, child (day) 11/01/2004 91155464 S5146 18 Foster care, child (month) 11/01/2004 12/31/2013 91155465 S5150 16 Respite care, in home (15 minutes) 11/01/2004 12/31/2013 91155466 S5151 08 Respite care, in home (day) 11/01/2004 91155467 S5170 13 Home delivered meals 11/01/2004 91155469 S9125 08 Crisis respite (day) 11/01/2004 91155470 S9128 UC 29 Extended speech therapy 11/01/2004 91155471 S9129 UC 29 Extended occupational therapy 11/01/2004 V.17.2 -- SSIS.MOD Page 5 of 14
MOD_ID CD 1 2 3 4 UTC Desc 91155472 S9131 UC 29 Extended physical therapy 11/01/2004 91155473 S9470 29 Nutritional counseling, diet 11/01/2004 91155474 E1399 12 Durable medical equipment 11/01/2004 05/31/2013 91155475 H0045 08 Respite care services, not in home 11/01/2004 91155476 G0154 16 Direct skilled nursing services - LPN or RN - home 11/01/2004 12/31/2015 91155477 G0156 16 Home health aide/extended home health aide 11/01/2004 06/30/2009 91155479 T1005 16 Crisis respite (15 minutes) 11/01/2004 91155480 T1002 16 RN, regular 11/01/2004 91155481 T1003 16 LPN, regular 11/01/2004 91155482 T1019 UC 16 Extended personal care 1:1 11/01/2004 91155483 T1021 29 Home health aide visit 11/01/2004 91155484 T1020 08 Personal care services 11/01/2004 09/30/2011 91155485 T2038 09 Trans Serv Deposits/Moving Exp 11/01/2004 91155487 S5135 16 Companion care, adult/personal support 11/01/2004 91155488 S5136 08 Personal support 11/01/2004 12/31/2013 91155490 H0040 08 Assertive Community Treatment (ACT) 07/01/2004 91172029 H2017 HM UD 16 Transition to Community Living by a mental health rehabilitation worker 08/31/2016 91172031 H2017 HM HW UD 16 Psychosocial rehab., indiv., transitional by rehab worker/state employee 12/31/2007 91172033 H2017 HM HW 16 Psychosocial rehab., indiv. by rehab worker/state employee 12/31/2007 91172035 H2017 HW UD 16 Psychosocial rehab., indiv., transitional by state employee 12/31/2007 V.17.2 -- SSIS.MOD Page 6 of 14
MOD_ID CD 1 2 3 4 UTC Desc 91172037 H2017 HQ HW 16 Psychosocial rehab., group by state employee 12/31/2007 91172045 T2028 U8 09 CDCS - Flexible case management 10/01/2004 91176169 H2017 16 Basic Living and Social Skills - individual; mental health professional or practitioner 91176171 H2017 HM 16 Basic Living and Social Skills - individual; mental health rehabilitation worker 91176173 H2017 HW 16 Psychosocial rehab., indiv. by state employee 12/31/2007 91176175 H2017 HQ 16 Basic Living and Social Skills - group; mental health professional or practitioner, or rehab. worker 91176177 H2017 UD 16 Transition to Community Living 08/31/2016 91176200 T2016 U9 08 Supported living services, adult, corporate AFC (day) 10/01/2006 91176280 H2017 HQ UD 16 Psychosocial rehab., group, transitional 91176281 H2017 HM HQ UD 16 Psychosocial rehab., group, transitional by rehab worker 91176282 H2017 HQ HW UD 16 Psychosocial rehab., group, transitional by state employee 12/31/2007 91176283 H2017 HM HQ HW UD 16 Psychosocial rehab., group, transitional by rehab worker/state employee 12/31/2007 91176284 H2017 HM HQ 16 Psychosocial rehab., group by rehab worker 91176285 H2017 HM HQ HW 16 Psychosocial rehab., group by rehab worker/state employee 12/31/2007 91176286 90882 27 Environmental or community intervention, mental health professional or practitioner 01/01/2002 91176287 90882 UD 27 Transition to Community Intervention 01/01/2002 08/31/2016 91176288 90882 HM UD 27 Transition to Community Intervention by a mental health rehabilitation worker 01/01/2002 08/31/2016 91176289 90882 HW UD 16 Community intervention, indiv., transitional by state employee 01/01/2002 12/31/2007 91176290 90882 HM HW UD 16 Community intervention, indiv., transitional by rehab worker/state employee 01/01/2002 12/31/2007 91176291 90882 HM 27 Environmental or community intervention, mental health rehabilitation worker 01/01/2002 V.17.2 -- SSIS.MOD Page 7 of 14
