Playbooks

The playbook lists all the requirements and guidelines from the SMHS billing manual, along with configuration recommendations and items Netsmart is tracking for development.

► MH Eligibility

Billing Manual	Description	Details
3.1.0	Client Eligibility	Specialty mental health clients must be enrolled in Medi-Cal in order for the MHP to be reimbursed through the SD/MC claiming system
3.1.1	Medi-Cal Eligibility Determination	-DHCS is responsible for instituting procedures for enrolling individuals in the Medi-Cal program -The determination of beneficiary eligibility and the collection of beneficiary eligibility data is typically the responsibility of the County Department of Social Services. -Detailed information regarding beneficiary eligibility criteria may be obtained through the DHCS Medi-Cal Eligibility Division website -The following information regarding Medi-Cal eligibility is integral to the management of Mental Health Medi-Cal claiming: · Medi-Cal eligibility is established on a monthly basis. · Medi-Cal eligibility may require that a beneficiary’s Share of Cost be met before MediCal will pay for any services. · Medi-Cal eligibility may be established retroactively through legislation, court hearings and/or decisions. · HIPAA 270/271 transactions are available from DHCS to verify beneficiary Medi-Cal eligibility. · MHPs should verify beneficiary Medi-Cal eligibility for the month of service prior to submitting claims for reimbursement.
3.1.2	Medi-Cal Eligibility Review	-Once Medi-Cal eligibility is established, beneficiary eligibility information may be reviewed by authorized MHP staff -With few exceptions, the source of this eligibility verification information will be the DHCS Point of Service system
3.1.2	Monthly MEDS Extract File	- The Monthly MEDS Extract File (MMEF) contains, among other data, all Aid Codes for which beneficiaries who are the county’s responsibility are eligible at the date/time the file was created. -The MMEF contains information for the current month and previous 15 months. -A new MMEF is available at the end of each month and applies to the following month’s eligibility. -MMEF data is not used to determine eligibility during adjudication. The adjudication process queries the Medi-Cal Eligibility Data System (MEDS) for eligibility data at the time the claim is being adjudicated
3.1.2	MEDS and MEDSLITE	-MEDS and MEDSLITE provide eligibility status code(s) for a beneficiary -For a particular month and year of service, if the eligibility is valid, then the approved Aid Code will be the highestpaying eligible SD/MC Aid Code -If a beneficiary is found in MEDS or MEDSLITE, but none of the Aid Codes assigned to the beneficiary are applicable to SD/MC, the claim will be denied. -MEDSLITE is an Internet-based program that allows MHPs to verify eligibility information but does not allow MHPs to view the Social Security Administration data that is contained within MEDS
3.2.0	Aid Codes	-During the Medi-Cal application and enrollment process, Aid Codes are assigned to Medi-Cal eligible clients to indicate the program(s) under which the client qualifies for services. -The DHCS Short Doyle Medi-Cal Aid Codes Master Chart (which includes both Mental Health and Drug Medi-Cal) can be found on the MedCCC Library. The Aid Codes Master Chart provides useful information about the following: · FFP · Aid codes · Type of benefits · Share of cost · Aid code descriptions · Indication of reimbursement through the DHCS Fiscal Intermediary, Drug Medi-Cal Program (DMC), Mental Health Plans, and/or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) programs.

► MH Covered Services

Billing Manual	Description	Details
4.1.1	Mental Health Services: State Plan Amendment (SPA) 12-025 and CCR Title 9: 1810.227	-Mental health services are outpatient services and include the following: *Assessment *Collateral *Plan Development *Rehabilitation *Therapy
4.1.2	Specialty Mental Health Services for Children and Youth	-Specialty Mental Health Services for Children and Youth include the following: *Intensive Care Coordination (ICC) *Intensive Home Based Services (IHBS) *Therapeutic Behavioral Services (TBS) *Therapeutic Foster Care (TFC) Services
4.1.3	Hospital Inpatient: CCR Title 9, 1820.205	-With the exception of Short-Doyle Medi-Cal (SD/MC) hospitals, inpatient services are not billed through the SD/MC system but are billed through the Fiscal Intermediary -SD/MC hospitals claim reimbursement for psychiatric inpatient hospital services through the SD/MC Claim System -For inpatient claims at an SD/MC hospital, SD/MC pays a bundled rate for inpatient routine, ancillary and professional services. Fee for Service Medi-Cal (FFS/MC) hospitals are reimbursed a bundled rate for routine and ancillary services. - MHPs reimburse professional services provided in a FFS/MC hospital and submit claims for federal reimbursement to the SD/MC
4.1.4	Hospital Inpatient Administrative Day Services: CCR Title 9, 1820.220	-During a hospital stay, the MHP shall authorize payment for administrative day services if the following criteria are met: (1) beneficiary no longer needs inpatient care, but has previously met medical necessity criteria for reimbursement of acute psychiatric inpatient hospital services, (2) there is no appropriate, non-acute treatment facility within a reasonable geographic area and (3) the hospital demonstrates attempts to transfer to a lower level of care by documenting contacts with a minimum of five appropriate, non-acute treatment facilities per week
4.1.5	Psychiatric Health Facility: CCR Title 9,1810.236 and 1820.205	Psychiatric Health Facility (PHF) is a facility licensed by DHCS under the provisions of CCR, Title 22. To be admitted to a psychiatric health facility, beneficiaries shall meet the medical necessity criteria indicating they require this level of care, described in CCR Title 9, § 1820.205.
4.1.6	Children's Crisis Residential Programs: Health and Safety Code 1502(a)(21)	Children’s Crisis Residential Programs (CCRP) provide children with Medi-Cal services, primarily crisis residential treatment services. CCRPs serve children experiencing mental health crises as an alternative to psychiatric hospitalization. CCRPs are a type of community care facility, and are, by definition, non-medical facilities
4.1.7	Crisis Residential Treatment Services: CCR Title 9, 1810.208	-Crisis Residential Treatment Services (CRTS) are therapeutic or rehabilitative services provided in a non-institutional residential setting. CRTS provide structured programs as an alternative to hospitalization for beneficiaries experiencing an acute psychiatric episode or crisis who do not have medical complications requiring nursing care. -CRTS are available 24 hours per day, seven days per week. Activities may include, but are not limited to: · Assessment · Plan Development · Therapy · Rehabilitation · Collateral · Crisis Intervention
4.1.8	Adult Residential Treatment Services: CCR Title 9, 1810.203	-Adult residential treatment services are rehabilitative services provided in a non-institutional residential setting for beneficiaries who would be at risk of hospitalization or other institutional placement if they were not in a residential treatment program. -Adult residential treatment services include a range of activities and services that support beneficiaries in their effort to restore, maintain and apply interpersonal and independent living skills and to access community support systems. The services are available 24 hours per day, seven days per week. Service activities may include but are not limited to: · Assessment · Plan Development · Therapy · Rehabilitation · Collateral
4.1.9	Crisis Stabilization: CCR Title 9, 1840.338 and 1840.348	-Crisis stabilization: is a service that lasts less than 24 hours and is provided to or on behalf of a beneficiary for a condition that requires a more timely response than a regularly scheduled visit. Service activities include, but are not limited to: · Assessment · Collateral · Therapy · Crisis Intervention · Medication Support Services · Referral -Crisis stabilization differs from crisis intervention in that stabilization is delivered by providers who meet contact, site, and staffing requirements for crisis stabilization described in CCR Title 9, §§ 1840.338 and 1840.348 -Crisis stabilization must be provided onsite at a licensed 24-hour health care facility, as part of a hospital-based outpatient program, certified by the State to perform crisis stabilization -The maximum allowance provided for in CCR, Title 22 for “Crisis Stabilization: Emergency Room” shall apply when the service is provided in a 24-hour facility, including a hospital outpatient department
4.1.10	Day Treatment Intensive: CCR Title 9, 1810.213	-Day Treatment Intensive is a structured, multi-disciplinary program of therapy that may be an alternative to hospitalization, avoids placement in a more restrictive setting, or maintains the individual in a community setting where services to a distinct group of individuals is provided. -Services are available for at least three hours and less than 24 hours each day the program is open. Service activities may include but are not limited to: · Assessment · Plan Development · Therapy · Rehabilitation · Collateral
4.1.11	Day Rehabilitation: CCR Title 9, 1810.212	-Day Rehabilitation is a structured program of rehabilitation and therapy to improve, maintain, or restore personal independence and functioning consistent with requirements for learning and development, which provides services to a distinct group of individuals. -Services are available for at least three hours and less than 24 hours each day the program is open. Service activities may include, but are not limited to: · Assessment · Plan Development · Therapy · Rehabilitation · Collateral
4.1.12	Targeted Case Management: CCR Title 9, 1810.249	-Targeted case management is a service that assists a beneficiary to access needed medical, educational, social, prevocational, vocational, rehabilitative or other community services. -The service activities may include but are not limited to: communication, coordination, and referral; monitoring service delivery to ensure patient access to service and the service delivery system; monitoring the patient’s progress; placement services and plan management.
4.1.13	Mental Health Services: Professional Inpatient (IP) Visit	Mental Health Services: Professional IP visit services are the same as mental health services, except they are provided in a Fee-for-Service inpatient setting by professional staff.
4.1.14	Medication Support: CCR Title 9, 1810.225	-Medication support is a service that can include the prescribing, administering, dispensing and monitoring of psychiatric medications or biologicals that are necessary to alleviate the symptoms of mental illness. -Medication support activities may include evaluating the need for medication; evaluating clinical effectiveness and side effects; obtaining informed consent; instruction in the use, risks, benefits and alternatives to medication.
4.1.15	Medication Support: Professional IP Visit	Medication Support: Professional IP Visit services are the same as Medication Support, except they are provided in a Fee-for-Service IP setting by professional staff.
4.1.16	Crisis Intervention: State Plan Amendment 12-025	-Crisis intervention services last less than 24 hours and are provided to (or on behalf of) a beneficiary for a condition that requires a more timely response than a regularly scheduled visit. The goal of crisis intervention is to stabilize an immediate crisis within a community or clinical treatment setting. -Crisis intervention may be provided face-to-face, by telephone or by telemedicine with the beneficiary and/or significant support persons and may be provided in a clinic setting or anywhere in the community -This service includes one or more of the following service components: · Assessment · Collateral · Therapy · Referral -Crisis intervention is distinguished from crisis stabilization by being delivered by providers who do not meet the crisis stabilization contact, site, and staffing requirements described in CCR Title 9 Section 1840.338 and 1840.348.
4.1.17	Crisis Intervention: Professional IP Visit	Crisis intervention: Professional IP visit services are the same services as crisis intervention except that the services are provided in a Fee-For-Service IP setting by professional staff.
4.1.18	Peer Support Services	-Peer support services are culturally competent individual and group services that promote recovery, resiliency, engagement, socialization, self-advocacy, development of natural supports, and identification of strengths through structured activities such as group and individual coaching to set recovery goals and identify steps to reach the goals. -Peer support services may be provided face-to-face, by telephone or by telehealth with the beneficiary or significant support person(s) and may be provided anywhere in the community. Peer support services are based on an approved plan of care. -This service includes one or more of the following service components: *Therapeutic Activity *Engagement *Educational Groups *Collateral
4.1.19	Community-Based Mobile Crisis Intervention Services	State Plan Amendment 22-0043 Community-based mobile crisis intervention services provide rapid response, individual assessment and community-based stabilization for Medi-Cal beneficiaries who are experiencing a mental health crisis. Mobile crisis services are provided by a multidisciplinary mobile crisis team at the location where the beneficiary a behavioral health crisis. Locations may include, but are not limited to the beneficiary’s home, school or workplace, on the street, or where a beneficiary socializes. Mobile crisis services cannot be provided in hospitals or other facility settings. Mobile crisis services shall be available to beneficiaries experiencing behavioral health crises 24 hours per day, seven days per week, 365 days per year.
4.2	Provider Certification	-Certification of SMHS services is validated using Mode of Service and Service Function Codes. -Any site certified to perform any Mode 15 service can provide any of the services listed in service tables 1-9. Service Table 10 provides a crosswalk of the service function codes associated with Modes 5 and 10 and the codes that can be claimed within Modes 5 and 10. -24-Hour services are identified by Mode of Service ’05,’ along with the following Service Functions codes: · 10-18: Acute Psychiatric Inpatient Hospital Services · 19: Administrative Day Services · 20-29: Psychiatric Health Facility · 40-49: Crisis Residential Treatment (Children and Adults) · 65-69: Adult Residential · 95: Therapeutic Foster Care -Day services are identified by Mode of Service ’10,’ along with the following Service Function codes: · 20-24: Crisis Stabilization – Emergency Room · 25-29: Crisis Stabilization – Urgent Care · 81-89: Day Treatment Intensive · 91-99: Day Rehabilitation

