CODES AND RATES FOR COVID-19 CRISIS EVENT FY 19-21
24-Hour Access to Care- 877-685-2415 Business Administrative Matters - 866.998.2597
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
99441 CRPhysician Telephone Patient Service, 5-10 min, COVID-19
Medicaid B 001 Physician per event $ 16.82 3/10/2020 TBD
99441 CRPhysician Telephone Patient Service, 5-10 min, COVID-19
Medicaid B 112 CNP per event $ 14.30 3/10/2020 TBD
99441 CRPhysician Telephone Patient Service, 5-10 min, COVID-19
Medicaid B 999 Physician Assistant per event $ 14.30 3/10/2020 TBD
99442 CR Phone E/M Phys/QHP 11-20 min, COVID-19 Medicaid B 001 Physician per event $ 33.50 3/10/2020 TBD
99442 CR Phone E/M Phys/QHP 11-20 min, COVID-19 Medicaid B 112 CNP per event $ 28.48 3/10/2020 TBD
99442 CR Phone E/M Phys/QHP 11-20 min, COVID-19 Medicaid B 999 Physician Assistant per event $ 28.48 3/10/2020 TBD
99443 CR Phone E/M 21-30 min, COVID-19 Medicaid B 001 Physician per event $ 75.00 3/10/2020 TBD
99443 CR Phone E/M 21-30 min COVID-19 COVID-19 Medicaid B 112 CNP per event $ 63.75 3/10/2020 TBD
99443 CR Phone E/M 21-30 min COVID-19 COVID-19 Medicaid B 999 Physician Assistant per event $ 63.75 3/10/2020 TBD
98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19
Medicaid B 109Licensed Doctoral Psychologist
per event $ 17.41 3/10/2020 TBD
98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19
Medicaid B 110 LCSW, LPC & LMFT per event $ 13.06 3/10/2020 TBD
98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19
Medicaid B 111Certified Clinical Nurse Specialist
per event $ 17.41 3/10/2020 TBD
98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19
Medicaid B 112 CNP per event $ 17.41 3/10/2020 TBD
98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19
Medicaid B 999 Physician Assistant per event $ 17.41 3/10/2020 TBD
98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19
Medicaid B 998Provisionally and Associate Level Licensed
per event $ 13.06 3/10/2020 TBD
98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19
Medicaid B 001 Physician per event $ 17.41 3/10/2020 TBD
Page 2 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19
Medicaid B 128 LPA per event $ 13.06 3/10/2020 TBD
98966 CRTelephone Assessment & Management provided by qualified helath care professional to established patient, 5-10, COVID-19
Medicaid B 129 LCAS per event $ 13.06 3/10/2020 TBD
98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19
Medicaid B 109Licensed Doctoral Psychologist
per event $ 34.82 3/10/2020 TBD
98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19
Medicaid B 110 LCSW, LPC & LMFT per event $ 26.12 3/10/2020 TBD
98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19
Medicaid B 111Certified Clinical Nurse Specialist
per event $ 34.82 3/10/2020 TBD
98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19
Medicaid B 112 CNP per event $ 34.82 3/10/2020 TBD
98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19
Medicaid B 999 Physician Assistant per event $ 34.82 3/10/2020 TBD
98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19
Medicaid B 998Provisionally and Associate Level Licensed
per event $ 26.12 3/10/2020 TBD
98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19
Medicaid B 001 Physician per event $ 34.82 3/10/2020 TBD
98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19
Medicaid B 128 LPA per event $ 26.12 3/10/2020 TBD
98967 CRTelephone Assessment & Management Service, 11-20 Minutes of Medical Discussion, COVID-19
Medicaid B 129 LCAS per event $ 26.12 3/10/2020 TBD
98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19
Medicaid B 109Licensed Doctoral Psychologist
per event $ 52.24 3/10/2020 TBD
98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19
Medicaid B 110 LCSW, LPC & LMFT per event $ 39.18 3/10/2020 TBD
98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19
Medicaid B 111Certified Clinical Nurse Specialist
per event $ 52.24 3/10/2020 TBD
98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19
Medicaid B 112 CNP per event $ 52.24 3/10/2020 TBD
98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19
Medicaid B 999 Physician Assistant per event $ 52.24 3/10/2020 TBD
Page 3 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19
Medicaid B 998Provisionally and Associate Level Licensed
per event $ 39.18 3/10/2020 TBD
98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19
Medicaid B 001 Physician per event $ 52.24 3/10/2020 TBD
98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19
Medicaid B 128 LPA per event $ 39.18 3/10/2020 TBD
98968 CRTelephone Assessment & Management Service, 21-30 Minutes of Medical Discussion, COVID-19
Medicaid B 129 LCAS per event $ 39.18 3/10/2020 TBD
99421 CR OL DIG E/M SVC 5-10 MIN, COVID-19 Medicaid B 112 CNP per event $ 18.88 3/10/2020 TBD
99421 CR OL DIG E/M SVC 5-10 MIN, COVID-19 Medicaid B 001 Physician per event $ 18.88 3/10/2020 TBD
99421 CR OL DIG E/M SVC 5-10 MIN, COVID-19 Medicaid B 999 Physician Assistant per event $ 18.88 3/10/2020 TBD
99422 CR OL DIG E/M SVC 11-20 MIN, COVID-19 Medicaid B 112 CNP per event $ 37.70 3/10/2020 TBD
99422 CR OL DIG E/M SVC 11-20 MIN, COVID-19 Medicaid B 001 Physician per event $ 37.70 3/10/2020 TBD
99422 CR OL DIG E/M SVC 11-20 MIN, COVID-19 Medicaid B 999 Physician Assistant per event $ 37.70 3/10/2020 TBD
99423 CR OL DIG E/M SVC 21+ MIN, COVID-19 Medicaid B 112 CNP per event $ 60.92 3/10/2020 TBD
99423 CR OL DIG E/M SVC 21+ MIN, COVID-19 Medicaid B 001 Physician per event $ 60.92 3/10/2020 TBD
99423 CR OL DIG E/M SVC 21+ MIN, COVID-19 Medicaid B 999 Physician Assistant per event $ 60.92 3/10/2020 TBD
99446 CR NTRPROF PH1/NTRNET/EHR 5-10, COVID-19 Medicaid B 001 Physician per event $ 22.50 3/10/2020 TBD
99447 CR NTRPROF PH1/NTRNET/EHR 11-20, COVID-19 Medicaid B 001 Physician per event $ 45.42 3/10/2020 TBD
99448 CR NTRPROF PH1/NTRNET/EHR 21-30, COVID-19 Medicaid B 001 Physician per event $ 67.92 3/10/2020 TBD
99449 CR NTRPROF PH1/NTRNET/EHR 31/>, COVID-19 Medicaid B 001 Physician per event $ 90.50 3/10/2020 TBD
Page 4 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
H2017 CRIndividual Rehabilitation, Coordination and Support, COVID-19, DIRCS
Medicaid Bper 15 min unit
$ 5.50 3/31/2020 1/31/2021
H2017 CRIndividual Rehabilitation, Coordination and Support, COVID-19, DIRCS
Medicaid Bper 15 min unit
$ 5.50 2/1/2021 TBD
T2013 TF CRCommunity Living & Supports Crisis/Disaster Related, COVID-19
Medicaid Bper 15 min unit
$ 5.84 4/1/2020 6/30/2022
T2013 TF HQ CRCommunity Living & Supports Group Crisis/Disaster Related, COVID-19
Medicaid Bper 15 min unit
$ 3.26 4/1/2020 6/30/2022
H0020 CR Opiod Treatment Crisis/Disaster Related, COVID-19 Medicaid B per day $ 2,200.00 3/13/2020 6/30/2020
YP760 CR Group Living Low, COVID-19 State per day $ 71.88 3/23/2020 6/30/2021
YP770 CR Group Living Mod, COVID-19 State per day $ 75.67 3/23/2020 6/30/2021
YP770 HG CR Group Living Mod CURES, COVID-19 State per day $ 75.67 3/23/2020 6/30/2021
YP710 CR Supervised Living Low, COVID-19 State per day $ 37.60 3/23/2020 6/30/2021
YP720 CR Supervised Living Mod, COVID-19 State per day $ 70.10 3/23/2020 6/30/2021
YP720 HG CR Supervised Living Mod CURES, COVID-19 State per day $ 70.10 3/23/2020 6/30/2021
YP780 CR Group Living High, COVID-19 State per day $ 183.96 3/23/2020 6/30/2021
S9484 CR Facility Based Crisis, COVID-19 Stateper 15 min unit
$ 20.71 3/23/2020 1/31/2021
S9484 CR Facility Based Crisis, COVID-19 Stateper 15 min unit
$ 16.73 2/1/2021 6/30/2021
S9484 HA CR Facility Based Crisis-Child, COVID-19 Stateper 15 min unit
$ 20.71 3/23/2020 1/31/2021
S9484 HA CR Facility Based Crisis-Child, COVID-19 Stateper 15 min unit
$ 16.73 2/1/2021 6/30/2021
S9484 CR Facility Based Crisis, COVID-19 Stateper 15 min unit
$ 30.00 7/1/2021 6/30/2022
S9484 HA CR Facility Based Crisis-Child, COVID-19 Stateper 15 min unit
$ 30.00 7/1/2021 6/30/2022
T2016 U1 U5 CR CLFS Level 1, COVID-19 Medicaid B per day $ 109.20 3/23/2020 12/31/2020
