Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review 100 All inclusive room and board 0 101 All inclusive room and board 0 104 Anesthesia, ECT 0 114 Room and Board- private psychiatric 0 116 Room and Board- private room detoxification 0 118 Room and Board- private rehabilitation 0 120 Residential Treatment 0 124 Room and Board -semi private psychiatric 0 128 Room and Board - semi private rehabilitation 0 134 Room and Board - 3-4 bed psychiatric 0 136 Room and Board- 3-4 bed detoxification 0 138 Room and Board - 3-4 bed rehabilitation 0 144 Room and board private psychiatric 0 146 Room and board private- detoxification 0 154 Room and Board- ward psychiatric 0 156 Room and Board- detoxification ward 0 158 Room and Board- ward rehabilitation 0 180 leave of absence from residential 0 183 Therapeutic home time 0 190 Sub Acute Inpatient 0 204 Intensive Care -psychiatric 0 240 Intensive Care -psychiatric 0 PRO_14033E Internal Approved 07232018 NJ8PROLTR14033E_0000
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review 450 Emergency Room 451 Emergency Room 510 Clinic encounter all inclusive Facility 513 Psych clinic Facility 516 Urgent Care Clinic Facility 0 519 Other clinic- med supervised withdrawal Facility 0 520 Freestanding clinic Facility 521 Rural Clinic Facility 529 Other freestanding clinic Facility 900 BH treatment services 901 ECT- electroshock treatment 0 905 Intensive Outpatient - providers should be instructed to use proper code with 915 Facility 0 906 Intensive Outpatient - providers should be instructed to use proper code with 915 Facility 0 910 BH treatment services Facility 0 911 Substance abuse rehabilitation Facility 914 Psychiatric/Psychological Services- Individual therapy Facility 916 Psychiatric/Psychological Services- Family therapy Facility 917 Biofeedback 0 918 Testing Facility Off Psychological Testing 919 Other BH treatment services Facility Off Medication Monitoring
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review 944 Drug Rehabilitation 945 Alcohol Rehabilitation 1001 Behavioral Health Residential- psychiatric 0 1002 Detox - Docimillary (DASA) 0 90785 Interactive complexity add-on code MD, NP 26, SA, 2A 26, Psychiatric diagnostic evaluation (no MD,NP,PHD, LICENSE 90791 UC medical Services) MASTER CLINICIAN Intake and Assessment: Psychiatric 26, SA, 2A 26, Diagnostic Evaluation (with no medical 90791 UC, HF services) 26, SA, 2A 26, Psychiatric diagnostic evaluation with 90792 UC, HF medical services MD, NP 26, SA, UC, MD,NP,PHD, LICENSE 90832 HF Psychotherapy, 30 mins MASTER CLINICIAN At visit 21 30 min psychotherapy add on code when performed with E/M Service- (list MD,NP 90833 SA, UC, HF separately) 90834 26, SA, UC, HF 90836 SA, UC, HF Psychotherapy, 45 mins 45 minute psychotherapy add on code when performed with E/M Service (list separately) 90837 Psychotherapy, 60 mins MD,NP,PHD, LICENSE MASTER CLINICIAN At visit 21 MD,NP MD,NP,PHD, LICENSE MASTER CLINICIAN At visit 21
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review 60 min psychotherapy when performed MD,NP,PHD, LICENSE 90838 with E/M service (list separately MASTER CLINICIAN MD,NP,PHD, LICENSE 90839 Psychotherapy for crisis, first 60 min. MASTER CLINICIAN At visit 21 crisis code add on for each additional 30 MD,NP,PHD, LICENSE 90840 min. MASTER CLINICIAN MD,NP,PHD, LICENSE 90845 Psychoanalysis MASTER CLINICIAN Family Psychotherapy, without patient PHD, LICENSED 90846 present MASTER CLINICIAN At visit 21 PHD, LICENSED 90847 UC, HF Family Psychotherapy, 45 min MASTER CLINICIAN At visit 21 PHD, LICENSED 90849 Multiple-family group psychotherapy MASTER CLINICIAN At visit 21 At visit 21 PHD, LICENSED 90 min & up to 12 people in substance abuse MASTER CLINICIAN 90853 SA, UC, HF Group psychotherapy facility 90863 Pharmacologic management, add on code MD,NP 90865 Narcosynthesis 90867 Therapeutic Repetitive Transcranial (TMS) 0 90868 Therapeutic Repetitive Transcranial (TMS) 0 90869 Therapeutic Repetitive Transcranial (TMS) 0