► MH Claim Processing

Claim Processing Logic	Cal-PM	MSO
SDMH will deny all claims in which service lines are submitted as $0	When creating batches, exclude zero dollar services. Forms: Create Interim Billing Batch File and Quick Billing Rule Definition	Form: Provider Fee Definition,  CPT Code Definition, Revenue Code Definition, Approve/Pend/Deny Rules Definition
SDMH will deny all claims when SOC hasn't been met	Process: Regular Loading of MMEF file	Process: Regular Loading of MMEF file
SDMH will deny claims if birth month/year do not match MEDS	Enhancement: 270/271 RTE Form Enhancements	Enhancement: 270/271 RTE Form Enhancements, Form available to MSO and ProviderConnect NX Users
The beneficiary's gender needs to be reported on the claim but will not be verified by SD/MC as of 7-1-2023.	Enhancement: 270/271 RTE Form Enhancements	Enhancement: 270/271 RTE Form Enhancements, Form available to MSO and ProviderConnect NX Users
A provider may not provide a service to a beneficiary after the beneficiary has died. SD/MC will deny all service lines with a date of service that occurred after the beneficiary’s date of death as recorded in MEDS.
For any single claim, all DOS must be withing the same calendar month. Exception is Psychiatric Inpatient hospital services. The discharge date on the claim for psychiatric inpatient hospital services may occur on the first day of the following month. For example, a claim for an individual who was admitted to the hospital on October 28 and discharged on November 1 would be admissible. SD/MC will deny service lines submitted with dates of service that do not conform to this guidance.	Form: Guarantor/Program Billing Defaults - Max Service Per Claim Enhancement: Add "Sort Claims by Month" field to the 837P and 837I sections of the Guarantor/Program Billing Defaults Form	Form: Approve/Pend/Deny Rules Definition Approve/Pend/Deny Rules - able to configure for one service per claim.
Multiple claims to be submitted for stays that cross 1 or more months Unless the date of discharge is on the first day of the month following the month in which the beneficiary was admitted to the hospital.	Form: Guarantor/Program Billing Defaults - Max Service Per Claim Enhancement: Add "Sort Claims by Month" field to the 837P and 837I sections of the Guarantor/Program Billing Defaults Form	Form: Approve/Pend/Deny Rules Definition
Inpatient, 24-Hour, and Day Services: -Claim would be considered a duplicate if all of the following data elements are the same for another already appoved service: · The beneficiary’s client Index Number (CIN) · The County submitting the claim · The facility location’s NPI · Date of services · Procedure Code · Units of service · The billed amount --Except for Crisis Stabilization, billed with S9484:HE:GT, all duplicate inpatient, 24-hour, and day services will be denied. Crisis Stabilization billed with S9484:HE:GT may duplicate a previously approved claim for Crisis Stabilization once without additional modifiers and Crisis Stabilization may be duplicated more than once with an appropriate over-riding modifier (i.e., 59, 76, or 77). ----------------------------------------------------------------------------------------------------- Outpatient Services: -Claim would be considered a duplicate if all of the following data elements are the same for another already approved service: · The beneficiary’s CIN · Rendering provider NPI · Procedure code(s)/modifier(s) · Date of service --If a provider renders two services to the same beneficiary on the same day in two or more separate encounters, all encounters must be claimed as one service to ensure the additional encounters are not denied as duplicate services.	Form: Duplicate Service Report	Form: Approve/Pend/Deny Rules Definition Configure Approve/Pend/Deny Rules for Duplicate Dervices During Adjudication
If multiple practitioners render services to the same beneficiary at the same time, each provider must submit a separate claim for the distinct service each practitioner rendered	Supported today in Cal-PM. Co-Practitioner Claiming Functionality - Guide on Netsmart Resource Center	Contracting Providers will submit a service for each co-practitioner.
-SD/MC will deny those service lines with oral or sign language interpretation whose units of service multiplied by 15 minutes exceed the total amount of time claimed for all primary services on the same claim. -Sign language or oral interpretation and interactive complexity must be submitted on the same claim as the primary service.	Supported when configuring Add-On codes. Form: Service Codes	Form: CPT Code Definition, Provider Fee Definition
-Original claims must be submitted within 12 months of the month of services. -An original claim submitted after 12 months from the month of service without a DHCS approved Delay Reason Code (DRC) will be denied.	Supported via standard billing.	Supported today thru HIPAA electronic transactions Enhancement: Replacement Claim Support in MSO for manually entered claims Enhancement: Delay Reason Code (DRC) Support in MSO​ for manually entered claims
The submitted service facility address must be a physical address. If a service facility address is submitted as a P.O. Box, Lock Box or Lock Bin, the associated service will be denied.	Form: Program Maintenance Ensure Programs are set up as a physical address.	See Cal-PM column
-When a service is rendered by a FFS/MC individual or group provider, the claim must include “FFS” in the Claim Note Segment and the first three digits of the rendering provider’s taxonomy code must be 103, 104, 106, 163, 193, 207, 208, 363, or 364 -SD/MC will deny the service line if the Claim Note Segment contains “FFS” and 25 the first three digits of the rendering provider’s taxonomy code does not start with 103, 104, 106, 163, 193, 207, 208, 363, or 364	Form: Practitioner Numbers by Guarantor and Program Ability to configure populating "FFS" in NTE segment for specified practitioners	See Cal-PM column
SD/MC will deny a service line if the organizational provider, as determined by the service facility NPI number on the claim, is not certified to provide the service billed, as determined by the procedure code on the service line	Form: Inhibit Billing by Reason Inhibit services until the org is certified	Form: Provider Fee Definitions Do not enable fee definition until the Provider is certified
SD/MC will deny all service lines for psychiatric inpatient hospital services that do not have a valid revenue code.	Form: Revenue Code Defintion, Service Fee/Cross Reference Maintenance Configure so that any services codes under the applicable program have a valid revenue code entered in for the guarantor.	Form: Revenue Code Definition, Provider Fee Definition
SD/MC will deny all service lines for psychiatric inpatient hospital services and 24-hour services that do not include an admission date.	Supported via standard billing.	See Cal-PM column
SD/MC will deny all service lines for administrative day services that occurred on the beneficiary’s date of admission to the hospital	Form: Advanced Billing Rule Definition	Form: Claim Adjudication Rules Definition Configure an Existance Rule
-SD/MC will deny service lines for outpatient services that do not contain the rendering provider’s taxonomy code. -SD/MC will deny all service lines for outpatient services where the first four characters of the rendering provider’s taxonomy code does not identify a SD/MC Allowable Discipline for the procedure code on the service line.	Supported via standard billing.	Enhancement: Support for Taxonomy Codes in MSO
SD/MC will deny service lines for services that have a telehealth modifier but are not in place of service 02 or 10, unless the service is mobile crisis	Form: Service Fee/Cross Reference Maintenance Configure so that correct modifier is sent, can base on location selected for service	Form: CPT Code Definition
-Must be provided for at least three hours before it is eligible for reimbursement. -One unit of service is equal to 1 hour of service. -SD/MC will deny service lines for day treatment intensive and day rehabilitation services with less than 3 units of service.	Form: Advanced Billing Rule Definition Event Rules section - Event Table = Treatment History, Event Field = Units of Service.	Form: CPT Code Definition, Approve/Pend/Deny Rules Definition Minimun units field - can enter 3 for the applicable codes. Also can configure Approve/Pend/Deny Rule for Adjudication
-SD/MC will deny all claims for outpatient services that do not include a place of service code. -SD/MC will deny service lines that contain place of service code that may not be billed with the procedure code on the service line -SD/MC will deny all service lines for outpatient services with place of service code 09 (Correction Facility) -Claims for therapeutic foster care must include a place of service code and the place of service code must be one of the following: 03 (School), 11 (Office), 12 (Home), or 16 (Temporary Lodging). SD/MC will deny a service line for Therapeutic Foster Care if the place of service is code is not one of the four listed above	Form: Advanced Billing Rule Definition Event Rules section - Event Table = Treatment History, Event Field = Location Form: Program Maintenance Form, Associated Locations Field, allows for the ability to restict which locations can be selected for a service rendered under a specified program.	Form: CPT Code Definition and Revenue Code Definition - Place of Service field (multi-select). Also can configure Approve/Pend/Deny Rule
SD/MC will deny a service line with the primary procedure code if a Dependent on Code was not billed on the same claim or approved on the same day for the same beneficiary in history	Enhancement: Advanced Billing Rule Definition Add 'Select Service(s) That Must Also Be Rendered For Distribution' field	Form: Claims Adjudication Rules Definition Configure an Existence rule
SD/MC will deny a service line when the county is responsible for 100 percent of the cost to provide the service	Form: Benefit Plans/Financial Eligibility Configure Benefit Plans appropriately	Several options in MSO to handle - Forms: CPT Code definition, Provider Fee definition
-SD/MC will deny a service line that is not billed in units or reports units that exceed the unit maximum -SD/MC will deny a service line billed with an add-on procedure code if the primary procedure code is not present in the same claim	Form: Service Fee/Cross Reference Maintenance 'Quantity' field allows for a maximum duration that will go on claim regardless of duration/units entered for the service. Form: Service Codes Supported when configuring Add-On codes.	Form: CPT Code Definition Maximum units field - can enter for the applicable codes.
-Providers must submit claims to Medicare for Medi-Cal eligible services performed by Medicare-certified Providers in a Medicare certified facility before submitting a claim to Medi-Cal. -If Medicare does not respond within 90 days, the provider may submit a claim to Medi-Cal on the 91st day. -The claim submitted to Medi-Cal must include Other Health Coverage (OHC) information. -If the rendering provider is not eligible to render Medicare services, The county may bill Medi-Cal directly.	Form: Financial Eligibility	MSO and ProviderConnectNX allows for capturing OHC as well as incoming 837 files into MSO
Providers must submit claims to a beneficiary’s other health coverage for eligible services before submitting a claim to Medi-Cal. The claim submitted to Medi-Cal must include Other Health Coverage (OHC) information. However, the following services may be billed to Medi-Cal directly: -Targeted Case Management (T1017) -Therapeutic Behavioral Services (H2019) -Therapeutic Foster Care (S5145) -H0025 or H0038: Peer Support Services H2011 with Place of Service 15:Mobile Crisis If the beneficiary's OHC does not respond within 90 days, the provider may submit a claim to Medi-Cal on the 91st Day	Forms: Benefit Plans and Financial Eligibility	MSO and ProviderConnectNX allows for capturing OHC as well as incoming 837 files into MSO. Also, ability to configure an Approve/Pend/Dney rule - Can set up a rule to have based of the denial code sent by SD/MC, to have an automatic retro claim adjudication take place.
SD/MC will deny service lines for services provided by facilities on this list when the following conditions are met: When the facility is a hospital, psychiatric health facility, mental health rehabilitation center, or nursing facility and the beneficiary is from 22 years of age through 65 years of age. When the facility is a Short-Term Residential Therapeutic Program, SD/MC will deny the service line without regard to the beneficiary’s age.	Forms: Advanced Billing Rule Definition	Several options in MSO to handle - Configure CPT code definition, Provider Fee Definition, Authorizations, etc.
Limits on the amount of time certain services may be provided to a beneficiary in a 24-hour period Crisis Intervention limited to 8 hours in a 24-hour period Medication Support Services limited to 4 hours in a 24-period Crisis Stabilation Services limited to 20 hours in a 24-hour period	Form: Advanced Billing Rule Definition Event Rules section - Event Table = Treatment History, Event Field = Duration (Minutes)	Enhancement: Claim Adjudication Rules Definition Form Enhancement
SD/MC prohibits some SMH services from being provided to a beneficiary on the same day	Form: Advanced Billing Rule Definition 'Combination of services that cannot be reimbursed on the same day' Field	Form: Claims Ajudication Rules Definition Configure Existence rule
The pregnancy indicator should be set to yes if the beneficiary is pregnant. SD/MC will deny a claim submitted for a beneficiary enrolled in an aid code restricted to pregnancy services if the pregnancy indicator is not set to yes.	Form: Women's Health History, Guarantors/Payors Pregnancy Indicator on Outbound Claims Enhancement  - released earlier this year (Avatar Cal-PM 2022 Update 19)	See Cal-PM column
SD/MC will deny any service line for an EPSDT service if the beneficiary is not under 21 years of age, or the beneficiary is not enrolled in an aid code that is EPSDT eligible: -Therapeutic Behavioral Services (TBS) -Intensive Care Coordination (ICC) -In-Home Behavioral Services (IHBS) -Therapeutic Foster Care (TFC)	Form: Advanced Billing Rule Definition Can configure to do both Age comparisons and Aid Code included in Event Rules.	Form: Claim Adjudication Rules Definition Configure a Comparison Rule (Client's Age)
-SD/MC will deny a replacement claim submitted more than 15 months after the month of service. -Replacement claims for outpatient services, day services, or 24-hour services must have the following data elements match the claim it is replacing: Billing Employer Identification Number, County Code, the same number of service lines, and patient identification code. -The replacement claim must also have two of the following four data elements on each service line in the replacement claim must match the corresponding service lines in the original claim: Procedure code or revenue code (as appropriate), date of service, place of service, and service facility NPI.	Supported via standard rebilling in Cal-PM	Replacement claims support in MSO via 837 Transactions Enhancement: MSO Replacement Claims Support for Manual Entry
MHPs may void a previously approved claim at any time. SD/MC does not require voids to be submitted within a certain time frame after the service was rendered.	Supported via standard rebilling in Cal-PM	Supported today via standard rebilling for electronic claims; Forms: Void claim assignment/retro claim adjudication
MHPs may request a Delay Reason Code (DRC) to submit an original claim more than 12 months from the month of service or a replacement claim more than 15 months from the month of service.	Supported via standard billing in Cal-PM	Replacement/DRC claims support in MSO via 837 Transactions, Configure Approve/Pend/Deny Rule Enhancement: MSO Replacement Claims Support for Manual Entry Enhancement: Delay Reason Code Support MSO for Manual Entry

► Cal-PM and MSO Enhancements

Cal-PM Enhancement Opportunity	Priority	Needed prior to 7/1/2023?		MSO Enhancement Opportunity	Priority	Needed prior to 7/1/2023?
Service Unit and Fee Override	1	Yes		Enable Fee Override Setting in MSO	1	Yes
Add "Sort Claims by Month" field to the 837P and 837I sections of the Guarantor/Program Billing Defaults Form	2	No		Add Effective Start/End Dates to A/P/D Rules	2	Yes
Advanced Billing Rule Definition- Add 'Select Service(s) That Must Also Be Rendered For Distribution' field	3	No		Support for Taxonomy Codes in MSO	3	No
Enhance Product Custom Logic for Active Problem List in Progress Notes	4	No		Update "Additional Checking" Registry Settings for CalAIM DOB Validations	4	No
Ability to Configure by Admission Program the Assignment of Susbcriber MEDS ID	5	No		Claims Adjudication Rule Definition Enhancements	5	No
270/271 RTE Form Enhancements	6	No
Add Payer ID Fields to Guarantor/Program Billing Defaults form (837P and 837I sections)	7	No
Display Diagnosing Practitioner in Problem List System Notes When Problem Is Added via the Diagnosis form	8	No
Add “Clinician” as a New Column in the Problem List Grid (Staff Look-up Field)	9	No
Update Status of Problem in Problem List when the Diagnosis Record that Added the Problem is Updated	10	No
Ability to Configure what Columns Display in the Problem List	11	No
Add “Resolving Practitioner” to the Diagnosis form	12	No
	Note: For items that are marked as "Yes" have been identified that there is a fundamental change needed to support the workflow/feature. Items that are marked as "No", are noted enhancement requests that have been added to the myAvatar Roadmap (Many of these are currently scheduled to be delivered prior to 7/1/2023).