T2016 U1 U5 CR CLFS Level 1, COVID-19 Medicaid B per day $ 96.60 1/1/2021 6/30/2022
Page 5 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
T2016 U2 U5 CR CLFS Level 2, COVID-19 Medicaid B per day $ 140.40 3/23/2020 12/31/2020
T2016 U2 U5 CR CLFS Level 2, COVID-19 Medicaid B per day $ 124.20 1/1/2021 6/30/2022
T2016 U3 U5 CR CLFS Level 3, COVID-19 Medicaid B per day $ 153.40 3/23/2020 12/31/2020
T2016 U3 U5 CR CLFS Level 3, COVID-19 Medicaid B per day $ 135.70 1/1/2021 6/30/2022
T2016 U4 U5 CR CLFS Level 4, COVID-19 Medicaid B per day $ 166.40 3/23/2020 12/31/2020
T2016 U4 U5 CR CLFS Level 4, COVID-19 Medicaid B per day $ 147.20 1/1/2021 6/30/2022
T2016 U5 CR CLFS Level 5, COVID-19 Medicaid B per day $ 179.67 3/23/2020 12/31/2020
T2016 U5 CR CLFS Level 5, COVID-19 Medicaid B per day $ 158.94 1/1/2021 6/30/2022
S9484 CR Facility Based Crisis, COVID-19 Medicaid Bper 15 min unit
$ 20.71 3/23/2020 1/31/2021
S9484 CR Facility Based Crisis, COVID-19 Medicaid Bper 15 min unit
$ 16.73 2/1/2021 6/30/2021
S9484 HA CR Facility Based Crisis-Child, COVID-19 Medicaid Bper 15 min unit
$ 20.71 3/23/2020 1/31/2021
S9484 HA CR Facility Based Crisis-Child, COVID-19 Medicaid Bper 15 min unit
$ 16.73 2/1/2021 6/30/2021
S9484 CR Facility Based Crisis, COVID-19 Medicaid Bper 15 min unit
$ 30.00 7/1/2021 6/30/2022
S9484 HA CR Facility Based Crisis-Child, COVID-19 Medicaid Bper 15 min unit
$ 30.00 7/1/2021 6/30/2022
S5145 CR Residential Treatment Level 2, COVID-19 Medicaid B per day $ 101.87 3/23/2020 4/30/2021
S5145 HK CR IAFT, COVID-19 Medicaid B per day $ 265.79 3/23/2020 4/30/2021
H0019 HQ CR Residential Level 3 (1-4 bed), COVID-19 Medicaid B per day $ 302.74 3/23/2020 12/31/2020
H0019 HQ CR Residential Level 3 (1-4 bed), COVID-19 Medicaid B per day $ 267.81 1/1/2021 4/30/2021
H0019 UR CR Residential Level 4 (5+ bed), COVID-19 Medicaid B per day $ 410.42 3/23/2020 12/31/2020
H0019 UR CR Residential Level 4 (5+ bed), COVID-19 Medicaid B per day $ 363.06 1/1/2021 4/30/2021
H0019 HK CR Residential Level 4 (1-4 bed), COVID-19 Medicaid B per day $ 410.42 3/23/2020 12/31/2020
Page 6 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
H0019 HK CR Residential Level 4 (1-4 bed), COVID-19 Medicaid B per day $ 363.06 1/1/2021 4/30/2021
H0019 TJ CR Residential Level 3 (5+ bed), COVID-19 Medicaid B per day $ 246.68 3/23/2020 12/31/2020
H0019 TJ CR Residential Level 3 (5+ bed), COVID-19 Medicaid B per day $ 218.22 1/1/2021 4/30/2021
H0019 YA CR Residential Level 3 (1-4 bed) SA Youth, COVID-19 Medicaid B per day $ 435.50 3/23/2020 12/31/2020
H0019 YA CR Residential Level 3 (1-4 bed) SA Youth, COVID-19 Medicaid B per day $ 385.25 1/1/2021 4/30/2021
T2014 CR Res Support Level 2, COVID-19Medicaid Innovations
per day $ 176.06 3/23/2020 12/31/2020
T2014 CR Res Support Level 2, COVID-19Medicaid Innovations
per day $ 155.74 1/1/2021 6/30/2022
T2014 CG CR Res S Lev 2 AF, COVID-19Medicaid Innovations
per day $ 176.06 3/23/2020 12/31/2020
T2014 CG CR Res S Lev 2 AF, COVID-19Medicaid Innovations
per day $ 155.74 1/1/2021 6/30/2022
T2020 CR Res Support Level 3, COVID-19Medicaid Innovations
per day $ 202.09 3/23/2020 12/31/2020
T2020 CR Res Support Level 3, COVID-19Medicaid Innovations
per day $ 178.77 1/1/2021 6/30/2022
T2020 CG CR Res Support Level 3 AFL, COVID-19Medicaid Innovations
per day $ 202.09 3/23/2020 12/30/2020
T2020 CG CR Res Support Level 3 AFL, COVID-19Medicaid Innovations
per day $ 178.77 1/1/2021 6/30/2022
T2016 HI CR Residential Supports, COVID-19Medicaid Innovations
per day $ 278.30 3/23/2020 12/31/2020
T2016 HI CR Residential Supports, COVID-19Medicaid Innovations
per day $ 246.19 1/1/2021 6/30/2022
T2016 HI CG CR Res Supports Level 5 AFL, COVID-19Medicaid Innovations
per day $ 285.16 3/23/2020 12/31/2020
T2016 HI CG CR Res Supports Level 5 AFL, COVID-19Medicaid Innovations
per day $ 252.25 1/1/2021 6/30/2022
T2033 CR Supported Living, COVID-19Medicaid Innovations
per day $ 198.21 3/23/2020 12/31/2020
T2033 CR Supported Living, COVID-19Medicaid Innovations
per day $ 175.34 1/1/2021 6/30/2022
T2033 U1 CR Supported Living, COVID-19Medicaid Innovations
per 15 min unit
$ 6.12 3/23/2020 12/31/2020
T2033 U1 CR Supported Living, COVID-19Medicaid Innovations
per 15 min unit
$ 5.41 1/1/2021 6/30/2022
Page 7 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
T2033 TF CR Supported Living, COVID-19Medicaid Innovations
per day $ 279.72 3/23/2020 12/31/2020
T2033 TF CR Supported Living, COVID-19Medicaid Innovations
per day $ 247.44 1/1/2021 6/30/2022
T2033 U2 CR Supported Living, COVID-19Medicaid Innovations
per 15 min unit
$ 6.12 3/10/2020 12/31/2020
T2033 U2 CR Supported Living, COVID-19Medicaid Innovations
per 15 min unit
$ 5.41 1/1/2021 6/30/2022
T2033 HI CR Supported Living, COVID-19Medicaid Innovations
per day $ 239.32 3/23/2020 12/31/2020
T2033 HI CR Supported Living, COVID-19Medicaid Innovations
per day $ 211.70 1/1/2021 6/30/2022
H2016 CR Res Supports Level 1, COVID-19Medicaid Innovations
per day $ 135.17 3/23/2020 12/31/2020
H2016 CR Res Supports Level 1, COVID-19Medicaid Innovations
per day $ 119.57 1/1/2021 6/30/2022
H2016 CG CR Res Supports Level 1 AFL, COVID-19Medicaid Innovations
per day $ 135.17 3/23/2020 12/31/2020
H2016 CG CR Res Supports Level 1 AFL, COVID-19Medicaid Innovations
per day $ 119.57 1/1/2021 6/30/2022
H2016 HI CR Res Supports Level 4, COVID-19Medicaid Innovations
per day $ 228.10 3/23/2020 12/31/2020
H2016 HI CR Res Supports Level 4, COVID-19Medicaid Innovations
per day $ 201.78 1/1/2021 6/30/2022
H2016 HI CG CR Res Supports Level 4 AFL, COVID-19Medicaid Innovations
per day $ 228.10 3/23/2020 12/31/2020
H2016 HI CG CR Res Supports Level 4 AFL, COVID-19Medicaid Innovations
per day $ 201.78 1/1/2021 6/30/2022
T2013 TF CR Community Living Supports (CLS), COVID-19Medicaid Innovations
per 15 min unit
$ 5.84 4/1/2020 6/30/2022
T2013 TF HQ CR Community Living Supports GROUP (CLS), COVID-19Medicaid Innovations
per 15 min unit
$ 3.26 4/1/2020 6/30/2022
T2013 TF U4 CR B3- Community Living Supports (CLS), COVID-19 Medicaid B3per 15 min unit
$ 5.84 4/1/2020 6/30/2022
T2013 TF HQ U4 CRB3- Community Living Supports GROUP (CLS), COVID-19
Medicaid B3per 15 min unit
$ 3.26 4/1/2020 6/30/2022
T2014 CG U4 CR B3- Res Support Level 2 AFL, COVID-19 Medicaid B3 per day $ 176.06 3/23/2020 12/31/2020
T2014 CG U4 CR B3- Res Support Level 2 AFL, COVID-19 Medicaid B3 per day $ 155.74 1/1/2021 6/30/2022
T2014 U4 CR B3- Res S L 2, COVID-19 Medicaid B3 per day $ 176.06 3/23/2020 12/31/2020
Page 8 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
T2014 U4 CR B3- Res S L 2, COVID-19 Medicaid B3 per day $ 155.74 1/1/2021 6/30/2022
T2020 U4 CR B3- Res Support Level 3, COVID-19 Medicaid B3 per day $ 202.09 3/23/2020 12/31/2020
T2020 U4 CR B3- Res Support Level 3, COVID-19 Medicaid B3 per day $ 178.77 1/1/2021 6/30/2022
T2020 CG U4 CR B3- Res Support Level 3 AFL, COVID-19 Medicaid B3 per day $ 202.09 3/23/2020 12/31/2020
T2020 CG U4 CR B3- Res Support Level 3 AFL, COVID-19 Medicaid B3 per day $ 178.77 1/1/2021 6/30/2022
H2016 HI U4 CR B3- Res Supports Level 4, COVID-19 Medicaid B3 per day $ 228.10 3/23/2020 12/31/2020
H2016 HI U4 CR B3- Res Supports Level 4, COVID-19 Medicaid B3 per day $ 201.78 1/1/2021 6/30/2022
H2016 HI CG U4 CR B3- Res Supports Level 4 AFL, COVID-19 Medicaid B3 per day $ 228.10 3/23/2020 12/31/2020
H2016 HI CG U4 CR B3- Res Supports Level 4 AFL, COVID-19 Medicaid B3 per day $ 201.78 1/1/2021 6/30/2022
H2016 U4 CR B3- Res Supports Level 1, COVID-19 Medicaid B3 per day $ 135.17 3/23/2020 12/31/2020
H2016 U4 CR B3- Res Supports Level 1, COVID-19 Medicaid B3 per day $ 119.58 1/1/2021 6/30/2022
S5135 U5 GTHome Monitoring through Virtual Supervision Systems, COVID-19
Medicaid Bper 15 min unit
$ 6.00 4/3/2020 6/30/2022
YA400 GT CRHome Monitoring through Virtual Supervision Systems, COVID-19
Stateper 15 min unit
$ 6.00 4/3/2020 6/30/2021
YA341 CR Assertive Engagement, COVID-19 Stateper 15 min unit
$ 15.00 3/10/2020 6/30/2021
