Transcription of MAGELLAN VA MEDICAID/DMAS
1 EFFECTIVE: 7/1/2017 CPT CODE Age or SettingModifierPHYSICIAN PSYCHOLOGISTMASTER'S LEVELCLINICAL NURSE SPECIALIST90791 IPw/ or w/o GT$ $ $ $ or w/o GT$ $ $ $ or w/o GT$ $ $ $ or w/o GT$ $ $ $ or w/o GT$ $ $ $ or w/o GT$ $ $ $ or w/o GT$ $ $ $ or w/o GT$ $ $ $ or w/o GT$ $ $ $ or w/o GT$ $ $ $ or w/o GT$ $ $ $ or w/o GT$ $ $ $ or w/o GT$ $ $ $ or w/o GT$ $ $ $ +90785$ $ $ $ or w/o GT$ $ or w/o GT$ $ +90833 IPw/ or w/o GT$ $ +90833 OPw/ or w/o GT$ $ +90836 IPw/ or w/o GT$ $ +90836 OPw/ or w/o GT$ $ +90838 IPw/ or w/o GT$ $ +90838 OPw/ or w/o GT$ $ $ $ or HK, GT$ or TS, GT$ <21/IPw/ or w/o GT$ $ <21/OPw/ or w/o GT$ $ >20/IPw/ or w/o GT$ $ >20/OPw/ or w/o GT$ $ <21/IPw/ or w/o GT$ $ <21/OPw/ or w/o GT$ $ >20/IPw/ or w/o GT$ $ >20/OPw/ or w/o GT$ $ <21/IPw/ or w/o GT$ $ <21/OPw/ or w/o GT$ $ >20/IPw/ or w/o GT$ $ >20/OPw/ or w/o GT$ $ <21/IPw/ or w/o GT$ $ <21/OPw/ or w/o GT$ $ >20/IPw/ or w/o GT$ $ >20/OPw/ or w/o GT$ $ <21/IPw/ or w/o GT$ $ <21/OPw/ or w/o GT$ $ >20/IPw/ or w/o GT$ $ >20/OPw/ or w/o GT$ $ <21/IPw/ or w/o GT$ $ <21/OPw/ or w/o GT$ $ >20/IPw/ or w/o GT$ $ >20/OPw/ or w/o GT$ $ <21/IPw/ or w/o GT$ $ <21/OPw/ or w/o GT$ $ >20/IPw/ or w/o GT$ $ >20/OPw/ or w/o GT$ $ <21/IPw/ or w/o GT$ $ <21/OPw/ or w/o GT$ $ >20/IPw/ or w/o GT$ $ >20/OPw/ or w/o GT$ $ <21/IPw/ or w/o GT$ $ <21/OPw/ or w/o GT$ $ Outpatient Visit, Established patient, minor*Office Outpatient Visit, Established patient, minimal*Office Outpatient Visit, Estbl patient, low to moderate severity*Psychotherapy w/ patient, 30 min*Psychotherapy w/ patient.
2 60 min, w/ E&M svc*Electroconvulsive Therapy ( )Group Psychotherapy*Office Outpatient Visit, Established patient, minimal*Office Outpatient Visit, Established patient, minor*Psychiatric Diagnostic Evaluation no medical svcs*Psychotherapy w/ patient, 45 min, w/ E&M svc*Electroconvulsive Therapy ( )Family/Couples Psychotherapy w/ patient present, 50 min*Family/Couples Psychotherapy w/o patient present, 50 min*Office Outpatient Visit, New patient, moderate severity*Office Outpatient Visit, New patient, moderate to high severity*Family/Couples Psychotherapy w/o patient present, 50 min*Office Outpatient Visit, New patient, moderate to high severity*Office Outpatient Visit, New patient, moderate to high severity*Psychotherapy w/ patient, 45 min, w/ E&M svc*Office Outpatient Visit, Estbl patient, moderate to high severity*Office Outpatient Visit, New patient, moderate severity* MAGELLAN VA MEDICAID/DMAS RATESI nteractive Complexity Add onFamily/Couples Psychotherapy w/ patient present, 50 min*Office Outpatient Visit, Established patient, minor*Psychotherapy w/ patient, 30 min, w/ E&M svc* Group Psychotherapy*Office Outpatient Visit, New patient, minor*Office Outpatient Visit, New patient, minor*Office Outpatient Visit, New patient.
