Centennial Care Reporting Instructions Utilization ... · Centennial Care Reporting Instructions...

Centennial Care Reporting InstructionsUtilization Management – Report #41

Utilization Management Report - #41 Rev. v6 2014-12 Page 1 of 58

Report ObjectiveTo monitor unduplicated member utilization of behavioral health (BH) services, physical health (PH)services and long-term care (LTC) services and the corresponding managed care organization (MCO)paid amounts for the services. The report captures member utilization by date of service for paidclaims.

General InstructionsThe managed care organization (MCO) is required to submit the Utilization Management (UM) report on aquarterly basis. This report is due on April 30, July 30, October 30, and January 30 of each year. Anannual supplement is also required for this report. The annual supplement is a restatement of all fourquarterly report submissions related to the reporting periods within the particular calendar year. Therestated reports are to reflect data as of March 30 of the following year, thus benefiting from the additionalpaid claims run out. Please adhere to the following reporting periods and due dates.

Quarter Reporting Period Report Due Date1 January 1 – March 31 April 302 April 1 – June 30 July 303 July 1 – September 30 October 304 October 1 – December 31 January 30

AnnualSupplement

January 1 – December 31 April 30 (following year)

An Excel workbook is provided as a separate attachment for submission. Quantitative data and anyqualitative data must be entered in the Excel workbook. The MCO must ensure that data is entered in allfields. The report will be considered incomplete if any field is left blank. Use “ND” if there is no dataavailable to report. Use “N/A” if the data field is not applicable. All formulas provided in the workbook arelocked and shall not be altered by the MCO. An electronic version of the report in Excel must besubmitted to the New Mexico Human Services Department (HSD) by the report due date listed above.The report shall be submitted via the State’s secure DMZ FTP site. The date of receipt of the electronicversion will serve as the date of receipt for the report.

To assist MCOs with the use of the template, all cells within the template are viewable. This allows theuser to move the cursor into any cell of the template and enables the user to see the formulas in the cellsthat calculate automatically. Although certain cells are locked and protected, the user’s ability to view theformulas should assist in the MCO’s understanding of the template and calculations performed. It isimportant to note that when populating the templates with data, users are not to use the “cut and paste”function in Excel, as this may cause errors to the cell formulas. Additionally, certain cells have beenshaded and locked to prevent data entry where data is not required or not applicable to the particular itemor category.

Please note that the majority of this report captures information based on paid claims with dates ofservice within each quarterly reporting period. For sections of this report that capture data for multiplereporting periods (both current and prior quarters), the MCO is required to restate previously submitteddata. Reporting data in this manner will take advantage of the most recent look at the claims paid data,thus benefiting from the additional months of claims paid run out. Amounts entered into this report are tobe based on actual data and exclude any estimates or accruals.



The MCO shall submit the electronic version of the report using the following file name labeling format:MCO Name.HSD41.Q1CY14.v1. With each report submission, please change the reporting periodreference (e.g., Q1), the calendar year (e.g., CY14), and the version number (e.g., v1), as appropriate.

The MCO’s name, the reporting period, and the report run date must be entered on the top portion of thefirst worksheet in the report. The report run date refers to the date that the data was retrieved from theMCO’s system. The dates and MCO name entered on the first worksheet will automatically appear on thetop of all other worksheets of the report. The start and end of the reporting period must be entered in theformat illustrated below:

Attestation and PenaltiesThe MCO shall ensure that all data is accurate and appropriately formatted in the workbook prior tosubmitting the report. Per Section 7.3 of the Centennial Care contract, failure to submit accurate reportsand/or failure to submit properly formatted reports in accordance with the contract may result in liquidateddamages of $5,000 per report, per occurrence.

The MCO shall include a signed attestation with each report. Failure to submit a signed attestation formby the report due date will result in the entire report being late. Per Section 7.3 of the Centennial Carecontract, failure to submit timely reports in accordance with the contract may result in liquidated damagesof $1,000 per report, per calendar day. The $1,000 per calendar day damage amounts will double everyten calendar days.

Related Contract Requirements1. Section 4.21 – Reporting Requirements 2. Section 7.3 – Failure to Meet Agreement

Requirements

DefinitionsEVALUATION HIERARCHY CRITERIA

When completing this report, the MCO must apply the program area-specific service categorizationcriteria by each program area beginning with the Behavioral Health program area, followed by the LTCprogram area, and ending with the PH program area. See Addendum A (Behavioral Health Codes andCategories), Addendum B (Physical Health Codes and Categories), and Addendum C (Long-Term CareCodes and Categories) for tables detailing the program area-specific service categorization criteria.

When assigning data to one of the three distinct program areas, the MCO is to follow the guidelines belowstarting with BH:

1. Behavioral Health Program Member Utilizationa. Assign data to the BH program area by applying the criteria detailed in the table below for

identifying behavioral health services.b. Assign BH program area data to the designated BH service categories using the provider types,

Reporting Period 1/1/2014MCO NameReport Run Date

through 3/31/2014MCO A4/1/2014



service codes (with modifiers when applicable), and any other distinguishing criteria detailedwithin Addendum A.

c. BH add-on CPT codes are to be used in conjunction with the other CPT codes identified withineach applicable BH category. BH add-on CPT codes are not to be reported as stand-aloneservices.

2. Long-Term Care Program Member Utilizationa. Assign data to the LTC program area according to the provider types, service codes (and

modifiers as applicable), and any other distinguishing criteria detailed within Addendum C.b. Assign LTC program area data to the designated LTC service categories using the provider

types, service codes (with modifiers when applicable), and any other distinguishing criteriadetailed within Addendum C.

3. Physical Health Program Member Utilizationa. Assign data to the PH program area according to the provider types, service codes, and any

other distinguishing criteria detailed within Addendum B.b. Assign PH program area data to the designated PH service categories using the provider types,

service codes, and any other distinguishing criteria detailed within Addendum B.

Note that all program area/service category/service-specific utilization data is to be reported mutuallyexclusive of any other utilization reported within this report. Once data has been assigned to a particularservice within a program area-specific service category grouping, it is not to be reported within any otherprogram area categories within this report.

Value added services must be excluded from the data included within this report.

IDENTIFYING BEHAVIORAL HEALTH SERVICES

Be certain to report a behavioral service only once even if the service meets more than one of thefollowing definitions for identifying behavioral health services:

1. Exclude any billing provider type 363 and 344 (community based services and waiver services)

2. Include any service for which a billing or rendering provider is one of the following:

a. Type 301, 302, 303 (physicians) with specialty 026, 047, 050 (psychiatry, child psychiatry, oraddictionologist).

b. Type 316 CNP with specialty 097 (psychiatric).c. One of the following provider types:

204 Inpatient – Psych. Unit in General Hospital205 Inpatient – Freestanding Psych. Hospital216 Accredited Residential Facility (ARTC)217 Non-accredited Residential Facility (RTC)218 Treatment Foster Care I & II (TFC I & TFC II)219 Residential Non-JACHO Group Home (GH)343 Methadone Clinic



430 Behavioral Health Worker431 Psychologist, (Ph.D., Ed.D., Psy.D.)432 Behavioral Health Agency433 Clinic, Mental Health Center (DOH certified) CMHC435 LPCC (Licensed Professional Clinical Counselor*)436 LMFT (Licensed Marriage & Family Therapist*)437 Social Worker, LMSW (Licensed Master's Level SW*)438 Psychologist School Certified439 Psychologist Associate Licensed440 LADAC Licensed Alcohol & Drug Abuse Counselor443 Psychiatric Clinical Nurse Specialist444 LISW (Licensed Independent Social Worker)445 Counselor, Master's Level, Licensed446 Core Service Agency (CSA)922 BH added value service providers

3. Include any service identified with one of the following procedure codes:ServiceCode Service Title Modifiers

Range:95970,95974-95975; 96020; 96101-96103; 96110-96111; 96116; 96118-96120; 96125;96150-96155; 97532-97533; 90785-90899; 90901-90911.

