Provider Service Code Guidelines - Providers - …

1 Billing Service CodesBundle Auth CodesUnits/FrequencyMaximum UnitsLevel of CareCommentsService DescriptionZ5008; T2023TJ1 Unit =1 MonthCare Management Co-OcurringH0046TJ1 Unit = 1 MonthCare Management - Behavioral Health HomeT2022HA1 Unit = 1 Month Care Management I/DD OnlyY9930 thru Y9999 CSC051 Unit = 1 DayOut of Home CareProvider Type 59 Initial auth: 120 daysY9930 thru Y9999 CSC052 Units = 1 DayOut of Home CareProvider Type 44 Initial auth: 120 daysH0043 HAU1Y9996, Y9997, Y9998 & Y9999T2016 HAU1, U2, U3, U4, U5 = DD OOH Service (Tx)T2033 HAU1, U2, U3, U4, U5= DD OOH Service (Tx)CSC262 Units = 1 DayOut of Home CareInitial auth: 120 daysH2020HA1 Unit = 1 DayUp to 5 DaysMissing DaysZ0170 CSC021 Unit = 1 HourPartial CareOP 912 - OP 913 CSC021 Unit = 1 HourPartial HospitalizationInitial auth up to 6 months, minimum 3 , 2 days/week, maximum 30hrs/wk, up to 5 hrs/day/weekend. Limit of 12 months/admission. For OOH referrals to PHP: Initial auth 90 days, all other parameters applyOP918 CSC021 Unit = 1 HourMaximum of 4 units per dayPsychological TestingRevised 06-29-16OP513, OP900, OP901, OP902, OP903, OP909, OP910, OP912, OP913, OP914, OP915, OP916, OP917, OP918, OP919, OP961 CSC021 Unit = is specific to each Rev CodeIndividual, Group and Family Therapy (outpatient), Medication Management, Initial Assessment/Evaluation 30 units for initial 30 days of CMO enrollment.

2 Ongoing request must conform to authorization (does not apply to transition/discharge plans)90801, 90804, 90805, 90806, 90807, 90847, 90847-22, 90853, 90862, 90870, 90899, 96105, 96111, Z0100, 90847, 90862, 90887 CSC021 Unit = is specific to the HCPCS codeIndividual, Group and Family Therapy (outpatient), Medication Management, Initial Assessment/Evaluation (excludes psychological testing)30 units for initial 30 days of CMO enrollment. 90862 CSC021 Unit = 1 VisitMedication MonitoringOP513, OP900, OP909, OP910, OP914, OP919, OP961 CSC021 Unit = is specific to each Rev CodeMedication MonitoringH2014TJ1 Unit=15 MinutesBehavioral Assistance, IndividualH2014 TJUN1 Unit=15 MinutesBehavioral Assistance, Small Group = 2H2014 TJUP1 Unit=15 MinutesBehavioral Assistance, Small Group = 3H0036 TJU11 Unit=15 MinutesIntensive in Home, Individual by LCSW H0036 UNU11 Unit=15 MinutesIntensive in Home, Group - 2 children by LCSWH0036 UPU11 Unit=15 MinutesIntensive in Home, Group - 3 children by LCSWH0036 TJU21 Unit=15 MinutesIntensive in Home, Individual Master Level H0036 UNU21 Unit=15 MinutesIntensive in Home, Group - 2 children Master LevelH0036 UPU21 Unit=15 MinutesIntensive in Home, Group - 3 children Master LevelZ03302 Units = Round TripClinic TransportationRevised 06-29-16H20331 Unit=15 MinutesMulti-System Therapy for Juveniles (MST) H20191 Unit=15 MinutesTherapeutic Behavioral services (FFT)