T2033 U1 XU CRSupported Living- Periodic, COVID-19 (Retainer Payments)
Medicaid Innovations
per 15 min unit
$ 4.71 3/13/2020 TBD
T2033 HI XU CRSupported Living Level II, COVID-19 (Retainer Payments)
Medicaid Innovations
per day $ 184.09 3/13/2020 TBD
T2033 TF XU CRSupported Living Level III, COVID-19 (Retainer Payments)
Medicaid Innovations
per day $ 215.17 3/13/2020 TBD
T2033 XU CRSupported Living Level I, COVID-19 (Retainer Payments)
Medicaid Innovations
per day $ 152.47 3/13/2020 TBD
T2027 XU CRDays Supports – Developmental Day, COVID-19 (Retainer Payments)
Medicaid Innovations
per 15 min unit
$ 25.52 3/13/2020 TBD
Page 9 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
T2021 HQ XU CR Day Supports - Group, COVID-19 (Retainer Payments)Medicaid Innovations
per hour $ 15.28 3/13/2020 TBD
T2021 XU CRDay Supports - Individual, COVID-19 (Retainer Payments)
Medicaid Innovations
per hour $ 25.72 3/13/2020 TBD
T2020 XU CRResidential Supports Level 3, COVID-19 (Retainer Payments)
Medicaid Innovations
per day $ 155.45 3/13/2020 TBD
T2020 CG XU CRResidential Supports Level 3, COVID-19 (Retainer Payments)
Medicaid Innovations
per day $ 155.45 3/13/2020 TBD
T2014 XU CR Residential Supports Level 2, COVID-19 (Retainer Payments)
Medicaid Innovations
per day $ 135.43 3/13/2020 TBD
T2014 CG XU CRResidential Supports Level 2, COVID-19 (Retainer Payments)
Medicaid Innovations
per day $ 135.43 3/13/2020 TBD
H2016 HI XU CRResidential Supports Level 4, COVID-19 (Retainer Payments)
Medicaid Innovations
per day $ 175.46 3/13/2020 TBD
H2016 XU CRResidential Supports Level 1, COVID-19 (Retainer Payments)
Medicaid Innovations
per day $ 103.98 3/13/2020 TBD
H2016 CG XU CRResidential Supports Level 1, COVID-19 (Retainer Payments)
Medicaid Innovations
per day $ 103.98 3/13/2020 TBD
H2016 HI CG XU CRResidential Supports Level 4, COVID-19 (Retainer Payments)
Medicaid Innovations
per day $ 175.46 3/13/2020 TBD
T2013 TF XU CR CLS Individual, COVID-19 (Retainer Payments)Medicaid Innovations
per 15 min unit
$ 5.56 3/13/2020 TBD
T2013 TF HQ XU CR CLS Group, COVID-19 (Retainer Payments)Medicaid Innovations
per 15 min unit
$ 3.10 3/13/2020 TBD
H2025 XU CRSupported Employment. COVID-19 (Retainer Payments)
Medicaid Innovations
per 15 min unit
$ 7.75 3/13/2020 TBD
H2025 TS XU CRSE Long Term Follow Along, COVID-19 (Retainer Payments)
Medicaid Innovations
per 15 min unit
$ 7.75 3/13/2020 TBD
H2025 TS CR SE Long Term Follow Up, COVId-19Medicaid
Innovationsper 15 min
unit $ 8.91 3/13/2020 6/30/2020
H2025 TS CR SE Long Term Follow Up, COVId-19Medicaid
Innovationsper 15 min
unit $ 9.30 7/1/2020 1/31/2021
H2025 TS CR SE Long Term Follow Up, COVId-19Medicaid
Innovationsper 15 min
unit $ 8.14 2/1/2021 6/30/2022
Page 10 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
H2015 HQ XU CRCommunity Networking Group, COVID-19 (Retainer Payments)
Medicaid Innovations
per 15 min unit
$ 9.30 3/13/2020 TBD
H2015 XU CRCommunity Networking – Individual, COVID-19 (Retainer Payments)
Medicaid Innovations
per 15 min unit
$ 5.61 3/13/2020 TBD
*911 Psychiatric Residential Treatment Facility (PRTF) Medicaid B per diem *Varies 4/20/2020 TBD
YP831 CR Behavioral Health Counseling, COVID-19 State per event $ 23.60 6/1/2020 6/30/2021
YP832 CRBEHAVIORAL HEALTH COUNSELING GROUP, COVID-19
State per event $ 8.70 6/1/2020 6/30/2021
YP834 CRBehavioral Health Counseling - Family Therapy without Client, COVID-19
State per event $ 23.60 6/1/2020 6/30/2021
YP835 CR Alcohol and/or Drug Group Counseling, COVID-19 State per event $ 6.10 6/1/2020 6/30/2021
Q3014 CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 112 CNP per day $ 25.00 6/1/2020 1/31/2021
Q3014 CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 112 CNP per day $ 21.87 2/1/2021 6/30/2021
Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 109Licensed Doctoral Psychologist
per day $ 25.50 6/1/2020 1/31/2021
Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 110 LCSW, LPC & LMFT per day $ 19.06 6/1/2020 1/31/2021
Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 999 Physician Assistant per day $ 25.50 6/1/2020 1/31/2021
Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 1 Physician per day $ 28.06 6/1/2020 1/31/2021
Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 109Licensed Doctoral Psychologist
per day $ 22.31 2/1/2021 6/30/2021
Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 110 LCSW, LPC & LMFT per day $ 16.67 2/1/2021 6/30/2021
Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 999 Physician Assistant per day $ 22.31 2/1/2021 6/30/2021
Q3014 GT CR Telehealth Originating Site Facility Fee, COVID-19 Medicaid 1 Physician per day $ 24.55 2/1/2021 6/30/2021
H0031 CR Mental Health Assessment, COVID-19 State per event $ 14.06 6/1/2020 1/31/2021
H0031 CR Mental Health Assessment, COVID-19 Medicaid per event $ 14.06 6/1/2020 1/31/2021
Page 11 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
H0031 CR Mental Health Assessment, COVID-19 State per event $ 12.31 2/1/2021 6/30/2021
H0031 CR Mental Health Assessment, COVID-19 Medicaid per event $ 12.31 2/1/2021 6/30/2021
99409 CRoutpatient treatment screening and eval by provisionally licensed staff, COVID-19
Medicaid 1 Physician per event $ 72.49 6/1/2020 7/31/2020
99409 CRoutpatient treatment screening and eval by provisionally licensed staff, COVID-19
Medicaid 110 LCSW, LPC & LMFT per event $ 72.49 6/1/2020 7/31/2020
99409 CRoutpatient treatment screening and eval by provisionally licensed staff, COVID-19
Medicaid 999 Physician Assistant per event $ 72.49 6/1/2020 7/31/2020
99408 CRoutpatient treatment screening and eval by provisionally licensed staff Seperate Structure, COVID-19
Medicaid 1 Physician per event $ 36.88 6/1/2020 7/31/2020
99408 CRoutpatient treatment screening and eval by provisionally licensed staff Seperate Structure, COVID-19
Medicaid 110 LCSW, LPC & LMFT per event $ 36.88 6/1/2020 7/31/2020
99408 CRoutpatient treatment screening and eval by provisionally licensed staff Seperate Structure, COVID-19
Medicaid 999 Physician Assistant per event $ 36.88 6/1/2020 7/31/2020
99407 CREP Smoking and tobacco use cessation counsel service provided under Medicaid EPSDT, COVID-19
Medicaid per event $ 26.83 6/1/2020 7/31/2020
99406 CRsmoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes, COVID-19
Medicaid 1 Physician per event $ 14.32 6/1/2020 7/31/2020
99406 CRsmoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes, COVID-19
Medicaid 112 CNP per event $ 14.32 6/1/2020 7/31/2020
99406 CRsmoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes, COVID-19
Medicaid 999 Physician Assistant per event $ 14.32 6/1/2020 7/31/2020
99357 CRprolonged physician service in inpatient setting, requiring, COVID-19
Medicaid 1 Physicianper time limit
$ 102.65 6/1/2020 7/31/2020
99357 CRprolonged physician service in inpatient setting, requiring, COVID-19
Medicaid 112 CNPper time limit
$ 79.32 6/1/2020 7/31/2020
99357 CRprolonged physician service in inpatient setting, requiring, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 93.31 6/1/2020 7/31/2020
99356 CRprolonged physician service in inpatient setting, requiring, COVID-19
Medicaid 1 Physicianper time limit
$ 101.94 6/1/2020 7/31/2020
Page 12 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
99356 CRprolonged physician service in inpatient setting, requiring, COVID-19
Medicaid 112 CNPper time limit
$ 78.78 6/1/2020 7/31/2020
99356 CRprolonged physician service in inpatient setting, requiring, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 92.68 6/1/2020 7/31/2020
99355 CRprolonged physician service in office or outpatient setting, COVID-19
Medicaid 112 CNPper time limit
$ 85.39 6/1/2020 7/31/2020
99355 CRprolonged physician service in office or outpatient setting, COVID-19
Medicaid 1 Physicianper time limit
$ 110.51 6/1/2020 7/31/2020
99354 CRprolonged physician service in office or outpatient setting, COVID-19
Medicaid 112 CNPper time limit
$ 86.26 6/1/2020 7/31/2020