MOD_ID CD 1 2 3 4 UTC Desc 91176292 90882 HW 16 Community intervention, indiv. by state employee 01/01/2002 12/31/2007 91176293 90882 HM HW 16 Community intervention, indiv. by rehab worker/state employee 01/01/2002 12/31/2007 91176294 T2025 09 Consumer Support Grant (CSG) 06/01/2006 91178000 H0025 16 Behaviorial Support, by analyst 10/01/2006 91178001 H0025 TF 16 Behaviorial Support, by specialist 10/01/2006 91178002 H0025 TG 16 Behaviorial Support, by professional 10/01/2006 91178003 H2032 16 Independent living skills, maintenance 10/01/2006 12/31/2013 91178004 H2032 TG 16 Independent living skills, individual therapy 10/01/2006 91178005 H2032 HQ 16 Independent living skills, group therapy 10/01/2006 91178007 T2020 08 DT&H, non-pilot/structured day program 10/01/2006 91178008 T2020 U5 22 DT&H, non-pilot 10/01/2006 12/31/2013 91178009 T2002 08 DT&H, non-pilot, transportation 10/01/2006 12/31/2013 91178010 T2021 TG 16 DT&H pilot, Rate A 10/01/2006 12/31/2013 91178011 T2021 TF 16 DT&H pilot, Rate B 10/01/2006 12/31/2013 91178012 T2021 UB 16 DT&H pilot, Rate C 10/01/2006 12/31/2013 91178013 T2021 16 DT&H pilot, Rate D/Structured day program 10/01/2006 91178014 T2024 26 DD screening (screen) 10/01/2006 05/31/2007 91178015 T2032 18 Residential care services (month) 10/01/2006 12/31/2013 91178016 T2032 U9 18 Supported living services, adult, corporate AFC (month) 10/01/2006 12/31/2013 91178017 T2032 HA 18 Supported living services, child (month) 10/01/2006 12/31/2013 V.17.2 -- SSIS.MOD Page 8 of 14
MOD_ID CD 1 2 3 4 UTC Desc 91178018 T2018 U5 22 Supported employment (partial day) 10/01/2006 12/31/2013 91178019 S0215 UC 14 Transportation, mileage (commercial vehicle) 10/01/2006 12/31/2012 91178020 T2038 TF 32 Housing access coordination 10/01/2006 12/31/2013 91178021 T2029 12 Assistive technology/supplies and equip., extended 10/01/2006 91178022 T2013 11 Specialist service 10/01/2006 91178023 T2017 HA 16 Supported living services, child (15 minutes) 10/01/2006 91178024 T2016 HA 08 Supported living services, child (day) 10/01/2006 91178025 T2017 16 Supported living services, adult (15 minutes) 10/01/2006 91178026 T2017 U9 16 Supported living services, adult, corporate AFC (15 minutes) 10/01/2006 91178027 T2016 08 Supported living services, adult (day) 10/01/2006 91178028 S5109 27 Consumer training and education 10/01/2006 91178029 T1016 UC 16 Waiver case management 10/01/2006 91178030 S5141 HQ 18 Foster care, adult (month) 10/01/2006 91178031 T2003 UC 28 Non-emergency transportation; encounter/trip (one way) 10/01/2006 91178032 T1019 UA 16 Supervision of PCA 10/01/2006 91178033 T2003 28 Non-emergency transportation; encounter/trip (one way) 10/01/2006 91178034 S5110 TF 16 CAC Family training 10/01/2006 04/30/2009 91178036 T2030 18 Customized living services (monthly) 10/01/2006 12/31/2013 91178037 T2030 TG 18 24-hour customized living (monthly) 10/01/2006 12/31/2013 91178038 T2030 TG U9 18 24-hour customized living (corporate) 10/01/2006 12/31/2013 V.17.2 -- SSIS.MOD Page 9 of 14