3 H0018 TJU1 H0018 TJU21 Unit = 1 HourMaximum of 2 Assessment per yearBiopsychosocial Needs AssessmentAssessments are authorized for 3 hours or 3 unitsT203822HA1 Unit=15 Minutes5 hours (20 units) per week and no more than 120 (480) units in 12 month period. 240 units in 90 day authorizationTransitioning Youth Life Skill Building SELT2038HA1 Unit=15 Minutes5 hours (20 units) per week and no more than 120 (480) units in 12 month period. 240 units in 90 day authorizationTransitioning Youth Life Skill Building SELS9485 TJSTAT - 1 Unit=72 Hrs. or one mobile response episodeInitial Mobile Crisis Response Dispatch Day plus 3 daysH0032TJ1 Unit = 15 MinutesUp to 8 weeks. Maximum is 128 units per 8 week periodCrisis Stabilization ManagementH0018TJ1 Unit = 1 DayMaximum of 7 daysCrisis Stabilization BedT202122HA1 Unit= 15 Minutes52 for 90 Day AuthorizationMasters Level Clinician (LCSW,LPC,LMFT,NADD) H2015 HAHNCSC301 Unit= 15 Minutes16 Hours in 24 Hour Period (for in home)(Behavioral Tech.) HS Diploma or GED with 3 years relevant experience H2016 HAHNCSC301 Unit= 15 Minutes16 Hours in 24 Hour Period (for in home)(Behavioral Tech.)

4 Bachelor s Level with one year of relevant experience Revised 06-29-16T202152HO1 Unit= 15 MinutesMaster s Level Clinician96152 HABehavior Consultative Supports (BCS) T2021 HAHNCSC311 Unit= 15 Minutes156 for 90 Day AuthorizationBachelors Level/Master's Level (BCaBA)T2021 HAHOCSC311 Unit= 15 Minutes156 for 90 Day AuthorizationMaster's Level BCBAH0031 HACSC321 Unit=1 Hour15 Functional Behavioral Assessment (BCaBA) H0031HA22 CSC321 Unit=1 Hour15 Functional Behavioral Assessment (BCBA) H2015HM1 Unit=15 MinutesIndividual Support -Technician 1: Assessment, Plan Development, Supervision-BA/BS with 1 year relevant experience H2016 HAHO1 Unit=15 MinutesIndividual Support Technician 2: BA/BS with 1 year of relevant experience H2015 HAHO1 Unit=15 MinutesIndividual Support Technician 3: HS Diploma/GED with 3 years of relevant experienceH0045TV221 Unit=15 Minutes100 Units Per MonthWeekend Respite by Agency S9125HA521 Unit=15 Minutes80 Units Per MonthAgency Hired RespiteT100522HA1 Unit=15 Minutes80 Units Per MonthSelf-Directed RespiteT201322HA1 Unit=15 Minutes320 Units Per MonthAfterschool Respite By AgencyH0045HA1 Unit = 1 Day6 Days Per Year Respite.

5 Overnight (Licensed)Flexible FundsCSA111 Unit = 1 Service Specify Daily/Wkly/Monthly One Time Only (When applicable)Educational/InstructionalRevi sed 06-29-16 CSA121 Unit = 1 Service Specify Daily/Wkly/Monthly One Time Only (When applicable)Professional ServicesCSA 131 Unit = 1 Service Specify Daily/Wkly/Monthly One Time Only (When applicable)Living Housing ExpensesCSA141 Unit = 1 Service Specify Daily/Wkly/Monthly One Time Only (When applicable)RecreationCSA171 Unit = 1 HourMentoringCSA181 Unit = 1 DayTreatment Homes (DCP&P/DMHS)CSA191 Unit = 1 DayResource Family Care (Foster Care)CSA201 Unit = 1 DaySubstance Use ServiceCSA211 Unit = 1 VisitMedicationCSA221 Unit = 1 DayShelter CareCSA231 Unit = 1 Service Specify Daily/Wkly/Monthly One Time Only (When applicable)TransportationCSA241 Unit = 1 Service Specify Daily/Wkly/Monthly One Time Only (When applicable)Personal Care ExpensesCSA251 Unit = 1 Service Specify Daily/Wkly/Monthly One Time Only (When applicable)UtilitiesCSA271 Unit = 1 DayWrap/Flex RespiteRevised 06-29-16 CSA291 Unit = 1 DayParent Mentoring S9970 HAOccurrenceRecreationalTracking PurposesCSA03 One Time OnlyParent Support, Family-to-Family SupportCSA451 Unit = 1 Service Specify Daily/Wkly/Monthly Third Party Liability/Commercial InsuranceCSA501 Unit = 1 Service Specify Daily/Wkly/Monthly One Time Only (When applicable)"Free services "Natural Family Support, services funded by grants, services through a churchCSA511 Unit = 1 DaySchool Reimbursed services (IEP's)CSA011 Unit = 1 DayInpatient Psychiatric Care Facilities/Specialty (State/County ONLY)Involuntary commitment primarily - State and County facilitiesCSC031 Unit = 1 DayHospital, Psychiatric, short-termCSC031 Unit = 1 DaySpecial Hospital and Rehab CenterCSC031 Unit = 1 DayInpatient Psychiatric Care Facilities/Specialty (non-gov)

