Assessment/Intake Codes: 90791-90792 GT; DJ; TK +90875 (Interactive complexity add-on code) Medicaid Adult Mental Health (MH) Services 4 visits per year per consumer. 1 unit per episode Prior authorization is required. Visits do not count against unmanaged limits. Diagnostic Assessment: T1023 T1023 (GT) E/M Assessment Codes: 99201-99205 (GT) E/M Established Patient Codes: 99211-99215 (GT) Electroconvulsive Therapy (ECT): 90870 Family Therapy Codes: 90846-90847 4 visits per year per consumer. Prior authorization is required. Visits do not count against unmanaged limits. E/M Codes have unlimited benefits. No prior approval or authorization is required. E/M Codes have unlimited benefits. No prior approval or authorization is required. AMA CPT Manual AMA CPT Manual Preauthorized by MCO MD AMA CPT Manual 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 Completion of Electroconvulsive Therapy (ECT) Checklist Initial: Tx Plan/ PCP and service order (valid for 1 year) Concurrent: Clinical information to justify medical necessity; new TX Plan /PCP annually. Page 1 of 9
Medicaid Adult Mental Health (MH) Services Group Therapy Codes: 90849; 90853 26 unmanaged outpatient visits per year. Authorization is required once unmanaged visits are exhausted. Concurrent: group therapy requests (after the unmanaged visits) will be no more than 20 visits per 90 days. 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. Outpatient Consultation Codes: 99241-99245 Limit of 4 visits per year; does not count against unmanaged visits. LOCUS/CALOCUS: 1 ASAM: 1 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 Psychological Testing: 96101; 96110; 96111; 96116; 96118; 96125 Trauma Focused-CBT: 90837ZI 90846ZI 90847ZI 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). 1 episode of testing per year with a limit of 8 hours for all codes. Counts as part of unmanaged visits. Prior authorization required Initial: 13 units per 90 days Concurrent: 13 units per 90 days 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. NA Psychological Testing Request Form is also the Service order. * Initial: Tx Plan/ PCP and service order (valid for 1 year) Concurrent: Clinical information to justify medical necessity; new Tx Plan/ PCP annually. Page 2 of 9
Medicaid Adult Mental Health (MH) Services Trauma Intensive Comprehensive Clinical Assessment (TICCA): Prior authorization required Up to 10 hours of assessment for a 3-month * Clinical information to justify medical necessity. 90791TI duration by Specialty Contract only. Does not count against unmanaged visits. Therapeutic Injection: 96372-96375 Up to 52 units per year; does not require authorization. AMA CPT Manual Assertive Community Treatment Team: H0040(DJ) Community Support Team: H2015HT(DJ) Critical Time Intervention (CTI): H0032U5 (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. Concurrent: 24 units per 6 months Initial: Up to 128 units per 60 days Concurrent: Up to 128 units per 60 days Pre-CTI: 12 units Phase I: 12 units weekly; 155 units per 3 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. LOCUS: 2-4 LOCUS: 1-4 -1 Initial: CCA, PCP and CCP, Service order Concurrent: Updated PCP 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. * Pre-CTI: Notification SAR only Phase I: CCA; phase plan and Service order. Authorization request for 104 units for three months. Phase II/III: Updated phase plan and authorization request for 156 units for six months. Page 3 of 9
Medicaid Adult Mental Health (MH) Services Mobile Crisis Management: H2011 32 units (8hours) per 24-hours unmanaged Crisis Plan after 32 units per 24- hour period. Partial Hospitalization: H0035(DJ) 0912; 0913(Inpatient Codes) Initial: 7-day Concurrent: 7 days LOCUS/CALOCUS: 4-5 Initial: SAR with justification on day of admission; PCP, CCP Service order w/in two business days of admission. Concurrent: Clinical updates Psychosocial Rehabilitation: 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. LOCUS: 2-5 w/progress notes. Initial: CCA, PCP, CCP, Service order Concurrent: Updated PCP Page 4 of 9
ADATC: 0126- Acute 0128-Rehabilitation Medicaid Adult Substance Use (SU) Services Initial: Up to 5 days Concurrent: Based on medical necessity; no more than 30 days total for both codes. Ambulatory Detox: H0014 Facility Based Crisis (FBC): S9484 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 Initial: Pass-through of 7 days. One day equals 16 hours. Concurrent: Limited to 8 days (128) units. Annual limit is 30 days from first date of admission. CALOCUS: 5-6 ASAM: 3.7 Acute ASAM: 3.5 Nonacute LOCUS: 4 ASAM: Level I-WM CA ASAM: 3.5-2 Initial: Prior Approval by Regional Referral Form, Live Review or Initial Inpatient Review Form. Concurrent: Inpatient Continuing Care Form. 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) Initial: Pass-through- Service order on file. Concurrent: Service order and clinical information to support medical necessity. Page 5 of 9
Non-Hospital Medical Detox: H0010 Medicaid Adult Substance Use (SU) Services Initial: Pass-Through of 3 days LOCUS: 5 Concurrent: Up to 7 days ASAM: 3.7 WM Outpatient Opioid Treatment: H0020 Substance Abuse Comprehensive Outpatient Treatment Program (SACOT): H2035 Substance Abuse Intensive Outpatient (SAIOP): H0015 Initial: 60 days Concurrent: 90 days 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 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: 2 ASAM: OTP ASAM: 2.5 ASAM: 2.1 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) Initial: Tx Plan, Service order Concurrent: Updated TX Plan w/each request Initial: PCP and CCP, Service order on file Concurrent: First requestsubmit above with updated PCP w/each additional request. Initial: PCP and CCP, Service order on file Concurrent: First requestsubmit above with updated PCP w/each additional request. Substance Abuse Medically Monitored Community Residential Treatment: H0013 Initial: Up to 10 days Concurrent: Up to 10 days; no more than 30 days per 12 months. ASAM: 3.7 Initial: PCP, CCP, Service order Concurrent: Updated PCP w/each request. Page 6 of 9
Substance Abuse Non-Medically Monitored Community Residential Treatment: H0012 Medicaid Adult Substance Use (SU) Services Initial: Up to 10 days LOCUS: 5 Concurrent: Up to 10 days; no more than 30 ASAM: 3.7 WM days per 12 months. Initial: PCP and CCP, Service order Concurrent: Updated PCP w/each request. NOTES * Indicates Partners In Lieu of Service Definition or Alternative Payment Agreement 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. Page 7 of 9
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 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 Attached to an Outpatient Code and refers to Treatment Alternative for Sexualized Kids (TASK) 90791TK TL Therapeutic Leave U4 Designates B-3 services U5 In-Lieu of Service Definition ZI Added to Outpatient Codes to designate Trauma Focused Cognitive Behavioral Therapy 90837ZI; 90846ZI; 90847ZI Designates Family Centered Treatment (FCT) Engagement and Transition from Core Phases Page 8 of 9
Medicaid Benefit Plan Revision Information Date of Change Service and Section Revised Actual Change 7/7/2017 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 Page 9 of 9