Regardlessof modifiers

H0001 METHADONE CLINIC INITIAL MEDICAL EXAM Regardlessof modifiers

H0015 INTENSIVE OUTPATIENT (IOP) Regardlessof modifiers

H0019 BEHAVIORAL HEALTH; LONG-TERM RESIDENTIAL (NON-MEDICAL,NON-ACUTE CARE IN A RESIDENTIAL TREATMENT PROGRAMWHERE STAY IS TYPICALLY LONGER THAN 30 DAYS), WITHOUTROOM AND BOARD, PER DIEM


H0020 METHADONE CLINIC SERVICES Regardlessof modifiers

H0031 MH ASSESS BY NON-MD Regardlessof modifiers

H0033 PROVIDERS WITH FEDERAL SUBXONE CERTFICIATION Regardlessof modifiers

H0039 ASSER COM TX FACE-FACE/15MIN Regardlessof modifiers

H2010 COMPREHENSIVE MED SVC 15 MIN Regardlessof modifiers

H2011 CRISIS INTERVEN SVC, 15 MIN TELEPHONE Regardlessof modifiers



H2012 BH DAY TREAT, PER HR Regardlessof modifiers

H2014 BEHAVIOR MANAGEMENT Regardlessof modifiers

H2015 COMP COMM SUPP SVC, 15 MIN Regardlessof modifiers

H2016 COMP COMM SUPP SVC, PER DIEM Regardlessof modifiers

H2017 PSYSOC REHAB SVC, PER 15 MIN Regardlessof modifiers

H2030 RECOVERY SERVICES Regardlessof modifiers

H2033 MULTISYSTEMIC THERAPY (MST) Regardlessof modifiers

S5110 FAMILY SUPPORT SERVICES (HOME CARE TRAINING, ADULTS PER15 MINUTES)


S5145 FOSTER CARE THERAPEUTIC, PER DIEM Regardlessof modifiers

T1007 TREATMENT PLAN DEVELOPMENT HVT1007 TREATMENT PLAN DEVELOPMENT U8

4. Include any Claim Type – Outpatient (CT O) with one of the following Revenue Codes: 0912,0914, 0915, 0916, 0919, 1000, 1001, 1002, or 1005.

5. Include any claim with the following billing NPI number: 1740333160.

Unduplicated Member CountService Level Count members only once for each service. Members who receive

multiple services during the reporting period should be only counted oncefor each service received. An example is provided below.

Service Category Level Count members only once for each service category (e.g., Residential,Physician, ABCB) for the reporting period. Members who receive multipleservices within a category should only be counted once for that servicecategory. For members who receive services in another service categoryduring the reporting period, the member shall be counted in each servicecategory as an unduplicated member. An example is provided below.

Program Area Level Count members only once for each program area level (BH, PH andLTC). Members who receive services in multiple program areas duringthe reporting period shall be counted only once in each program area asan unduplicated member. An example is provided below.

Total MCO – Any Service inAny Program Area Level

Total unduplicated count of the MCO’s members who utilized anyprogram-area specific service during the applicable reporting period.

Total MCO Level Total unduplicated count of the MCO’s members for the applicablereporting period, regardless of whether the member utilized any services.



Example The following is an example for determining unduplicated member countsfor a member receiving physical health services.

An MCO member was seen at the Primary Care Physician’s (PCP’s)office and was transported via emergency ground ambulance to an acutecare Diagnosis Related Group (DRG) hospital with acute abdominal pain.The member was seen in the emergency room by an emergency room(ER) physician. The physician ordered an abdominal ultrasound and acomplete blood count (CBC). When the results returned, the patient wasdiagnosed with acute appendicitis. A surgical consult was done, and themember was scheduled for surgery as an out-patient. A chest x-ray, EKGand blood type and cross were ordered prior to surgery.

The member would be counted as an unduplicated member at thefollowing levels:

Program Area Level:

1. Physical Health – 1 Count

Service Category Level:

1. Physician Services – 1 Count2. Transportation Services – 1 Count3. Hospital Category – 1 Count

Service Level:

1. Physician Services (E&M Codes for PCP, ER physician; surgeon –other current procedural terminology (CPT) code) – 1 Count

2. Ground Ambulance (A0427) – 1 Count3. Outpatient Services (EKG) – 1 Count4. Laboratory (CBC, blood type and cross) – 1 Count5. Radiology (abdominal ultrasound, chest x-ray) – 1 Count6. Emergency Room – 1 Count

Section I: SummaryThis section of the report provides summary information of cumulative and aggregate data captured inSections III through V of the report. The summary section consists of multiple tabs that contain tables andcharts of aggregated data. This section of the report is useful for high level analysis and monitoringcumulative utilization of each program area of the report. The MCO’s name, the reporting period, and thereport run date must be entered on the top portion of the first worksheet. Data entry is not required in anyother field in this section of the report.

Summary - YTD Charts

Two separate unduplicated member counts are required to be input by the MCO within thissection of the report.



Ensure that the “Summary – YTD Charts” tab is selected. Enter the following unduplicated membercounts within the two yellow-shaded cells within the “Program Area – YTD Unduplicated Member Count”table.

1. Within the row labeled “ANY”, enter the total unduplicated count of the MCO’s members whoutilized any program-area specific service during the applicable reporting period.

2. Within the row labeled “TOTAL MCO”, enter the total unduplicated count of the MCO’s membersfor the applicable reporting period, regardless of whether the member utilized any services.

Please note that these two cells requiring data entry will only display the yellow shading if there are nocounts entered within the respective cells. Once a count is entered in the cell, the yellow shading will nolonger be visible.

Section II: AnalysisBefore entering data in the workbook, ensure that the “Analysis” tab is selected. This section of the reportcollects qualitative analysis regarding the utilization of services. Please respond to the following questionsin the analysis worksheet, taking into consideration the data reported for the reporting period. For eachquestion, identify any changes compared to previous reporting periods and trends over time and providean explanation of the identified changes. Additionally, describe any action plans or performanceimprovement activities addressing any negative changes found during the current reporting period orprevious reporting periods.

1. Identify and explain any trends observed within the reported data. As part of the explanation,describe any action steps/performance improvement measures to be taken to address thechanges. How does this compare to previous reporting periods? Please be specific to eachprogram area (Behavioral Health, Physical Health, and Long-Term Care).

2. For each program area (Behavioral Health, Physical Health, and Long-Term Care), discuss anyabnormalities, irregularities or exceptions that were observed in the quarter. An explanation is tobe provided that describes any action steps to be taken to address the issues. How does thiscompare to previous reporting periods?

3. Identify and explain any system changes that might have affected the reported data. Theexplanation should address the impact of the change on reported data in the current reportingperiod and the expected impacts to data to be reported in the next report submission. How doesthis compare to previous reporting periods? Please be specific to each program area (BehavioralHealth, Physical Health, and Long-Term Care).

4. Provide any additional information pertinent to the quarter. Please be specific to each programarea (Behavioral Health, Physical Health, and Long-Term Care).

5. Please list all services that were not utilized (0 in the total number of services row) for thereporting period. Please specify the applicable program area (Behavioral Health, Physical Health,and Long-Term Care), service category, and service. How does this compare to previousreporting periods?

6. Identify any strategies the MCO is using to address the lack of utilization associated with theservices identified in Question 5 above. Please be specific to each program area (BehavioralHealth, Physical Health, and Long-Term Care).

Section III: Behavioral Health UtilizationBefore entering data in the workbook, ensure that the “BH” tab is selected. This section of the reportcaptures utilization information on behavioral health services by each type of service/category based on



the date of service for paid claims. The services captured in this report include only services billed by aCPT, revenue or Healthcare Common Procedure Code (HCPC).

This section captures quarterly and year-to-date (YTD) data for each service and service categoryoutlined below. The MCO is required to restate previously submitted data. Reporting data in this mannerwill take advantage of the most recent look at the claims paid data, thus benefiting from the additionalmonths of claims paid run out.

PROGRAM AREA LEVEL – TOTAL BH – ALL CATEGORIES – ALL AGES

Row Header Row DescriptionTotal Number of UnduplicatedMembers Receiving Services atProgram Level (BH)

8 The total number of unduplicated members who receivedBH services during the reporting period based on the dateof service for paid claims. The MCO must manually enterdata for each reporting period and calculate the YTD count.The MCO must restate data for previous report periods.

Total Dollar Amount All ServiceCategories at Program Level(BH)

9 The total dollar amount expended on BH services duringthe reporting period based on date of service for paidclaims. Data entry is not required in this field.

PROGRAM AREA LEVEL – TOTAL BH – ALL CATEGORIES – AGE BREAKDOWN

Row Header Row DescriptionTotal Number of UnduplicatedMembers Receiving Services atProgram Level (BH)

14 The total number of unduplicated members (per each agegroup) who received BH services during the reportingperiod based on date of service for paid claims. The MCOmust manually enter data for each reporting period andcalculate the YTD count. The MCO must restate data forprevious report periods.

Total Dollar Amount All ServiceCategories at Program Level(BH)

15 The total dollar amount expended (per each age group) onBH services during the reporting period based on date ofservice for paid claims. Data entry is not required in thisfield.

For the Behavioral Health Utilization section only, the MCO must stratify data by age groups and servicecategories.

Age Groups

Member age classifications are based on the age of the member at the end of the reporting period.

Column Header Column DescriptionUnder 18 B,G,L,Q Members under the age of 18 as of the last day of the

reporting period.18-20 C,H,M,R Members between the age of 18 and 20 as of the last day

of the reporting period.



Column Header Column Description21-64 D,I,N,S Members between the age of 21 and 64 as of the last day

of the reporting period.65+ E,J,O,T Members 65 years or older as of the last day of the

reporting period.Total (Quarter) F,K,P,U These columns capture a quarterly total for each reporting

period. The MCO must restate the quarterly columns for anunduplicated count of members. All other quarterlycalculations do not require data entry from the MCO.