99354 CRprolonged physician service in office or outpatient setting, COVID-19
Medicaid 1 Physicianper time limit
$ 111.64 6/1/2020 7/31/2020
99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19
Medicaid 112 CNPper time limit
$ 191.80 6/1/2020 1/31/2021
99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 225.64 6/1/2020 1/31/2021
99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19
Medicaid 1 Physicianper time limit
$ 248.20 6/1/2020 1/31/2021
99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19
State 112 CNPper time limit
$ 191.80 6/1/2020 1/31/2021
99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19
State 999 Physician Assistantper time limit
$ 225.64 6/1/2020 1/31/2021
99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19
State 1 Physicianper time limit
$ 248.20 6/1/2020 1/31/2021
99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19
Medicaid 112 CNPper time limit
$ 167.82 2/1/2021 6/30/2022
99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 197.43 2/1/2021 6/30/2022
99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19
Medicaid 1 Physicianper time limit
$ 217.17 2/1/2021 6/30/2022
99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19
State 112 CNPper time limit
$ 167.82 2/1/2021 6/30/2022
99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19
State 999 Physician Assistantper time limit
$ 197.43 2/1/2021 6/30/2022
Page 13 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
99245 CRoutpt. consult, severe - phys time approx 80 min, COVID-19
State 1 Physicianper time limit
$ 217.17 2/1/2021 6/30/2022
99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19
Medicaid 112 CNPper time limit
$ 156.05 6/1/2020 1/31/2021
99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 183.59 6/1/2020 1/31/2021
99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19
Medicaid 1 Physicianper time limit
$ 201.95 6/1/2020 1/31/2021
99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19
State 112 CNPper time limit
$ 156.05 6/1/2020 1/31/2021
99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19
State 999 Physician Assistantper time limit
$ 183.59 6/1/2020 1/31/2021
99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19
State 1 Physicianper time limit
$ 201.95 6/1/2020 1/31/2021
99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19
Medicaid 112 CNPper time limit
$ 136.54 2/1/2021 6/30/2022
99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 160.64 2/1/2021 6/30/2022
99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19
Medicaid 1 Physicianper time limit
$ 176.70 2/1/2021 6/30/2022
99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19
State 112 CNPper time limit
$ 136.54 2/1/2021 6/30/2022
99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19
State 999 Physician Assistantper time limit
$ 160.64 2/1/2021 6/30/2022
99244 CRoutpt. consult, severe - phys time approx 60 min, COVID-19
State 1 Physicianper time limit
$ 176.70 2/1/2021 6/30/2022
99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19
Medicaid 1 Physicianper time limit
$ 135.96 6/1/2020 1/31/2021
99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19
Medicaid 112 CNPper time limit
$ 105.06 6/1/2020 1/31/2021
99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 123.60 6/1/2020 1/31/2021
99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19
State 1 Physicianper time limit
$ 135.96 6/1/2020 1/31/2021
Page 14 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19
State 112 CNPper time limit
$ 105.06 6/1/2020 1/31/2021
99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19
State 999 Physician Assistantper time limit
$ 123.60 6/1/2020 1/31/2021
99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19
Medicaid 1 Physicianper time limit
$ 118.97 2/1/2021 6/30/2021
99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19
Medicaid 112 CNPper time limit
$ 91.93 2/1/2021 6/30/2021
99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 108.15 2/1/2021 6/30/2022
99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19
State 1 Physicianper time limit
$ 118.97 2/1/2021 6/30/2021
99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19
State 112 CNPper time limit
$ 91.93 2/1/2021 6/30/2021
99243 CRoutpt. consult, severe - phys time approx 40 min, COVID-19
State 999 Physician Assistantper time limit
$ 108.15 2/1/2021 6/30/2021
99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19
Medicaid 1 Physicianper time limit
$ 98.87 6/1/2020 1/31/2021
99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19
Medicaid 112 CNPper time limit
$ 76.40 6/1/2020 1/31/2021
99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 89.88 6/1/2020 1/31/2021
99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19
State 1 Physicianper time limit
$ 98.87 6/1/2020 1/31/2021
99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19
State 112 CNPper time limit
$ 76.40 6/1/2020 1/31/2021
99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19
State 999 Physician Assistantper time limit
$ 89.88 6/1/2020 1/31/2021
99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19
Medicaid 1 Physicianper time limit
$ 86.51 2/1/2021 6/30/2022
99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19
Medicaid 112 CNPper time limit
$ 66.85 2/1/2021 6/30/2022
99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 78.65 2/1/2021 6/30/2022
Page 15 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19
State 1 Physicianper time limit
$ 86.51 2/1/2021 6/30/2021
99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19
State 112 CNPper time limit
$ 66.85 2/1/2021 6/30/2021
99242 CRoutpt. consult, moderate - phys time approx 30 min, COVID-19
State 999 Physician Assistantper time limit
$ 78.65 2/1/2021 6/30/2021
99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19
Medicaid 1 Physicianper time limit
$ 52.78 6/1/2020 1/31/2021
99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19
Medicaid 112 CNPper time limit
$ 40.78 6/1/2020 1/31/2021
99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 47.98 6/1/2020 1/31/2021
99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19
State 1 Physicianper time limit
$ 52.78 6/1/2020 1/31/2021
99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19
State 112 CNPper time limit
$ 40.78 6/1/2020 1/31/2021
99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19
State 999 Physician Assistantper time limit
$ 47.98 6/1/2020 1/31/2021
99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19
Medicaid 1 Physicianper time limit
$ 46.18 2/1/2021 6/30/2022
99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19
Medicaid 112 CNPper time limit
$ 35.68 2/1/2021 6/30/2022
99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 41.98 2/1/2021 6/30/2022
99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19
State 1 Physicianper time limit
$ 46.18 2/1/2021 6/30/2021
99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19
State 112 CNPper time limit
$ 35.68 2/1/2021 6/30/2021
99241 CRoutpt. consult, minor - phys time approx 15 min, COVID-19
State 999 Physician Assistantper time limit
$ 41.98 2/1/2021 6/30/2021
99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19
Medicaid 1 Physician per day $ 81.66 6/1/2020 1/31/2021
Page 16 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19
Medicaid 112 CNP per day $ 63.10 6/1/2020 1/31/2021
99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19
Medicaid 999 Physician Assistant per day $ 74.23 6/1/2020 1/31/2021
99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19
State 1 Physician per day $ 81.66 6/1/2020 1/31/2021
99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19
State 112 CNP per day $ 63.10 6/1/2020 1/31/2021
99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19
State 999 Physician Assistant per day $ 74.23 6/1/2020 1/31/2021
99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19
Medicaid 1 Physician per day $ 71.45 2/1/2021 6/30/2022
99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19
Medicaid 112 CNP per day $ 55.21 2/1/2021 6/30/2022