► MH Funding

6.1.0	Federal Share: FMAP percentage and Aid Codes	-After a claim passes all the adjudication edits, SD/MC determines the total amount eligible for reimbursement, which is called the total approved amount. SD/MC multiplies the total approved amount by an FMAP percentage to determine the amount of federal funds to reimburse the county. -the FMAP percentage depends upon a combination of the service provided and the beneficiary’s aid code. If a beneficiary is assigned more than one aid code, SD/MC will select the aid code eligible for the service billed with the highest FMAP. -The federal share for all services provided to a beneficiary enrolled in Medi-Cal, including State Only Medi-Cal, who is pregnant is 65 percent of the total approved amount. The service line must set the pregnancy indicator to yes to indicate that the beneficiary is pregnant. -The federal share for services funded by the American Rescue Plan Act (ARPA) is 85 percent of the total approved. Mobile crisis services are currently the only ARPA-funded services. -The federal share for non-pregnancy services provided to a beneficiary enrolled in the State Only Medi-Cal program is 0 percent. The federal government does not reimburse states for the cost of non-emergency and non-pregnancy services provided to beneficiary’s with unsatisfactory immigration status.
6.2.0	State Share and Proposition 30	-Proposition 30 requires the state to reimburse counties a portion of the non-federal share of increased costs incurred to implement new requirements for the Medi-Cal specialty mental health services program established after 2011 realignment. -The state must reimburse counties one hundred percent of the non-federal share for new requirements imposed by the State and fifty percent of the non-federal share for new requirements imposed by the federal government. -If a beneficiary is eligible for services as a result of the Affordable Care Act (ACA), the state will be responsible for 100 percent of the non-federal share - If the beneficiary is eligible for services as a result of Family First Prevention Services Act (FFPSA), the state will be responsible for 50 percent of the non-federal share - If the beneficiary is eligible as a result of Senate Bill (SB) 75, young adult expansion, older adult expansion, or is receiving continuum of care services, the state will be responsible one hundred percent of the non-federal share.
6.2.1	State Required Specialty Mental Health Services	-The state will reimburse counties 100 percent of the non-federal share for specialty mental health services provided as a result of a new state requirement implemented after 2011 realignment. -Either the beneficiary aid code or service modifier identifies whether the service was provided as a result of a new state requirement -This subsection discusses each of the new state requirements implemented after 2011 realignment and whether SD/MC uses a modifier or the beneficiary’s aid code to identify the service as a state requirement
6.2.1	Affordable Care Act Optional Expansion Population	-Beneficiaries enrolled in Medi-Cal as a result of the ACA Optional Expansion are assigned  specific aid codes (i.e., ACA aid codes) -Counties are required to provide Specialty Mental Health Services to a Medi-Cal Beneficiaries enrolled in ACA aid codes -The state reimburses counties 100 percent of the non-federal share of the total approved amount for specialty mental health services provided to beneficiaries enrolled in ACA aid codes -Services provided to beneficiaries enrolled in ACA aid codes do not need a modifier to be reimbursed 100 percent of the non-federal share
6.2.1	Continuum of Care Reform	-The State implemented Continuum of Care Reform in January of 2017. Continuum of Care Reform required mental health plans to assess children and youth before being placed in an STRTP and to participate in a child and family team when the child or youth needs mental health treatment. -To indicate that a service was provided as part of continuum of care reform, the MHP should use modifier HW with that service -Service tables 1-9 indicate which procedure codes can be used with modifier HW in the “Allowable Modifiers” column.
6.2.1	Senate Bill 75 - Medi-Cal for All Children	-Children under 19 years of age are eligible for full-scope Medi-Cal benefits regardless of immigration status, as long as they meet all other eligibility requirements -As a result, children under 19 years of age who do not have satisfactory immigration status are enrolled in the State Only Medi-Cal Program - SD/MC determines which beneficiaries are eligible for the State-Only Medi-Cal Program as a result of SB 75 by the beneficiaries’ aid code. -The state will reimburse MHPs 100 percent of the non-federal share for Specialty Mental Health Services provided to beneficiaries enrolled in the State Only Medi-Cal Program pursuant to SB 75 beneficiaries. The service does not need a modifier.
6.2.1	Young Adult Expansion	-As of January 1, 2020, young adults under the age of 26 are eligible for full-scope Medi-Cal regardless of immigration status, as long as they meet all other eligibility requirements -As a result, young adults from 20 through 25 years of age who do not have satisfactory immigration status are enrolled in the State Only Medi-Cal Program. -SD/MC determines which beneficiaries are eligible for Medi-Cal as a result of the young adult expansion by the beneficiaries’ aid code. -The state will reimburse MHPs 100 percent of the non-federal share for Specialty Mental Health Services provided to beneficiaries enrolled through the Young Adult Expansion. The service does not need a modifier.
6.2.1	Older Adult Expansion	-Older adults over 50 years of age are eligible for full-scope Medi-Cal regardless of immigration status, as long as they meet all other eligibility requirements. -As a result, older adults over 50 years of age who have unsatisfactory immigration status are enrolled in the State Only Medi-Cal Program. -SD/MC determines which beneficiaries are eligible for the State Only Medi-Cal Program as a result of older adult expansion by the beneficiaries’ aid code. -The state will reimburse MHPs for 100 percent of the non-federal share of the cost of care for Older Adult Expansion beneficiaries. The service does not need a modifier.
6.2.1	Community Based Mobile Crisis Intervention Services	MHPs should use modifier HW to indicate that the mobile crisis service was provided as a result of a State mandate and is subject to Proposition 30.
6.2.2	Federally Required Specialty Mental Health Services	-The state will reimburse counties 50 percent of the non-federal share for specialty mental health services provided as a result of a new federal requirement implemented after 2011 realignment. -Either the beneficiary aid code or service modifier identifies whether the service was provided as a result of a new federal requirement. -This subsection discusses each of the new federal requirements implemented after 2011 realignment and whether SD/MC uses a modifier or the beneficiary’s aid code to identify the service as a state requirement.
6.2.2	Family First Prevention Services Act (FFPSA)	-The Family First Prevention Services Act (FFPSA) requires a qualified individual to provide certain services to children and youth before they are placed and while they are placed in a Short-Term Residential Therapeutic Program (STRTP); and states to provide 6-months of aftercare services after a child or youth is discharged from an STRTP -FFPSA can only be claimed for a child under 21 -To indicate that a service was provided as a result of FFPSA, the MHP must use modifier HV with that service -Service tables 1-11 indicate which procedure codes can be used with modifier HV in the “Allowable Modifiers” column -The state will reimburse the MHP 50 percent of the non-federal share if the service was provided to a child under 21 and has an HV modifier -If the child has unsatisfactory immigration status and is only eligible for these specific services as a result of FFPSA, SD/MC will deny the service line unless the HV modifier is present. -If the HV modifier is present, the state will reimburse the MHP for 100 percent of the non-federal share of the cost of FFPSA services.
6.3.0	County Share	-Counties are responsible for the share of all approved services that are not reimbursed with federal and/or state funds. -Counties are not responsible for any portion of the amount approved for state required specialty mental health services as described in Section 6.2.1 -Counties are responsible for half of the non-federal share of the amount approved for federally required specialty mental health services as described in Section 6.2.2 -Counties are responsible for all the non-federal share of the amount approved for all other specialty mental health services. -Some specialty mental health services provided to some beneficiaries are not eligible for federal and/or state reimbursement. The county is responsible for 100 percent of the cost to provide these services. The following discusses those services.
6.3.0	Qualified Non-Citizens	-California provides full scope Medi-Cal benefits to Qualified Non-Citizens who are not federally eligible because they have not been in the United States for at least five years -Federal reimbursement is not available for Non-emergency and Non-pregnancy services provided to Qualified Non-Citizens enrolled in the State Only Medi-Cal Program. -State reimbursement is not available for specialty mental health services provided to Qualified Non-Citizens unless the service was provided as a result of a State Requirement as described in Section 6.2.1 or a Federal Requirement as described in Section 6.2.2. -Counties are responsible for 100 percent of the cost of all other services provided to Qualified Non-Citizens. -Qualified Non-Citizens are enrolled in specific aid codes that are listed in the Aid Code Master Chart.
6.3.0	Permanently Residing Under Color of Law (PRUCOL)	-California provides full scope Medi-Cal benefits to individuals Permanently Residing in the United States Under Color of Law (PRUCOL) who are otherwise eligible for Medi-Cal - Some of PRUCOL beneficiaries are not eligible for federal benefits and are enrolled in the State Only Medi-Cal Program - Federal reimbursement is not available for non-emergency and non-pregnancy services provided to PRUCOL beneficiaries enrolled in the State Only Medi-Cal Program. -State reimbursement is not available for Specialty Mental Health Services provided to PRUCOL beneficiaries enrolled in the State Only Medi-Cal Program unless the service was provided as a result of a State Requirement as described in Section 6.2.1 or a Federal Requirement as described in Section 6.2.2 -Counties are responsible for 100 percent of the cost of all other services provided to PRUCOL beneficiaries enrolled in the State Only Medi-Cal Program. -PRUCOL beneficiaries enrolled in the State Only Medi-Cal program are enrolled in specific aid codes that are listed in the Aid Code Master Chart.

► MH Out-of-State Claims

Billing Manual	Description	Details
7.1.0	Out-of-State: Outpatient Services	Title 9, CCR, s§ 1810.355(b) states that out-of-state specialty mental health services cannot be billed to SD/MC except when it is customary practice to receive medical services in a border community outside the State. Border communities are listed in Title 9, CCR, § 1820.115(i).
7.2.0	Out-of-State: Inpatient Services	Title 22, CCR, § 51006 states that emergency services are available for emergency conditions. Emergency conditions include emergency psychiatric conditions. To be reimbursed for out-ofstate inpatient emergency services, providers will need an approved Treatment Authorization Request (TAR). Please refer to Medi-Cal: Out-of-State Provider FAQs for additional details or call out-of-state provider support at (916) 636-1960.

► Disciplines

Abbreviations	Discipline
MD	Medical Doctor
DO	Doctor of Osteopathy
Pharm	General Pharmacist or Advanced Practice Pharmacist
CNS	Clinical Nurse Specialist
NP	Nurse Practitioner
RN	Registered Nurse
SW	Social Worker
LVN	Licensed Vocational Nurse
OT	Occupational Therapist
PCC	Professional Clinical Counselor
MFT	Marriage and Family Therapist
MHRS	Mental Health Rehabilitation Specialist
PhD	Doctor of Philosophy, Clinical Psychologist
PsyD	Doctor of Psychology, Clinical Psychologist
PA	Physician Assistant
Peer	Certified Peer Specialist
PT	Psychiatric Technician
Other	Other Qualified Provider

► POS for Professional Claims

Place of Service Code	Place of Service Name	Place of Service Description
01	Pharmacy	A facility where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients.
02	Telehealth Provided Other than in Patient’s Home	The location where service and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
03	School	A facility whose primary purpose is education
04	Homeless Shelter	A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters)
05	Indian Health Service Free-Standing Facility	A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization.
06	Indian Health Service ProviderBased Facility	A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients.
07	Tribal 638 Free-Standing Facility	A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members who do not require hospitalization.
08	Tribal 638 Provider-Based Facility	A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members admitted as inpatients or outpatie
09	Prison/Correctional Facility	A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either Federal, State, or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders.
10	Telehealth Provided in Patient’s Home	The location where health services and health related services are provided or received, through telecommunication technology. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology
11	Office	Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis and treatment of illness or injury on an ambulatory basis
12	Home	Location, other than a hospital or other facility, where the patient receives care in a private residence.
13	Assisted Living Facility	Congregate residential facility with self-contained units providing assessment of each resident’s needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services.
14	Group Home	A residence with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial services, and minimal services (e.g., medication administration).
15	Mobile Unit	A facility/unit that moves from place to place equipped to provide preventive screening, diagnostic, and/or treatment services.
16	Temporary Lodging	A short-term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care and which is not identified by any other Place of Service code.
17	Walk-in Retail Health Clinic	A walk-in retail clinic, other than an office, urgent care facility, pharmacy, or independent clinic and not described by any other Place of Service code that is located within a retail operation and provides, on an ambulatory basis, preventive and primary care services.
18	Place of Employment-Worksite	A location, not described by any other Place of Service code, owned and operated by a public or private entity where the patient is employed, and where a health professional provides on-going or episodic occupational medical, therapeutic or rehabilitative services to the individual.
19	Off Campus—Outpatient Hospital	A portion of an off-campus hospital provider-based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
20	Urgent Care Facility	Location, distinct from a hospital emergency room, an office or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.
21	Inpatient Hospital	A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
22	On-Campus Outpatient Hospital	A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
23	Emergency Room—Hospital	A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.
24	Ambulatory Surgical Center	A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis.
25	Birthing Center	A facility, other than a hospital’s maternity facilities or a physician’s office, which provides a setting for labor, delivery, and immediate postpartum care as well as immediate care of newborn infants.
26	Military Treatment Facility	A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).
31	Skilled Nursing Facility	A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing or rehabilitative services but does not provide the level of care or treatment available in a hospital.
32	Nursing Facility	A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than individuals with intellectual disabilities.
33	Custodial Care Facility	A facility that provides room, board, and other personal assistance services, generally on a long-term basis, and which does not include a medical component.
34	Hospice	A facility, other than a patient’s home, in which palliative and supportive care for terminally ill patients and their families are provided.
41	Ambulance—Land	A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.
42	Ambulance—Air or Water	An air or water vehicle specifically designed, equipped, and staffed for lifesaving and transporting the sick or injured.
49	Independent Clinic	A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.
50	Federally Qualified Health Center	A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.
51	Inpatient Psychiatric Facility	A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.
52	Psychiatric Facility—Partial Hospitalization	A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.
53	Community Mental Health Center (CMHC)	A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of CMHC’s mental health services area who have been discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services.
54	Intermediate Care Facility/Individuals with Intellectual Disabilities	A facility which primarily provides health-related care and services above the level of custodial care to individuals with intellectual disabilities but does not provide the level of care or treatment available in a hospital or SNF.
55	Residential Substance Abuse Treatment Facility	A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.
56	Psychiatric Residential Treatment Center	A facility or a distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.
57	Non-residential Substance Abuse Treatment Facility	A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.
58	Non-residential Opioid Treatment Facility	A location that provides treatment for opioid use disorder on an ambulatory basis. Services include methadone and other forms of Medication Assisted Treatment (MAT).
60	Mass Immunization Center	A location where providers administer pneumococcal pneumonia or influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting.
61	Comprehensive Inpatient Rehabilitation Facility	A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetic services.
62	Comprehensive Outpatient Rehabilitation Facility	A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.
65	End-Stage Renal Disease Treatment Facility	A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis.
71	Public Health Clinic	A facility maintained by either State or local health departments that provides ambulatory primary medical care under the general direction of a physician.
72	Rural Health Clinic	A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the direction of a physician.
81	Independent Laboratory	A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician’s office.
99	Other Place of Service	Other place of service not identified above.