YTD V, W, X,Y, Z

These columns capture the year-to-date (YTD) totals foreach service and each age category. The MCO mustrestate the YTD columns for an unduplicated count ofmembers. All other YTD calculations do not require dataentry from the MCO.

Services and Service Categories

The table below outlines the service categories for this section of the report. Each service categorycontains a list of services relevant to the service category. At the end of each service category is asection that automatically calculates the total dollar amount paid for services per service category foreach age group and reporting period. The MCO is required to manually populate the total unduplicatedmember count for each service and service category level for each reporting period and YTD. Refer to thedefinitions section on calculating the unduplicated member count at the service category level.

Note: YTD unduplicated member count is not a summation of multiple quarters. The YTD must bedetermined independently from quarterly totals. See definition section for additional guidance.

Row Header RowNumber Description

Inpatient Services Category 18-94 BH services classified as inpatient services.Residential Services Category 98-150 BH services classified as residential services.Intensive Outpatient ServicesCategory

154-198 BH services classified as intensive outpatientservices.

Recovery Services Category 202-262 BH services classified as recovery services.Outpatient Services Category 266-622 BH services classified as outpatient services.

Each service listed in Column A requires the MCO to report the following information for each reportingperiod, based on the age of the member at the end of the reporting period and the date of service of paidclaims.

Note: The MCO must refer to Addendum A “Behavioral Health Codes and Categories” todetermine the appropriate unit calculation and codes for each service.

Row Header DescriptionTotal Number of Unduplicated MembersReceiving Service

The total number of unduplicated members receiving theservice for each age group and reporting period. The MCO



Row Header Descriptionmust report an unduplicated count of members for eachservice based on date of service for paid claims. Member ageclassifications are based on the age of the member at the endof the reporting period.

Total Number of Services The total number of services rendered based on a normalizedsum of service units for each age group and reporting period.Service units are converted into common unit types using themultiplier factor in Addendum A.

It is critical the MCO use correct unit calculations foraccurate reporting.

Service units based on minutes or 15 minute increments mustbe converted to hours when indicated in the unit value column.For example; one 15-minute unit, when instructed to bereported in the unit of an hour, would be reported as .25 units.

Service units based on days or per diem are reported as “perdiem” as indicated in the unit value column which is thenumber of days, not including a discharge day for an inpatientor residential stay.

Other unit types (session, visit and product) are reported asindicated in the unit value column.

[Unit Type] Per Client Receiving Service The total number of services divided by the total number ofunduplicated members receiving services for each age groupand reporting period. Data entry is not required in this field.

Note: The unit of measurement may differ from one service toanother. It is imperative the MCO reviews Addendum A todetermine the correct unit calculation for each service.

Total Dollar Amount for Service(s) The total MCO paid dollar amount for the service for each agegroup and reporting period.

Section IV: Physical Health UtilizationBefore entering data in the workbook, ensure that the “PH” tab is selected. This section of the reportcaptures utilization information on physical health services by each type of service/category based on thedate of service for paid claims. The services captured in this report include only services billed by aCPT, Current Dental Terminology (CDT), revenue or HCPC code.

This section captures quarterly and YTD data for each service and service category outlined below. TheMCO is required to restate previously submitted data. Reporting data in this manner will take advantageof the most recent look at the claims paid data, thus benefiting from the additional months of claims paidrun out.



PROGRAM AREA LEVEL – TOTAL PH – ALL CATEGORIES

Row Header Row DescriptionTotal Number of UnduplicatedMembers Receiving Services atProgram Level (PH)

8 The total number of unduplicated members who receivedPH services during the reporting period based on the dateof service for paid claims. The MCO must manually enterdata for each reporting period and calculate the YTD count.The MCO must restate data for previous report periods.

Total Dollar Amount All ServiceCategories at Program Level(PH)

9 The total dollar amount expended on PH services duringthe reporting period based on date of service for paidclaims. Data entry is not required in this field.


The table below outlines the service categories for this section of the report. Each service categorycontains a list of services relevant to the service category. At the end of each service category is asection that automatically calculates the total dollar amount paid for services per service category for thereporting period. The MCO is required to manually populate the total unduplicated member count for eachservice and service category level for each reporting period and YTD. Refer to the definitions section oncalculating the unduplicated member count at the service category level.



Hospital Services Category 12-96 PH services classified as hospital services.Other Facilities and ServicesCategory

100-144 PH services classified as other facilities and services.

Physician Services Category 148-192 PH services that are classified as physician services.Other Healthcare ServicesCategory

196-376 PH services classified as other healthcare physicianservices.

Ancillary Services Category 380-400 PH services classified as ancillary services.Transportation ServicesCategory

404-592 All services classified as transportation services.

Each service listed in Column A requires the MCO to report the following information for each reportingperiod, based on the date of service of paid claims.

Note: The MCO must refer to Addendum B “Physical Health Codes and Categories” to determinethe appropriate unit calculation and codes for each service.


The total number of unduplicated members receiving theservice for each reporting period. The MCO must report anunduplicated count of members for each service based on



Row Header Descriptiondate of service for paid claims.

Total Number of Services The total number of services rendered based on a normalizedsum of service units for each reporting period. Service unitsare converted into common unit types using the multiplierfactor in Addendum B.




Other unit types (session, visit, product, encounter, admission,diagnostic test, 1-way transport, mile, meal and payment) arereported as indicated in the unit value column.

[Unit Type] Per Client Receiving Service The total number of services divided by the total number ofunduplicated members receiving services for each reportingperiod. Data entry is not required in this field.

Note: The unit of measurement may differ from one service toanother service. It is imperative the MCO reviews AddendumB to determine the correct unit calculation for each service.

Total Dollar Amount for Service(s) The total MCO paid dollar amount for the service for eachreporting period.

Section V: Long-Term Care Benefit UtilizationBefore entering data in the workbook, ensure that the “LTC” tab is selected. This section of the reportcaptures utilization information on LTC services by each type of service/category based on the date ofservice for paid claims. The services captured in this report include only services billed by a CPT,revenue or HCPC code.

This section captures quarterly and YTD data for each service and service category outlined below. TheMCO is required to restate previously submitted data. Reporting data in this manner will take advantageof the most recent look at the claims paid data, thus benefiting from the additional months of claims paidrun out.

PROGRAM AREA LEVEL – TOTAL LTC – ALL CATEGORIES

Row Header Row Description



Row Header Row DescriptionTotal Number of UnduplicatedMembers Receiving Services atProgram Level (LTC)

8 The total number of unduplicated members who receivedLTC services during the reporting period based on date ofservice for paid claims. The MCO must manually enter datafor each reporting period and calculate the YTD count. TheMCO must restate data for previous report periods.

Total Dollar Amount All ServiceCategories at Program Level(LTC)

9 The total dollar amount expended on LTC services duringthe reporting period based on date of service for paidclaims. Data entry is not required in this field.


The table below outlines the service categories for this section of the report. Each service categorycontains a list of services relevant to the service category. At the end of each service category is asection that automatically calculates the total dollar amount paid for services per service category for thereporting period. The MCO is required to manually populate the total unduplicated member count for eachservice and service category level for each reporting period and YTD. Refer to the definitions section oncalculating the unduplicated member count at the service category level.



Nursing Facility ServicesCategory

12-48 LTC services classified as nursing facility services.

Agency-Based CommunityBenefit (ABCB) ServicesCategory

52-232 LTC services classified as ABCB services.

Self-Directed CommunityBenefit (SDCB) ServicesCategory

236-688 LTC services classified as SDCB services.

Each service listed in Column A requires the MCO to report the following information for each reportingperiod, based on the date of service of paid claims.

Note: The MCO must refer to Addendum C “Long-Term Care Codes and Categories” to determinethe appropriate unit calculation and codes for each service.


The total number of unduplicated members receiving theservice for each reporting period.

The MCO must report an unduplicated count of members foreach service based on date of service for paid claims.

Total Number of Services The total number of services rendered based on a normalized



Row Header Descriptionsum of service units for each reporting period. Service unitsare converted into common unit types using the multiplierfactor in Addendum C.




Other unit types (visit, session, per service, per project, day,month, mile, and invoice) are reported as indicated in the unitvalue column.

[Unit Type] Per Client Receiving Service The total number of services divided by the total number ofunduplicated members receiving services for each reportingperiod. Data entry is not required in this field.

Note: The unit of measurement may differ from one service toanother. It is imperative the MCO reviews Addendum C todetermine the correct unit calculation for each service.

Total Dollar Amount for Service(s) The total MCO paid dollar amount for the service for eachreporting period.