99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19
Medicaid 999 Physician Assistant per day $ 64.95 2/1/2021 6/30/2022
99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19
State 1 Physician per day $ 71.45 2/1/2021 6/30/2021
99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19
State 112 CNP per day $ 55.21 2/1/2021 6/30/2021
99226 CRSubsequent observation care, per day, for the evaluation and management high complexity, COVID-19
State 999 Physician Assistant per day $ 64.95 2/1/2021 6/30/2021
99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19
Medicaid 1 Physician per day $ 54.61 6/1/2020 1/31/2021
99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19
Medicaid 112 CNP per day $ 42.19 6/1/2020 1/31/2021
99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19
Medicaid 999 Physician Assistant per day $ 49.64 6/1/2020 1/31/2021
Page 17 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19
State 1 Physician per day $ 54.61 6/1/2020 1/31/2021
99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19
State 112 CNP per day $ 42.19 6/1/2020 1/31/2021
99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19
State 999 Physician Assistant per day $ 49.64 6/1/2020 1/31/2021
99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19
Medicaid 1 Physician per day $ 47.79 2/1/2021 6/30/2022
99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19
Medicaid 112 CNP per day $ 36.92 2/1/2021 6/30/2022
99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19
Medicaid 999 Physician Assistant per day $ 43.44 2/1/2021 6/30/2022
99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19
State 1 Physician per day $ 47.79 2/1/2021 6/30/2021
99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19
State 112 CNP per day $ 36.92 2/1/2021 6/30/2021
99225 CRSubsequent observation care, per day, for the evaluation and management moderate complexity, COVID-19
State 999 Physician Assistant per day $ 43.44 2/1/2021 6/30/2021
99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19
Medicaid 1 Physician per day $ 30.74 6/1/2020 1/31/2021
99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19
Medicaid 112 CNP per day $ 23.76 6/1/2020 1/31/2021
99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19
Medicaid 999 Physician Assistant per day $ 27.95 6/1/2020 1/31/2021
99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19
State 1 Physician per day $ 30.74 6/1/2020 1/31/2021
99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19
State 112 CNP per day $ 23.76 6/1/2020 1/31/2021
99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19
State 999 Physician Assistant per day $ 27.95 6/1/2020 1/31/2021
Page 18 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19
Medicaid 1 Physician per day $ 26.90 2/1/2021 6/30/2022
99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19
Medicaid 112 CNP per day $ 20.79 2/1/2021 6/30/2022
99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19
Medicaid 999 Physician Assistant per day $ 24.45 2/1/2021 6/30/2022
99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19
State 1 Physician per day $ 26.90 2/1/2021 6/30/2021
99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19
State 112 CNP per day $ 20.79 2/1/2021 6/30/2021
99224 CRSubsequent Observation Care, Per Day, for the Evaluation and, COVID-19
State 999 Physician Assistant per day $ 24.45 2/1/2021 6/30/2021
99220 CRinitial observation care, per day, high complexity, COVID-19
Medicaid 1 Physician per day $ 177.31 6/1/2020 7/31/2020
99220 CRinitial observation care, per day, high complexity, COVID-19
Medicaid 112 CNP per day $ 137.02 6/1/2020 7/31/2020
99219 CRinitial observation care, per day, moderate complexity, COVID-19
Medicaid 1 Physician per day $ 126.43 6/1/2020 7/31/2020
99219 CRinitial observation care, per day, moderate complexity, COVID-19
Medicaid 112 CNP per day $ 97.69 6/1/2020 7/31/2020
99219 CRinitial observation care, per day, moderate complexity, COVID-19
Medicaid 999 Physician Assistant per day $ 114.94 6/1/2020 7/31/2020
99218 CRinitial observation care, per day, low complexity, COVID-19
Medicaid 1 Physician per day $ 76.34 6/1/2020 7/31/2020
99218 CRinitial observation care, per day, low complexity, COVID-19
Medicaid 112 CNP per day $ 58.99 6/1/2020 7/31/2020
99217 CRobservation care discharge day management, COVID-19
Medicaid 1 Physician per event $ 80.94 6/1/2020 7/31/2020
99217 CRobservation care discharge day management, COVID-19
Medicaid 112 CNP per event $ 62.54 6/1/2020 7/31/2020
99217 CRobservation care discharge day management, COVID-19
Medicaid 999 Physician Assistant per event $ 20.45 6/1/2020 7/31/2020
99215 CRov estab pt, severe phys time approx 40 min, COVID-19
Medicaid 1 Physicianper time limit
$ 150.48 6/1/2020 1/31/2021
Page 19 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
99215 CRov estab pt, severe phys time approx 40 min, COVID-19
Medicaid 112 CNPper time limit
$ 116.28 6/1/2020 1/31/2021
99215 CRov estab pt, severe phys time approx 40 min, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 136.80 6/1/2020 1/31/2021
99215 CRov estab pt, severe phys time approx 40 min, COVID-19
State 1 Physicianper time limit
$ 150.48 6/1/2020 1/31/2021
99215 CRov estab pt, severe phys time approx 40 min, COVID-19
State 112 CNPper time limit
$ 116.28 6/1/2020 1/31/2021
99215 CRov estab pt, severe phys time approx 40 min, COVID-19
State 999 Physician Assistantper time limit
$ 136.80 6/1/2020 1/31/2021
99215 CRov estab pt, severe phys time approx 40 min, COVID-19
Medicaid 1 Physicianper time limit
$ 131.67 2/1/2021 6/30/2022
99215 CRov estab pt, severe phys time approx 40 min, COVID-19
Medicaid 112 CNPper time limit
$ 101.75 2/1/2021 6/30/2022
99215 CRov estab pt, severe phys time approx 40 min, COVID-19
Medicaid 999 Physician Assistantper time limit
$ 119.70 2/1/2021 6/30/2022
99215 CRov estab pt, severe phys time approx 40 min, COVID-19
State 1 Physicianper time limit
$ 131.67 2/1/2021 6/30/2021
99215 CRov estab pt, severe phys time approx 40 min, COVID-19
State 112 CNPper time limit
$ 101.75 2/1/2021 6/30/2021
99215 CRov estab pt, severe phys time approx 40 min, COVID-19
State 999 Physician Assistantper time limit
$ 119.70 2/1/2021 6/30/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 1 Physicianper time limit
$ 5.23 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 109Licensed Doctoral Psychologist
per time limit
$ 4.75 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 110 LCSW, LPC & LMFTper time limit
$ 3.56 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 111Certified Clinical Nurse Specialist
per time limit
$ 4.04 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 112 CNPper time limit
$ 4.04 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 128 LPAper time limit
$ 3.56 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 129 LCASper time limit
$ 3.56 6/1/2020 1/31/2021
Page 20 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
90785 CR Interactive Complexity Add-on, COVID-19 State 999 Physician Assistantper time limit
$ 3.42 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 998Provisionally and Associate Level Licensed
per time limit
$ 3.56 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 1 Physicianper time limit
$ 5.23 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 109Licensed Doctoral Psychologist
per time limit
$ 4.75 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit
$ 3.56 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 111Certified Clinical Nurse Specialist
per time limit
$ 4.04 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 112 CNPper time limit
$ 4.04 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 128 LPAper time limit
$ 3.56 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 129 LCASper time limit
$ 3.56 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 3.42 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 998Provisionally and Associate Level Licensed
per time limit