3 Low to moderate severity*Psychiatric Diagnostic Evaluation w/ medical svcs*Office Outpatient Visit, New patient, minor*Office Outpatient Visit, New patient, minor*Office Outpatient Visit, New patient, low to moderate severity*Psychotherapy w/ patient, 60 min, w/ E&M svc*Office Outpatient Visit, New patient, moderate to high severity*Office Outpatient Visit, New patient, moderate to high severity*Psychiatric Diagnostic Evaluation no medical svcs*Psychotherapy w/ patient, 30 min*Psychotherapy w/ patient, 45 min*DESCRIPTIONO ffice Outpatient Visit, New patient, moderate to high severity*Office Outpatient Visit, New patient, moderate to high severity*Office Outpatient Visit, Estbl patient, moderate to high severity*Office Outpatient Visit, New patient, low to moderate severity*Office Outpatient Visit, New patient, moderate severity*Office Outpatient Visit, Estbl patient, low to moderate severity*Office Outpatient Visit, Established patient, minimal*Office Outpatient Visit, Established patient, minor*Psychotherapy w/ patient, 45 min*Psychotherapy w/ patient, 60 min*Psychiatric Diagnostic Evaluation w/ medical svcs*Psychotherapy w/ patient, 30 min, w/ E&M svc*IACCT Initial Assessment*IACCT Follow Up Assessment*Office Outpatient Visit, Estbl patient, low to moderate severity*Office Outpatient Visit, Estbl patient, low to moderate severity*Office Outpatient Visit, Established patient, minimal*Psychotherapy w/ patient, 60 min*Office Outpatient Visit, New patient, moderate to high severity*Office Outpatient Visit, New patient, low to moderate severity*Office Outpatient Visit, New patient, moderate severity*Version: 10/1/2017 Effective: 7/1/2017 Page 1 of 7VA DMAS official fee schedules can be found at: EFFECTIVE.
4 7/1/2017 MAGELLAN VA MEDICAID/DMAS RATESCPT CODE Age or SettingModifierPHYSICIAN PSYCHOLOGISTMASTER'S LEVELCLINICAL NURSE SPECIALIST99214>20/IPw/ or w/o GT$ $ >20/OPw/ or w/o GT$ $ <21/IPw/ or w/o GT$ $ <21/OPw/ or w/o GT$ $ >20/IPw/ or w/o GT$ $ >20/OPw/ or w/o GT$ $ <21$ >20$ <21$ >20$ <21$ >20$ <21$ >20$ <21w/ or w/o GT$ >20w/ or w/o GT$ <21w/ or w/o GT$ >20w/ or w/o GT$ <21w/ or w/o GT$ >20w/ or w/o GT$ <21w/ or w/o GT$ $ >20w/ or w/o GT$ $ <21w/ or w/o GT$ $ >20w/ or w/o GT$ $ <21w/ or w/o GT$ $ >20w/ or w/o GT$ $ <21$ >20$ <21$ >20$ <21$ >20$ <21$ >20$ <21$ >20$ $ $ $ $ $ $ $ $ $ $ +99354<21/IP$ $ $ $ +99354<21/OP$ $ $ $ +99354>20/IP$ $ $ $ +99354>20/OP$ $ $ $ +99355<21/IP$ $ $ $ +99355<21/OP$ $ $ $ +99355>20/IP$ $ $ $ +99355>20/OP$ $ $ $ +99356<21$ $ $ $ +99356>20$ $ $ $ +99357<21$ $ $ $ +99357>20$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ <21/IP$ $ $ $ <21/OP$ $ $ $ >20/IP$ $ $ $ Hospital Care, low complexity*Observation or Inpatient Care, moderate complexityOffice Outpatient Visit, Estbl patient, moderate to high severity*Initial Hospital Care, high complexity*Initial Hospital Care, high complexity*Initial Observation Care; high complexityDischarge Day management 30 min or lessObservation or Inpatient Care, high complexityObservation or Inpatient Care, moderate complexityOffice Outpatient Visit, Estbl patient, moderate to high severity*Subsequent Hospital Care, moderate complexity*Observation or Inpatient Care, low complexitySubsequent Hospital Care, high complexity*Observation Care DischargeInitial Hospital Care, moderate complexity*Initial Hospital Care, low complexity*Prolonged Service, in office or outpatient setting; addtl 30 min Discharge Day management 30 min or lessDischarge Day management more than 30 minSubsequent Hospital Care, low complexity*Discharge Day management more than 30 minSubsequent Hospital Care, moderate complexity*Initial Observation Care.