Addendum A: Behavioral Health Codes & Categories*ANY AGE UNLESS OTHERWISE SPECIFIED

Codes:Revenue, CPTand or HCPC

Modifier Unit Value Units Description Type and/or Age*Category

INPATIENT SERVICES CATEGORYInpatient Hospitalization – Psychiatric Free Standing or Psych. Unit – Facility Charges (INPATIENT Category)0114 Per Diem 1.00 Inpatient – Room & Board Provider Type 204 &

Provider Type 2050124 Per Diem 1.00 Inpatient – Room & Board Provider Type 204 &




Provider Type 2050204 Per Diem 1.00 Inpatient – Psych. ICU service Provider Type 201, 204,

& 205Inpatient Hospital Care – PH Services Performed by a BH Practitioner (INPATIENT Category)99221 Hour .50 Initial Hospital Care – New or Established

Patient – Low complexity, 30 minutesProvider must meet BHservice definition

99222 Hour 1.00 Initial Hospital Care – New or EstablishedPatient – Moderate Complexity, 50 minutes

Provider must meet BHservice definition

99223 Hour 1.25 Initial Hospital Care New or Established Patient– High Complexity, 70 minutes


99231 Hour .25 Subsequent Hospital Care, 15 minutes Provider must meet BHservice definition







99234 Hour .75 Observation or inpatient hospital care for theevaluation and management of patient – LowSeverity


99235 Hour 1.0 Observation or inpatient hospital care for theevaluation and management of patient –Moderate Level


99236 Hour 1.25 Observation or inpatient hospital care for theevaluation and management of patient –Moderate Level


Initial Inpatient Consultations – PH Services Performed by a BH Practitioner (INPATIENT Category)99251 Hour .50 Inpatient Consultation, 20 minutes Provider must meet BH

service definition99252 Hour .75 Inpatient Consultation, 40 minutes Provider must meet BH

service definition

99253 Hour 1.00 Inpatient Consultation, 55 minutes Provider must meet BHservice definition



Initial Observation Care, Per Day – PH Services Performed by a BH Practitioner (INPATIENT Category) Inpatient Hospitalizationrules apply to this section99217 Per Diem 1.00 Observation and discharge day management Provider must meet BH





service definition99218 Per Diem 1.00 Initial Observation Care per day – Low Severity Provider must meet BH

service definition99219 Per Diem 1.00 Initial Observation Care per day – Moderate

SeverityProvider Must meet BHservice definition

99220 Per Diem 1.00 Initial Observation Care per day – High Severity Provider must meet BHservice definition

Inpatient Professional Services – Nursing Facility PH Services Performed by a BH Practitioner (INPATIENT Category)99304 Hour .50 Initial evaluation and management – Low

Severity, 25 minutesProvider must meet BHservice definition

99305 Hour .75 Initial evaluation and management – ModerateSeverity, 35 minutes


99306 Hour .75 Initial evaluation and management – HighSeverity, 45 minutes


99307 Hour .25 Subsequent evaluation and management.Patient stable, recovering, or improving. 10minutes


99308 Hour .25 Subsequent evaluation and management.Patient not responding to therapy or minorcomplications have developed. 15 minutes


99309 Hour .50 Subsequent evaluation and management.Patient has developed significant complicationsor new problems. 25 minutes


99310 Hour .75 Subsequent evaluation and management. Highcomplications. Patient unstable or new,significant complications have developed. 35minutes






Room and Board – Psych. Awaiting Placement (DAP) – Free Standing or Psych. Unit (INPATIENT Category) InpatientHospitalization rules apply to this section0169 Per Diem 1.00 Inpatient Waiting Placement (DAP) Provider type 204 or

Provider type 205Hospital Discharge Services PH Service Performed by BH Provider (INPATIENT Category)99238 Hour .50 Hospital Discharge Day management 30

minutesProvider must meet BHservice definition

99239 Hour .50 Hospital Discharge Day management, 30minutes


Observation Room Free Standing or Psych. Unit (Facility Charges Only) (INPATIENT Category)0762 Per Diem 1.00 Observation Room, 23 hours Provider Type 204 or

Provider Type 205Other Behavioral Health Treatment/Services – Indian Health Service (IHS) & Tribal Facility (INPATIENT Category)0919 Per Diem 1.00 Inpatient Services – IHS & Tribal Facility IHS/638s Only Provider

type 221 or otherwiseknown to be an inpatientclaim from an IHS facility

RESIDENTIAL SERVICES CATEGORY – Services provided to under 21 onlyBH Accommodation – Group Home – (RESIDENTIAL Category)1005 Per Diem 1.00 Behavioral Health Accommodations – Group

Home<21

BH Accommodation – Residential Treatment (Accredited RTC) – (RESIDENTIAL Category)1001 Per Diem 1.00 Residential Treatment – Psych. <211002 Per Diem 1.00 Residential Treatment – SA <211000 Per Diem 1.00 Residential Treatment – Specialized

Populations<21

BH Accommodation – Residential Treatment (Non-Accredited RTC) – (RESIDENTIAL Category)0190 Per Diem 1.00 Non-Accredited Residential Treatment <21





Include only Providertype 217 Non AccreditedRTC

0191 Per Diem 1.00 Residential Treatment Facility – DESERT HILLSGIRLS TREATMENT UNIT ONLY

<21Include only Providertype 216 Accredited RTC

BH Accommodation – Residential Treatment (Sub Acute) – (RESIDENTIAL Category)0194 Per Diem 1.00 Sub-acute Hospital-based residential services

(For a residential service in an accreditedresidential treatment center that meets criteriaestablished by the MCO for sub-acute care –provided only under managed care – notincluded in FFS.)

<21

Foster Care Therapeutic (TFC I) – (RESIDENTIAL Category)S5145 Per Diem 1.00 Foster Care, Therapeutic, Per Diem Level I <21

Foster Care Therapeutic (TFC II) – (RESIDENTIAL Category)S5145 U1 Per Diem 1.00 Foster Care, Therapeutic, Per Diem Level II <21

INTENSIVE OUTPATIENT SERVICES CATEGORYIntensive Outpatient Program Services – (INTENSIVE OUTPATIENT Category)H0015 Hour 1.00 Alcohol and/or Drug Services; Intensive

Outpatient Program (IOP) – Substance Abuseor Integrated MH/SA

The provider must be aCSA (type 446), a CMHC(type 443) or aBehavioral HealthAgency (type 432)

T1007 U6 Product 1.00 Alcohol and/or Substance Abuse Services, The provider must be a





NOT PSRTreatment Plan Modification or Update Medicaid CSA (type 446), a CMHC

(type 443) or aBehavioral HealthAgency (type 432)

Multi-Systemic Therapy – (INTENSIVE OUTPATIENT Category)H2033 HO Hour 0.25 Multi-systemic Therapy for Juveniles, per 15

minutes – Masters (or higher) LevelAges >=10 to <=18The provider must be aCSA (type 446), a CMHC(type 443) or aBehavioral HealthAgency (type 432)

H2033 HN Hour 0.25 Multi-systemic Therapy for Juveniles, per 15minutes – Bachelor’s Level

Ages >=10 to <=18 Theprovider must be a CSA(type 446), a CMHC(type 443) or aBehavioral HealthAgency (type 432)

Partial Hospitalization – (INTENSIVE OUTPATIENT Category)0912 Per Diem 1.00 Partial Hospitalization Services For Provider Type 205

<=21For Provider Type 204 –any age

Hospital Outpatient Psychiatric Services – Outpatient Hospital Professional Component BH Services – (INTENSIVE OUTPATIENTCategory)0914 Session 1.00 Individual Therapy PROVIDER TYPE 204 or

2050915 Session 1.00 Family Therapy PROVIDER TYPE 204

(any age) or 205 (<21)0916 Session 1.00 Group Therapy PROVIDER TYPE 204 or





205RECOVERY SERVICES CATEGORYComprehensive Community Support Services – (RECOVERY Category)H2015 HM Hour 0.25 Comprehensive Community Support Services,

per 15 minutes; HM modifier is paraprofessionalor less than a bachelor’s)


H2015 HN Hour 0.25 Comprehensive Community Support Services,per 15 minutes; HN modifier is bachelor’s level


H2015 HO Hour 0.25 Comprehensive Community Support Services,per 15 minutes; HO is master’s level or above


Behavior Management Skills Development (BMS) – (RECOVERY Category)H2014 Hour 0.25 Skills Training and Development, per 15

minutes – Behavior Management <21

Adaptive Skills Building – (RECOVERY Category)H2014 U1 Hour 0.25 Adaptive Skills Building Training and

Development, per 15 minutesPsychosocial Rehab SVCS-PSR – (RECOVERY Category)H2017 Hour 0.25 Psychosocial Rehab Services, per 15 minutes >=18H2017 HQ or

blank

HQ justemphasizes that it isa groupservice

Hour 0.25 Psychosocial Rehab Services, per 15 minutes –Group or classroom

>=18

Family Support Services – (RECOVERY Category)S5110 Hour 0.25 Family Support Services CSA only





Recovery Services – (RECOVERY Category)H2030 Hour 0.25 Recovery Services CSA only

BH Respite Care Services – (RECOVERY Category)T1005 Hour 0.25 Respite Care Services For children and youth

up to 21 years of agediagnosed with a seriousemotional or behavioralhealth disorder, respiteservices are limited to720 hours per year or 30days.