► Modifiers

Modifier	Definition	When to Use	Codes/Code Types This Modifier Applies To
27	Multiple Outpatient Hospital Evaluation and Management (E/M) Encounters on the Same Date: For hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct E/M encounters performed in multiple outpatient hospital settings on the same date may be reported by adding modifier 27 to each appropriate level of outpatient and/or emergency department E/M code(s). This modifier provides a means of reporting circumstances involving evaluation and management services provided by physician(s) in more than one (multiple) outpatient hospital setting(s) (e.g., hospital emergency department, clinic).	Use this modifier, as appropriate, to override those lockout codes that can be overridden with a modifier. The lockout codes that can be overridden have ** next to them in service tables 1-10. This modifier needs to be used even if the over ridable lockout combinations were provided by that same provider to the same beneficiary in different settings because when SDMC is determining whether two services cannot be billed together (i.e., are “locked out”), it compares the service code billed only to previously approved service codes on the submitted claim and in the beneficiary’s history. If two service codes cannot be billed together, whichever code is processed second will be denied.	This modifier will only be used with CPT codes that are part of an over-ridable lockout combination.
59	Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.	Use this modifier, as appropriate, to override those lockout codes that can be overridden with a modifier. The codes that can be overridden have * or ** next to them. This modifier is also to be used by any appropriate professional to override a 24-hour or day duplicate services lockout for S9484 (crisis stabilization). Do not use this code for crisis intervention. This modifier may be used by a licensed, pre-licensed or otherwise qualified healthcare professional employed by the county and/or contracted provider. This does not mean that if a provider performs an outpatient service while a patient is in a crisis stabilization unit, they can submit a separate claim for that service. Doing so would cause the service to be denied. These modifiers need to be used even if the over-ridable lockout combinations were provided by that same provider to the same beneficiary in different settings because when SDMC is determining whether two services cannot be billed together (i.e., are “locked out”), it compares the service code billed only to previously approved service codes on the submitted claim and in the beneficiary’s history. If two service codes cannot be billed together, whichever code is processed second will be denied.	This modifier will be used with: • CPT codes that are part of an over-ridable lockout combination • S9484
76	Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional: It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. Note: This modifier should not be appended to an E/M service.	Use this modifier to override 24-hour or day duplicate services lockout for S9484 (crisis stabilization). Do not use this code for crisis intervention. This modifier may be used by a licensed, pre-licensed or otherwise qualified healthcare professional employed by the county and/or contracted provider.	This modifier will be used with: • CPT codes that are part of an over-ridable lockout combination • S9484
77	Repeat Procedure by Another Physician or Other Qualified Health Care Professional: It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service. Note: This modifier should not be appended to an evaluation and management service.	Use this modifier to override 24-hour or day duplicate services lockout for S9484 (crisis stabilization). Do not use this code for crisis intervention or any other outpatient service. This modifier may be used by a licensed, pre-licensed or otherwise qualified healthcare professional employed by the county and/or contracted provider. This does not mean that if a provider performs an outpatient service while a patient is in a crisis stabilization unit, they can submit a separate claim for that service. Doing so would cause the service to be denied.	This modifier will be used with S9484
93	Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunication System: Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified professional. The totality of the communication of information exchanged between the physician or other qualified health care professional during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a faceto-face interaction.	Use this modifier when a health care professional is providing services and benefits via telephone. If using this modifier, indicate that the service was provided in Place of Service 02 or 10.	This modifier will be used with CPT codes that can be provided in a telehealth place of service and via telephone.
95	Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunication System. Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.	Use this modifier when a health care professional is providing services and benefits via telehealth. If using this modifier, indicate that the service was provided in Place of Service 02 or 10.	This modifier will be used with CPT codes that can be provided in a telehealth place of service.
SC	Valid for codes when the service was provided via telephone or audio-only systems.	Use this modifier when a health care professional is providing services and benefits via telephone or audio-only and that service is described by a HCPCS code. If using this modifier, indicate that the service was provided in Place of Service 02 or 10.	This modifier only applies to HCPCS codes.
GT	Via telehealth in 24-hour or day facilities.	Use this modifier on day or 24-hour claims when the service was provided via telehealth.
GC	This service has been performed in part by a resident under the direction of a teaching physician.	Use this modifier when the service was performed by a physician resident. If the pre-licensed professional has an NPI, they may report their own NPI. If they do not, the supervising physician’s NPI would be reported with modifier GC after the service to indicate that the service was performed by a resident. If the service was performed by a pre-licensed professional who is not a resident, use modifier HL.
HA	Child/adolescent program	Use this modifier when billing for Children’s Crisis Residential Program (CCRP) services or psychiatric inpatient: administrative day under 21.
HB	Adult program, non-geriatric	Use this modifier when billing for crisis residential treatment services provided to adults from 21 through 64 years of age.
HC	Adult program, geriatric	Use this modifier when billing for crisis residential treatment services provided to adults 65 years of age.
HE	Mental health program	Use this modifier when billing for 24-hour and day services. For additional information about when this modifier is required refer to service table 12. Do not use this modifier when claiming for outpatient services.
HK	Specialized mental health programs for high-risk populations	Use this modifier to indicate that an IHBS or ICC service was provided.
HL	Intern	Use this modifier when the service was performed by a registrants and interns who are working in clinical settings under supervision to obtain licensure. If the pre-licensed professional has an NPI, they may report their own NPI. If they do not, the supervising clinician’s NPI would be reported with modifier HL after the service to indicate that the service was performed by a pre-licensed professional. If the service was performed by a resident, use modifier GC.	Services provided by individuals  who are currently registered with the applicable Board.
HQ	Group Setting	Use this modifier to indicate that a therapy service was provided in a group setting.	This modifier should be used with add-on code G2212 when that code adds time to 90849 (multiple family group psychotherapy) or 90853 (group psychotherapy other than a multiple-family group)
HV	The State covers 50 percent of the nonfederal share, as the service was determined to be covered under Proposition 30. Please note that this definition does not correspond to the national description reference; the definition reflects state policy.	Use this modifier to identify services that the county provided as a result of a federal mandate that are subject to Proposition 30. Currently, services provided by the Qualified Individual (QI) as a result of the federal requirements contained in the Family First Prevention Services Act (FFPSA), such as intensive care coordination services, should use the modifier HV. Likewise, aftercare services (for six months after discharge from an STRTP) are a new requirement of the FFPSA, and specialty mental health services provided as part of a High-Fidelity Wraparound program should also use the modifier HV.
HW	The State covers 100 percent of the nonfederal share, as the service was determined to be covered under Proposition 30.	Use this modifier to identify services that the county provided as a result of a state mandate that are subject to Proposition 30. Currently continuum of care services provided as a result of AB 403 should use the HW modifier.
TG	Complex/high tech level of care	Use this modifier when billing for day treatment intensive and crisis stabilization. For additional information about when this modifier is required refer to service table 12. Do not use this modifier when claiming for outpatient services.
XE	Separate encounter, a service that is distinct because it occurred during a separate encounter.	Use this modifier, as appropriate, to override those lockout codes that can be overridden with a modifier. The codes that can be overridden have * or ** next to them. These modifiers need to be used even if the over-ridable lockout combinations were provided by that same provider to the same beneficiary in different settings because when SDMC is determining whether two services cannot be billed together (i.e., are “locked out”), it compares the service code billed only to previously approved service codes on the submitted claim and in the beneficiary’s history. If two service codes cannot be billed together, whichever code is processed second will be denied.
XP	Separate practitioner, a service that is distinct because it was performed by a separate practitioner.	Use this modifier, as appropriate, to override those lockout codes that can be overridden with a modifier. The codes that can be overridden have ** next to them. These modifiers need to be used even if the over-ridable lockout combinations were provided by that same provider to the same beneficiary in different settings because when SDMC is determining whether two services cannot be billed together (i.e., are “locked out”), it compares the service code billed only to previously approved service codes on the submitted claim and in the beneficiary’s history. If two service codes cannot be billed together, whichever code is processed second will be denied.
XU	Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service.	Use this modifier, as appropriate, to override those lockout codes that can be overridden with a modifier. The codes that can be overridden have * or ** next to them. These modifiers need to be used even if the over-ridable lockout combinations were provided by that same provider to the same beneficiary in different settings because when SDMC is determining whether two services cannot be billed together (i.e., are “locked out”), it compares the service code billed only to previously approved service codes on the submitted claim and in the beneficiary’s history. If two service codes cannot be billed together, whichever code is processed second will be denied.