5 Straightforward/low complexityER Consultation, high complexity/life threateningSmoking and tobacco cessation counseling; > 10 minInitial Hospital Care, moderate complexity*Subsequent Hospital Care, low complexity*Initial Observation Care; high complexityInitial Observation Care; moderate complexitySubsequent Hospital Care, high complexity*Observation or Inpatient Care, low complexityAlcohol/SA structured screening and brief intervention 15 30 minAlcohol/SA structured screening and brief intervention 15 30 minER Consultation, low to moderate complexityER Consultation, minorER Consultation, high complexityER Consultation, moderate complexityObservation or Inpatient Care, high complexityOffice Emergency ServicesProlonged Service, in inpatient or observation setting; 60 min Prolonged Service, in inpatient or observation setting; addtl 30 min Smoking and tobacco cessation counseling; 3 to 10 minSmoking and tobacco cessation counseling; > 10 minSmoking and tobacco cessation counseling; 3 to 10 minProlonged Service, in office or outpatient setting; 60 min Prolonged Service, in office or outpatient setting; 60 min Prolonged Service, in office or outpatient setting; addtl 30 min Prolonged Service, in office or outpatient setting; addtl 30 min Prolonged Service, in office or outpatient setting; 60 min Alcohol/SA structured screening and brief intervention 15 30 minProlonged Service, in inpatient or observation setting; addtl 30 min Prolonged Service, in inpatient or observation setting; 60 min Prolonged Service, in office or outpatient setting; addtl 30 min Initial Observation Care; moderate complexityOffice Outpatient Visit, Estbl patient, moderate to high severity*Office Outpatient Visit, Estbl patient, moderate to high severity*Prolonged Service, in office or outpatient setting; 60 min Observation Care DischargeInitial Observation Care.
6 Straightforward/low complexityOffice Outpatient Visit, Estbl patient, moderate to high severity*Office Outpatient Visit, Estbl patient, moderate to high severity*DESCRIPTIONV ersion: 10/1/2017 Effective: 7/1/2017 Page 2 of 7VA DMAS official fee schedules can be found at: EFFECTIVE: 7/1/2017 MAGELLAN VA MEDICAID/DMAS RATESCPT CODE Age or SettingModifierPHYSICIAN PSYCHOLOGISTMASTER'S LEVELCLINICAL NURSE SPECIALIST99408>20/OP$ $ $ $ <21/IP$ $ $ $ <21/OP$ $ $ $ >20/IP$ $ $ $ >20/OP$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ or w/o GT$ $ or w/o GT$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ CODED esignationRATEH2027$ <21$ <21$ <21$ <21$ $ $ $ $ $ $ $ $ <21$ >20$ <21$ <21$ <21$ <21$ $ SMI Assessment for Eligibility Determination Short Form*H0032$ SMI Assessment for Eligibility Determination Long Form*H0032$ $ $ $ $ $ or w/o GTAssessment, Therapeutic Day Treatment for Adults*Therapeutic Day Treatment, Child per unit 1 unit = 2 to hours 2 units = 3 to hours 3 units = 5 plus hoursDESCRIPTIONOne on one Support in Residential per hourCmnty Based Residential Group Home, Level A Per DiemU9 or U9.
7 GTAlcohol/SA structured screening and brief intervention > 30 minNeurobehavioral Status Exam*Neuropsychological Testing Admin by ComputerNeuropsychological Testing Admin by TechnicianAlcohol/SA structured screening and brief intervention 15 30 minAlcohol/SA structured screening and brief intervention > 30 minHBHADay Treatment, Adult per unit 1 unit 2 hours 2 units 4 hours 3 units 7 or more hoursIntensive In Home AssessmentAssessment, Intensive Community Treatment*Intensive Community Treatment per hourIntensive In Home Services, per hourIn Home Behavioral Therapies for juveniles, per 15 min Assessment, Intensive Community Treatment*Intensive Community Treatment per hourAssessment, Psychosocial Rehab*Therapeutic, prophylactic, or diagnostic injectionPsychological Testing Admin by TechnicianDESCRIPTIONP sychological TestingTherapeutic or Diagnostic Injection; Intravenous PushNeurobehavioral Status Exam*Psychological Testing Admin by ComputerPsychological Testing Admin by TechnicianPsychosocial Rehabilitation svcs.
