* Referenced http://bh.medicaid.ohio.gov/manuals (Behavioral Health Provider Manual FINAL Version 1.4 12/4/17)
Butler County Mental Health and Addiction Recovery Services Board BH Redesign Codes and Prices
Effective: January 1, 2018
Page* Covered Services Provider TypeEvaluation and Management Office Visit
29 E/M New Patient MD/DO 99201 - $49.38 99202 - $84.67 99203 - $122.93 99204 - $188.51 99205 - $236.92
CNS/CNP/PA 99201 - $41.97 99202 - $71.97 99203 - $104.49 99204 - $160.23 99205 - $201.38
29 E/M Established Patient MD/DO 99211 - $22.31 99212 - $48.97 99213 - $82.85 99214 - $122.27 99215 - $165.15
CNS/CNP/PA 99211 - $22.31 99212 - $41.62 99213 - $70.42 99214 - $103.93 99215 - $140.38RN/LPN 99211 - $22.31
Evaluation & Management Home Visit
30 E/M Home Visit New Patient MD/DO 99341 - $63.65 99342 - $91.90 99343 - $150.80 99344 - $210.78 99345 - $255.57
CNS/CNP/PA 99341 - $54.10 99342 - $78.12 99343 - $128.18 99344 - $179.16 99345 - $217.23
30 MD/DO 99347 - $64.00 99348 - $97.38 99349 - $148.16CNS/CNP/PA 99347 - $54.40 99348 - $82.77 99349 - $125.94
Prolonged Visits
31 Prolonged Visit - First 60 Mins MD/DO
CNS/CNP/PA
PSYLISW/LIMFT/LPCC/LICDC (SUD ONLY)/LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC III (SUD ONLY)/LCDCII (SUD ONLY)
PSY ASSISTANT
SW-T/MFT-T/C-T/CDC-A (SUD ONLY)
32 MD/DO
CNS/CNP/PA
PSYLISW/LIMFT/LPCC/LICDC (SUD ONLY)/LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC III (SUD ONLY)/LCDC II (SUD ONLY)
PSY ASSISTANT
SW-T/MFT-T/C-T/CDC-A (SUD ONLY)
+99355 - $75.85
+99355 - $89.24Prolonged Visit - Each Additional
30 Minutes
+99355 - $89.24
Codes
+99354 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 85% of maximum fee if supervisor NPI not included
+99354 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 72.25% of maximum fee if supervisor NPI not included
+99354 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 85% of maximum fee if supervisor NPI not included
+99354 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 72.25% of maximum fee if supervisor NPI not included
+99354 - $89.90
+99354 - $76.42
+99354 - $89.90
+99354 - $76.42
+99354 - $76.42
+99355 - $75.85
+99355 - $75.85
E/M Home Visit Established Patient
99350 - $205.7999350 - $174.92
Psychiatric Diagnostic Evaluation
33 MD/DO/PSYCNS/CNP/PA/LISW/LIMFT/LPCC/LICDC (SUD ONLY) LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC III (SUD ONLY)/LCDC II (SUD ONLY)
PSY ASSISTANT
SW-T/MFT-T/C-T/CDC-A (SUD ONLY)
33 MD/DOCNS/CNP/PA
Medication Administered by Medical Personnel
35 Medication Administered by Medical Personnel J2315 - $3.18 J8499 - $1.20
35Other Medication Administration MD/DO/CNS/CNP/PA/RN/LPN
Laboratory Services36 Alcohol (ethonal) breath 82075 - $15.08
Psychotherapy for Crisis
42 MD/DO/PSYCNS/CNP/PA/LISW/LIMFT/LPCC LICDC (SUD ONLY)/LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC III (SUD ONLY)/LCDC II (SUD ONLY)
PSY ASSISTANT
SW-T/MFT-T/C-T/CDC-A (SUD ONLY)
43 MD/DO/PSYCNS/CNP/PA/LISW/LIMFT/LPCC /LICDC (SUD ONLY) LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC III (SUD ONLY)/LCDC II (SUD ONLY)
PSY ASSISTANT
SW-T/MFT-T/C-T/CDC-A (SUD ONLY)
90791 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 85% of maximum fee if supervisor NPI not included
90791 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 72.25% of
maximum fee if supervisor NPI not included
90839 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 85% of maximum fee if supervisor NPI not included