$ 3.56 6/1/2020 1/31/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 1 Physicianper time limit
$ 4.58 2/1/2021 6/30/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 109Licensed Doctoral Psychologist
per time limit
$ 4.16 2/1/2021 6/30/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 110 LCSW, LPC & LMFTper time limit
$ 3.12 2/1/2021 6/30/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 111Certified Clinical Nurse Specialist
per time limit
$ 3.54 2/1/2021 6/30/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 112 CNPper time limit
$ 3.54 2/1/2021 6/30/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 128 LPAper time limit
$ 3.12 2/1/2021 6/30/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 129 LCASper time limit
$ 3.12 2/1/2021 6/30/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 999 Physician Assistantper time limit
$ 2.99 2/1/2021 6/30/2021
90785 CR Interactive Complexity Add-on, COVID-19 State 998Provisionally and Associate Level Licensed
per time limit
$ 3.12 2/1/2021 6/30/2021
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 1 Physicianper time limit
$ 4.58 2/1/2021 6/30/2022
Page 21 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 109Licensed Doctoral Psychologist
per time limit
$ 4.16 2/1/2021 6/30/2022
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit
$ 3.12 2/1/2021 6/30/2022
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 111Certified Clinical Nurse Specialist
per time limit
$ 3.54 2/1/2021 6/30/2022
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 112 CNPper time limit
$ 3.54 2/1/2021 6/30/2022
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 128 LPAper time limit
$ 3.12 2/1/2021 6/30/2022
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 129 LCASper time limit
$ 3.12 2/1/2021 6/30/2022
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 2.99 2/1/2021 6/30/2022
90785 CR Interactive Complexity Add-on, COVID-19 Medicaid 998Provisionally and Associate Level Licensed
per time limit
$ 3.12 2/1/2021 6/30/2022
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 1 Physician per event $ 165.52 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 109Licensed Doctoral Psychologist
per event $ 150.47 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 110 LCSW, LPC & LMFT per event $ 112.85 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 111Certified Clinical Nurse Specialist
per event $ 127.90 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 112 CNP per event $ 127.90 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 128 LPA per event $ 112.85 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 129 LCAS per event $ 112.85 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 999 Physician Assistant per event $ 108.47 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 998Provisionally and Associate Level Licensed
per event $ 112.85 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 1 Physician per event $ 165.52 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 109Licensed Doctoral Psychologist
per event $ 150.47 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 110 LCSW, LPC & LMFT per event $ 112.85 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 111Certified Clinical Nurse Specialist
per event $ 127.90 6/1/2020 1/31/2021
Page 22 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 112 CNP per event $ 127.90 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 128 LPA per event $ 112.85 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 129 LCAS per event $ 112.85 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 999 Physician Assistant per event $ 108.47 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 998Provisionally and Associate Level Licensed
per event $ 112.85 6/1/2020 1/31/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 1 Physician per event $ 144.83 2/1/2021 6/30/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 109Licensed Doctoral Psychologist
per event $ 131.66 2/1/2021 6/30/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 110 LCSW, LPC & LMFT per event $ 98.74 2/1/2021 6/30/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 111Certified Clinical Nurse Specialist
per event $ 111.91 2/1/2021 6/30/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 112 CNP per event $ 111.91 2/1/2021 6/30/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 128 LPA per event $ 98.74 2/1/2021 6/30/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 129 LCAS per event $ 98.74 2/1/2021 6/30/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 999 Physician Assistant per event $ 94.91 2/1/2021 6/30/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 State 998Provisionally and Associate Level Licensed
per event $ 98.74 2/1/2021 6/30/2021
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 1 Physician per event $ 144.83 2/1/2021 6/30/2022
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 109Licensed Doctoral Psychologist
per event $ 131.66 2/1/2021 6/30/2022
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 110 LCSW, LPC & LMFT per event $ 98.74 2/1/2021 6/30/2022
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 111Certified Clinical Nurse Specialist
per event $ 111.91 2/1/2021 6/30/2022
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 112 CNP per event $ 111.91 2/1/2021 6/30/2022
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 128 LPA per event $ 98.74 2/1/2021 6/30/2022
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 129 LCAS per event $ 98.74 2/1/2021 6/30/2022
Page 23 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 999 Physician Assistant per event $ 94.91 2/1/2021 6/30/2022
90791 CR Psychiatric Diagnostic Evaluation, COVID-19 Medicaid 998Provisionally and Associate Level Licensed
per event $ 98.74 2/1/2021 6/30/2022
90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19
State 1 Physician per event $ 138.05 6/1/2020 1/31/2021
90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19
State 112 CNP per event $ 106.67 6/1/2020 1/31/2021
90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19
State 999 Physician Assistant per event $ 90.00 6/1/2020 1/31/2021
90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19
Medicaid 1 Physician per event $ 138.05 6/1/2020 1/31/2021
90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19
Medicaid 112 CNP per event $ 106.67 6/1/2020 1/31/2021
90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19
Medicaid 999 Physician Assistant per event $ 90.00 6/1/2020 1/31/2021
90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19
State 1 Physician per event $ 120.79 2/1/2021 6/30/2021
90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19
State 112 CNP per event $ 93.33 2/1/2021 6/30/2021
90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19
State 999 Physician Assistant per event $ 78.75 2/1/2021 6/30/2021
90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19
Medicaid 1 Physician per event $ 120.79 2/1/2021 6/30/2022
90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19
Medicaid 112 CNP per event $ 93.33 2/1/2021 6/30/2022
90792 CRPsychiatric Diagnostic Evaluation w/ medical svc, COVID-19
Medicaid 999 Physician Assistant per event $ 78.75 2/1/2021 6/30/2022
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 1 Physicianper time limit
$ 68.96 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist
per time limit
$ 62.69 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit
$ 47.02 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist
per time limit
$ 53.28 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 112 CNPper time limit
$ 53.28 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 128 LPAper time limit
$ 47.02 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 129 LCASper time limit
$ 47.02 6/1/2020 1/31/2021
Page 24 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 45.13 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed
per time limit