8 Per unit 1 unit 2 hours 2 units 4 hours 3 units 7 or more hoursHW (CSA)Alcohol/SA structured screening and brief intervention > 30 minU7 or U7, GTU7HW (CSA)HK (non CSA)Neuropsychological Testing Admin by TechnicianInitial Assessment, In Home Behavioral Therapies for juveniles, per hour Alcohol/SA structured screening and brief intervention > 30 minCmnty Based Residential Group Home, Level B Per DiemCmnty Based Residential Group Home, Level B Per DiemCmnty Based Residential Group Home, Level A Per DiemCrisis Stabilization, per hourCrisis Stabilization, per hourNeuropsychological TestingNeuropsychological TestingPsychological TestingMODIFIERHK (non CSA)UC or UC, GTUB or UB, GTU6 or U6, GTU9 or U9, GTUAT elehealth, originating site fee*Psychological Testing Admin by ComputerCrisis Intervention, MH per 15 min*Crisis Intervention, MH per 15 min*Assessment, Therapeutic Day Treatment for Childrenw/ or w/o GTNeuropsychological Testing Admin by ComputerCrisis Intervention, MH (ECO) per 15 min*32 or GT, 32 Crisis Intervention, MH (ECO) per 15 min*32 or GT, 32 Version: 10/1/2017 Effective: 7/1/2017 Page 3 of 7VA DMAS official fee schedules can be found at: EFFECTIVE.
9 7/1/2017 MAGELLAN VA MEDICAID/DMAS RATESHCPCS CODED esignationRATEH0032 Urban$ $ $ $ $ $ Case Management Low intensity*H0023$ $ $ $ $ ^$ $ $ ^$ ^CPT CODEAgePHYSICIAN PSYCHOLOGISTMASTER'S LEVELCLINICAL NURSE SPECIALIST99211<21$ $ >20$ $ <21$ $ >20$ $ <21$ $ >20$ $ <21$ $ >20$ $ <21$ $ >20$ $ /HCPCS CODEM odifierRATEH0014$ $ ^H0020$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Support Services Individual (Mental Health)Peer Support Services Group (Mental Health)H0006T1012S9445 HCPCS/Rev CODEA ssessment, Mental Health Skill Building ServicesU8 Office Outpatient Visit, Estbl patient, low to moderate severityOffice Outpatient Visit, Estbl patient, low to moderate severityOffice Outpatient Visit, Estbl patient, moderate to high severityOffice Outpatient Visit, Estbl patient, moderate to high severityOffice Outpatient Visit, Estbl patient, moderate to high severityOffice Outpatient Visit, Estbl patient, moderate to high severityPresumptive drug class screening, any drug class, direct optical observation onlyPresumptive drug class screening, any drug class, instrument assisted direct optical observationPresumptive drug class screening, any drug class.
10 Instrument chemistry analyzersDESCRIPTIONM edication AdministrationAlcohol BreathalyzerSubstance Use Care CoordinationOpioid treatment services IndividualOpioid treatment services GroupDefinitive drug classes 1 7 drug classesDefinitive drug classes 8 14 drug classesSyphilis test, non treponemal antibody; qualitativeAssessment, Mental Health Skill Building ServicesMental Health Skill Building Services 1 unit 1 hours 2 units 3 hours 3 units 5 hours 4 units 7 or more hoursMental Health Skill Building Services 1 unit 1 hours 2 units 3 hours 3 units 5 hours 4 units 7 or more hoursCase Management, Foster Care Per MonthCase Management, Mental Health, per monthUB or UB, GTMH Case Management High intensity*UC or UC, GTOffice Outpatient Visit, Established patient, minorADDICTION AND RECOVERY TREATMENT SERVICES (ARTS)U8 Office Outpatient Visit, Established patient, minimalOffice Outpatient Visit, Established patient, minorPartial Hospitalization ASAM level Treatment Programs (OTP) / Office Based Opioid Treatment (OBOT)Peer Support Services Individual (Substance Use Disorder)Peer Support Services Group (Substance Use Disorder)Intensive Outpatient ASAM level Use Case Management (licensed by DBHDS)