90839 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 72.25% of maximum fee if supervisor NPI not included
+90840 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 85% of maximum fee if supervisor NPI not included
+90840 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 72.25% of maximum fee if supervisor NPI not included
90792 - $144.3590792 - $122.70
90791 - $111.11
90791 - $111.11
90791 - $130.72
90839 - $132.08
90839 - $112.27
90839 - $112.27
+90840 - $63.04
+90840 - $53.58
+90840 - $53.58
96372 - $21.39
Psychotherapy for Crisis - 60 Minutes
Psychiatric Diagnostic Evaluation w/ Medical
Psychiatric Diagnostic Evaluation w/o Medical
Psychotherapy for Crisis - addition 30 minutes
Individual Psychotherapy
44 MD/DO/PSY
CNS/CNP/PA/LISW/LIMFT/LPCC LICDC (SUD ONLY)/LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC III (SUD ONLY)/LCDC II (SUD ONLY)
PSY ASSISTANT
SW-TRAINEE/MFT-TRAINEE/C-T/CDC-A (SUD ONLY)
44 & 45 MD/DO/PSY
CNS/CNP/PA/LISW/LIMFT/LPCC LICDC (SUD ONLY)/LIC SCHOOL PSY
LSW/LMFT/LPCC/LCDC III (SUD ONLY) LCDC II (SUD ONLY)
PSY ASSISTANT
SW-TRAINEE/MFT-TRAINEE/C-T/CDC-A (SUD ONLY)
45 & 46 MD/DO/PSYCNS/CNP/PA
LISW/LIMFT/LPCC/LICDC (SUD ONLY)/LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC III (SUD ONLY) /LCDC II (SUD ONLY)
PSY ASSISTANT
SW-T/MFT-T/C-T/CDC-A (SUD ONLY)
46 MD/DO +90833 - $65.37 +90836 - $83.03CNS/CNP/PA +90833 - $55.56 +90836 - $70.58
90834 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 72.25% of maximum fee if supervisor NPI not included
90837 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 85% of maximum fee if supervisor NPI not included
90837 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 72.25% of
maximum fee if supervisor NPI not included
90832 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 85% of maximum fee if supervisor NPI not included
90832 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 72.25% of
maximum fee if supervisor NPI not included
90834 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 85% of maximum fee if supervisor NPI not included
90832 - $63.11
90832 - $53.64
90832 - $53.64
90834 - $82.05
90834 - $69.74
90834 - $69.74
90837 - $120.36
90837 - $102.31
90837 - $102.31
90837 - $102.31
+90838 - $109.53+90838 - $93.10
Individual Psychotherapy with E/M Service
Individual Psychotherapy - 60+ minutes
Individual Psychotherapy - 45 minutes
Individual Psychotherapy - 30 minutes
Family Psychotherapy
47 MD/DO/PSYCNS/CNP/PA/LISW/LIMFT/LPCC LICDC (SUD ONLY)/LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC III (SUD ONLY)/LCDC II (SUD ONLY)
PSY ASSISTANT
SW-T/MFT-T/C-T/CDC-A (SUD ONLY)
47 & 48 MD/DO/PSY
CNS/CNP/PA/LISW/LIMFT/LPCC LICDC (SUD ONLY)/LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC III (SUD ONLY)/LCDC II (SUD ONLY)
PSY ASSISTANT
SW TRAINEE/MFT TRAINEE/CDC-A (SUD ONLY)/C-T
48 MD/DO/PSY
CNS/CNP/PA/LISW/LIMFT/LPCC LICDC (SUD ONLY)/LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC III (SUD ONLY)/LCDC II (SUD ONLY)
PSY ASSISTANT
SW-T/MFT-T/C-T/CDC-A (SUD ONLY)
50 MD/DO/PSY
CNS/CNP/PA/LISW/LIMFT/LPCC LICDC (SUD ONLY)/LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC III (SUD ONLY) /LCDC II (SUD ONLY)
PSY ASSISTANT
SW-T/MFT-T/C-T/CDC-A (SUD ONLY)
90849 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 85% of maximum fee if supervisor NPI not included
90849 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 72.25% of maximum fee if supervisor NPI not included