$ 47.02 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 1 Physicianper time limit
$ 68.96 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 109Licensed Doctoral Psychologist
per time limit
$ 62.69 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit
$ 47.02 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 111Certified Clinical Nurse Specialist
per time limit
$ 53.28 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 112 CNPper time limit
$ 53.28 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 128 LPAper time limit
$ 47.02 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 129 LCASper time limit
$ 47.02 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 999 Physician Assistantper time limit
$ 45.13 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 998Provisionally and Associate Level Licensed
per time limit
$ 47.02 6/1/2020 1/31/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 1 Physicianper time limit
$ 60.33 2/1/2021 6/30/2022
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist
per time limit
$ 54.85 2/1/2021 6/30/2022
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit
$ 41.14 2/1/2021 6/30/2022
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist
per time limit
$ 46.62 2/1/2021 6/30/2022
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 112 CNPper time limit
$ 46.62 2/1/2021 6/30/2022
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 128 LPAper time limit
$ 41.14 2/1/2021 6/30/2022
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 129 LCASper time limit
$ 41.14 2/1/2021 6/30/2022
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 39.49 2/1/2021 6/30/2022
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed
per time limit
$ 41.14 2/1/2021 6/30/2022
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 1 Physicianper time limit
$ 60.33 2/1/2021 6/30/2021
Page 25 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 109Licensed Doctoral Psychologist
per time limit
$ 54.85 2/1/2021 6/30/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit
$ 41.14 2/1/2021 6/30/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 111Certified Clinical Nurse Specialist
per time limit
$ 46.62 2/1/2021 6/30/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 112 CNPper time limit
$ 46.62 2/1/2021 6/30/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 128 LPAper time limit
$ 41.14 2/1/2021 6/30/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 129 LCASper time limit
$ 41.14 2/1/2021 6/30/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 999 Physician Assistantper time limit
$ 39.49 2/1/2021 6/30/2021
90832 CR Psychotherapy, 16 - 37 mins, COVID-19 State 998Provisionally and Associate Level Licensed
per time limit
$ 41.14 2/1/2021 6/30/2021
90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 State 1 Physicianper time limit
$ 46.08 6/1/2020 1/31/2021
90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 State 112 CNPper time limit
$ 35.60 6/1/2020 1/31/2021
90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 State 999 Physician Assistantper time limit
$ 29.15 6/1/2020 1/31/2021
90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 Medicaid 1 Physicianper time limit
$ 46.08 6/1/2020 1/31/2021
90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 Medicaid 112 CNPper time limit
$ 35.60 6/1/2020 1/31/2021
90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 29.15 6/1/2020 1/31/2021
90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 State 1 Physicianper time limit
$ 40.32 2/1/2021 6/30/2021
90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 State 112 CNPper time limit
$ 31.15 2/1/2021 6/30/2021
90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 State 999 Physician Assistantper time limit
$ 25.50 2/1/2021 6/30/2021
90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 Medicaid 1 Physicianper time limit
$ 40.32 2/1/2021 6/30/2022
90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 Medicaid 112 CNPper time limit
$ 31.15 2/1/2021 6/30/2022
90833 CR Psychotherapy, 16 - 37 mins with E/M svc, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 25.50 2/1/2021 6/30/2022
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 1 Physicianper time limit
$ 89.56 6/1/2020 1/31/2021
Page 26 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 109Licensed Doctoral Psychologist
per time limit
$ 81.42 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit
$ 61.07 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 111Certified Clinical Nurse Specialist
per time limit
$ 69.20 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 112 CNPper time limit
$ 69.20 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 128 LPAper time limit
$ 61.07 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 129 LCASper time limit
$ 61.07 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 999 Physician Assistantper time limit
$ 58.42 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 998Provisionally and Associate Level Licensed
per time limit
$ 61.07 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 1 Physicianper time limit
$ 89.56 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist
per time limit
$ 81.42 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit
$ 61.07 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist
per time limit
$ 69.20 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 112 CNPper time limit
$ 69.20 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 128 LPAper time limit
$ 61.07 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 129 LCASper time limit
$ 61.07 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 58.42 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed
per time limit
$ 61.07 6/1/2020 1/31/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 1 Physicianper time limit
$ 78.37 2/1/2021 6/30/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 109Licensed Doctoral Psychologist
per time limit
$ 71.24 2/1/2021 6/30/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit
$ 53.43 2/1/2021 6/30/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 111Certified Clinical Nurse Specialist
per time limit
$ 60.55 2/1/2021 6/30/2021
Page 27 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 112 CNPper time limit
$ 60.55 2/1/2021 6/30/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 128 LPAper time limit
$ 53.43 2/1/2021 6/30/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 129 LCASper time limit
$ 53.43 2/1/2021 6/30/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 999 Physician Assistantper time limit
$ 51.11 2/1/2021 6/30/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 State 998Provisionally and Associate Level Licensed
per time limit
$ 53.43 2/1/2021 6/30/2021
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 1 Physicianper time limit
$ 78.37 2/1/2021 6/30/2022
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist
per time limit
$ 71.24 2/1/2021 6/30/2022
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit
$ 53.43 2/1/2021 6/30/2022
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist
per time limit
$ 60.55 2/1/2021 6/30/2022
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 112 CNPper time limit
$ 60.55 2/1/2021 6/30/2022
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 128 LPAper time limit
$ 53.43 2/1/2021 6/30/2022
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 129 LCASper time limit
$ 53.43 2/1/2021 6/30/2022
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 51.11 2/1/2021 6/30/2022
90834 CR Psychotherapy, 38 - 52 mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed
per time limit
$ 53.43 2/1/2021 6/30/2022
90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 State 1 Physicianper time limit
$ 74.87 6/1/2020 1/31/2021
90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 State 999 Physician Assistantper time limit
$ 47.35 6/1/2020 1/31/2021
90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 State 112 CNPper time limit
