Connecticut Behavioral Health Plan
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Coverage 1= HUSKY MCO – All diagnoses
Responsibility 2= BHP - All diagnoses
Legend: 3= BHP for Primary Diagnoses 291-316, HUSKY MCO all other diagnoses
  4= Not covered
   
  Note: PSR = Provider Specific Rate
Code General Hospital Inpatient Coverage BHP Fee
110 Room & Board- Private 3 PSR
111 Room & Board- Private -Med/Surg/Gyn 3 PSR
112 Room & Board- Private -OB 3 PSR
113 Room & Board- Private -Pediatric 3 PSR
114 Room & Board – Private- Psychiatric 2 PSR
115 Room & Board- Private -Hospice 3 PSR
116 Room & Board – Private - Detox 2 PSR
117 Room & Board- Private -Oncology 3 PSR
118 Room & Board- Private -Rehab 3 PSR
119 Room & Board- Private -Other 3 PSR
120 Room & Board-Semi-Private/2 Bed 3 PSR
121 Room & Board-Semi-Private/ 2 Bed- Med/Surg/Gyn 3 PSR
122 Room & Board-Semi-Private/ 2 Bed -OB 3 PSR
123 Room & Board-Semi-Private/ 2 Bed-Pediatric 3 PSR
124 Room & Board – Semi-Private/2 Bed - Psychiatric 2 PSR
125 Room & Board-Semi-Private/ 2 Bed-Hospice 3 PSR
126 Room & Board -Semi-Private/2 Bed -Detox 2 PSR
127 Room & Board-Semi-Private/ 2 Bed-Oncology 3 PSR
128 Room & Board-Semi-Private/ 2 Bed-Rehab 3 PSR
129 Room & Board-Semi-Private/ 2 Bed-Other 3 PSR
130 Room & Board-Semi-Private/3-4 Bed 3 PSR
131 Room & Board-Semi-Private/3-4 Bed- Med/Surg/Gyn 3 PSR
132 Room & Board-Semi-Private/3-4 Bed-OB 3 PSR
133 Room & Board-Semi-Private/3-4 Bed-Pediatric 3 PSR
134 Room & Board -Semi-Private/3-4 Bed - Psychiatric 2 PSR
135 Room & Board-Semi-Private/3-4 Bed-Hospice 3 PSR
136 Room & Board -Semi-Private/3-4 Bed- Detox 2 PSR
137 Room & Board-Semi-Private/3-4 Bed-Oncology 3 PSR
138 Room & Board-Semi-Private/3-4 Bed-Rehab 3 PSR
139 Room & Board-Semi-Private/3-4 Bed-Other 3 PSR
140 Room & Board-Private-Deluxe 3 PSR
141 Room & Board-Private-Deluxe- Med/Surg/Gyn 3 PSR
142 Room & Board-Private - Deluxe-OB 3 PSR
143 Room & Board-Private - Deluxe-Pediatric 3 PSR
144 Room & Board -Private -Deluxe - Psychiatric 2 PSR
145 Room & Board-Private - Deluxe-Hospice 3 PSR
146 Room & Board – Private – Deluxe – Detox 2 PSR
147 Room & Board-Private - Deluxe-Oncology 3 PSR
148 Room & Board-Private - Deluxe-Rehab 3 PSR
149 Room & Board-Private - Deluxe-Other 3 PSR
150 Room & Board – Ward 3 PSR
151 Room & Board – Ward - Med/Surg/ Gyn 3 PSR
152 Room & Board – Ward – OB 3 PSR
153 Room & Board – Ward – Pediatric 3 PSR
154 Room & Board - Ward - Psychiatric 2 PSR
155 Room & Board – Ward – Hospice 3 PSR
156 Room & Board - Ward - Detox 2 PSR
157 Room & Board – Ward – Oncology 3 PSR
158 Room & Board – Ward – Rehab 3 PSR
159 Room & Board – Ward - Other 3 PSR
160 Other Room & Board 3 PSR
164 Other Room & Board – Sterile Environment 3 PSR
167 Other Room & Board – Self Care 3 PSR
169 Other Room & Board - Other 3 PSR
170 Room & Board- Nursery 3 PSR
171 Room & Board- Nursery – Newborn 3 PSR
172 Room & Board- Nursery – Premature 3 PSR
175 Room & Board- Nursery – Neonatal ICU 3 PSR
179 Room & Board- Nursery - Other 3 PSR
190 Subacute Care 3 PSR
200 Intensive Care 3 PSR
201 Intensive Care – Surgical 3 PSR
202 Intensive Care – Medical 3 PSR
203 Intensive Care – Pediatric 3 PSR
204 Intensive Care – Psychiatric 2 PSR
205 Intensive Care – Post ICU 3 PSR
207 Intensive Care – Burn Treatment 3 PSR
208 Intensive Care – Trauma 3 PSR
209 Intensive Care – Other 3 PSR
210 Coronary Care 3 PSR
211 Coronary Care – Myocardial Infarction 3 PSR
212 Coronary Care – Pulmonary 3 PSR
213 Coronary Care – Heart Transplant 3 PSR
214 Coronary Care – Post CCU 3 PSR
219 Coronary Care – Other 3 PSR
224 Late discharge/Medically necessary 4 N/A
Note: MCOs cover alcohol detoxification on a medical floor.