The provider must beprovider type 218,Treatment Foster Careprovider or another BHprovider licensed forrespite.

OUTPATIENT SERVICES CATEGORY – Specialized BH ServicesPsychiatric Emergency Services – (OUTPATIENT Category)0459 Visit 1.00 Psychiatric Emergency Services (UNM ONLY) Provider Type 2010450 Visit 1.00 Emergency Service Provider type 204 or

provider type 205Assertive Community Treatment – (OUTPATIENT Category)H0039 U1 Hour 0.25 Assertive Community Treatment (face-to-face) >=18H0039 U2 Hour 0.25 Assertive Community Treatment (collateral) >=18H0039 U3 Hour 0.25 Assertive Community Treatment (assertive) >=18BH Day Treatment – (OUTPATIENT Category )





H2012 Per Diem 1.00 Behavior Health Day Treatment, per hour <21MH Assessment & Initial Treatment Plan Non Physician – (OUTPATIENT Category)H0031 U8 Product 1.00 Mental Health Assessment by non-physician –

Multi-disciplinary assessment and initialtreatment plan

CSAs – any age

Not part of PSRBH Treatment Plan Update – (OUTPATIENT Category)T1007 U8 Product 1.00 Alcohol and/or Substance Abuse Services,

Treatment Plan Modification or Update MedicaidCSAs - any age

Not part of PSRBrief Office Visit for Purpose of Monitoring or Changing Drug – (OUTPATIENT Category)M0064 Hour 0.25 Brief Office Visit for Drug Monitoring/Changing

RxCrisis Intervention – (OUTPATIENT Category)H2011 U6 Hour 0.25 Crisis Intervention Services Not part of PSR.H2011 U6 & U2 Hour 0.25 Crisis Intervention Services (face-to-face) Not part of PSR.H2011 U6 & U3 Hour 0.25 Crisis Intervention Services (mobile) Not part of PSR.Suboxone Induction – (OUTPATIENT Category)H0033 Product 1.00 Induction Phase of Suboxone Treatment >=16

Other Behavioral Health Treatment/Services – Indian Health Service (IHS) & Tribal Facility – (OUTPATIENT Category )0919 Per Diem 1.00 Other Behavioral Health Treatment/Services –

IHS or 638 Tribal FacilityOther Behavioral Health Treatment/Service – Federally Qualified Health Centers (FQHC) or Rural Health Clinics (OUTPATIENTCategory)0919 Per Diem 1.00 Behavioral Health Treatment Services – FQHC

or RHCCrisis Intervention – PSR – (OUTPATIENT Category)H2011 U1 Hour 0.25 Crisis Intervention Services, per 15 minutes 18 and above





With U8 orotherwiseknown tobe PSR

Crisis PSR – Telephone Provider must meet BHservice definition

PSRH2011 U2

With U8 orotherwiseknown tobe PSR

Hour 0.25 Crisis Intervention Services, per 15 minutesCrisis Face-to-Face/PSR

18 and abovePSR

H2011 U3With U8 orotherwiseknown tobe PSR

Hour 0.25 Crisis Intervention Services, per 15 minutesPSR (mobile)

18 and above

PSR

Group Psychotherapy – PSR (OUTPATIENT Category)90853 U8 Hour 0.25 Group Psychotherapy 18 and above

PSR

Use 90853 in conjunctionwith 90785 for specifiedpatient when grouppsychotherapy includesinteractive complexity.

90785 U8 Hour 0.25 Interactive Group Psychotherapy 18 and above

PSRIndividual Psychotherapy – PSR (OUTPATIENT Category)





90832 U8 Hour 0.50 Psychotherapy – 30 minutes 18 and above



90833 U8 Hour 0.50 Add on code 30 minutes with an E&M service 18 and above



MH Assessment & Initial Treatment Plan Non Physician – PSR – (OUTPATIENT Category)H0031 U8 Product 1.00 Mental Health Assessment by a non-physician

non-independently licensed in an agency –Medicaid PSRMaster Treatment Plan – annually assessed

18 and above

PSR

Specialized Consultation – PSR – (OUTPATIENT Category)90791 U8 Product 1.00 An initial evaluation provided by a non-physician 18 and above PSR90792 U8 Product 1.00 An initial evaluation provided by a physician 18 and above+ PSR90899 U8 Hour 0.25 Specialized consultation 18 and above+ PSRBH Treatment Plan Update – PSR – (OUTPATIENT Category)T1007 U8 Product 1.00 Alcohol and/or Substance Abuse Services,

Treatment Plan Modification or Update –Medicaid PSR

18 and above

Pharmacological Management – PSR – (OUTPATIENT Category)90863 U8 Hour 0.25 Add on Code – Pharmacological Management

when provided with psychotherapy18 and abovePSR





H2010 U8 Hour 0.25 Medication Monitoring 18 and above PSRIndividual Psychotherapy – non-PSR – (OUTPATIENT Category)90832 Do not

includemodifiersU8 or TR

Hour 0.50 Psychotherapy – 30 minutes

90834 Do notincludemodifiersU8 or TR





Hour 0.50 Add on code 30 minutes with an E&M service





Methadone Maintenance (OUTPATIENT Category)H0001 Product 1.00 Initial Medical Exam by Methadone Clinic

program physicianH0020 Product 1.00 Administering or dispensing methadone or other

narcotic replacement or agonist drug itemsAssessment of Aphasia w/Interpretation & Report – (OUTPATIENT Category)96105 Hour 1.00 Assessment of Aphasia with Interpretation and





Report, per hourDevelopmental Testing w/Interpretation & Report by BH Provider – (OUTPATIENT Category)96110 Hour 0.25 Developmental Testing with Interpretation and

ReportProvider must meet BHservice definition

96111 Hour 0.25 Developmental Testing, Extended Provider must meet BHservice definition

Family Psychotherapy – (OUTPATIENT Category)90846 Do not


Hour 0.25 Family Psychotherapy (without patient)


Hour 0.25 Family Medical Psychotherapy (with patient)

Functional Family Therapy – (OUTPATIENT Category)90846 HK Hour 0.25 Patient-Child/Adolescent

90847 HK Hour 0.25 Patient-Child/AdolescentGroup Psychotherapy – (OUTPATIENT Category)90853 Do not


Hour 0.25 Group Psychotherapy (other than multi-family) Use 90853 in conjunctionwith 90785 for specifiedpatient when grouppsychotherapy includesinteractive complexity.


Hour 0.25 Interactive Group Psychotherapy

Smoking and Tobacco – Counseling Visits – (OUTPATIENT Category)99406 Hour 0.25 Smoking and tobacco use cessation counseling Provider must meet BH





visit; greater than 3 minutes up to 10 minutes service definition99407 Hour 0.25 Smoking and tobacco use cessation counseling

visit; intensive, greater than 10 minutesProvider must meet BHservice definition

G0436 Hour 0.25 Smoking and tobacco cessation counseling visitfor the asymptomatic patient; intermediate,greater than 3 minutes, up to 10 minutes


G0437 Hour 0.25 Smoking and tobacco cessation counseling visitfor the asymptomatic patient; intensive, greaterthan 10 minutes


S9075 Hour 0.25 Smoking cessation treatment with a primarydiagnosis code of 305.1 (tobacco use disorder)


S9453 Hour 0.25 Smoking cessation classes, non-physicianprovider, per session


Multiple Family Group Psychotherapy – (OUTPATIENT Category)90849 Hour 0.25 Multiple – Family Group Medical PsychotherapyNarcosynthesis for Psych. Diag.TX – (OUTPATIENT Category)90865 Session 1.00 Narcosynthesis for Psychiatric Diagnostic and

therapeutic purposesNeurobehavioral Status w/Interpretation & Report – (OUTPATIENT Category)96116 Hour 1.00 Neurobehavioral Status ExamNeuropsychological Testing w/Interpretation & Report – (OUTPATIENT Category)96118 Hour 1.00 Neuropsychological Testing Interpretation &

Reporting per hour by a psychologist96119 Hour 1.00 Neuropsychological Testing per hour by a

technician96120 Product 1.00 Neuropsychological Testing by Computer96150 Product 1.00 Health and Behavior Assessment and

Intervention





96151 Product 1.00 Health and Behavior Reassessment andIntervention

Office/Outpatient Consultations – (OUTPATIENT Category)99241 Hour 0.25 Office or Other Outpatient Consultation, 15


99242 Hour 0.50 Office or Other Outpatient Consultation, 30minutes








Office/Outpatient Visits for Evaluation & Management – (OUTPATIENT Category)99201 Hour 0.25 Office or Other Outpatient Visit for the

evaluation and management of a new patientProvider must meet BHservice definition

99202 Hour 0.50 Outpatient Office Visit – New Patient, 20minutes








99211 Hour 0.25 Outpatient Office Visit – Established Patient, 5minutes




99213 Hour 0.25 Outpatient Office Visit – Established Patient, 15 Provider must meet BH





minutes service definition99214 Hour 0.50 Outpatient Office Visit – Established Patient, 25