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review 90870 Electroconvulsive Therapy 0 Ind psycho therapy incorporating bio MD 90875 feedback 30 min Ind psycho therapy incorporating bio MD 90876 feedback 45 min 90880 Hypnotherapy MD 0 90882 Complex care management 90885 Psych eval of hospital records MD Interpretation or explan of results of psych MD, NP, PHD, At visit 21 exam and procedures Outpatient LICENSED MASTER Group Therapy- 20 min; Family conference (25 90887 UC, SA, HF Collateral, 15 min. CLINICIAN min) 90889 Prep of report of pt psych status MD 0 90899 Unlisted Psychiatric procedure 0 96001 comp.comput.motion analysis 96020 Functional brain mapping 96101 Psychological testing after 5 Hours 96102 Psychological testing after 5 Hours 96103 Psychological testing after 5 Hours 96105 Assessment of Aphasia of speech/lang 0 96110 Developmental screening with interp 96111 Developmental testing after 5 Hours 96116 Neurobehavioral status exam w clin assess after 5 Hours 96118 Neuropsychological Testing per hour after 5 Hours 96119 Neuropsych Testing Admin by Technician per hour after 5 Hours
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review Neuropsych Testing Admin by Computer 96120 per occurrence after 5 Hours 96125 Standardized cognitive perf testing after 5 Hours 96127 Brief emotional needs assessment 96150 Nursing Assessment and Care-Initial Nursing Assessment and Care-Re- 96151 Assessment 96152 H&B individual intervention 96153 H&B group intervention Health & Behavior Intervention with 96154 patient present Health & Behavior Intervention without 96155 patient present Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized 96160 instrument 96161 Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument 96372 Medication administration 97537 Community integration counseling 0
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review 99051 Services rendered after hours 99058 Office Emergency Services 99201 HF New Patient Office Visit Level 1 MD,NP 99202 HF New Patient Office Visit Level 2 MD,NP 99203 New Patient Office Visit Level 3 MD,NP 99204 New Patient Office Visit Level 4 MD,NP 99205 New Patient Office Visit Level 5 MD,NP 99211 HF Est Patient Office Visit Level 1 MD,NP 99212 Est Patient Office Visit Level 2 MD,NP 99213 Est Patient Office Visit Level 3 MD,NP 99214 Est Patient Office Visit Level 4 MD,NP 99215 Est Patient Office Visit Level 5 MD,NP Initial Hospital Care-comprehensive; low 99221 complexity MD,NP Initial Hospital Care-comprehensive; 99222 moderate complexity MD,NP Initial Hospital Care-comprehensive; high 99223 complexity MD,NP 99224 Subsequent observation Care 99225 Subsequent observation Care 99226 Subsequent observation Care Subsequent Hospital Care-focused; low 99231 complexity MD,NP Subsequent Hospital Care-focused; 99232 moderate complexity MD,NP
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review Subsequent Hospital Care-focused; high 99233 complexity MD,NP Observation-comprehensive; low 99234 complexity MD,NP Observation-comprehensive; moderate 99235 complexity MD,NP Observation-comprehensive; high 99236 complexity MD,NP 99238 Discharge Day Management- 30 min or less MD,NP Discharge Day Management-more than 30 99239 min MD,NP 99241 Problem focused; straightforward-15 min 99242 Expanded; straightforward-30 min 99243 Detailed; low complexity-40 min 99244 Comprehensive; moderate complexity-60 min 99245 Comprehensive; high complexity-80 min 99251 Initial Consultation-focused, straightforward MD,NP 99252 Initial Consultation-expanded, straightforward MD,NP 99253 Initial Consultation-detailed, low complexity MD,NP
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review Initial Consultation-comprehensive, 99254 moderate complexity MD,NP Initial Consultation-comprehensive, high 99255 complexity MD,NP 99281 ER Consultation-focused, straightforward MD,NP 99282 ER Consultation-expanded; low complexity MD,NP 99283 ER Consultation-expanded; moderate complexity MD,NP 99284 ER Consultation-detailed; moderate complexity MD,NP 99285 ER Consultation-comprehensive; high complexity MD,NP 99304 Nursing facility consultation 25 min 99305 Nursing facility consultation 35 min 99306 Nursing facility consultation 45 min 99307 Evaluation Management nursing facility 10 min 99308 Evaluation Management nursing facility 15 min 99309 Evaluation Management nursing facility 25 min 99310 Evaluation Management nursing facility 35 min 99341 Home visit, new patient