Code General Hospital Emergency Department Coverage BHP Fee
450 Emergency Room General Classification 1 N/A
451 EMTALA Emergency Medical Screening Services 1 N/A
452 Emergency Room Beyond EMTALA Screening 1 N/A
456 Urgent Care 1 N/A
459 Other Emergency Room 1 N/A
762 Observation room 3 PSR
981 Professional Fee – Emergency Department 1 N/A
Code General Hospital Outpatient Coverage BHP Fee
490 Ambulatory Surgery 1 N/A
762 Observation room 3 PSR
900 Psychiatric Services General (Evaluation) 2 $106.54
901 Electroconvulsive Therapy** 2 $104.41
905 Intensive Outpatient Services – Psychiatric 2 PSR
906 Intensive Outpatient Services – Chemical Dependency 2 PSR
907 Community Behavioral Health Program (Day Treatment) 2 PSR
913 Partial Hospital 2 PSR
914 Individual Therapy 2 $65.52
915 Group Therapy 2 $34.43
916 Family Therapy 2 $78.53
918 Psychiatric Service – Testing 3 $63.96
919 Other - Med Admin 2 $49.06
961 Professional Fees-Psychiatric 4 N/A
All others   1 N/A
Code General Hospital Outpatient - Enhanced Care Clinic (ECC) Coverage BHP Fee
490 Ambulatory Surgery 1 N/A
762 Observation room 3 PSR
900 Psychiatric Services General (Evaluation) 2 $141.00
901 Electroconvulsive Therapy** 2 $104.41
905 Intensive Outpatient Services – Psychiatric 2 PSR
906 Intensive Outpatient Services – Chemical Dependency 2 PSR
907 Community Behavioral Health Program (Day Treatment) 2 PSR
913 Partial Hospital 2 PSR
914 Individual Therapy 2 $82.03
915 Group Therapy 2 $34.43
916 Family Therapy 2 $98.17
918 Psychiatric Service – Testing 3 $63.96
919 Other - Med Admin 2 $52.76
961 Professional Fees-Psychiatric 4 N/A
All others   1 N/A
Code Psychiatric Hospital Inpatient (includes state operated hospitals) Coverage BHP Fee
100 All inclusive room and board plus ancillary 4 N/A
124 Room and Board-Psychiatric 2 PSR
126 Room & Board -Semi-Private/2 Bed -Detox 2 PSR
128 Room & Board-Semi-Private/ 2 Bed-Rehab 4 N/A
190 Subacute Care 2 PSR
224 Late discharge/Medically necessary 4 N/A
Code Psychiatric Hospital Outpatient Coverage BHP Fee
490 Ambulatory Surgery 1 N/A
762 Observation room 2 PSR
900 Psychiatric Services General (Evaluation) 2 $106.54
901 Electroconvulsive Therapy 2 $104.41
905 Intensive Outpatient Services - Psychiatric 2 PSR
906 Intensive Outpatient Services - Chemical Dependency 2 PSR
907 Community Behavioral Health Program (Day Treatment) 2 PSR
913 Partial Hospital-More Intensive 2 PSR
914 Psychiatric Service-Individual Therapy 2 $65.52
915 Psychiatric Service-Group Therapy 2 $34.43
916 Psychiatric Service-Family Therapy 2 $78.53
918 Psychiatric Service-Testing 2 $63.96
919 Other - Med Admin 2 $49.06
Code Alcohol and Drug Abuse Center (Non-hospital Inpatient Detox) Coverage BHP Fee
H0011 Acute Detoxification (residential program inpatient) 2 PSR
Code Alcohol and Drug Abuse Center (Ambulatory Detoxification) Coverage BHP Fee
H0014 Ambulatory Detoxification 2 $26.50
Code PRTF Coverage BHP Fee
T2048 Psychiatric health facility service, per diem 2 PSR
Code DCF Residential Coverage BHP Fee
N/A DCF Funded residential facility 2 PSR
Code Long Term Care Facility Coverage BHP Fee
100 Per diem rate 1 N/A
183 Home reserve 1 N/A
185 Inpatient hospital reserve 1 N/A
189 Non-covered reserve 4 N/A
Note: Includes inpatient at special care hospitals.