Pharmacological Management – (OUTPATIENT Category)90863 Do not


Hour 0.25 Add on Code – Pharmacological Managementwhen provided with psychotherapy

H2010 Hour 0.25 Comprehensive Medication Services Provider must meet BHservice definition

Preparation of Report – (OUTPATIENT Category)90889 Product 1.00 Preparation of report of patient’s status, history,

treatment or progressProvider must meet BHservice definition

Prolonged Physician Service with Direct Patient Contact – (OUTPATIENT Category)99354 Hour 1.25 Prolonged Physician Service with Direct (face-

to-face) Patient Contact, 30-74 minutes – officeor outpatient setting


99355 Hour 1.25 Prolonged Physician Service with Direct (face-to-face) Patient Contact each additional 30minutes used in conjunction with 99354


99356 Hour 1.25 Prolonged Physician Service with Direct (face-to-face) Patient Contact, 30-74 minutes –Inpatient setting (list separately in conjunctionwith codes 99221-233


99357 Hour 1.25 Prolonged Physician Service with Direct (face-to-face) Patient Contact each additional 30minutes used in conjunction with 99356






Psychological Testing with w/Interpretation & Report (Hourly) – (OUTPATIENT Category)96101 Hour 1.00 Psychological Testing96102 Hour 1.00 Psychological Testing – by Technician96103 Hour 1.00 Psychological Testing – by ComputerPsychiatric Diagnostic Interview (Product) – (OUTPATIENT Category)90791 Do not


Product 1.00 An initial evaluation provided by a non-physician


Product 1.00 An initial evaluation provided by a physician

Family Psychotherapy – (OUTPATIENT Category – School Based Health Center (SBHC) Sub-Category)90846 TR Hour 0.25 Family Psychotherapy without patient present <2190847 TR Hour 0.25 Family Psychotherapy with patient School

Based<21

Group Psychotherapy – (OUTPATIENT Category – SBHC Sub-Category)90853 TR Hour 0.25 Group Psychotherapy School Based <21Individual Psychotherapy – (OUTPATIENT Category – SBHC Sub-Category)90832 TR Hour 0.50 Psychotherapy – 30 minutes <2190834 TR Hour 0.75 Psychotherapy – 45 minutes <2190837 TR Hour 1.00 Psychotherapy – 60 minutes <2190833 TR Hour 0.50 Add on code 30 minutes with an E&M service <2190836 TR Hour 0.75 Add on code 30 minutes with an E&M service <21

90838 TR Hour 1.00 Add on code 60 minutes with an E&M service <21Pharmacological Management – (OUTPATIENT Category – SBHC Sub-Category)90863 TR Hour 0.25 Add on Code – Pharmacological Management

when provided with psychotherapy<21





Psychiatric Diagnostic Interview (Product) – (OUTPATIENT Category – SBHC Sub-Category)90791 TR Product 1.00 An initial evaluation provided by a non-physician <2190792 TR Product 1.00 An initial evaluation provided by a physician <21School Based Screening – (OUTPATIENT Category – SBHC Sub-Category)T1023 TR Product 1.00 Screening and interpreting SHQ <21



Addendum B: Physical Health Codes & Categories*ANY AGE UNLESS OTHERWISE SPECIFIED

Service Code OtherCodes Unit Value Units Description Type and/or

Age* CategoryHOSPITAL SERVICES CATEGORYInpatient AdmissionsClaim Type Inpatient, DRGrange 001-999

Admission 1.00 DRG hospital stays per admission, unduplicated,per member (includes admissions which hit stoploss & become per diem/percentage of billedcharges except for transplants)

Provider Type201

Claim Type INPATIENT,DRG range 001-999

Admission 1.00 DRG – Other Hospital Stays per admission,unduplicated per member – per diem, LTACH, orChildren’s specialty hospital out-of-network(single-case agreements except for transplants)

Provider Type201 (andLTACH &children’sspecialtyhospitals whichmay beprovider type202 or 203 ifpaid at DRGamts)

Claim Type Inpatient Admission 1.00 Non-DRG – Other Hospital Stays per admission,unduplicated per member per diem, LTACH, orChildren’s specialty hospital; out-of-network(single-case agreements except for transplants)

Provider Type201 (andLTACH whichmay beprovider type202 or 203 notpaid at DRGamts)

Claim Type Inpatient Admission 1.00 Transplant – single-case agreement (includes up Provider Type




Age* Categoryto one year post-transplant care) 201

Claim Type Inpatient Admission 1.00 In-patient Rehabilitation Hospital – per admission,unduplicated per member

Provider Type202, 203 andknown to be aninpatient PHrehab hospitalor recognizedspecialty unit inan acute carehospital

Outpatient Hospital VisitsClaim Type OutpatientHospital Claim – Revenuecodes0280-0289, 0360-0369,0380-0399,0410-0449, 0460-0539,0700-0709, 0720-0769

Code isNOT anADA CDTcodeD0120-D9999

Visit 1.00 Out-Patient Services – Unduplicated, permember, excluding dental

Provider Type201

Claim Type Outpatienthospital0300-0319

Visit 1.00 Laboratory – Unduplicated, per member Provider Type201

Claim Type Outpatienthospital0320-0359, 0400-0409,0610-0622

Visit 1.00 Radiology – Unduplicated, per member Provider Type201

Claim Type outpatienthospital0450-0458

Visit 1.00 Emergency Room/Urgent Care – Unduplicated,per member

Provider Type201

Claim Type OutpatientHospital Revenue Codes

CDTCodes

Visit 1.00 Outpatient Dental Surgery – per member, one ormultiple procedures during one scheduled time

Provider Type201




Age* Category0360-0361 D0120-

D9999OTHER FACILITIES & SERVICES CATEGORYFQHC & RHC – Non-Dental and DentalRevenue Codes

0510, 0519, 05290521-0525, 0528

Code notan ADACDT codeD0120-D9999

Encounter 1.00 Number of visits, per encounter, unduplicatedClinic General ClassificationFree-standing ClinicFree-standing Clinic – Rural health

Provider Type313, 314

Revenue Codes

0510, 0512, 0519, 0529

Code ISan ADACDT codeD0120-D9999

Encounter 1.00 Number of visits, per encounter, unduplicatedClinic – Dental (counted exclusively from otherclinic visits)


Home HealthRevenue Codes0570-0609

Visit 1.00 Home Health visits, unduplicated, per member Provider Type361

HospiceRevenue Codes0650-0659

Visit 1.00 Hospice visits, unduplicated, per member Provider Type362

Dialysis FacilityRevenue Codes 0820-0859, 0880-0889

Visit 1.00 Dialysis Facility Services

PHYSICIAN SERVICES CATEGORYCPT Codes – 10021-69990, 90281-9074990935-99499;99460-99499

Visit 1.00 PCPs – Family Practice, General Practice,Internal Medicine, PediatricsPCPs w/Specialties – Gerontology, Obstetrics,Gynecology – unduplicated, per member

RenderingProvider Types301, 302 –Specialty 008,001, 041, 037,015, 016




Age* Category

Or if there is norenderingprovider, billingprovider type311, 312,

10021-69990, 90281-90749, 90935-99499,99460-99499

Visit 1.00 PCPs – Certified Nurse Practitioners, ClinicalNurse Specialist, Certified Nurse Midwives,Licensed midwives, Physician Assistants –unduplicated, per member

RenderingProvider Types316 other thanspecialty 097,306, 322, 323,305

10021-69990, 90281-90749, 90935-99499,99460-99499

Visit 1.00 Specialists – Oral Surgery, Lay Midwife,Podiatrist, ENT, Ophthalmologist, Cardiology,Dermatology, Endocrinology, Gastroenterology,General Surgery, Hematology/Oncology,Neurology, Orthopedic, Pain Control,Plastic/Reconstructive, Pulmonary,Rheumatology, Urology, Vascular – unduplicated,per member

RenderingProvider Types301 or 302 withone of thefollowingspecialties:002, 003, 004,005, 006, 007,010, 011, 012,013, 014, 017,018, 019, 020,021, 022, 023,024, 025, 027,028, 029, 030,032, 033, 034,036, 038, 039,040, 042, 043,044, 046, 048,




Age* Category049, 140, 141,142, 143, 144,145, 146, 147,148

Or one of thefollowing types:325

80047-89398 Diag. test 1.00 Pathology – professional component –unduplicated, per member

RenderingProvider Types301, 302, 303

70010-79999 Diag. test 1.00 Radiology – professional component –unduplicated, per member