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review 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 99350 Home visit, est patient Prolonged evaluation and mgmt psycho 99354 therapy svs Prolonged evaluation and mgmt psycho 99355 therapy svs 99366 Medical team conference 99367 Medical team conference with family 99368 Medical team conference without family MD,NP, PHD,MASTER 99401 Preventive counseling, individual LICENSED CLINICIAN 99402 Preventive counseling, individual 30 min 99403 Preventive counseling, individual 45 min MD,NP, PHD,MASTER 99404 Preventive counseling, individual LICENSED CLINICIAN 99406 Smoking cessation 99407 Smoking cessation Alcohol substance abuse BH change 99408 intervention
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review Alcohol and substance abuse screening and 99409 brief intervention 99411 Preventive counseling, individual 60 min Preventive medicine group counseling- 60 99412 min 99510 Home visit, single, family counseling 0359T Behavior Identification Assessment (ABA) 0 Observational Behavioral Follow-up 0360T & 0361T Assessment 0 0362T, 0363T Exposure Behavioral Follow-up Assessment 0 0364T, 0365T Adaptive Behavior Treatment By Protocol 0 0366T Group adaptive behavior treatment by protocol, In-Clinic 0 0367T Group adaptive behavior treatment by protocol, Additional 30 mins 0 0368T & 0369T Adaptive Behavior Treatment With Protocol Modification 0 0370T Family Adaptive Behavior Treatment Guidance 0 0371T Multiple-family group adaptive behavior treatment guidance, In-Clinic 0 0372T Adaptive behavior treatment social skills group, In-Clinic 0
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review Exposure adaptive behavior treatment with 0373T protocol modification, In-Clinic 0 Exposure adaptive behavior treatment with protocol modification Additional 30 mins, 0374T In-Clinic 0 Community behavioral program (day 907, H2012 treatment) 0 915 and G0410, G0411, or H0035 Partial Hospitalization 0 915, H0015 BH intensive outpatient substance abuse 0 915, S9480 BH intensive outpatient psychiatric 0 Recreation, related to the care and treatment of patients disabling mental health problems; per session (45 minutes G0176 or more) G0177 G0396 Training and educational services related to the care and treatment of patients disabling mental health problems per session (45 minutes or more) Alcohol/subs interv 15-30mn
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review G0397 Alcohol/subs interv >30 min Social work and psychological services, directly relating to and/or furthering the G0409 patient s rehabilitation goals Interactive group psychotherapy, in a partial hospitalization setting, G0410 approximately 45 to 50 minutes 0 Interactive group psychotherapy, in a partial hospitalization setting, G0411 approximately 45 to 50 minutes 0 G0436 Tobacco-use counsel 3-10 min G0437 Tobacco-use counsel>10min G0442 Annual alcohol misuse screening 15 min Alcohol mis use and screening -various markets; Iowa=face to face BH counseling- G0443 15 min G0444 Depression Screening G0445 High intensity BH counseling 30 min G0446 Intensive BH therapy G0447 Face to face behavioral counseling-15 min G0451 Developmental testing with I & R G0463 Hospital outpatient clinic visit
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review G0473 Face to face behavioral counseling 15 min H0001 Alcohol and/or drug assessment Behavioral Health Screen to determine eligibility for admission to treatment H0002 program Alcohol and/or drug screening; laboratory analysis of specimens for presence of H0003 HF alcohol or drugs Behavioral health counseling and therapy; H0004 per 15 minutes Alcohol and/or drug services; group H0005 counseling by a clinician H0006 Alcohol and/or drug services; case management H0007 Alcohol and/or drug services; crisis intervention (outpatient) H0008 Alcohol and/or drug services; sub acute detoxification (outpatient) 0 H0009 Alcohol and/or drug services; acute detoxification (hospital inpatient) 0.