6 CSC031 Unit = 1 DayPsychiatric Hospital extended stayCSA401 Unit = 1 DayJJC - Day ProgramCSA411 Unit = 1 DayJuvenile DetentionCSA421 Unit = 1 DayJJC - IncarcerationCSA43 1 Unit = 1 DayJJC - Community FacilityCSA441 Unit = 1 DayDepartment of Corrections (Adults age 18+)CSA Wrap FundsCSA121 Unit = 1 Service Specify Daily/Wkly/Monthly One Time Only (When applicable)Professional ServicesT101322HA1 Unit= 15 MinutesInterpreter ServicesT2036HA1 Unit = 1 DayUp to 6 NightsCamp-OvernightT2037HA1 Unit = 1 DayUp to 10 DaysCamp-DayRevised 06-29-16S5150HA1 Unit=1 HourUp to 10 Days1:1 Aide T10021 Unit=15 MinutesRN ServicesMedical Service - Registered Nurse T10031 Unit=15 MinutesLPN ServicesMedical Service - Licensed Practical Nurse Substance Use (SU)H0001HA1 Unit=30 MinutesMaximum annual limit 24 unitsAssessment only (pre-admission) H0018HA1 Unit=30 Minutes 4 Bio Psychosocial Needs AssessmentIn facility H0010HA 1 Unit=1 Day7 UnitsDetox - sub acute residential90791AJ1 Unit=1 Hour2 Assessment LicensedClinical 90791AJ521 Unit=1 Hour2 Assessment Non Licensed Clinical H0015HA1 Unit=1 HourPartial Care Co-OccurringH0003HA CSC201 Unit=1 Day1 Time Per DayUrine Drug Screening8 per month - CSC20 $ limitH0049 HACSC201 Unit=1 Day1 Time Per DayOral Swab 8 per month - CSC20 $ limit86580 HACSC201 Unit=1 Day1 Time Per DayTB Test2 per month - CSC20 $ limitH0006 HACSC211 Unit=15 Minutes8 Times Per DayCo-Care Management8 per month - CSC21 $ limit90791 HACSC211 Unit=30 Minutes6 Time Per Day Comprehensive Intake Evaluation6 per month - CSC21 $ limitH0007HA CSC211 Unit=15 Minutes4 Times Per Day Crisis Intervention - Individual8 per month - CSC21 $ limit9084722 HACSC211 Unit=30 Minutes2 Times Per DayFamily Therapy (with patient)

7 10 per month - CSC21 $ limit9084622 HACSC211 Unit=30 Minutes2 Times Per Day Family Therapy (without patient)7 per month - CSC21 $ limit9083222 HACSC211 Unit=30 Minutes2 Times Per DayIndividual Therapy - Half session10 per month - CSC21 $ limit9083722 HACSC211 Unit=1 Day2 Times Per DayIndividual Therapy - Full session10 per month - CSC21 $ limit90853 HACSC211 Unit=30 Minutes1 Time Per Day Co-occurring - Group Therapy 10 per month - CSC21 $ limit90887 HACSC211 Unit=15 Minutes4 Times Per Day Clinical Consultation6 per month - CSC21 $ limit90863 HACSC221 Unit=15 Minutes2 Times Per DayMedication Monitoring6 per month - CSC22 $ limit90791 HACSC231 Unit=15 Minutes6 Times Per DayPsychiatric Evaluation6 per month - CSC23 $ limit per month $ limit per year90792 HACSC231 Unit=15 MinutesPsychiatric EvaluationH0003 HACSC20SJ1 Unit=1 Day1 Time Per DayUrine Drug Screening8 per month - CSC20SJ $ limitH0049 HACSC20SJ1 Unit=1 Day1 Time Per DayOral Swab 8 per month - CSC20SJ $ limit86580 HACSC20SJ1 Unit=1 Day1 Time Per Day TB Test2 per month - CSC20SJ $ limitH0006 HACSC21SJ1 Unit=15 Minutes8