RenderingProvider Types301, 302, 303

OTHER HEALTHCARE SERVICES CATEGORYVisit 1.00 Physical Therapy or Occupational Therapy –

unduplicated, per memberRenderingPhysicalTherapistProvider Type453 and 454

RenderingOccupationalTherapyProvider Type451 and 452

Or RenderingComprehensiveOutpatient




Age* CategoryRehab FacilityProvider Type455

Visit 1.00 Speech/Language Therapy – unduplicated, permember

RenderingSpeech/Language PathologistProvider Type457

HCPCS CodesV2100-V2299,V2500-V2531,V2715-V2799

CPT Codes92310-92317,92340, 92341, 92370,92371

Visit or item(such asglasses)

1.00 Vision Services – unduplicated, per member RenderingProvider Types334, 335

and

RenderingProvider Types301 and 302with Specialty018

Visit or itemsuch ashearing aid)

1.00 Hearing Services – unduplicated per member RenderingProvider Types412 and 331

Visit orservice

1.00 Dialysis Services RenderingProvider Type447

CaseManagement Services

1.00 Case Management Services by CaseManagement Agency

RenderingProvider Type462

S5135 Hour .25 Community Intervener, Companion, Adult Rendering




Age* CategoryCommunity (S5135) Provider Type

904Dental Services – Ages 20 and Under – Note that outpatient hospital claims may have these codes as the procedure code on theUB format – so do not include claims billed on the UB format under this sectionD0120-D0999 Visit 1.00 Diagnostic Services – unduplicated, per member Provider Types

421, 423Under age 21

D1000-D1999 Visit 1.00 Preventive Services – unduplicated, per member Provider Types421 423Under age 21

D2000-D2999 Visit 1.00 Restorative Services – unduplicated, per member Provider Types421, 423 Underage 21

D3000-D3999 Visit 1.00 Endodontic Services – unduplicated, per member Provider Types421, 423 Underage 21

D4000-D4999 Visit 1.00 Periodontic Services – unduplicated, per member Provider Types421, 423 Underage 21

D7000-D7999 Visit 1.00 Oral/Maxillofacial Surgery & Services –unduplicated, per member

Provider Types421, 423 Underage 21

D8000-D8999 Visit 1.00 Orthodontics – unduplicated, per member Provider Types421, 423 Underage 21

D9110-D9999 Visit 1.00 Adjunct Services – unduplicated, per member Provider Types421, 423 Underage 21

Dental Services – Ages 21 and Over – Note that outpatient hospital claims may have these codes as the procedure code on theUB format – do not include claims billed on the UB format under this section




Age* CategoryD0120-D0999 Visit 1.00 Diagnostic Services – unduplicated, per member Provider Types

421, 423; age21 and over

D1000-D1999 Visit 1.00 Preventive Services – unduplicated, per member Provider Types421, 423age 21 andover

D2000-D2999 Visit 1.00 Restorative Services – unduplicated, per member Provider Types421, 423age 21 andover

D3000-D3999 Visit 1.00 Endodontic Services – unduplicated, per member Provider Types421, 423 age21 and over

D4000-D4999 Visit 1.00 Periodontic Services – unduplicated, per member Provider Types421, 423 age21 and over

D7000-D7999 Visit 1.00 Oral/Maxillofacial Surgery & Services –unduplicated, per member

Provider Types421, 423 age21 and over

D9110-D9999 Visit 1.00 Adjunct Services – unduplicated, per member Provider Types421, 423 age21 and over

ANCILLARY SERVICES CATEGORYDME/ Supplies, Orthotics & Prosthetics

A4206-A9999B4034-B9999,E0100-E9999,J0120-J9999,

Product 1.00 Supplies and DevicesEnteral/Parenteral TherapyDME – EquipmentDrugs Administered Other Than Oral

ProviderType,414, 336,337, 338




Age* CategoryK0001-K0900

L0112-L9900 Product 1.00 OrthoticsProsthetics

Provider Type414, 336, 337,338

TRANSPORTATION SERVICES CATEGORYA0430 Each 1-Way

Transport1.00 Air Ambulance – Fixed Wing – unduplicated, per

memberProvider Type401

A0431 Each 1-WayTransport

1.00 Air Ambulance – Rotary Wing – unduplicated, permember

Provider Type401


1.00 Air Ambulance – Unlisted ambulance service (usefor other transports only, no supplies) –unduplicated, per member

Provider Type401


1.00 Ground Ambulance – ALS, Emergency, level 1 –unduplicated, per member

Provider Type402


1.00 Ground Ambulance – BLS, Emergency –unduplicated, per member

Provider Type402


1.00 Ground Ambulance – ALS, Non-Emergency, level2 – unduplicated, per member

Provider Type402


1.00 Ground Ambulance – ALS, Non-Emergency, level1 – unduplicated, per member

Provider Type402


1.00 Ground Ambulance – BLS, Non-Emergency –unduplicated, per member

Provider Type402


1.00 Ambulance Response & Treatment, no transport– unduplicated, per member

Provider Type402


1.00 Ambulance service, neonatal Transport,emergency – unduplicated, per member

Provider Type402


1.00 Paramedic intercept, rural area – unduplicated,per member

Provider Type402

A0434 Each 1-Way 1.00 Specialty Care Transport – unduplicated, per Provider Type




Age* CategoryTransport member 402

A0100-A0130 Each 1-WayTransport

1.00 Non-Emergency Transportation – Recipient –unduplicated, per member


T2001 Each 1-WayTransport

1.00 Non-Emergency Transportation – PatientAttendant/Escort – unduplicated, per member


A0080, A0090 Mile 1.00 Mileage Reimbursement, per mile – unduplicated,per member


Other Transportation NotReported under AboveCodes

Each 1-WayTransport

1.00 Other transportation not reported under abovecodes paid to transportation provider

Provider type402. 403, or404

Other Transportation NotReported under AboveCodes

EachPayment

1.00 Other transportation not reported under abovecodes paid directly to recipient

A0190 Meal 1.00 Meals – Recipient – unduplicated, per member Provider Type346

A0210 Meal 1.00 Meals – Escort – unduplicated, per member Provider Type346

A0180 Day 1.00 Lodging – Recipient – unduplicated, per member Provider Type346

A0200 Day 1.00 Lodging – Escort – unduplicated, per member Provider Type346

Other Meals and LodgingNot Reported Under AboveCodes

Eachpayment

1.00 Other meals and lodging not reported underabove codes paid to meals and lodging provider

Provider Type346

Other Meals and LodgingNot Reported under AboveCodes

Eachpayment

1.00 Other meals and lodging not reported underabove codes paid directly to recipient



Addendum C: Long-Term Care Codes & Categories*ANY AGE UNLESS OTHERWISE SPECIFIED

Service Code Modifier Unit Value Units Description Type and/orAge* Category

NURSING FACILITY SERVICES CATEGORYRevenue Code0190

None Admission 1.00 Nursing Facility, State owned– unduplicated, permember (includes short-term stays post-acutehospitalization)

Provider Type212

Revenue Code0199

None Admission 1.00 Nursing Facility, State owned – unduplicated, permember

Provider Type212

Revenue Code0190

None Admission 1.00 Nursing Facility, Private – unduplicated, permember (includes short-term stays post-acutehospitalization)

Provider Type211

Revenue Code0199

None Admission 1.00 Nursing Facility, Private – unduplicated, permember

Provider Type211

*ANY AGE UNLESS OTHERWISE SPECIFIED


AGENCY BASED COMMUNITY BENEFIT (ABCB) SERVICES CATEGORYAdult Day HealthS5100 Hour .25 Minimum of two hours per day or more days per

weekCommunityBenefitsProvider type363

Assisted Living




T2031 Month 1.00 The following services will not be provided torecipients in Assisted Living facilities: PersonalCare, Respite, Environmental Modifications,Emergency Response or Adult Day Health. TheAssisted Living Program is responsible for all ofthese services at the Assisted Living Facility.

CommunityBenefitsProvider type363

Community Transition ServicesT2038 Service 1.00 Community Transition Services do not include

monthly rental or mortgage expense, food, regularutility charges, and/or household appliances oritems that are intended for purelydiversional/recreational purposes. CommunityTransition Services are limited to $3,500 perperson every five years. In order to be eligible forthis service, the person must have a nursingfacility stay of at least 90 days prior totransition to the community.


Emergency ResponseS5161 Month 1.00 Eligible recipient must have a landline phone. Community

BenefitsProvider type363

Emergency Response High NeedS5161 U1 Month 1.00 Same service as above except this has a different

transmitter/receiver box that is voice activated.CommunityBenefitsProvider type363

Environmental Modification




S5165 Project 1.00 Environmental Modification services are limited tofive thousand dollars ($5,000) every five (5) years.Additional services may be requested if an eligiblerecipient’s health and safety needs exceed thespecified limit.


Behavior Support ConsultationH2019 Hour .25 Based on the eligible recipient’s care plan,

services are delivered in an integrated/naturalsetting or in a clinical setting.