► Assessment Codes Service Table

Service	Code	SD/MC Allowable Disciplines	Allowable Place of Service	Lockout Codes Note: The below outpatient services are locked out against inpatient and 24-hour services except for the date of admission	Dependent on Codes	Medicare COB Required?	Maximum Units that Can be Billed	Allowable Modifiers
Psychiatric Diagnostic Evaluation, 15 Minutes	90791	MD/DO · PA · PhD/PsyD (Licensed or Waivered) · SW (Licensed, Registered or Waivered) · MFT (Licensed, Registered or Waivered) · NP or CNS (Certified) and · PCC (Licensed or Registered)	All except 09	Cannot be billed with: 90792 90832-90834 90836-90838 90839-90840* 90847 90849 90853 90865 90867-90870* 90880 90885* 90887* 96112 96113 96116 96121 96127* 96161* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99241-99245** 99251-99255** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99366-99368** 99441-99443** 99451** 99605-99606**	None	Yes	1	59 93 95 GC HK HL HV HW XE XP XU
Psychiatric Diagnostic Evaluation with Medical Services, 15 Minutes	90792	· MD/DO · PA  · NP or CNS (Certified)	All except 09	90791 90832-90834 90836-90838 90839-90840* 90847 90849 90853 90865 90867-90870* 90880 90885* 90887* 96112 96113 96116 96121 96127* 96161* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99241-99245** 99251-99255** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99366-99368** 99441-99443** 99451** 99605-99606**	None	Yes	1	59 93 95 GC HK HL HV HW XE XP XU
Psychiatric Evaluation of Hospital Records, Other Psychiatric Reports, Psychometric and/or Projective Tests, and Other Accumulated Data for Medical Diagnostic Purposes, 15 Minutes	90885	· MD/DO · PA · PhD/PsyD (Licensed or Waivered)  · SW (Licensed, Registered or Waivered)  · MFT (Licensed, Registered or Waivered) · NP or CNS (Certified) · PCC (Licensed or Registered)	All except 09	90791 90792 90839-90840	No	No	1	59 95 GC HK HL HV HW XE XP XU
Assessment of Aphasia, per Hour	96105	· MD/DO · PA · PhD/PsyD (Licensed or Waivered) · NP or CNS (Certified)	All except 09	96110* 96125* 96127* 96146* 96161*	No	Yes	1	95 GC HK HL HV HW
Developmental Screening, 15 Minutes	96110	· MD/DO  · PA · PhD/PsyD (Licensed or Waivered) · SW (Licensed, Registered or Waivered)  · MFT (Licensed, Registered or Waivered)  · NP or CNS (Certified) · PCC (Licensed or Registered)  · RN	All except 09	96105 96116 96121 96125* 96130 96131-96133 96136-96139 96146* 96161	No	No	1	59 95 GC HK HL HV HW XE XP XU
Developmental Testing, First Hour	96112	· MD/DO · PA · PhD/PsyD (Licensed or Waivered) · NP or CNS (Certified)	All except 09	90791-90792* 90832-90834* 90836-90839* 90845* 90847* 90849* 90853* 90865* 90870* 90880* 96116 96121 96125* 96127* 96130-96131* 96146* 96161* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350**	No	Yes	1	59 95 GC HK HL HV HW XE XP XU
Developmental Testing, Each Additional 30 Minutes	96113	· MD/DO · PA · PhD/PsyD (Licensed or Waivered) · NP or CNS (Certified)	All except 09	90791-90792* 90832-90834* 90836-90839* 90845* 90847* 90849*90853* 90865* 90870* 90880* 96121 96125* 96127* 96130 96131* 96138 96146* 96161* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350**	Must code 96112 (first hour) before coding 96113 (each additional 30 minutes) before coding 96113.	Yes	44	59 95 GC HK HL HV HW XE XP XU
Neurobehavioral Status Exam, First Hour	96116	· MD/DO  · PA · PhD/PsyD (Licensed or Waivered) · SW (Licensed, Registered or Waivered) · NP or CNS (Certified)  · PCC (Licensed or Registered)  · RN	All except 09	90791 90792 90832-90834 90836-90840 90845 90847 90849 90853 90865  90880  96110*  96112*  96125*  96127*  96146*  96161*  99202-99205  99212-99215  99217-99220 99231-99236 99304-99310  99324-99328 99334-99337  99341-99345  99347-99350	No	Yes	1	59 95 GC HK HL HV HW XE XP XU
Neurobehavioral Status Exam, Each Additional Hour	96121	MD/DO • PA • PhD/PsyD (Licensed or Waivered) • SW (Licensed, Registered or Waivered) • MFT (Licensed, Registered or Waivered)NP or CNS (Certified) • PCC (Licensed or Registered) • RN	All except 09	90792  96110* 96112-96113*  96125*  96127*  96146  96161*	Must code 96116 before coding 96121.	Yes	22	95 GC HK HL HV HW
Standardized Cognitive Performance Testing, per Hour	96125	· MD/DO · PhD/PsyD (Licensed or Waivered)  · PA  · NP or CNS (Certified)	All except 09	96105 96110 96112-96113 96116 96121 96127* 96130-96133 96136-96139 96146* 96161* 99202-99205 99212-99215 99217-99220 99231-99236 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350	No	Yes	1	59 95 GC HK HL HV HW XE XP XU
Brief Emotional/Behavioral Assessment, 15 Minutes Service	96127	· MD/DO  · PA  · PhD/PsyD (Licensed or Waivered)  · SW (Licensed, Registered or Waivered) · MFT (Licensed, Registered or Waivered) · NP or CNS (Certified)  · PCC (Licensed or Registered)  · RN	All except 09	90791-90792 90832-90834 90836-90840 90845 90847 90849 90853 90865 90867-90870 90880 96105 96112-96113 96116 96121 96125 96130-96133 96136-96139 96146* 96161* 99217-99220 99231-99236 99251-99255 99304-99310 99366-99368 99441-99443 99451 99484	No	Yes	1	59 95 GC HK HL HV HW XE XP XU
Psychological Testing Evaluation, First Hour	96130	· MD/DO · PhD/PsyD (Licensed or Waivered) · PA · NP or CNS (Certified)	All except 09	96110* 96112 96113* 96125* 96127* 96161* 96146* 99202-99205 99212-99215 99217-99220 99231-99236 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350	No	Yes	1	59 95 GC HK HL HV HW XE XP XU
Psychological testing Evaluation, Each Additional hour	96131	· MD/DO · PhD/PsyD (Licensed or Waivered) · PA · NP or CNS (Certified)	All except 09	96110*  96112  96113*  96125*  96127* 96161* 96146*	Must code 96130 before coding 96131.	Yes	22	59  93  95  GC  HK  HL  HV  HW  XE  XP  XU
Neuropsychological Testing Evaluation, First Hour	96132	· MD/DO  · PhD/PsyD (Licensed or Waivered)  · PA · NP or CNS (Certified)	All except 09	96110* 96125* 96127* 96146* 96161* 99202-99205 99212-99215 99217-99220 99231-99236 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350	No	Yes	1	59 95 GC HK HL HV HW XE XP XU
Neuropsychological Testing Evaluation, Each Additional Hour	96133	· MD/DO · PhD/PsyD (Licensed or Waivered) · PA · NP or CNS (Certified)	All except 09	96110* 96125* 96127* 96146* 96161*	Must code 96132 before coding 96133.	Yes	22	95 GC HK HL HV HW
Psychological or Neuropsychological Test Administration, First 30 Minutes	96136	· MD/DO · PhD/PsyD (Licensed or Waivered)  · PA · NP or CNS (Certified)	All except 09	96110* 96125* 96127* 96138* 96146* 96161* 99202-99205 99212-99215 99217-99220 99231-99236 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350	No	Yes	1	59 95 GC HK HL HV HW XE XP XU
Psychological or Neuropsychological Test Administration, Each Additional 30 Minutes	96137	· MD/DO · PhD/PsyD (Licensed or Waivered) · PA · NP or CNS (Certified)	All except 09	96110* 96125* 96127* 96138* 96146* 96161*	Must code 96136 before coding 96137.	Yes	45	95 GC HK HL HV HW
Psychological or Neuropsychological Test Administration by Technician, First 30 Minutes	96138	PT	All except 09	96110* 96113* 96125* 96127* 96146* 96161* 96136-96137 99202-99205 99212-99215 99217-99220 99231-99236 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350	No	Yes	1	59 95 GC HK HL HV HW XE XP XU
Psychological or Neuropsychological Test Administration, Each Additional 30 Minutes	96139	PT	All except 09	96110* 96125* 96127* 96146* 96161*	96138 before coding 96139.	Yes	45	95 GC HK HL HV HW
Psychological or Neuropsychological Test Administration, 15 Minutes	96146	· MD/DO · PhD/PsyD (Licensed or Waivered)  · PA  · NP or CNS (Certified)	All except 09	96105 96110 96112-96113 96116 96121 96125 96127 96130-96133 96136-96139 96161* 99202-99205 99212-99215 99217-99220 99231-99236 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350	No	Yes	1	59 95 GC HK HL HV HW XE XP XU
Telephone Assessment and Management Service, 5-10 Minutes	98966	· PA · PhD/PsyD (Licensed or Waivered) · SW (Licensed, Registered or Waivered) · MFT (Licensed, Registered or Waivered) · NP or CNS (Certified) · PCC (Licensed or Registered)	02 10	98967 98968 99484	No	Yes	1	59 93 HK HL HV HW XE XP XU
Telephone Assessment and Management Service, 11-20 Minutes	98967	· PA · PhD/PsyD (Licensed or Waivered)  · SW (Licensed, Registered or Waivered)  · MFT (Licensed, Registered or Waivered)  · NP or CNS (Certified) · PCC (Licensed	02 10	98966 98968 99484	No	Yes	1	59 HK HL HV HW XE XP XU
Telephone Assessment and Management Service, 21-30 Minutes	98968	· PA · PhD/PsyD (Licensed or Waivered)  · SW (Licensed, Registered or Waivered) · MFT (Licensed, Registered or Waivered)  · NP or CNS (Certified)  · PCC (Licensed or Registered)	02 10	98966 98967 99484	No	Yes	1	59 93 HK HL HV HW XE XP XU
Initial Observation Care, per Day, for the Evaluation and Management of a Patient, 20-39 Minutes	99218	· MD/DO · PA  · NP or CNS (Certified)	19 22 23	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96365* 96369* 96372-96374* 96377* 99202-99205** 99212-99215** 99217** 99219-99220 99234-99236 99304-99306 99307-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV HW XE XP XU
Initial Observation Care, per Day, for the Evaluation and Management of a Patient, 40-59 Minutes	99219	· MD/DO  · PA  · NP or CNS (Certified)	19 22 23	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99202-99205** 99212-99215** 99217-99218** 99220-99223 99234-99236 99304-99306 99307-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV HW XE XP XU
Initial Observation Care, per Day, for the Evaluation and Management of a Patient, 60-79 Minutes	99220	· MD/DO · PA  · NP or CNS (Certified)	19 22 23	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99202-99205** 99212-99215** 99217-99219** 99234-99236 99304-99306 99307-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV HW XE XP XU
Observation or Inpatient Hospital Care, Including Admission and Discharge on the Same Date, 35-44 Minutes	99234	· MD/DO · PA  · NP or CNS (Certified)	19 21-23 26 51 61	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99202-99205** 99212-99215** 99217-99220** 99231-99233** 99235-99236 99307-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV HW XE XP XU
Observation or Inpatient Hospital Care, Including Admission and Discharge on the Same Date, 45-53 minutes	99235	· MD/DO · PA · NP or CNS (Certified)	19 21-23 26 51 61	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99202-99205** 99212-99215** 99217-99220** 99231-99234** 99236 99307-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV HW XE XP XU
Observation or Inpatient Hospital Care, Including Admission and Discharge on the Same Date, 54-60 Minutes	99236	· MD/DO  · PA · NP or CNS (Certified)	19 21-23 26 51 61	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99202-99205** 99212-99215** 99217 99219-99223** 99234-99236** 99304-99306 99307-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV HW XE XP XU
Telephone Evaluation and Management Service, 5-10 Minutes	99441	· MD/DO · PA  · NP or CNS (Certified)	02 10	90791 90792 90832-90834 90836-90838 96127* 99442 99443 99484	No	Yes	1	27 59 GC HK HL HV HW XE XP XU
Telephone Evaluation and Management Service, 11-20 Minutes	99442	· MD/DO · PA · NP or CNS (Certified)	02 10	90791 90792 90832-90834 90836-90838 96127* 99441 99443 99484	No	Yes	1	27 59 GC HK HL HV HW XE XP XU
Telephone Evaluation and Management Service, 21-30 Minutes	99443	· MD/DO · PA  · NP or CNS (Certified)	02 10	90791 90792 90832-90834 90836-90838 96127* 99441 99442 99484	No	Yes	1	27 59 GC HK HL HV HW XE XP XU
Mental Health Assessment by Non-Physician, 15 Minutes	H0031	· Pharmacist · PhD/PsyD (Licensed or Waivered)  · SW (Licensed, Registered or Waivered) · MFT (Licensed, Registered or Waivered) · PCC (Licensed or Registered)  · Psychiatric Technician  · PA  · NP or CNS (Certified)  · RN  · LVN  · MHRSP  · Occupational Therapist  · Other Qualified Practition	All except 09	No	No	No	96	HK HV HW SC
Comprehensive Multidisciplinary Evaluation, 15 Minutes	H2000	All disciplines including non- licensed practitioners	All except 09	No	No	No	96	GC HK HL HV HW SC
Nursing Assessment/Evaluation, 15 Minutes	T1001	· Psychiatric Technician · NP or CNS (Certified)  · RN  · LVN	All except 09	No	No	No	96	HK HL HV HW SC

► Crisis Intervention Codes

Service	Code	SD/MC Allowable Disciplines	Allowable Place of Service	Lockout Codes Note: The below outpatient services are locked out against inpatient and 24-hour services except for the date of admission	Dependent on Codes	Medicare COB Required?	Maximum Units that Can be Billed	Allowable Modifiers
Psychotherapy for Crisis, First 30-74 Minutes	90839	· MD/DO · PhD/PsyD (Licensed or Waivered) · SW (Licensed, Registered or Waivered) · PCC (Licensed, Registered or Waivered) · MFT (Licensed, Registered or Waivered) · PA · NP or CNS (Certified)	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	Cannot be billed with: 90785 90791-90792 90832-90834 90836-90838 90845 90847 90849 90853 90865 90867-90870* 90880 90885* 90887* 96112-96113 96116* 96127* 99605-99606**	No	Yes	1	59 GC HL HV XE XP XU
Psychotherapy for Crisis, Each Additional 30 Minute	90840	· MD/DO · PhD/PsyD (Licensed or Waivered) · SW (Licensed, Registered or Waivered) · PCC (Licensed, Registered or Waivered) · MFT (Licensed, Registered or Waivered) · PA · NP or CNS (Certified)	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	Cannot be billed with: 90785 90791-90792 90832-90834 90836-90838 90845 90847 90849 90853 90865 90867-90870* 90880 90885* 90887* 96116* 96127* 99605-99606**	90839	Yes	13	59 GC HL HV XE XP XU
Crisis Intervention Service, per 15 Minutes	H2011	All disciplines including non- licensed practitioners	All except 09 and 15	No	No	No	32	GC HL HV SC