Code MH Clinic Coverage BHP Fee
90801 Psychiatric Diagnostic Interview 2 $106.54
90802 Interactive Psychiatric Diagnostic Interview 2 $112.75
90804 Individual Psychotherapy- Office or other Outpatient (20-30 min) 2 $45.25
90805 Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $50.48
90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $65.52
90807 Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $73.91
90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $96.90
90809 Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $101.78
90810 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $50.61
90811 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $54.92
90812 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $82.91
90813 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $76.36
90814 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $101.99
90815 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $106.57
90846 Family Psychotherapy (without the patient present) 2 $63.78
90847 Family Psychotherapy(conjoint psychotherapy) (with the patient present) 2 $78.53
90849 Multi-group family psychotherapy 2 $30.79
90853 Group psychotherapy 2 $30.91
90857 Interactive group psychotherapy 2 $33.79
90862 Pharmacologic management 2 $44.82
90887 Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons. 2 $52.45
96101 Psychological testing, per hour 2 $71.06
96110 Developmental testing and report, limited 2 $11.95
96111 Developmental testing and report, extended 2 $131.82
96118 Neuropsychological testing battery, per hour 2 $115.79
H0015 Intensive Outpatient-Substance Dependence* 2 PSR
H0035 Mental health partial hospitalization, treatment, less than 24 hours (CMHC)* 2 PSR
H0037 Community psychiatric supportive treatment program, per diem 4 N/A
H2012 Extended Day Treatment 2**** PSR
H2013 Partial Hospitalization (non-CMHC)* 2* PSR
H2019 Therapeutic Behavioral Services, per 15 minutes (IICAPS, MST, MDFT, FFT, FST, HVS) (Clients under 21 only) 2*** $18.62
J1630 Injection, Haloperidol, up to 5 mg 2 $2.12
J1631 Injection, Haloperidol decanoate, per 50 mg 2 $5.25
J2680 Injection, Fluphenazine decanoate, up to 25 mg 2 $1.49
M0064 Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders 2 $23.91
S9475 Ambulatory setting, substance abuse treatment or detoxification services 4 N/A
S9480 Intensive Outpatient-Mental Health 2 PSR
S9484 Emergency mobile mental health service, follow-up (Clients under 21 only) 2*** $68.80
S9485 Emergency mobile mental health service, initial evaluation (Clients under 21 only) 2*** $121.73
T1016 Case Management - Coordination of health care services - each 15 min. 2 $15.00
T1017 Case management - home/community, each 15 minutes (part of home-based services only - IICAPS, MST, MDFT, FFT, FST, HVS) (Clients under 21 only) 2 $18.62
*Coverage restricted to providers approved by DSS to provide this service
*** Coverage restricted to providers certified by DCF to provide this service
****Coverage restricted to providers licensed by DCF to provide this service
Code MH Clinic- Enhanced Care Clinic (ECC) Coverage BHP Fee
90801 Psychiatric Diagnostic Interview 2 $141.00
90802 Interactive Psychiatric Diagnostic Interview 2 $140.94
90804 Individual Psychotherapy- Office or other Outpatient (20-30 min) 2 $56.56
90805 Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $65.12
90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $81.90
90807 Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $94.44
90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $121.13
90809 Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $127.23
90810 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $63.27
90811 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $68.65
90812 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $102.61
90813 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $95.46
90814 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $127.49
90815 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $133.21
90846 Family Psychotherapy (without the patient present) 2 $79.72
90847 Family Psychotherapy(conjoint psychotherapy) (with the patient present) 2 $98.17
90849 Multi-group family psychotherapy 2 $35.86
90853 Group psychotherapy 2 $34.64
90857 Interactive group psychotherapy 2 $37.98
90862 Pharmacologic management 2 $56.03
90887 Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons. 2 $75.25
96101 Psychological testing, per hour 2 $71.06
96110 Developmental testing and report, limited 2 $11.95
96111 Developmental testing and report, extended 2 $131.82
96118 Neuropsychological testing battery, per hour 2 $115.79