90853 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 85% of maximum fee if supervisor NPI not included
90853 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 72.25% of maximum fee if supervisor NPI not included
90849 - $26.59
90849 - $26.59
90853 - $25.45
90853 - $21.63
90853 - $21.63
90846 - $86.94
90847 - $100.72
90847 - $85.61
90847 - $85.61
90849 - $31.28 per patient
90847 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 85% of maximum fee if supervisor NPI not included
90847 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 72.25% of
maximum fee if supervisor NPI not included
90846 - $102.28
90846 - $86.94
90846 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 85% of maximum fee if supervisor NPI not included
90846 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 72.25% of
maximum fee if supervisor NPI not included
Group Psychotherapy (not multi-family group)
Family Psychotherapy (conjoint, w/ patient present) 50 mins
Family Psychotherapy without patient - 50 minutes
Multiple Family Group Psychotherapy
Interactive Complexity
52 Interactive Complexity MD/DO/PSY
CNS/CNP/PA/LISW/LIMFT/LPCC LICDC (SUD ONLY)/LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC III (SUD ONLY)/LCDC II (SUD ONLY)
PSY ASSISTANT
SW-T/MFT-T/C-T/CDC-A (SUD ONLY)
Therapeutic Behavioral Services (TBS)
57 PSY ASSISTANT (MASTER'S)SW-T (MASTER'S)
SW-T (BACHELOR'S)
SW-A (MASTER'S)
SW-A (BACHELOR'S)
MFT-T (MASTER'S)
MFT TRAINEE (BACHELOR'S)
C-T (MASTER'S)
C-T (BACHELOR'S)
QMHS (BACHELOR'S)
QMHS (MASTER'S)
QMHS (HIGH SCHOOL AND 3+ YEARS EXP.)
57 & 58 PSY ASSISTANT (MASTER'S)SW-T (MASTER'S)
SW-T (BACHELOR'S)
SW-A (MASTER'S)
SW-A (BACHELOR'S)
MFT-T (MASTER'S)
MFT-T (BACHELOR'S)
C-T (MASTER'S)
C-T (BACHELOR'S)
QMHS (BACHELOR'S)
QMHS (MASTER'S)QMHS (HIGH SCHOOL AND 3+ YEARS EXP.)
+90785 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 85% of maximum fee if supervisor NPI not included
+90785 - paid @ direct supervisor rate when supervisor NPI on claim. paid at 72.25% of
maximum fee if supervisor NPI not included
+90785 - $13.81
+90785 - $11.74
+90785 - $11.74
H2019 - $22.47 - provided in the office, $28.59 - provided in the community
H2019 - $22.47 - provided in the office, $28.59 - provided in the community
H2019 - $19.96 - provided in the office, $25.46 - provided in the community
H2019 - $22.47 - provided in the office, $28.59 - provided in the community
H2019 - $19.96 - provided in the office, $25.46 - provided in the community
H2019 - $22.47 - provided in the office, $28.59 - provided in the community
H2019 - $19.96 - provided in the office, $25.46 - provided in the community
H2019 - $5.62 provided in the office
H2019 - $5.62 provided in the office
H2019 - $4.99 provided in the office
H2019 - $22.47 - provided in the office, $28.59 - provided in the community
H2019 - $19.96 - provided in the office, $25.46 - provided in the community
H2019 - $22.47 - provided in the office, $28.59 - provided in the community
H2019 - $19.96 - provided in the office, $25.46 - provided in the community
H2019 - $19.96 - provided in the office, $25.46 - provided in the community
H2019 - $4.99 provided in the office
H2019 - $4.99 provided in the office
H2019 - $5.62 provided in the officeH2019 - $4.99 provided in the office
H2019 - $5.62 provided in the office
H2019 - $4.99 provided in the office
H2019 - $5.62 provided in the office
H2019 - $4.99 provided in the office
H2019 - $5.62 provided in the office