MOD_ID CD 1 2 3 4 UTC Desc 91178039 T2019 16 Supported employment (15 minutes) 10/01/2006 91178040 T2018 08 Supported employment (day) 10/01/2006 12/31/2013 91178042 T1016 TF UC 16 Waiver case management by paraprofessional 10/01/2006 91178043 S5150 UB 16 Respite care, out of home 10/01/2006 91178045 T2015 11 Prevocational services (hour) 10/01/2006 91178046 T2014 08 Prevocational services (day) 10/01/2006 91178047 H2032 TF 16 Independent living skills, counseling 10/01/2006 91178048 T2001 UC 03 Transportation, extra attendant 10/01/2006 91178049 T2031 08 Customized living services (daily) 10/01/2006 91178050 T2033 08 Residential care services (day) 10/01/2006 91238006 T1016 16 AC Conversion 07/01/2001 91238036 T2003 UC 25 Non-emergency transportation; round trip 10/01/2006 09/30/2007 91238039 T2032 34 Supported living services, adult (semi-monthly) 10/01/2006 12/31/2013 91238042 S0215 UC 14 Transportation, mileage 10/01/2006 91238047 T2032 U9 34 Supported living services, adult, corporate AFC (semi-monthly) 10/01/2006 12/31/2013 91238050 T2032 HA 34 Supported living services, child (semi-monthly) 10/01/2006 12/31/2013 91238313 T2032 18 Supported living services, adult (month) 10/01/2006 12/31/2013 91238326 X5527 09 AC Discretionary service 07/01/1999 91238333 H0019 08 Intensive Residential Rehab. Treatment (IRT) 07/01/2004 91238364 T2025 UD 09 Family Support Grant (FSG) with CSG 06/01/2006 07/31/2012 V.17.2 -- SSIS.MOD Page 10 of 14
MOD_ID CD 1 2 3 4 UTC Desc 91238374 S5140 U9 08 Foster care, adult, corporate (day) 11/01/2004 91238376 S5141 U9 18 Foster care, adult, corporate (month) 11/01/2004 12/31/2013 91238380 T2038 U1 09 Transitional services, furniture 11/01/2004 91238383 T2038 U2 09 Transitional services, supplies 11/01/2004 91238594 T2024 16 DD Screening (15 minutes) 06/01/2007 91261022 T1030 29 Home health skilled nurse 11/01/2004 91261024 T1030 GT 09 Home health telehomecare 11/01/2004 91299000 H2019 UA 16 Therapeutic behavioral services, Level I MHBA 07/01/2004 91299002 H2019 HM UA 16 Therapeutic behavioral services, Level II MHBA 07/01/2004 91299004 H2019 HE UA 16 Therapeutic behavioral services, direction of MHBA 07/01/2004 91308964 S5100 U7 16 Family adult day services (FADS) (15 minutes) 01/01/2008 91308966 S5102 U7 08 Family adult day services (FADS) (day) 01/01/2008 91308974 T1023 16 Life/disability evaluation: Face-to-face LTCC assessment under age 65 04/01/2008 91309042 T1017 16 Relocation Service Coordination (RSC-TCM) 09/01/2008 91413000 T1004 16 Home health aide/extended home health aide 07/01/2009 91413001 S5165 U3 12 Environmental accessibility adaptations, square footage 08/01/2009 91413134 H0001 26 Alcohol and/or drug assessment 07/01/2009 91413136 H0002 26 Behavioral health eligibility screening 07/01/2009 91413239 S9484 HN 11 Crisis assessment, intervention and stabilization, non-residential, ind. by practitioner 01/01/2010 91413243 90882 HK 27 Community intervention, crisis response 01/01/2010 V.17.2 -- SSIS.MOD Page 11 of 14
