https://providers.amerigroup.com Behavioral Health Covered Benefits The matrix below lists the available behavioral health benefits for members enrolled in the Iowa Health and Wellness Plan. Outpatient 81000 Urinalysis 90785 Interactive complexity add-on code 90791 Psychiatric diagnostic interview 90792 Psychiatric diagnostic interview with medical 90832 Individual psychotherapy (20-30 ) 90833 Psychotherapy, 30 30 with patient and/or family member with evaluation and management (E&M) 90834 Individual psychotherapy (45-50 ) 90836 Psychotherapy, 30 45-50 with patient and/or family member with E&M 90837 Psychotherapy, 60 60 90838 Psychotherapy, 60 60 with patient and/or family member with E&M 90839 Crisis psychotherapy (first 60 ) 60 90840 Crisis psychotherapy (each additional 30 ) 30 90846 Family therapy without patient 90847 Family therapy with patient IAPEC-0685-17 April 2017
Outpatient (cont.) 90849 Multi-family group counseling 90853 Group therapy 96372 Theralactic, prophylactic or diagnostic injection H0007 Alcohol and/or drug ; crisis intervention (outpatient and/or mobile) H0014 HG Alcohol and/or drug ; ambulatory detoxification H0037 Community psychiatric supportive treatment program (low intensity) H0037 TF Community psychiatric supportive treatment H0038 program (high intensity) Self-help/peer support: mental health per month H0038 HF Self-help/peer support: substance abuse (SA) per month H0040 Assertive community treatment H0049 Alcohol and/or drug Monthly per diem, per documents Monthly per diem, per documents screening S9123 Home health nursing One hour S9123 TF Psychiatric nursing visit One hour T1013 Interpreter 15 Q3014 GT Telemedicine 99408 Alcohol and/or SA structured screening and brief intervention ; 15-30 99409 Alcohol and/or SA structured screening and brief intervention ; greater than 30 99341 Home health nursing; Post-inpatient follow-up Per item Per item Page 2 of 6
Outpatient (cont.) 99510 U1 Mobile counseling, one hour 99510 Mobile counseling, single, family counseling 99510 TG Initial mobile counseling, follow-up S9485 TD Emergency nursing assessment One hour authorization if SA mental health (MH) diagnosis authorization if SA MH diagnosis authorization if SA MH diagnosis Intensive outpatient/partial hospitalization 0905 Intensive outpatient program (IOP), psychiatric 0906 IOP, SA/chemical dependency H0015 TG Intensive outpatient, SA with housing H0015 Intensive outpatient, SA H2012 Intensive outpatient day treatment, per hour One hour 0912 Partial hospitalization H0035 Partial hospitalization (MH, SA, eating disorder) Page 3 of 6
Applied behavioral analysis/behavioral health intervention (BHIS) G9012 HO/HP Case oversight and management of treatment team by licensed mental health professional or Board Certified Behavioral Analyst (BCBA), per 15 H0031 HO/HP Functional behavioral One hour assessment, per hour H2014 HO/HP/HN Skill development H2019 HO/HP/HN Skills training, child and adolescent H2019 HO/HP/HN Direct applied behavioral analysis, by a paraprofessional or BCBA provider, per 15 S5108 HO/HP/HN Home care training to home care client, per 15 H0032 HO/HP Functional behavioral 15 assessment, per 15 H2011 BHIS crisis intervention 15 H2014 HB Skill development, adult (individual > 21) H2014 HQ Skill development, adult (group > 21) H2019 HA Skill development, adult (individual < 21) H2019 HQ Skill development, adult (group < 21) H2019 HR Skills training, child and adolescent (family < 21) Page 4 of 6
Psychological testing 96101 Psychological testing with interpretation and report 96110 Developmental testing, limited 96111 Developmental testing, extended 96116 Neurobehavioral status examination 96118 Neuropsychological testing battery 96120 Neuropsychological testing administered by computer, after three units ER and inpatient 0450 ER MH and substance use (SU) 190 Inpatient psychiatric sub-acute 0762 23-hour observation 100, 114, 120, 124, 134, 144, 154, 204 116, 126, 136, 138, 146, 156, 204 118, 128, 138, bed Inpatient psychiatric (institutions of mental disease are allowed for members age 21 and under or 65 and older) 148, 158 901/90870 Electroconvulsive treatment Inpatient detoxification Inpatient SU treatment Page 5 of 6
Evaluation and management Procedure code Modifiers Service description Unit/event Authorization 99201-99205 New patient 99211-99215 Established patient 99217-99220 Observation 99221-99223 Hospital initial care 99231-99233 Hospital subsequent care 99234-99236 Hospital observation care 99238-99239 Hospital discharge 99251-99255 Inpatient consultation/evaluation 99281-99285 Emergency department Page 6 of 6