► Medication Support Codes

Service	Code	SD/MC Allowable Disciplines	Allowable Place of Service	Lockout Codes Note: The below outpatient services are locked out against inpatient and 24-hour services except for the date of admission	Dependent on Codes	Medicare COB Required?	Maximum Units that Can be Billed	Allowable Modifiers
Narcosynthesis for Psychiatric Diagnostic and Therapeutic Purposes, 15 Minutes	90865	MD/DO  PA  NP or CNS (Certified)	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	90791 90792 90832-90834 90836-90840 90845 90847 90849 90853 90867-90870 90880 96112-96113 96116* 96127* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99605-99606**	No	Yes	1	59 GC HL HV XE XP XU
Intravenous Infusion, for Therapy, Prophylaxis, or Diagnosis, 1-60 Minutes	96365	MD/DO  PA  NP or CNS (Certified) RN	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	90870 96372* 96374* 96377* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350**	No	Yes	1	59 GC HL HV XE XP XU
Intravenous Infusion, for Therapy, Prophylaxis, Each Additional 30-60 Minutes past 96365	96366	MD/DO  PA  NP or CNS (Certified) RN	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	90867-90870	96365	Yes	4	59 GC HL HV XE XP XU
Intravenous Infusion, for Therapy, Prophylaxis, or Diagnosis; Additional Sequential Infusion, 1-60 Minutes after 96365	96367	MD/DO  PA  NP or CNS (Certified) RN	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	90867-90870 99231-99233 99307-99310	96365 96374	Yes	1	59 GC HL HV XE XP XU
Intravenous Infusion, for Therapy, Prophylaxis, or Diagnosis; Concurrent Infusion, 15 Minutes	96368	MD/DO  PA  NP or CNS (Certified) RN	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	90867-90870	96365 96366	Yes	1	59 GC HL HV XE XP XU
Subcutaneous Infusion for Therapy or Prophylaxis, Initial, 15-60 Minutes	96369	MD/DO  PA  NP or CNS (Certified) RN	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	96372* 96377* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350**	No	Yes	1	59 GC HL HV XE XP XU
Subcutaneous Infusion for Therapy or Prophylaxis, Each Additional 30-60 Minutes after 96369	96370	MD/DO  PA  NP or CNS (Certified) RN	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	No	96369	Yes	7	GC HL HV
Subcutaneous Infusion for Therapy or Prophylaxis, Additional Pump Set-Up, 15 Minutes	96371	MD/DO  PA  NP or CNS (Certified) RN	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	No	96369	Yes	13	GC HL HV
Therapeutic, Prophylactic, or Diagnostic Injection; Subcutaneous or Intramuscular, 15 Minutes. Do not use this code to indicate administration of vaccines/toxoids or intradermal cancer immunotherapy injection.	96372	MD/DO  PA  NP or CNS (Certified) RN	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	90870 96365 96369 96374 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350**	No	Yes	16	59 GC HL HV XE XP XU
Therapeutic, Prophylactic, or Diagnostic Injection; Intra-Arterial, 15 Minutes	96373	MD/DO  PA  NP or CNS (Certified) RN	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	99202-99205** 99212-99215** 99217-99223** 99231-99236** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350**	No	Yes	1	59 GC HL HV XE XP XU
Therapeutic, Prophylactic, or Diagnostic Injection; Intravenous Push, Single or Initial Substance/Drug, 15 Minutes	96374	MD/DO  PA  NP or CNS (Certified) RN	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	90870 96365 96372* 96377* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350**	No	Yes	1	59 GC HL HV XE XP XU
Therapeutic, Prophylactic, or Diagnostic Injection; Each Additional Sequential Intravenous Push of a New Substance/Drug, 15 Minutes	96375	MD/DO  PA  NP or CNS (Certified) RN	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	90870 99231-99233 99307-99310	96365 96374	Yes	13	59 GC HL HV XE XP XU
Therapeutic, Prophylactic, or Diagnostic Injection; Each Additional Sequential Intravenous Drug Provided in a Facility; Has to be More than 30 Minutes after a Reported Push of the Same Drug, 1-14 Minutes	96376	MD/DO  PA  NP or CNS (Certified) RN	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	90870	96365 96374	No	1	59 GC HL HV XE XP XU
Application of On-body Injector for Timed Subcutaneous Injection, 15 Minutes	96377	MD/DO  PA  NP or CNS (Certified) RN	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81 99	90870 96365 96369 96374 99202-99205** 99212-99215** 99217-99223 99231-99236 99241-99245** 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350	No	Yes	1	59 GC HL HV XE XP XU
Office or Other Outpatient Visit of New Patient, 15-29 Minutes	99202	MD/DO  PA  NP or CNS (Certified)	01-08 10-20 22-26 31-34 41-42 49-50 52-55 57-58 60 62 65 71-72 81 99	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365 96369 96372-96374 96377 99203-99205 99212-99215** 99218-99220 99234-99236 99304-99306 99605-99606**	No	Yes	1	27 59 95 GC HK HL HV XE XP XU
Office or Other Outpatient Visit of a New patient, 30-44 Minutes	99203	MD/DO  PA  NP or CNS (Certified)	01-08 10-20 22-26 31-34 41-42 49-50 52-55 57-58 60 62 65 71-72 81 99	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365 96369 96372-96374 96377 99202** 99204-99205 99212-99215** 99218-99220 99234-99236 99304-99306	No	Yes	1	27 59 95 GC HK HL HV XE XP XU
Office or Other Outpatient Visit of a New Patient, 45-59 Minutes	99204	MD/DO  PA  NP or CNS (Certified)	01-08 10-20 22-26 31-34 41-42 49-50 52-55 57-58 60 62 65 71-72 81 99	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365 96369 96372-96374 96377 99202-99203** 99205 99212-99215** 99218-99220 99234-99236 99304-99306 99605-99606**	No	Yes	1	27 59 95 GC HK HL HV XE XP XU
Office or Other Outpatient Visit of a New Patient, 60-74 Minutes	99205	MD/DO  PA  NP or CNS (Certified)	01-08 10-20 22-26 31-34 41-42 49-50 52-55 57-58 60 62 65 71-72 81 99	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365 96369 96372-96374 96377 99202-99204** 99212-99215** 99218-99220 99234-99236 99304-99306 99605-99606	No	Yes	1	27 59 95 GC HK HL HV XE XP XU
Office or Other Outpatient Visit of an Established Patient, 10-19 Minutes	99212	MD/DO  PA  NP or CNS (Certified)	01-08 10-20 22-26 31-34 41-42 49-50 52-55 57-58 60 62 65 71-72 81 99	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365 96369 96372-96374 96377 99202-99205 99213-99215 99218-99220 99234-99236 99304-99306 99605-99606**	No	Yes	1	27 59 95 GC HK HL HV XE XP XU
Office or Other Outpatient Visit of an Established Patient, 20-29 Minutes	99213	MD/DO  PA  NP or CNS (Certified)	01-08 10-20 22-26 31-34 41-42 49-50 52-55 57-58 60 62 65 71-72 81 99	90791 90792 90832 90834 90837 90845 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 99212** 99214-99215 99218-99220 99234-99236 99304-99306 99605-99606**	No	Yes	1	27 59 95 GC HK HL HV XE XP XU
Office or Other Outpatient Visit of an Established Patient, 30-39 Minutes	99214	MD/DO  PA  NP or CNS (Certified)	01-08 10-20 22-26 31-34 41-42 49-50 52-55 57-58 60 62 65 71-72 81 99	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365 96369 96372-96374 96377 99202-99205 99212-99213** 99215 99218-99220 99234-99236 99304-99306 99605-99606**	No	Yes	1	27 59 95 GC HK HL HV XE XP XU
Office or Other Outpatient Visit of an Established Patient, 40-54 Minutes	99215	MD/DO  PA  NP or CNS (Certified)	01-08 10-20 22-26 31-34 41-42 49-50 52-55 57-58 60 62 65 71-72 81 99	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365 96369 96372-96374 96377 99202-99205 99212-99214** 99218-99220 99234-99236 99304-99306 99605-99606**	No	Yes	1	27 59 95 GC HK HL HV XE XP XU
Domiciliary or Rest Home Visit of a New Patient, 15-25 Minutes	99324	MD/DO  PA  NP or CNS (Certified)	04 12-16 26 31-34 54-56	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99325-99328 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Domiciliary or Rest Home Visit of a New Patient, 26-35 Minutes	99325	MD/DO  PA  NP or CNS (Certified)	04 12-16 26 31-34 54-56	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99324** 99326-99328 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Domiciliary or Rest Home Visit of a New Patient, 36-50 Minutes	99326	MD/DO  PA  NP or CNS (Certified)	04 12-16 26 31-34 54-56	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99324-99325** 99327-99328 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Domiciliary or Rest Home Visit of a New Patient, 51-65 Minutes	99327	MD/DO  PA  NP or CNS (Certified)	04 12-16 26 31-34 54-56	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99324-99326** 99328 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Domiciliary or Rest Home Visit of a New Patient, 66-80 Minutes	99328	MD/DO  PA  NP or CNS (Certified)	04 12-16 26 31-34 54-56	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99324-99327** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Domiciliary or Rest Home Visit of an Established Patient, 10-20 Minutes	99334	MD/DO  PA  NP or CNS (Certified)	04 12-16 26 31-34 54-56	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99335-99337 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Domiciliary or Rest Home Visit of an Established Patient, 21-35 Minutes	99335	MD/DO  PA  NP or CNS (Certified)	04 12-16 26 31-34 54-56	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99334** 99336-99337 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Domiciliary or Rest Home Visit of an Established Patient, 36-50 Minutes	99336	MD/DO  PA  NP or CNS (Certified)	04 12-16 26 31-34 54-56	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99334-99335** 99337 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Domiciliary or Rest Home Visit of an Established Patient, 51-70 Minutes	99337	MD/DO  PA  NP or CNS (Certified)	04 12-16 26 31-34 54-56	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99334-99336** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Home Visit of a New Patient, 15-25 Minutes	99341	MD/DO  PA  NP or CNS (Certified)	04 12-16 31-34	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99342-99345 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Home Visit of a New Patient, 26-35 Minutes	99342	MD/DO  PA  NP or CNS (Certified)	04 12-16 31-34	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99341** 99343-99345 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Home Visit of a New Patient, 36-50 Minutes	99343	MD/DO  PA  NP or CNS (Certified)	04 12-16 31-34	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99341-99342** 99344-99345 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Home Visit of a New Patient, 51-65 Minutes	99344	MD/DO  PA  NP or CNS (Certified)	04 12-16 31-34	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99341-99343** 99345 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Home Visit of a New Patient, 66-80 Minutes	99345	MD/DO  PA  NP or CNS (Certified)	04 12-16 31-34	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99341-99344** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Home Visit of an Established Patient, 10-20 Minutes	99347	MD/DO  PA  NP or CNS (Certified)	04 12-16 31-34	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99348-99350 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Home Visit of an Established Patient, 21-35 Minutes	99348	MD/DO  PA  NP or CNS (Certified)	04 12-16 31-34	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99347** 99349-99350 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Home Visit of an Established Patient, 36-50 Minutes	99349	MD/DO  PA  NP or CNS (Certified)	04 12-16 31-34	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99347-99348** 99350 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Home Visit of an Established Patient, 51-70 Minutes	99350	MD/DO  PA  NP or CNS (Certified)	04 12-16 31-34	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99304-99306 99347-99349** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Medication Therapy Management Service(s) Provided by a Pharmacist, Individual, Face-to-Face with New Patient with Assessment and Intervention, 15 Minutes	99605	Pharm	All except 09	90791 90792 90832-90834 90836-90840 90845 90847 90849 90853 90865 90870 99202-99205 99212-99215 99217-99220 99231-99236 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350 99484 99606**	No	No	1	27 59 95 HK HL HV XE XP XU
Medication Therapy Management Service(s) Provided by a Pharmacist, Individual, Face-to-Face with Established Patient with Assessment and Intervention, 15 Minutes	99606	Pharm	All except 09	90791 90792 90832-90834 90836-90840 90845 90847 90849 90853 90865 90870 99202-99205 99212-99215 99217-99220 99231-99236 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350 99484 99605	No	No	1	27 59 95 HK HL HV XE XP XU
Medication Therapy Management Service(s) Provided by a Pharmacist, Individual, Face-to-Face with Patient with Assessment and Intervention, each Additional 15 Minutes beyond 99605 or 99606.	99607	Pharm	All except 09	99484	99605 99606	No	15	27 59 95 HK HL HV XE XP XU
Prolonged Office or Other Outpatient Evaluation and Management Service(s) beyond the Maximum Time; Each Additional 15 Minutes	G2212	MD/DO  PA  NP or CNS (Certified)	All except 09	No	90791 90792 90837 90838 90845 90847 90849 90853 90865 90870 90880 90885 96105 96110 96125 96127 96146 96367 96368 96372 96373 96376 96377 99205 99215 99220 99233 99236 99245 99255 99306 99310 99337 99350	Yes	14	GC HK HL HV SC
Oral Medication Administration, Direct Observation, 15 Minutes	H0033	All disciplines, including non-licensed.	All except 09	No	No	No	16	GC HK HL HV SC
Medication Training and Support, per 15 Minutes	H0034	MD/DO · Pharmacist · PA · NP or CNS (Certified) · RN LVN PT	All except 09	No	No	No	16	GC HK HL HV SC

► Mobile Crisis Intervention

Service	Code	SD/MC Allowable Disciplines	Allowable Place of Service	Lockout Codes Note: The below outpatient services are locked out against inpatient and 24-hour services except for the date of admission	Dependent on Codes	Medicare COB Required?	Maximum Units that Can be Billed	Allowable Modifiers
Mobile Crisis	H2011	N/A	15	No	No	No	24	GT SC HW

► Peer Support Service Codes

Service	Code	SD/MC Allowable Disciplines	Allowable Place of Service	Lockout Codes Note: The below outpatient services are locked out against inpatient and 24-hour services except for the date of admission	Dependent on Codes	Medicare COB Required?	Maximum Units that Can be Billed	Allowable Modifiers
Behavioral health prevention education service (delivery of services with target population to affect knowledge, attitude and/or behavior)	H0025	Peer	All except 09	No	No	No	96	HK SC
Self-help/peer services per 15 minutes	H0038	Peer	All except 09	No	No	No	96	HK SC

► Plan Development Codes

Service	Code	SD/MC Allowable Disciplines	Allowable Place of Service	Lockout Codes Note: The below outpatient services are locked out against inpatient and 24-hour services except for the date of admission	Dependent on Codes	Medicare COB Required?	Maximum Units that Can be Billed	Allowable Modifiers
Medical Team Conference with Interdisciplinary Team of Health Care Professionals, Participation by Non Physician. Face-to-face with Patient and/or Family. 30 Minutes or More	99366	· Pharm · PhD/PsyD (Licensed or Waivered) · SW (Licensed, Registered or Waivered) · PCC (Licensed, Registered or Waivered) · MFT (Licensed, Registered or Waivered) · PA · NP or CNS (Certified) · RN	All except 09	90791 90792 90832-90834 90836-90838 96127* 99451 99484	No	No	1	27 59 93 95 GC HK HL HV XE XP XU
Medical Team Conference with Interdisciplinary Team of Health Care Professionals, Participation by Physician. Patient and/or Family not Present. 30 Minutes or More	99367	MD/DO	All except 09	90791 90792 90832-90834 90836-90838 96127* 99484	No	No	1	27 59 93 95 GC HK HL HV XE XP XU
Medical Team Conference with Interdisciplinary Team of Health Care Professionals, Participation by Non-Physician. Patient and/or Family Not Present. 30 Minutes or More	99368	· Pharm · PhD/PsyD (Licensed or Waivered) · SW (Licensed, Registered or Waivered) · PCC (Licensed, Registered or Waivered) · MFT (Licensed, Registered or Waivered) · PA · NP or CNS (Certified) · RN	All except 09	90791 90792 90832-90834 90836-90838 96127* 99484	No	No	1	27 59 93 95 GC HK HL HV XE XP XU
Care Management Services for Behavioral Health Conditions, Directed by Physician. At Least 20 Minutes	99484	· MD/DO  · Pharm  · PhD/PsyD (Licensed or Waivered) · SW (Licensed, Registered or Waivered)  · PCC (Licensed, Registered or Waivered) · MFT (Licensed, Registered or Waivered) · PA · NP or CNS (Certified) · RN · PT · LVN	01-08 10-20 22-26 33-34 41-42 49-50 52-53 57-58 60 62 65 71 72 81 99	96127* 98966-98968* 99366-99368** 99441-99443** 99605-99607**	No	Yes	1	93 95 GC HK HL HV
Mental Health Service Plan Developed by Non-Physician, 15 Minutes	H0032	· Pharm · PhD/PsyD (Licensed or Waivered) · SW (Licensed, Registered or Waivered) · PCC (Licensed, Registered or Waivered) · MFT (Licensed, Registered or Waivered) · PA · NP or CNS (certified) · RN · PT · LVN · MHRS  · OT  · Other	All except 09	No	No	No	96	GC HK HL HV SC