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review Alcohol and/or drug services; sub-acute Med Nec Criteria = SUD - Residential (covered detoxification (residential addiction Medicaid recipients aged 21 and younger and 65 H0010 HF program inpatient) and older) Alcohol and/or drug services; acute detoxification (residential addiction H0011 program inpatient) 0 Alcohol and/or drug services; sub-acute detoxification (residential addiction H0012 program outpatient) 0 H0013 Alcohol and/or drug services; acute 0 Alcohol and/or drug services; ambulatory H0014 detoxification 0 H0015 H0016 H0017 HF HF 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 0 Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory setting) 0 Behavioral health; residential (hospital residential treatment program), without room and board; per diem 0
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review REQUIREMENT CODE MODIFIER LEVEL OF CARE PROVIDER TYPE Behavioral health; short-term residential (non hospital residential treatment program), without room and board; per H0018 HF diem Behavioral health; long term residential (non-medical, non-acute care in a U1, U1 52, residential treatment program where stay U2, U3, U3 is typically longer than 30 days), without H0019 52, U5 room and board; per diem Alcohol and/or drug services; methadone administration and/or service (provisions of the drug by a licensed program) Med Nec Criteria = SUD - Residential (covered Medicaid recipients aged 21 and younger and 65 and older) Group home, currently no MN criteria, managed by market for LTSS only. Opioid treatement methadone - wkly bundled rate & methadone medication/dispensing (per diem) H0020 HF, HF 26 H0021 U1, U1 52, U2, U3, U3 52, U5 Alcohol and Drug training service for staff Alcohol and/or drug intervention service H0022 HF, HF 26 (planned facilitation) H0023 Behavioral health outreach service Behavioral health prevention information dissemination service (one way direct or non-direct contact with service audiences H0024 to affect knowledge and attitude); 15 minutes
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review Behavioral health prevention education service (delivered of services with target population to affect knowledge, attitude H0025 and/or behavior); 15 minutes Alcohol and/or drug intervention service H0026 (planned facilitation) H0027 Alcohol and drug prevention service H0028 Alcohol and/or drug prevention problem identification and referral service Alcohol and/or drug prevention alternatives service (services for H0029 populations that exclude alcohol and other drug use e.g. alcohol free social events) H0030 Behavioral health hotline service Mental health assessment, by nonphysician H0031 Mental health service plan development by H0032 non-physician **opioid treatment non-methadone - weekly Oral medication administration, direct bundled rate; AND **non-methadone H0033 HF, HF 26 observation Off medication/dispensing (per diem) Medication training and support; per 15 H0034 minutes
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review REQUIREMENT CODE MODIFIER LEVEL OF CARE PROVIDER TYPE Mental health partial hospitalization, H0035 HF, HF 26 treatment, less than 24 hours H0036 H0037 H0038 H0039 HQ 52, 52, HQ, HM, HM Community psychiatric supportive HQ treatment, face to face Community psychiatric supportive treatment program; per diem HQ 52, 52, HQ, HM, HM HQ HN HQ, HN, HQ TE, TE Self-help/peer services; per 15 minutes Assertive Community Treatment; per 15 min Partial Care (Per Hour; Max of 5 hours/day). 2 yr Associate degree group (15 min unit) & HS, peer group/indiv (15 min unit) 0 Bachelor group (15 min unit) & LPN individual (15 min unit) H0040 22 Assertive Community Treatment; per diem Monthly rate; 2 hrs per month HN HQ, HN, H0041 HQ TE, TE Foster Care child, non therapeutic per diem H0042 22 Foster Care child, non therapeutic per month H0043 Supported housing; per diem H0044 Supported housing; per month Respite care services, not in the home; per H0045 diem H0046 Mental Health Services NOS
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review Alcohol and drug services not otherwise H0047 specified 0 Alcohol and/or other drug testing: collection and handling only, specimens H0048 other than blood H0049 Alcohol and/or drug Screening Alcohol and/or Drug Service, Brief H0050 Intervention; per 15 minutes H1000 Prenatal care, at-risk assessment Prenatal care, at-risk enhanced service; H1001 antepartum management Prenatal care, at risk enhanced service; H1002 care coordination Prenatal care, at-risk enhanced service; H1003 education Prenatal care, at-risk enhanced service; H1004 follow-up home visit Prenatal care, at-risk enhanced service H1005 package (includes H1001-H Non-medical family planning education; H1010 per session Family assessment by licensed behavioral health professional for state defined H1011 purposes
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review H2000 HE Comprehensive multidisciplinary evaluation APN individual, physician individual (15 min unit) H2001 Rehab program 1/2 day H2010 Comprehensive medication services; per 15 H2011 Crisis Intervention Services; per 15 Minutes. H2012 HE Behavioral health day treatment; per hour 0 H2013 H2014 H2015 He, HE HO, HE TD Psychiatric health facility service per diem Skills training and development; per 15 minutes Comprehensive community support services; per 15 minutes 0.. Master's, licensed professional of the healing arts indvidual, RN, psychologist