99241 Office consult, new/established patient, approx 15 min 2 $50.69
99242 Office consult, new/established patient, approx 30 min 2 $92.71
99243 Office consult, new/established patient, approx 40 min 2 $126.80
99244 Office consult, new/established patient, approx 60 min 2 $184.76
99245 Office consult, new/established patient, approx 80 min 2 $229.59
H0015 Intensive Outpatient-Substance Dependence* 2 PSR
H0035 Mental health partial hospitalization, treatment, less than 24 hours (CMHC)* 2 PSR
H0037 Community psychiatric supportive treatment program, per diem 4 N/A
H2012 Extended Day Treatment 2**** PSR
H2013 Partial Hospitalization (non-CMHC)* 2* PSR
H2019 Therapeutic Behavioral Services, per 15 minutes (IICAPS, MST, MDFT, FFT, FST, HVS) (Clients under 21 only) 2*** $18.62
J1630 Injection, Haloperidol, up to 5 mg 2 $2.12
J1631 Injection, Haloperidol decanoate, per 50 mg 2 $5.25
J2680 Injection, Fluphenazine decanoate, up to 25 mg 2 $1.49
M0064 Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders 2 $29.89
S9475 Ambulatory setting, substance abuse treatment or detoxification services 4 N/A
S9480 Intensive Outpatient-Mental Health 2 PSR
S9484 Emergency mobile mental health service, follow-up (Clients under 21 only) 2*** $68.80
S9485 Emergency mobile mental health service, initial evaluation (Clients under 21 only) 2*** $121.73
T1016 Case Management - Coordination of health care services - each 15 min. 2 $15.00
T1017 Case management - home/community, each 15 minutes (part of home-based services only - IICAPS, MST, MDFT, FFT, FST, HVS) (Clients under 21 only) 2 $18.62
*Coverage restricted to providers approved by DSS to provide this service
*** Coverage restricted to providers certified by DCF to provide this service
****Coverage restricted to providers licensed by DCF to provide this service
Code FQHC Mental Health Clinic Coverage BHP Fee
90801 Psychiatric Diagnostic Interview 2 $-
90802 Interactive Psychiatric Diagnostic Interview 2 $-
90804 Individual Psychotherapy- Office or other Outpatient (20-30 min) 2 $-
90805 Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $-
90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $-
90807 Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $-
90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $-
90809 Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $-
90810 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $-
90811 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $-
90812 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $-
90813 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $-
90814 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $-
90815 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $-
90846 Family Psychotherapy (without the patient present) 2 $-
90847 Family Psychotherapy(conjoint psychotherapy) (with the patient present) 2 $-
90849 Multi-group family psychotherapy 2 $-
90853 Group psychotherapy 2 $-
90857 Interactive group psychotherapy 2 $-
90862 Pharmacologic management 2 $-
90887 Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons. 2 $-
96101 Psychological testing, per hour 2 $-
96110 Developmental testing and report, limited 2 $-
96111 Developmental testing and report, extended 2 $-
96118 Neuropsychological testing battery, per hour 2 $-
H0015 Intensive Outpatient-Substance Dependence* 2 PSR
H0020 Methadone service; rate includes all services for which the source of service is the methadone maintenance clinic. 2 $-
H0037 Community psychiatric supportive treatment program, per diem 4 N/A
H2012 Extended Day Treatment 2**** PSR
H2013 Partial Hospitalization (non-CMHC)* 2* PSR
J1630 Injection, Haloperidol, up to 5 mg 2 $-
J1631 Injection, Haloperidol decanoate, per 50 mg 2 $-
J2680 Injection, Fluphenazine decanoate, up to 25 mg 2 $-
M0064 Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders 2 $-
S9475 Ambulatory setting, substance abuse treatment or detoxification services 4 N/A
S9480 Intensive Outpatient-Mental Health 2 PSR
S9484 Emergency mobile mental health service, follow-up (Clients under 21 only) 2*** $-
S9485 Emergency mobile mental health service, initial evaluation (Clients under 21 only) 2*** $-
T1015 Clinic visit/encounter all-inclusive (For use by FQHC MH Clinics) 2 PSR
*Coverage restricted to providers approved by DSS to provide this service
*** Coverage restricted to providers certified by DCF to provide this service
****Coverage restricted to providers licensed by DCF to provide this service
Code Rehabilitation Clinic Coverage BHP Fee
90801 Psychiatric Diagnostic Interview 3 $106.54
90804 Individual Psychotherapy- Office or other Outpatient (20-30 min) 3 $45.25