Individual Therapeutic Behavioral Services (TBS) 15 minutes
Group Therapeutic Behavioral Services (TBS) - 15 minutes
RN and LPN Nursing Services
58 Nursing Services - Individual RN
LPN58 Nursing Services - Group RN
Mental Health Day Treatment
59 PSY
LISW/LIMFT/LPCC/LIC SCHOOL PSY
LSW/LMFT/LPCPSY ASSISANT/SW-T (MASTER'S)/SW-A (MASTER'S) MFT-T (MASTER'S)/C-T (MASTER'S)/QMHS (MASTER'S)
PSY ASSISANT (BACHELOR'S)/SW-T (BACHELOR'S)/ SW-A (BACHELOR'S)/MFT-T (BACHELOR'S) C-T (BACHELOR'S)/QMHS (BACHELOR'S)
QMHS 3 + YEARS
59 MH Day Treatment per diem PSY
LISW/LIMFT/LPCC/LIC SCHOOL PSY
LSW/LMFT/LPC
PSY ASSISANT/SW-T (MASTER'S) SW-A (MASTER'S)/MFT-T (MASTER'S) C-T (MASTER'S)/QMHS (MASTER'S)
PSY ASSISANT (BACHELOR'S)/SW-T (BACHELOR'S)/ SW-A (BACHELOR'S)/MFT-T (BACHELOR'S) C-T (BACHELOR'S)/QMHS (BACHELOR'S)QMHS 3 + YEARS
Psychosocial Rehabilitation (PSR)
60 SW-T
SW-A
MFT-T
C-T
QMHS (HIGH SCHOOL)QMHS (ASSOCIATE'S)
H2019 - $31.92 provided in the office - $41.00 provided in the community
H2012 - $21.05
H2012 - $18.54
H2012 - $18.54
H2020 - $140.51
H2020 - $140.51
H2017 - $22.54 provided in the office - $29.13 provided in the communityH2019 - $7.98 provided in the office
H2012 - $28.10
H2012 - $28.10
H2012 - $28.10
H2017 - $15.84 - provided in the office, $20.32 - provided in the community
H2017 - $15.84 - provided in the office, $20.32 - provided in the community
H2017 - $15.84 - provided in the office, $20.32 - provided in the community
H2017 - $15.84 - provided in the office, $20.32 - provided in the community
H2017 - $15.84 - provided in the office, $20.32 - provided in the community H2017 - $15.84 - provided in the office, $20.32 - provided in the community
H2020 - $140.51
H2020 - $117.05
H2020 - $104.55H2020 - $104.55
MH Day Treatment per hour up to 2 hours - group
Psychosocial Rehabilitation (PSR)
Screening, Brief Intervention and Referral to Treatment
61 SBIRT (15 TO 30 Minutes) MD/DO/CNS/CNP/PA/PSY/RN/LPN/LISW LIMFT/LPCC/LIC SCHOOL PSY
LSW/LMFT/LPC
PSY ASSISTANT/SW-T/MFT-T/C-T
61 SBIRT (OVER 30 Minutes) MD/DO/CNS/CNP/PA/PSY/RN/LPN/LISW LIMFT/LPCC/LIC SCHOOL PSY
LSW/LMFT/LPC
PSY ASSISTANT/SW-T/MFT-T/C-T
Community Psychiatric Supportive Treatment (CPST)
62 MD/DO
CNS/CNP/PA/PSY
LISW/LIMFT/LPCC/LIC SCHOOL PSY
LSW/LMFT/LPC
PSY ASSISTANT/SW-T/SW-A/MFT-T/C-T
QMHS (3 YEARS + EXP)/QMHS (HIGH SCHOOL)
QMHS (ASSOCIATE'S)/QMHS (BACHELOR'S) QMHS (MASTER'S)
62 & 63 MD/DO
CNS/CNP/PA/PSY
LISW/LIMFT/LPCC/LIC SCHOOL PSY
LSW/LMFT/LPC
PSY ASSISTANT/SW-T/SW-A/MFT-T/C-TQMHS (3 YEARS + EXP)/QMHS (HIGH SCHOOL) QMHS (ASSOCIATE'S)/QMHS (BACHELOR'S)
QMHS (MASTER'S)
MH Behavioral Health Counseling *
63 Behavioral Health Counseling LSW/LMFT/LPC
LSW/LMFT/LPC
Assertive Community Treatment (ACT)
64 MD/DO
CNP/CNS/PALICENSED PRACTIONER/MH PRACTIONER W/ MASTER'S
MH PRACTIONER W/ BACHELOR'S PEER RECOVERY SUPPORTER
Intensive Home Based Treatment (IHBT)
64 PSY
LISW/LIMFT/LPCCLSW/LMFT/LPC
Intensive Home Based Treatment
G0396 - $25.05
G0396 - $25.05
G0396 - $25.05
H0036 - $19.54
H0036 - $19.54
H0036 - $19.54
H0036 - $19.54
H0036 - $8.99
G0397 - $47.68
G0397 - $47.68
G0397 - $47.68
H0036 - $19.54
H0036 - $19.54
H0040 - $159.24
H0036 - $8.99
H0036 - $8.99
H0036 - $8.99
H0036 - $8.99
H0036 - $8.99
*H0004 - $9.87 with HQ Procedure Modifier
* This code will only be available until June 30, 2018. For individual and group counseling services provided on and after July 1, 2018, these practitioners will need to use CPT
individual and group psychotherapy codes.