$ 57.85 6/1/2020 1/31/2021
90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 Medicaid 1 Physicianper time limit
$ 74.87 6/1/2020 1/31/2021
90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 47.35 6/1/2020 1/31/2021
90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 Medicaid 112 CNPper time limit
$ 57.85 6/1/2020 1/31/2021
90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 State 1 Physicianper time limit
$ 65.51 2/1/2021 6/30/2021
Page 28 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 State 999 Physician Assistantper time limit
$ 41.43 2/1/2021 6/30/2021
90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 State 112 CNPper time limit
$ 50.62 2/1/2021 6/30/2021
90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 Medicaid 1 Physicianper time limit
$ 65.51 2/1/2021 6/30/2022
90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 41.43 2/1/2021 6/30/2022
90836 CR Psychotherapy, 38 - 52 mins with E/M svc, COVID-19 Medicaid 112 CNPper time limit
$ 50.62 2/1/2021 6/30/2022
90837 CR Psychotherapy, 53+ mins, COVID-19 State 1 Physicianper time limit
$ 131.23 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 109Licensed Doctoral Psychologist
per time limit
$ 119.30 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit
$ 89.48 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 111Certified Clinical Nurse Specialist
per time limit
$ 101.41 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 112 CNPper time limit
$ 101.41 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 128 LPAper time limit
$ 89.48 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 129 LCASper time limit
$ 89.48 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 999 Physician Assistantper time limit
$ 85.55 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 998Provisionally and Associate Level Licensed
per time limit
$ 89.48 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 1 Physicianper time limit
$ 131.23 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist
per time limit
$ 119.30 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit
$ 89.48 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist
per time limit
$ 101.41 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 112 CNPper time limit
$ 101.41 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 128 LPAper time limit
$ 89.48 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 129 LCASper time limit
$ 89.48 6/1/2020 1/31/2021
Page 29 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 85.55 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed
per time limit
$ 89.48 6/1/2020 1/31/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 1 Physicianper time limit
$ 114.83 2/1/2021 6/30/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 109Licensed Doctoral Psychologist
per time limit
$ 104.39 2/1/2021 6/30/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit
$ 78.30 2/1/2021 6/30/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 111Certified Clinical Nurse Specialist
per time limit
$ 88.74 2/1/2021 6/30/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 112 CNPper time limit
$ 88.74 2/1/2021 6/30/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 128 LPAper time limit
$ 78.30 2/1/2021 6/30/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 129 LCASper time limit
$ 78.30 2/1/2021 6/30/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 999 Physician Assistantper time limit
$ 74.85 2/1/2021 6/30/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 State 998Provisionally and Associate Level Licensed
per time limit
$ 78.30 2/1/2021 6/30/2021
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 1 Physicianper time limit
$ 114.83 2/1/2021 6/30/2022
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist
per time limit
$ 104.39 2/1/2021 6/30/2022
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit
$ 78.30 2/1/2021 6/30/2022
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist
per time limit
$ 88.74 2/1/2021 6/30/2022
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 112 CNPper time limit
$ 88.74 2/1/2021 6/30/2022
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 128 LPAper time limit
$ 78.30 2/1/2021 6/30/2022
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 129 LCASper time limit
$ 78.30 2/1/2021 6/30/2022
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 74.85 2/1/2021 6/30/2022
90837 CR Psychotherapy, 53+ mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed
per time limit
$ 78.30 2/1/2021 6/30/2022
90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 State 1 Physicianper time limit
$ 120.90 6/1/2020 1/31/2021
Page 30 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 State 112 CNPper time limit
$ 93.42 6/1/2020 1/31/2021
90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 State 999 Physician Assistantper time limit
$ 78.61 6/1/2020 1/31/2021
90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 Medicaid 1 Physicianper time limit
$ 120.90 6/1/2020 1/31/2021
90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 Medicaid 112 CNPper time limit
$ 93.42 6/1/2020 1/31/2021
90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 78.61 6/1/2020 1/31/2021
90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 State 1 Physicianper time limit
$ 105.79 2/1/2021 6/30/2021
90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 State 112 CNPper time limit
$ 81.74 2/1/2021 6/30/2021
90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 State 999 Physician Assistantper time limit
$ 68.79 2/1/2021 6/30/2021
90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 Medicaid 1 Physicianper time limit
$ 105.79 2/1/2021 6/30/2022
90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 Medicaid 112 CNPper time limit
$ 81.74 2/1/2021 6/30/2022
90838 CR Psychotherapy, 53+ mins with E/M svc, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 68.79 2/1/2021 6/30/2022
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 1 Physicianper time limit
$ 165.37 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 109Licensed Doctoral Psychologist
per time limit
$ 150.34 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 110 LCSW, LPC & LMFTper time limit
$ 112.75 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 111Certified Clinical Nurse Specialist
per time limit
$ 127.79 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 112 CNPper time limit
$ 127.79 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 128 LPAper time limit
$ 112.75 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 129 LCASper time limit
$ 112.75 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 999 Physician Assistantper time limit
$ 150.34 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 State 998Provisionally and Associate Level Licensed
per time limit
$ 112.75 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 1 Physicianper time limit
$ 165.37 6/1/2020 1/31/2021
Page 31 of 58
Trillium Table Rate for COVID-19 Crisis Event FY 19-21May 14, 2021
Service Code
Mod1 Mod2 Mod3 Mod4 RevCode ServiceDescription Funding Specialty Spec Name RateUnit UnitRate Effective
dateEnd Date
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 109Licensed Doctoral Psychologist
per time limit
$ 150.34 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 110 LCSW, LPC & LMFTper time limit
$ 112.75 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 111Certified Clinical Nurse Specialist
per time limit
$ 127.79 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 112 CNPper time limit
$ 127.79 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 128 LPAper time limit
$ 112.75 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 129 LCASper time limit
$ 112.75 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 999 Physician Assistantper time limit
$ 150.34 6/1/2020 1/31/2021
90839 CR Psychotherapy for Crisis, 30 - 74 mins, COVID-19 Medicaid 998Provisionally and Associate Level Licensed
per time l