Behavior Support Consultation, Clinic BasedH2019TT Hour .25 Clinic Based – same service as above except

services are delivered in a clinic settingCommunityBenefitsProvider type363

Employment SupportsH2024 Day 1.00 Payment shall not be made for incentive

payments, subsidies, or unrelated vocationaltraining expenses such as the following: 1)Incentive payments made to an employer toencourage or subsidize the employer'sparticipation in a supported employment program;2) Payments that are passed through to users ofsupported employment programs; or 3) Paymentsfor training that is not directly related to anindividual's supported employment program.Federal financial participation cannot be claimedto defray expenses associated with starting up oroperating a business.





Home Health Aide ServicesS9122 Hour 1.00 Community


Personal Care Services99509 Hour 1.00 Directed model Community


T1019 Hour .25 Delegated model CommunityBenefitsProvider type363

S5110 Hour .25 Training for Directed model only CommunityBenefitsProvider type363

G9006 Month 1.00 Administrative Fee for Directed model onlyPrivate Duty Nursing for AdultsT1002 Hour .25 All services provided under Private Duty Nursing

require the skills of a Licensed Registered Nurseor a Licensed Practical Nurse (LPN) underwrittenphysician’s order in accordance with the NewMexico Nurse Practice Act, Code of FederalRegulation for Skilled Nursing.


T1003 Hour .25 LPN – same service as above, but provided by aLPN

CommunityBenefitsProvider type



Service Code Modifier Unit Value Units Description Type and/orAge* Category363

T1002 U1 Hour .25 Respite RN (Registered Nurse) Services providea recipient’s primary caregiver with a limited leaveof absence. These services must be skilled andperformed by an RN or LPN


T1003 U1 Hour .25 Respite LPN services provide a recipient’sprimary caregiver with a limited leave of absence.These services must be skilled and performed byan RN or LPN


Respite Services99509 U1 Hour 1.00 Respite services are limited to a maximum of 100

hours annually per care plan year provided thereis a primary caretaker. Additional hours may berequested if an eligible recipient’s health andsafety needs exceed the specified limit.


For childrenand youth up to21 years of agediagnosed witha seriousemotional orbehavioralhealth disorder,respite servicesare limited to720 hours ayear or 30 days

Physical Therapy ServicesG0151 Hour .25 Community

Benefits



Service Code Modifier Unit Value Units Description Type and/orAge* CategoryProvider type363

Occupational Therapy ServicesG0152 Hour .25 Community


Speech Language TherapyG0153 Hour .25 Community


*ANY AGE UNLESS OTHERWISE SPECIFIED


SELF-DIRECTED COMMUNITY BENEFIT (SDCB) SERVICES CATEGORYCustomized Community SupportsS5100 Hour .25 Minimum of four hours per day or more days per

weekCommunityBenefitsProvider type363

Emergency ResponseS5161 Month 1.00 Monthly Fee

Eligible recipient must have a landline phoneCommunityBenefitsProvider type363

S5160 Each 1.00 Testing and maintenance Community



Service Code Modifier Unit Value Units Description Type and/orAge* CategoryBenefitsProvider type363

Environmental ModificationS5165 Project 1.00 Environmental Modification services are limited to

five thousand dollars ($5,000) every five (5) years.Additional services may be requested if an eligiblerecipient’s health and safety needs exceed thespecified limit.


Behavior Support ConsultationH2019 Hour .25 Based on the eligible recipient’s care plan,

services are delivered in an integrated/naturalsetting or in a clinical setting.


Employment SupportsT2019 Hour .25 Job Coach

Payment shall not be made for incentivepayments, subsidies, or unrelated vocationaltraining expenses such as the following: 1)Incentive payments made to an employer toencourage or subsidize the employer'sparticipation in a supported employment program;2) Payments that are passed through to users ofsupported employment programs; or 3) Paymentsfor training that is not directly related to anindividual's supported employment program.Federal financial participation cannot be claimedto defray expenses associated with starting up oroperating a business.





T2019 Each 1.00 Job developer T2019JD(FOCoSCommunityBenefitsProvider type363)

Home Health Aide ServicesS9122 Hour 1.00 Community


Homemaker/Direct Support99509 Hour 1.00 Community


Private Duty Nursing for AdultsT1002 Hour .25 All services provided under Private Duty nursing

require the skills of a Licensed Registered Nurseunderwritten physician’s order in accordance withthe New Mexico Nurse Practice Act, Code ofFederal Regulation for Skilled Nursing.


T1003 Hour .25 LPN – same service as above, but provided by aLPN


T1005 Hour .25 Respite RN Services provide a recipient’s primarycaregiver with a limited leave of absence. Theseservices must be skilled and performed by an RN.

T1005RN(FOCoS)Community




T1005 Hour .25 Respite LPN services provide a recipient’sprimary caregiver with a limited leave of absence.These services must be skilled and performed byan LPN.

T1005LPN(FOCoS)CommunityBenefitsProvider type363

Respite Services T1005 Hour .25 Standard Respite services are limited to a

maximum of 100 hours annually per care planyear provided there is a primary caretaker.Additional hours may be requested if an eligiblerecipient’s health and safety needs exceed thespecified limit.

T1005SD(FOCoS)CommunityBenefitsProvider type363

For childrenand youth up to21 years of agediagnosed witha seriousemotional orbehavioralhealth disorder,respiteservices arelimited to 720hours a year or30 days




T1005 Hour .25 Respite services provided by a Home Health Aide T1005HHA(FOCoS)CommunityBenefitsProvider type363

Physical Therapy ServicesG0151 Hour .25 Community


Occupational Therapy ServicesG0152 Hour .25 Community


Speech Language TherapyG0153 Hour .25 Community


Nutritional CounselingS9470 Hour 1.00 Adults Community


Specialized Therapy Services – Acupuncture97810 Hour .25 Acupuncture Community

BenefitsProvider type




Specialized Therapy Services – Biofeedback90901 Visit 1.00 Biofeedback Community


Specialized Therapy Services – Chiropractic98940 Visit 1.00 Chiropractic Community


Specialized Therapy Services – Cognitive Rehab Therapy97532 Hour .25 Cognitive Rehab Therapy Community


Specialized Therapy Services – HippotherapyS8940 Visit 1.00 Hippotherapy Community


Specialized Therapy Services – Massage Therapy97124 Hour .25 Massage Therapy Community


Specialized Therapy Services – NaprapathyS8990 Visit 1.00 Naprapathy Community





Specialized Therapy Services – Native American HealingS9445 Session 1.00 Native American Healing Community


Transportation TimeT2007 Hour 1.00 Non-medical Community


Transportation TripT2003 Each 1.00 Non-medical Community


Transportation MileT2049 Mile 1.00 Non-medical Community


Transportation Commercial Carrier Pass T2004 Each 1.00 Non-medical Community


Related Goods – T1999T1999CP-I Invoice 1.00 Fees and Memberships Community





T1999CE-I Invoice 1.00 Coaching/Education for Parents, Spouse orothers (not available for paid caregivers)


T1999CL-I Invoice 1.00 Coaching/Education for Parents, Spouse orothers-classes only (not available for paidcaregivers)


T1999CS-I Invoice 1.00 Coaching/Education for Parents, Spouse orothers-conferences and seminars (not availablefor paid caregivers)


T1999TS Each 1.00 Technology for Safety and Independence CommunityBenefitsProvider type363

T1999CELL Each 1.00 Cell Phone Service CommunityBenefitsProvider type363

T1999CPEP Each 1.00 Cell Phone and Related Equipment CommunityBenefitsProvider type363

T1999CPL Each 1.00 Cell Phone/Landline CommunityBenefitsProvider type363

T1999IS Each 1.00 Internet Service Community




T1999LS Each 1.00 Landline Service CommunityBenefitsProvider type363

T1999IC Each 1.00 Internet/Cell Phone CommunityBenefitsProvider type363

T1999ICL Each 1.00 Internet/Cell Phone/Landline CommunityBenefitsProvider type363

T1999IL Each 1.00 Internet/Landline CommunityBenefitsProvider type363

T1999FX Each 1.00 Fax Machine CommunityBenefitsProvider type363

T1999CR Each 1.00 Computer CommunityBenefitsProvider type363

T1999OS Each 1.00 Office Supplies CommunityBenefitsProvider type




T1999PR Each 1.00 Printer CommunityBenefitsProvider type363

T1999HR-I Invoice 1.00 Health-Related Equipment and Supplies CommunityBenefitsProvider type363

T1999AE-I Invoice 1.00 Adaptive Equipment and Supplies CommunityBenefitsProvider type363

T1999EE-I Invoice 1.00 Exercise Equipment and Related Items CommunityBenefitsProvider type363

T1999NS-I Invoice 1.00 Nutritional Supplements CommunityBenefitsProvider type363

T1999OM-I Invoice 1.00 Over the Counter Medications CommunityBenefitsProvider type363

T1999HG-I Invoice 1.00 Household Related Goods CommunityBenefitsProvider type363

T1999AI-I Invoice 1.00 Appliances for Independence Community




T1999AF-I Invoice 1.00 Adaptive Furniture CommunityBenefitsProvider type363

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