► Referral Codes

Service	Code	SD/MC Allowable Disciplines	Allowable Place of Service	Lockout Codes Note: The below outpatient services are locked out against inpatient and 24-hour services except for the date of admission	Dependent on Codes	Medicare COB Required?	Maximum Units that Can be Billed	Allowable Modifiers
Inter-Professional Telephone/Internet/ Electronic Health Record Assessment Provided by a Consultative Physician, 5-15 Minutes	99451	· MD/DO	02 10	90791-90792 90832-90834 90836-90838 90867-90870 96127* 99217-99223 99231-99236 99241-99245 99251-99255 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350 99366	No	Yes	1	27 59 95 GC HK HL HV XE XP XU
Targeted Case Management, Each 15 Minutes	T1017	All disciplines including non- licensed practitioners	All except 09	No	No	No	96	GC HK HL HV HW SC

► Rehabilitation Codes

Service	Code	SD/MC Allowable Disciplines	Allowable Place of Service	Lockout Codes Note: The below outpatient services are locked out against inpatient and 24-hour services except for the date of admission	Dependent on Codes	Medicare COB Required?	Maximum Units that Can be Billed	Allowable Modifiers
Psychosocial Rehabilitation, per 15 Minutes	H2017	All disciplines, including nonlicensed practitioners	All except 09	No	No	No	96	GC HK HL HV SC
Community-Based Wrap-Around Services, per 15 Minutes	H2021	All disciplines including non- licensed practitioners	All except 09	No	No	No	96	GC HK HL HV SC

► Supplemental Service Codes

Service	Code	SD/MC Allowable Disciplines	Allowable Place of Service	Lockout Codes Note: The below outpatient services are locked out against inpatient and 24-hour services except for the date of admission	Dependent on Codes	Medicare COB Required?	Maximum Units that Can be Billed	Allowable Modifiers
Interactive Complexity	90785	All disciplines including nonlicensed practitioners	All except 09	90839-90840	90791-90792 90832-90834 90836-90838 90853 99202-99205 99212-99215 99217-99220 99231-99236 99241-99245 99251-99255 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350	Yes	1 per allowed procedure per provider per beneficiary	93 95 GC HK HL HV HW
Interpretation or Explanation of Results of Psychiatric or Other Medical Procedures to Family or Other Responsible Persons, 15 Minutes	90887	MD/DO Pharm PhD/PsyD (Licensed or Waivered) SW (Licensed,Registered or Waivered) PCC (Licensed, Registered or Waivered) MFT (Licensed, Registered or Waivered) PA NP/CNS (Certified) OT	All except 09	90791 90792 90839-90840	90832 90834 90837 90845 90847 90849 90853 90865 90867 90870 96105 96110 96112 96116 96125 96127 96130 96132 96136 96138 96146 99202-99205 99212-99215 99217-99220 99231-99236 99241-99245 99251-99255 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350 99366-99368 99484 99605-99606	No	1	59 93 95 GC HK HL HV HW
Caregiver Assessment Administration of Care-Giver Focused Risk Assessment, 15 Minutes	96161	MD/DO Pharm PhD/PsyD (Licensed or Waivered) SW (Licensed, Registered or Waivered) PCC (Licensed, Registered or Waivered) MFT (Licensed, Registered or Waivered) PA NP/CNS (Certified) OT RN LVN	All except 09	90791 90792 90832-90834 90836-90838 96105 96110* 96112-96113 96116 96121 96125 96127 96130-96133 96136-96139 96146	90885 96110 98966-98968 99218-99220 99234-99236 99441-99443 H0031 H2000 T1001	Yes	1 per calendar year	59 93 95 GC HK HL HV HW XE XP XU
Sign Language or Oral Interpretive Services, 15 Minutes	T1013	All disciplines including non- licensed practitioners	All except 09	No	90791-90792 90832-90834 90836-90840 90845 90847 90849 90853 90865 90867-90870 90880 90885 96105 96110 96112-96113 96116 96121 96125 96127 96130-96133 96136-96139 96365-96377 98966-98968 99202-99205 99212-99215 99217-99220 99231-99236 99241-99245 99251-99255 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350 99366-99368 99441-99443 99484 99605-99607 G2212 H0031 H0032 H0033 H0034 H2000 H2011 H2017 H2019 H2021 S5145 T1001 T1017	No	Variable	GC HK HL HV HW SC

► Therapeutic Behavioral Services

Service	Code	SD/MC Allowable Disciplines	Allowable Place of Service	Lockout Codes Note: The below outpatient services are locked out against inpatient and 24-hour services except for the date of admission	Dependent on Codes	Medicare COB Required?	Maximum Units that Can be Billed	Allowable Modifiers
Therapeutic Behavioral Services, per 15 Minutes	H2019	All disciplines including nonlicensed practitioners	All except 09	No	No	No	96	GC HK HL HV SC