8 Times Per DayCo-Care Management8 per month - CSC21 $ limit90791 HACSC21SJ1 Unit=30 Minutes6 Times Per DayComprehensive Intake Evaluation6 per month - CSC21SJ $ limitH0007 HACSC21SJ1 Unit=15 Minutes4 Times Per DayCrisis Intervention - Individual8 per month - CSC21SJ $ limit9084722 HACSC21SJ1 Unit=30 Minutes2 Times Per DayFamily Therapy (with patient)10 per month - CSC21SJ $ limitRevised 06-29-169084622 HACSC21SJ1 Unit=30 Minutes2 Times Per DayFamily Therapy (without patient)10 per month - CSC21SJ $ limit9083222 HACSC21SJ1 Unit=30 Minutes2 Times Per DayIndividual Therapy - Half session10 per month - CSC21SJ $ limit9083722 HACSC21SJ1 Unit=1 Hour2 Times Per DayIndividual Therapy - Full session10 per month - CSC21SJ $ limit90853 HACSC21SJ1 Unit=30 Minutes1 Time Per DayCo-occurring - Group Therapy 10 per month - CSC21SJ $ limit90887 HACSC21SJ1 Unit=15 Minutes4 Times Per DayClinical Consultation6 per month - CSC21SJ $ limit90863 HACSC22SJ1 Unit=15 Minutes2 Times Per DayMedication Monitoring6 per month - CSC22SJ $ limit90791 HACSC23SJ1 Unit=15 Minutes6 Times Per Day Psychiatric Evaluation6 per month - CSC23SJ $ limit per month $ limit per yearT1006 HACSC271 Unit=30 Minutes72 for 90 Day AuthorizationOutpatient Counseling/Education24 per month $ limit per month90832 HACSC271 Unit=30 Minutes72 for 90 Day AuthorizationOutpatient Individual Counseling24 per month $ limit per monthH0005 HAAJCSC271 Unit=30 Minutes72 for 90 Day AuthorizationOutpatient

9 Group24 per month $ limit per monthT1006 HACSC281 Unit=30 MinutesIntensive Outpatient/Engagement/Family Counseling/Education36 per month - Maximum limits per episode of Tx - CSC28 $ limit90832 HACSC281 Unit=30 MinutesIntensive Outpatient Individual36 per month - Maximum limits per episode of Tx - CSC28 $ limitH0005 HAAJCSC281 Unit=30 MinutesIntensive Outpatient Engagement Group36 per month - Maximum limits per episode of Tx- CSC28 $ limitS9475 HACSC291 Unit=1 DayIntensive Outpatient100 - Annual limitsH0015HA1 Unit=1 HourPartial CareVoucher ServicesSUT011 Unit=30 Minutes72 for 90 Day AuthorizationOutpatientSUT021 Unit=1 Day90 for 90 Day AuthorizationIntensive OutpatientSUT031 Unit=1 DayPartial CareT202822 HAOccurrenceAssistive Technology: Assessment for DevicesT2028 HAOccurrenceAssistive Technology: Assessment for Environment and Vehicle modificationsT2029 HAOccurrence$11, per 3 yearsAssistive Technology: Assistive DevicesT2039 HAOccurrence$11, per 3 yearsAssistive Technology: Vehicle ModificationsRevised 06-29-16S5165 HAOccurrence$11, per 3 yearsAssistive Technology: Environmental ModificationsCSA301 Unit = 1 DaySubstance Use ServiceCSA321 Unit = 1 DayShelter CareCSA341 Unit = 1 DayMentoringCSA351 Unit = 1 DayFamily Care HomeCSA361 Unit = 1 DayIntensive in HomeCSA371 Unit = 1 DayBehavioral AssistanceCSA381 Unit = 1 DayTreatment Homes (DCP&P/DMHS)CSA391 Unit = 1 DayResource Family Care (Foster Care)Revised 06-29-16