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review H2016 H2017 H2018 H2019 H2020 H2021 He, HE HO, HE TD Comprehensive community support services; per diem Psychosocial rehabilitation services; per 15 minutes Psychosocial rehabilitation services; per diem Therapeutic behavioral services; per 15 minutes Therapeutic behavioral services; per diem In NE Therapeutic group home Community-based wrap-around services; per 15 min. 0. Community-based wrap-around services; H2022 per diem (intensive in-home services) 0 H2023 Supported employment; per 15 minutes H2024 Supported employment; per diem going support to maintain employment; H2025 per 15 minutes going support to maintain employment; H2026 per diem
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review H2027 See Notes - per 15 minutes Off Use MN Criteria for Psych Education Sexual offender treatment service, per 15 H2028 minutes H2029 Sex Offend Tx Svc, Per Diem 0 H2030 Clubhouse services ; per 15 min FACILITY;CMHC H2031 Clubhouse services; per diem H2032 Activity Therapy Multi-systemic Therapy for Juveniles; per H2033 15 minutes 0 Alcohol and/or drug abuse halfway house H2034 services; per diem H2035 H2036 Alcohol and/or drug treatment program; per hour Alcohol and/or other drug treatment program; per diem.. SUD: Partial care treatment in substance abuse facility (per diem)
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review H2037 Developmental delay prevention activities, dependent child of client, per 15 minutes 0 Brief Office Visit for the Sole Purpose of Monitoring or Changing Drug Prescriptions M0064 Used in the Treatment of Mental Psychoneurotic and Personality Disorders Q3014 Telehealth original site facility S0109 Methadone, oral, 5mg Alcohol and/or drug treatment program; S0201 per hour 0 Home care training to home care client, per S5108 15 minutes 0 S5110 Home care training, family; per 15 minutes 0 S5145 Behavioral health specialized foster care 0 S5150 Unskilled respite care, not hospice; per 15 minutes 0 S9110 In home telemonitoring S9123 In home psychiatric nursing 0 S9475 Ambulatory setting substance abuse treatment or detoxification services; per diem 0
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review Intensive outpatient psychiatric services; per diem; in IL use 913 in combination with S9480 this code 0 Family stabilization services; per 15 S9482 minutes 0 S9484 Crisis intervention mental health services; per hour S9485 Crisis intervention mental health services; per diem T1001 Nursing Assessment/ Evaluation 0 T1002 RN services up to 15 minutes T1003 LPN/ LVN services up to 15 minutes 0 T1005 Respite care services, up to 15 minutes Alcohol and/or substance abuse services, T1006 family/couple counseling Alcohol and/or substance abuse services, treatment plan development and/or T1007 modification Alcohol and/or substance abuse services, T1012 skills development Sign language or oral interpretive services; T1013 per 15 minutes T1014 Telehealth telemedicine
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review T1015 Clinic encounter all inclusive T1016 Case management, each 15 minutes Targeted Case Management with PATH Targeted case management, each 15 Homelessness Transition and Justice Services (15 T1017 52 minutes min) T1019 Personal care services; per 15 minutes 0 T1020 Personal care services; per diem 0 Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol; T1023 per encounter T1024 52 Team evaluation & management T1027 Family training & counseling T1502 Psychotropic Medication Administration Non emergency transportation; patient T2001 attendant/escort 0 T2002 T2003 T2004 Non-emergency transportation; per diem Non-emergency transportation; encounter/trip Non-emergency transport; commercial carrier, multi-pass 0 0 0 T2005 Non-emergency transportation; stretch van 0
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review Preadmission screening and resident review (pasrr) level i identification T2010 screening; per screen Preadmission screening and resident T2011 review level ii evaluation; per evaluation T2012 Children s Day Treatment T2014 Pre-vocational Services - per diem T2015 Pre-Vocational Services - per hour T2017 Community integration counseling T2018 Supported Employment Job Development T2019 Supported Employment T2020 Day Habiliitation T2021 Pre admission PASSR assessment T2022 Other specified case management service not elsewhere classified 0 T2023 Targeted Case Management- per month 0 T2024 Service Assessment Plan of Care Dev T2025 Waiver Services; Not Otherwise Specified (NOS) T2027 Specialized childcare, waiver; per 15 minutes 0 T2033 Psychiatric residential treatment facilityper diem 0
Auth Required Key: = Authorization Required for Medical Necessity review; Off= No Authorization Required; Auto-Approve = Provider calls Intake for auto-approval but no medical necessity review Therapeutic camping, overnight, waiver; T2036 each session 0 Therapeutic camping, day, waiver; each T2037 session 0 Behavioral health; long-term care residential (non-acute care in a residential treatment program community based per T2048 diem 0