► Theraphy Codes

Service	Code	SD/MC Allowable Disciplines	Allowable Place of Service	Lockout Codes Note: The below outpatient services are locked out against inpatient and 24-hour services except for the date of admission	Dependent on Codes	Medicare COB Required?	Maximum Units that Can be Billed	Allowable Modifiers
Psychotherapy, 30 Minutes with Patient	90832	· MD/DO · PA · PhD/PsyD (Licensed or Waivered) · SW (Licensed, Registered or Waivered) · MFT (Licensed, Registered or Waivered) · NP or CNS (Certified) and · PCC (Licensed or Registered)	All except 09	Cannot be billed with 90791 90792 90833-90834 90836-90840 90845 90847 90849 90853 90865 90867-90869* 90870 90880 96112-96113 96116* 96127* 96161* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99241-99245** 99251-99255** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99366-99368** 99441-99443** 99451** 99605-99606**	None	Yes	1	59 93 95 GC HK HL HV XE XP XU
Psychotherapy, 30 Minutes with Patient when Performed with an Evaluation and Management Service	90833	· MD/DO PA NP or CNS (Certified)	All except 09	90791 90792 90832* 90834 90836-90840 90845 90847 90849 90853 90865 90867-90869* 90870 90880 96112-96113 96116* 96127* 96161* 99366-99368** 99441-99443** 99451** 99605-99606**	99202-99205 99212-99215 99217-99220 99231-99236 99241-99245 99251-99255 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350	Yes	1	59 93 95 GC HK HL HV XE XP XU
Psychotherapy, 45 Minutes with Patient	90834	· MD/DO PA PhD/PsyD (Licensed or Waivered) SW (Licensed, Registered or Waivered) MFT (Licensed, Registered or Waivered) NP or CNS (Certified) and PCC (Licensed or Registered	All except 09	90791 90792 90832-90833* 90836-90840 90845 90847 90849 90853 90865 90867-90869* 90870 90880 96112-96113 96116* 96127* 96161* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99241-99245** 99251-99255** 99304-99310** 99324-99328** 99334-99337** 99341-99350** 99366-99368** 99441-99443** 99451** 99605-99606**	None	Yes	1	59 93 95 GC HK HL HV XE XP XU
Psychotherapy, 45 Minutes with Patient when Performed with an Evaluation and Management Service	90836	· MD/DO PA NP or CNS (Certified)	All except 09	90791 90792 90832-90834* 90837-90840 90845 90847 90849 90853 90865 90867-90869* 90870 90880 96112-96113 96116* 96127* 96161* 99366-99368** 99441-99443** 99451** 99605-99606**	99202-99205 99212-99215 99217-99220 99231-99236 99241-99245 99251-99255 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350	Yes	1	59 93 95 GC HK HL HV XE XP XU
Psychotherapy, 60 Minutes with Patient	90837	· MD/DO PA PhD/PsyD (Licensed or Waivered) SW (Licensed, Registered or Waivered) MFT (Licensed, Registered or Waivered) NP or CNS (Certified) and PCC (Licensed or Registered)	All except 09	90791 90792 90832-90834* 90836* 90838-90840 90845 90847 90849 90853 90865 90867-90869* 90870 90880 96112-96113 96116* 96127* 96161* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99241-99245** 99251-99255** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99366-99368** 99441-99443** 99451** 99605-99606**	None	Yes	1	59 95 GC HK HL HV XE XP XU
Psychotherapy, 60 Minutes with Patient when Performed with an Evaluation and Management Service	90838	· MD/DO PA NP or CNS (Certified)	All except 09	90791 90792 90832-90834* 90836-90837* 90839-90840 90845 90847 90849 90853 90865 90867-90869* 90870 90880 96112-96113 96116* 96127* 96161* 99366-99368** 99441-99443** 99451** 99605-99606**	99202-99205 99212-99215 99217-99220 99231-99236 99241-99245 99251-99255 99304-99310 99324-99328 99334-99337 99341-99345 99347-99350	Yes	1	59 93 95 GC HK HL HV XE XP XU
Psychoanalysis, 15 Minutes	90845	· MD/DO PA PhD/PsyD (Licensed or Waivered) SW (Licensed, Registered or Waivered) MFT (Licensed, Registered or Waivered) NP or CNS (Certified) and PCC (Licensed or Registered)	All except 09	90832-90834 90836-90840 90865 90867-90870 90880 96112-96113 96116* 96127* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99605-99606**	None	Yes	1	59 93 95 GC HK HL HV XE XP XU
Family Psychotherapy [Conjoint Psychotherapy] (with Patient Present), 50 Minutes	90847	· MD/DO PA PhD/PsyD (Licensed or Waivered) SW (Licensed, Registered or Waivered) MFT (Licensed, Registered or Waivered) NP or CNS (Certified) and PCC (Licensed or Registered)	All except 09	90791 90792 90832-90834* 90836-90838* 90839-90840 90865* 90867-90869 90870* 90880 96112-96113 96116* 96127* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99605-99606**	None	Yes	1	59 93 95 GC HK HL HV XE XP XU
Multiple-Family Group Psychotherapy, 15 Minutes	90849	· MD/DO PA PhD/PsyD (Licensed or Waivered) SW (Licensed, Registered or Waivered) MFT (Licensed, Registered or Waivered) NP or CNS (Certified) and PCC (Licensed or Registered)	All except 09	90791 90792 90832-90834* 90836-90838* 90839-90840 90853 90865* 90867-90869 90870* 90880 96112-96113 96116* 96127* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99605-99606**	None	Yes	1	59 93 95 GC HK HL HV XE XP XU
Group Psychotherapy (Other Than of a Multiple-Family Group), 15 Minutes	90853	· MD/DO PA PhD/PsyD (Licensed or Waivered) SW (Licensed, Registered or Waivered) MFT (Licensed, Registered or Waivered) NP or CNS (Certified) and PCC (Licensed or Registered)	All except 09	90791 90792 90832-90834* 90836-90838* 90839-90840 90849* 90865* 90867-90869 90870* 90880 96112-96113 96116* 96127* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99307-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99605-99606**	None	Yes	1	59 93 95 GC HK HL HV XE XP XU
Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS) Treatment; Initial, Including Cortical Mapping, Motor Threshold Determination,	90867	· MD/DO PA NP or CNS (Certified)	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81	90791 90792 90832-90834 90836-90840 90845* 90847* 90849* 90853* 90865* 90870* 90880* 96127* 96366-96368* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99241-99245** 99251-99255** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99451	No	No	1	59 GC HK HL HV XE XP XU
Subsequent Delivery and Management of TMS, per Session	90868	· MD/DO PA NP or CNS (Certified)	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81	90791 90792 90832-90834 90836-90840 90845* 90847* 90849* 90853* 90865* 90870* 90880* 96127* 96366-96368* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99241-99245** 99251-99255** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99451	Deny the service line if there is not a previously approved service line with 90867 provided to the same beneficiary by the same rendering provider. Service must be rendered on a different DOS.	No	1	59 GC HK HL HV XE XP XU
TMS Treatment Subsequent Motor Threshold Re-Determination with Delivery and Management	90869	· MD/DO PA NP or CNS (Certified)	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81	90791 90792 90832-90834 90836-90840 90845* 90847* 90849* 90853* 90865* 90870* 90880* 96127* 96366-96368* 99202-99205** 99212-99215** 99217-99223** 99231-99236** 99241-99245** 99251-99255** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99451	Deny the service line if there is not a previously approved service line with 90868 provided to the same beneficiary by the same rendering provider. Service must be rendered on a different DOS.	No	1	59 GC HK HL HV XE XP XU
Electroconvulsive Therapy (Includes Necessary Monitoring)	90870	· MD/DO PA NP or CNS (Certified)	01 03-08 11-26 31-34 41-42 49-58 60-62 65 71-72 81	90791 90792 90832-90834* 90836-90838* 90839-90840 90845* 90847 90849 90853 90865* 90867-90869 90880* 96112-96113 96127* 96365-96368* 96372* 96374-96377* 99241-99245** 99251-99255** 99605-99606** 99451	No	Yes	1	59 GC HK HL HV XE XP XU
Hypnotherapy	90880	· MD/DO PhD/PsD (Licensed or Waivered) SW (Licensed, Registered or Waivered) MFT (Licensed, Registered or Waivered) NP or CNS (Certified) and PCC (Licensed or Registered) PA NP/CNS (Certified)	All except 09	90791 90792 90832-90834 90836-90840 90845 90847 90849 90853 90865* 90867-90870 96112-96113 96116* 96127* 99202-99205** 99212-99215** 99217-99220** 99231-99236** 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350**	No	Yes	1	59 95 GC HK HL HV XE XP XU
Observation Care Discharge Day Management, 15 Minutes	99217	· MD/DO PA NP or CNS (Certified)	19 22 23 26 31 32 54	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99218-99220 99234-99236 99451 99605-99606**	No	Yes	1	27 59 GC HK HV XE XP XU
Initial haospital care, per day, for the evaluation and management of a patient. Usually, the problem(s) requiring admission are of low severity. 20-39 minutes	99221	• MD/DO • PA  • NP or CNS (Certified)	21 26 34 51 61	90791-90792 90832  90834 90837 90845 90865 90880 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99202-99205**  99212-99215**  99217-99220** 99222-99223 99231-99233** 99234-99236 99304-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99451 99605-99606**	No	Yes	1	27 59 GC HK HV  XE  XP  XU
Initial hospital care, per day, for the evaluation and management of a patient. Usually, the problem(s) requiring admission are of moderate severity. 40-59 mins	99222	• MD/DO • PA • NP or CNS (Certified)	21 26  34 51 61	90791 90792 90832 90834 90837 90845 90865 90880 96116* 96125*  96127*  96130* 96132*  96136*  96138*  96146*  96365*  96372*  96373*  96374* 96377*  99202** 99203** 99204** 99205** 99212** 99213** 99214** 99215** 99217** 99218** 99219** 99220** 99221** 99223  99231**  99232**  99233**  99234 99235  99236  99304**  99305**  99306**  99307**  99308**  99309**  99310**  99324**  99325** 99326** 99327** 99341** 99342** 99343** 99344** 99345** 99347** 99348** 99349** 99350** 99451  99605** 99606**	No	Yes	1	27  59 GC HK HV  XE  XP  XU
Initial hospital care, per day, for the evaluation and management of a patient. Usually, the problem(s) requiring admission are of high severity. (60-79 mins)	99223	• MD/DO • PA • NP or CNS (Certified)	21 26 34 51 61	90791-90792 90832  90834  90837 90845 90865 90880 96116*  96125* 96127* 96130*  96132*  96136*  96138*  96146*  96365*  96369*  96372-96374*  96377*  99202-99205** 99212-99215** 99217-99222** 99231-99233**  99234-99236  99304-99310**  99324-99328** 99334-99337**  99341-99345**  99347-99350** 99451 99605-99606**	No	Yes	1	27 59 GC HK HV XE XP XU
Subsequent Hospital Care, per Day, for the Evaluation and Management of a Patient. Usually, Patient is Stable, Recovering or Improving, 6-19 Minutes	99231	· MD/DO PA NP or CNS (Certified)	21 26 34 51 61	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365 96367 96369 96372-96375 96377* 99232-99236 99304-99306 99451 99605-99606**	No	Yes	1	27 59 GC HK HV XE XP XU
Subsequent Hospital Care, per Day, for the Evaluation and Management of a Patient. Usually, the Patient is Responding Inadequately to Therapy or has Developed a Minor Complication, 20-29 Minutes	99232	· MD/DO PA NP or CNS (Certified)	21 26 34 51 61	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365 96367 96369 96372-96375 96377* 99231** 99233-99236 99304-99306 99451 99605-99606**	No	Yes	1	27 59 GC HK HV XE XP XU
Subsequent Hospital Care, per Day, for the Evaluation and Management of a Patient. Usually, the Patient is Unstable or has Developed a Significant New Problem, 30-40 Minutes	99233	· MD/DO PA NP or CNS (Certified)	21 26 34 51 61	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365 96367 96369 96372-96375 96377* 99221-99223 99231-99232** 99234-99236 99304-99306 99451 99605-99606**	No	Yes	1	27 59 GC HK HV XE XP XU
Office Consultation for New or Established Patient. Usually, the Presenting Problem(s) are Self-Limited or Minor, 10-20 Minutes	99241	· MD/DO PA NP or CNS (Certified)	01-08 10-20 22-26 31-34 41-42 49-50 52-58 60 62 65 71-72 81 99	90791 90792 90832 90834 90837 90867-90870 96377 99242-99245 99251-99255 99451	No	No	1	27 59 95 GC HK HL HV XE XP XU
Office Consultation for a New or Established Patient. Usually, the Presenting Problem(s) are of Low Severity, 21-34 Minutes	99242	· MD/DO PA NP or CNS (Certified)	01-08 10-20 21-26 31-34 41-42 49-50 52-58 60 62 65 71-72 81 99	90791 90792 90832 90834 90837 90867-90870 96377 99241 99243-99245 99251-99255 99451	No	No	1	27 59 95 GC HK HL HV XE XP XU
Office Consultation for a New or Established Patient. Usually, the Presenting Problem(s) are of Moderate Severity, 35-49 Minutes	99243	· MD/DO PA NP or CNS (Certified)	01-08 10-20 21-26 31-34 41-42 49-50 52-58 60 62 65 71-72 81 99	90791 90792 90832 90834 90837 90867-90870 96377 99241-99242 99244-99245 99251-99255 99451	No	No	1	27 59 95 GC HK HL HV XE XP XU
Office Consultation for a New or Established Patient. Usually, the Presenting Problem(s) are of Moderate to High Severity, 50-70 Minutes	99244	· MD/DO PA NP or CNS (Certified)	01-08 10-20 21-26 31-34 41-42 49-50 52-58 60 62 65 71-72 81 99	90791 90792 90832 90834 90837 90867-90870 96377 99241-99243 99245 99251-99255 99451	No	No	1	27 59 95 GC HK HL HV XE XP XU
Office Consultation for a New or Established Patient. Usually, the Presenting Problem(s) are of Moderate to High Severity, 71-90 Minutes	99245	· MD/DO PA NP or CNS (Certified)	01-08 10-20 21-26 31-34 41-42 49-50 52-58 60 62 65 71-72 81 99	90791 90792 90832 90834 90837 90867-90870 96377 99241-99244 99251-99255 99451	No	No	1	27 59 95 GC HK HL HV XE XP XU
Inpatient Consultation for a New or Established Patient. Usually, the Presenting Problems(s) are Self-Limited or Minor, 16-29 Minutes	99251	· MD/DO PA NP or CNS (Certified)	21 26 31 32 34 51 61	90791 90792 90832 90834 90837 90867-90870 96127* 99241-99245 99252-99255 99451	No	No	1	27 59 GC HK HL HV XE XP XU
Inpatient Consultation for a New or Established Patient. Usually, the Presenting Problems(s) are of Low Severity, 30-49 Minutes	99252	· MD/DO PA NP or CNS (Certified)	21 26 31 32 34 51 61	90791 90792 90832 90834 90837 90867-90870 96127* 99241-99245 99251 99253-99255 99451	No	No	1	27 59 GC HK HL HV XE XP XU
Inpatient Consultation for a New or Established Patient. Usually, the Presenting Problems(s) are of Moderate Severity, 50-69 Minutes	99253	· MD/DO PA NP or CNS (Certified)	21 26 31 32 34 51 61	90791 90792 90832 90834 90837 90867-90870 96127* 99241-99245 99251-99252 99254-99255 99451	No	No	1	27 59 GC HK HL HV XE XP XU
Inpatient Consultation for a New or Established Patient. Usually, the Presenting Problems(s) are of Moderate to High Severity, 70-90 Minutes	99254	· MD/DO PA NP or CNS (Certified)	21 26 31 32 34 51 61	90791 90792 90832 90834 90837 90867-90870 96127* 99241-99245 99251-99253 99255 99451	No	No	1	27 59 GC HK HL HV XE XP XU
Office Consultation for a New or Established Patient. Usually, the Presenting Problem(s) are of Moderate to High Severity, 91-130 Minutes	99255	· MD/DO PA NP or CNS (Certified)	21 26 31 32 34 51 61	90791 90792 90832 90834 90837 90867-90870 96127* 99241-99245 99251-99254 99451	No	No	1	27 59 GC HK HL HV XE XP XU
Initial Nursing Facility Care per Day, for the Evaluation and Management of a Patient. Usually, the Problem(s) requiring Admission are of Low Severity, 16-29 Minutes	99304	· MD/DO PA NP or CNS (Certified)	26 31 32	90791 90792 90832 90834 90837 90845 90847 90849 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99202-99205** 99212-99215** 99218-99220** 99221-99223 99231-99233** 99305-99306 99307-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Initial Nursing Facility Care per Day, for the Evaluation and Management of a Patient. Usually, the Problem(s) Requiring Admission are of Moderate Severity, 30-39 Minutes	99305	· MD/DO PA NP or CNS (Certified)	26 31 32	90791 90792 90832 90834 90837 90845 90847 90849 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99202-99205** 99212-99215** 99218-99220** 99221-99223 99231-99233** 99304** 99306 99307-99310** 99324-99328** 99334-99337** 99341-99345** 99347-99350** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Initial Nursing Facility Care per Day, for the Evaluation and Management of a Patient. Usually, the Problem(s) Requiring Admission are of High Severity, 40-60 Minutes	99306	· MD/DO PA NP or CNS (Certified)	26 31 32	90791 90792 90832 90834 90837 90845 90847 90849 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365* 96369* 96372-96374* 96377* 99202-99205** 99212-99215** 99218-99223** 99234-99236** 99304-99306** 99308-99310** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Subsequent Nursing Facility Care per Day for the Evaluation and Management of a Patient. Usually, the Patient is Stable, Recovering or Improving, 1-12 Minute	99307	· MD/DO PA NP or CNS (Certified)	26 31 32	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365 96367 96369 96372-96375 96377* 99218-99223 99234-99236 99304-99306 99308-99310 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Initial Nursing Facility Care per Day, for the Evaluation and Management of a Patient. Usually, the Patient is Responding Inadequately to Therapy or Has Developed a Minor Complication, 13-19 Minutes	99308	· MD/DO PA NP or CNS (Certified)	26 31 32	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365 96367 96369 96372-96375 96377* 99218-99223 99234-99236 99304-99306 99307** 99309-99310 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Initial Nursing Facility Care per Day, for the Evaluation and Management of a Patient. Usually, the Patient has Developed a Significant Complication or a Significant New Problem, 20-29 Minutes	99309	· MD/DO PA NP or CNS (Certified)	26 31 32	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365 96367 96369 96372-96375 96377* 99218-99223 99234-99236 99304-99306 99307-99308** 99310 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU
Initial Nursing Facility Care per Day, for the Evaluation and Management of a Patient. The Patient May Be Unstable or May Have Developed a Significant New Problem Requiring Immediate Physician Attention, 30-40 Minutes	99310	· MD/DO PA NP or CNS (Certified)	26 31 32	90791 90792 90832 90834 90837 90845 90847 90849 90853 90865 90867-90869 90880 96112-96113 96116* 96125* 96127* 96130* 96132* 96136* 96138* 96146* 96365 96367 96369 96372-96375 96377* 99218-99223 99234-99236 99304-99306 99307-99309** 99451 99605-99606**	No	Yes	1	27 59 GC HK HL HV XE XP XU

► Existing 24-HR and Day Services

Category	Procedure Code and Modifier	Revenue Code	Description	Mode of Service	Service Function	Medicare COB Required?
Existing 24-Hour Service	H2015:HE	100	General Psychiatric Inpatient	5	10-18	Yes
Existing 24-Hour Service	H2015:HE:HA	100	Psychiatric Hospital Inpatient: Under Age 21	5	10-18	Yes
Existing 24-Hour Service	H2015:HE:HC	100	Psychiatric Hospital Inpatient: over age 64	5	10-18	Yes
Existing 24-Hour Service	H0046:HE	101	General hospital inpatient: Administrative Day	5	19	No
Existing 24-Hour Service	H0046:HE:HA	101	Psychiatric Hospital Inpatient: Administrative Day Under 21	5	19	No
Existing 24-Hour Service	H0046:HE:HC	101	Psychiatric Hospital Inpatient: Administrative Day Over 64	5	19	No
Existing 24-Hour Service	H2013:HE	NA	Psychiatric Health Facility	5	20-29	No
Existing 24-Hour Service	S5145:HE	NA	Therapeutic Foster Care	5	95	No
Existing 24-Hour Service	H0018:HE:HC	NA	Children’s-Adult Crisis Residential: Geriatric	5	40-49	No
Existing 24-Hour Service	H0018:HE:HB	NA	Children’s-Adult Crisis Residential: Non-Geriatric	5	40-49	No
Existing 24-Hour Service	H0018:HE:HA	NA	Children’s-Adult Crisis Residential	5	40-49	No
Existing 24-Hour Service	H0019:HE:HC	NA	Adult Residential: Geriatric	5	65-69	No
Existing 24-Hour Service	H0019:HE:HB	NA	Adult Residential: Non-Geriatric	5	65-69	No
Existing Day Service	S9484:HE:TG	NA	Crisis Stabilization: Emergency Room	10	20-24	No
Existing Day Service	S9484:HE:TG	NA	Crisis Stabilization: Urgent Care	10	25-29	No
Existing Day Service	H2012:HE:TG	NA	Day Treatment Intensive: Half Day	10	81-84	No
Existing Day Service	H2012:HE:TG	NA	Day Treatment Intensive: Full Day	10	85-89	No
Existing Day Service	H2012: HE	NA	Day Rehabilitation: Half Day	10	91-94	No
Existing Day Service	H2012:HE	NA	Day Rehabilitation: Full Day	10	95-99	No