MOD_ID CD 1 2 3 4 UTC Desc 91530002 S5116 TF 32 Caregiver assessment 04/01/2010 06/30/2013 91534000 S5160 12 Emergency response system-installation and testing 05/01/2010 91538000 S5161 12 Emergency response system-service fee, per month 05/01/2010 91538002 S5162 12 Emergency response system-purchase 05/01/2010 91807008 H0040 U6 08 Assertive Community Treatment, MHM 06/01/2013 91807049 H2015 U6 16 Comprehensive community support services, MHM 06/01/2013 91807073 T1016 U6 16 Case management, MHM 06/01/2013 91807099 T2038 U6 09 Transition plan development, MHM 06/01/2013 91807125 T2038 UD U6 09 Transition coordination, MHM 06/01/2013 12/31/2015 91807151 A0180 U6 09 Non-emergency transportation: ancillary lodging, recipient, MHM 06/01/2013 91807161 A0200 U6 09 Non-emergency transportation: lodging for caseworker, escort, parent, MHM 06/01/2013 91807195 S5135 UA U6 16 Overnight Assistance, MHM 06/01/2013 91807205 S5160 U6 12 Emergency response system installation and testing, MHM 06/01/2013 91807213 S5161 U6 12 Emergency response system service fee per month, MHM 06/01/2013 91807221 S5162 U6 12 Emergency response system purchase, MHM 06/01/2013 91807229 S5165 U6 12 Environmental accessibility adaptations, MHM 06/01/2013 91807237 S9970 U6 12 Health club membership, annual, MHM 06/01/2013 07/31/2014 91807243 T1028 U6 12 Adaptations - home assessment, MHM 06/01/2013 91807251 T1999 U6 12 Tools, clothing and equipment for employment, MHM 06/01/2013 91807259 T2038 U1 U6 09 Transitional services, furniture, MHM 06/01/2013 V.17.2 -- SSIS.MOD Page 12 of 14
MOD_ID CD 1 2 3 4 UTC Desc 91807265 T2038 U2 U6 09 Transitional services, supplies, MHM 06/01/2013 91807271 T2038 UA U6 09 Transitional services, housing deposit, MHM 06/01/2013 91817000 S5115 16 Caregiver training/education 07/01/2013 91817010 S5115 TF 16 Caregiver Coaching and Counseling/Caregiver Assessment 07/01/2013 91822024 T2011 26 PASRR Level II Screening 09/01/2012 91836004 S5150 16 Respite care, in home (15 minutes) 01/01/2014 91857000 T2029 U6 12 Assistive technology/supplies and equip., extended, MHM 12/01/2013 12/31/2015 91876000 S9970 U5 U6 18 Health club membership, monthly, MHM 08/01/2014 91904000 H2015 16 Community Living Assistance Services, in person 01/01/2015 91907010 H2016 08 Community Living Assistance Services, remote 01/01/2015 91915000 S5115 TG 16 Family Caregiver Coaching and Counseling/Family Memory Care 07/01/2015 91918000 E1399 NU 12 Durable medical equipment, new 06/01/2013 91918012 E1399 RB 12 Durable medical equipment, repair 06/01/2013 91918020 E1399 RR 12 Durable medical equipment, rental 06/01/2013 91946000 T1017 U6 16 Transition coordination, MHM 01/01/2016 91946030 T2029 U6 NU 12 Durable medical equipment, new, MHM 01/01/2016 91949000 T2029 U6 RB 12 Durable medical equipment, repair, MHM 01/01/2016 91949008 T2029 U6 RR 12 Durable medical equipment, rental, MHM 01/01/2016 91949016 T2029 U6 UE 12 Durable medical equipment, used, MHM 01/01/2016 91949026 E1399 UE 12 Durable medical equipment, used 01/01/2016 V.17.2 -- SSIS.MOD Page 13 of 14
MOD_ID CD 1 2 3 4 UTC Desc 91949034 T2029 NU 12 Durable medical equipment, new 01/01/2016 91949042 T2029 RB 12 Durable medical equipment, repair 01/01/2016 91949050 T2029 RR 12 Durable medical equipment, rental 01/01/2016 91949058 T2029 UE 12 Durable medical equipment, used 01/01/2016 92020000 H2017 U3 16 Basic living and social skills, transitioning to community living (TCL), mental health professional 09/01/2016 92020006 H2017 HM U3 16 Basic skills, transitioning to community living (TCL) by a mental health rehabilitation worker, less 09/01/2016 92020008 90882 U3 27 Environmental or community intervention; transition to community living (TCL) intervention 09/01/2016 92020010 90882 HM U3 27 Environmental or community intervention; transition to community living intervention, less than bach 09/01/2016 V.17.2 -- SSIS.MOD Page 14 of 14