*H0004 - $22.50
Community Psychiatric Supportive Treatment - Group
H2015 - $33.26
H2015 - $33.26H2015 - $33.26
H0040 - $615.64
H0040 - $352.75
H0040 - $251.91
H0040 - $199.70
Community Psychiatric Supportive Treatment - Individual
Assertive Community Treatment
SUD Assessment
65 SUD Assessment PSY ASSISTANT
SW-T
MFT-T
CDC-AC-T
SUD Peer Recovery Support
65 SUD Individual Peer Recovery Support PRS
65 SUD Group Peer Recovery Support PRS
SUD Individual Counseling
66 Individual Counseling LSW*/LMFT*/LP*/LCDC III*/LCDC II*
PSY ASSISTANT
SW-T
MFT-T
CDC-A
C-T
67 Group Counseling
Group Counseling MD/DO
CNS/CNP/PA/PSY/LISW/LIMFT/LPCC/LICDC
LSW/LMFT/LPC/LCDC III/LCDC II
PSY ASSISTANT
SW-T
MFT-T
CDC-AC-T
H0004 - $19.31
H0004 - $19.31
* This code will only be available until June 30, 2018. For individual and group counseling services provided on and after July 1, 2018, these practitioners will need to use CPT individual and group psychotherapy codes.
H0004 - $19.31
H0004 - $19.31
H0004 - $19.31
H0005 - $7.21
H0005 - $8.48
H0001 - $77.22
H0001 - $77.22H0001 - $77.22
H0038 - $15.51
H0038 - $1.94
H0001 - $77.22
H0001 - $77.22
*H004 - $22.50
H0005 - $7.21
H0005 - $6.44
H0005 - $6.44
H0005 - $6.44H0005 - $6.44
H0005 - $6.44
SUD Case Management
68 SUD Case Management MD/DO
CNS/CNP/PA/PSY
LISW/LIMFT/LPCC/LICDC/LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC II/LCDC III
PSY ASSISTANT
SW-T
SW-A
MFT-T
CDC-A
C-T
CMS HIGH SCHOOL/CMS ASSOCIATE'S/CMS BACHELOR'S CMS MASTER'S
SUD Urine Drug Screening
69 MD/DO/CNS/CNP/PA/RN/LPN/PSY/LISW LIMFT/LPCC/LICDC/LIC SCHOOL PSY
LSW/LMFT/LPC/LCDC II/LCDC IIPSY ASSISTANT/SW-T/SW-A/MFT-T CDC-A/C-T/CMS HIGH SCHOOL CMS ASSOCIATE'S/CMS BACHELOR'S/CMS MASTER'S
SUD RN and LPN Nursing Services
70 Nursing Services - Individual RN
LPN70 Nursing Services - Group RN
Intensive Outpatient Level of Care Group Counseling
70 MD/DO/CNS/CNP/PA/PSY
LISW/LIMFT/LPCC/LICDC
LSW/LMFT/LPC/LCDC III/ LCDC IIPSY ASSISTANT/SW-T/MFT-T/CDC-A/C-T
71 MD/DO/CNS/CNP/PA/PSY
LISW/LIMFT/LPCC/LICDC
LSW/LMFT/LPC/LCDC III/ LCDC IIPSY ASSISTANT/SW-T/MFT-T/CDC-A/C-T
SUD Urine Drug Screening - Collection, handling and point of
service testing
Partial Hospitalization (PH) Level of Care Group Counseling
H0048 - $14.48
H0048 - $14.48
T1002 - $31.92 - provided in the office - $41.00 provided in the community
T1003 - $22.54 - provided in the office - $29.13 provided in the communityT1002 - $7.98
H0006 - $19.54
H0006 - $19.54
H0015 - $224.82
H0015 - $224.82H0015 - $154.56
H0015 - $149.88
H0015 - $149.88
H0015 - $149.88H0015 - $103.04
H0015 - $224.82
H0006 - $19.54
H0006 - $19.54
H0048 - $14.48
H0006 - $19.54
H0006 - $19.54
H0006 - $19.54
H0006 - $19.54
H0006 - $19.54
H0006 - $19.54
H0006 - $19.54
Group Counseling IOP Level of Care
Group Counseling PH Level of Care
SUD Withdrawal Management w/ Extended On-Site Monitoring
72 RN
LPNWithdrawal Management Per Diem ASAM 2 WM MD/DO/CNS/CNP/PA
954 SUD Residential Treatment: SUD Withdrawal Management w/ Extended On-Site Monitoring
72 Withdrawal Management Per
Diem ASAM 2 WM MD/DO/CNS/CNP/PA
Clinically Managed Low-Intensity Residential Treatment
73Clinically Managed Low-Intensity Residential Treatment ASAM 3.1 AGENCY
Clinically Managed Residential Withdrawal Management
73 Clinically Managed Residential Withdrawal Management ASAM 3.2 WM AGENCY
Clinically Managed Population - Specific High Intensity Residential Treatment (Adults)
73 Clinically Managed Pop. - High Intensity Residential Treatment ASAM 3.3 (Adults) AGENCY
Clinically Managed High Intensity Residential Treatment
74Clinically Managed High Intensity Residential Treatment ASAM 3.5 AGENCY
Medically Monitored Inpatient Withdrawal Management
75 Medically Monitored Inpatient Withdrawal Management ASAM 3.7WM AGENCY
H0012 - $360.36
H0010 - $256.33
H2036 - $213.70
H2036 - $213.70
H0014 - $127.68
H0014 - $90.16
H0012 - $360.36
H2034 - $152.57
H0011 - $392.86
Withdrawal Management Hourly ASAM 2 WM
Page Non-Payable/Non-Covered ServicesElectrocardiogram
34 Electrocardiogram - at least 12 leads with interpretation & report 93000
Electrocardiogram - tracing only without interpretation & report 93005Electrocardiogram - interpretation & report only 93010
Medication Administered by Medical Personnel
35 Medication Administered by Medical Personnel J0400 J0401 J1200 J1630 J1631
J2060 J2310 J2358 J2680 J2794J2426 J3360 J2212 J2310 J2310
Laboratory Services
36 Skin test; tuberculosis, intradermal 86580
Alcohol (ethonal) breath 82075Collection of venous blood by venipuncture 36415
Covered Vaccines for Behavioral Health Providers
39 90460 90471 +90472 90633 90634
90632 90371 90650 90649 90644
90698 90654 90658 90660 90670
90680 90681 90696 90713 90707
90710 90714 90715 90716 90736
90732 90733 90734 90740 9074690747
Psychological Testing
55 Psychological Testing 96101
55 Developmental Testing 96111
56 Neurobehavioral Status Exam 9611656 Neuropsychological Testing 96118
74
H2036
Medically Monitored Inpatient Withdrawal Management74 & 75 Medically Monitored Inpatient Withdrawal Management ASAM 3.7 WM H0011
Medically Monitored Intensive Inpatient Treatment (Adults) & Medically Monitored High-Intensity Inpatient Services (Adolescent) ASAM 3.7
Medically Monitored Intensive Inpatient Treatment (Adults) & Medically Monitored High-Intensity Inpatient Services (Adolescent)
Codes