90805 Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 3 $50.48
90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 3 $65.52
90807 Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 3 $73.91
90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 3 $96.90
90809 Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 3 $101.78
90846 Family psychotherapy (without the patient present) 3 $63.78
90847 Family psychotherapy (conjoint) 3 $78.53
90853 Group psychotherapy 3 $30.91
90857 Interactive Group therapy 3 $33.79
96118 Neuropsychological testing battery, per hour 3 $115.79
All others   1 N/A
Code Freestanding Medical Clinic (including non-FQHC School-Based Health Centers) Coverage BHP Fee
90782 Therapeutic or diagnostic injection; subcutaneous or intramuscular 1 N/A
90783 Therapeutic or diagnostic injection; intra-arterial 1 N/A
90784 Therapeutic or diagnostic injection; intravenous 1 N/A
90801 Psychiatric Diagnostic Interview 3 $95.88
90804 Individual psychotherapy (20-30 min) 3 $40.72
90805 Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $45.43
90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $58.97
90807 Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $66.52
90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $87.21
90846 Family psychotherapy (without the patient present) 3 $57.40
90847 Family psychotherapy (conjoint psychotherapy w/patient present) 3 $70.68
90853 Group psychotherapy (other than of a multiple-family group) 3 $27.82
90862 Pharmacologic management 2 $40.34
99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. (Typically 5 minutes) 1 N/A
99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: problem focused history; problem focused examination; straightforward medical decision-making. (Typically 10 minutes face-to-face) 1 N/A
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: expanded problem focused history; expanded problem focused examination; medical decision making of low complexity. (Typically 15 minutes face-to-face) 1 N/A
99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: detailed history; detailed examination; medical decision making of moderate complexity (Typically 25 minutes face-to-face) 1 N/A
99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: comprehensive history; comprehensive examination; medical decision making of high complexity (Typically 40 minutes face-to-face) 1 N/A
All others   1 N/A
Code FQHC Medical Clinics (including those operating asSchool-Based Health Centers) Coverage BHP Fee
90782 Therapeutic or diagnostic injection; subcutaneous or intramuscular 1 N/A
90783 Therapeutic or diagnostic injection; intra-arterial 1 N/A
90784 Therapeutic or diagnostic injection; intravenous 1 N/A
90801 Psychiatric Diagnostic Interview 3 $-
90804 Individual psychotherapy (20-30 min) 3 $-
90805 Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $-
90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $-
90807 Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $-
90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $-
90846 Family psychotherapy (without the patient present) 3 $-
90847 Family psychotherapy (conjoint psychotherapy w/patient present) 3 $-
90853 Group psychotherapy (other than of a multiple-family group) 3 $-
90862 Pharmacologic management 2 $-
99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. (Typically 5 minutes) 1 N/A
99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: problem focused history; problem focused examination; straightforward medical decision-making. (Typically 10 minutes face-to-face) 1 N/A
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: expanded problem focused history; expanded problem focused examination; medical decision making of low complexity. (Typically 15 minutes face-to-face) 1 N/A
99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: detailed history; detailed examination; medical decision making of moderate complexity (Typically 25 minutes face-to-face) 1 N/A
99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: comprehensive history; comprehensive examination; medical decision making of high complexity (Typically 40 minutes face-to-face) 1 N/A
T1015 Clinic visit/encounter all-inclusive (For use by FQHC Clinics) 2 PSR
All others   1 N/A
       
Code Methadone Clinic Coverage BHP Fee
H0020 Methadone service; rate includes all services for which the source of service is the methadone maintenance clinic. 2 PSR
       
Code MD, DO and APRN other than Psychiatrist or Psychiatric APRN Coverage BHP Fee
00104 Anesthesia for electroconvulsive therapy 1 N/A
80100 Drug screen, qualitative, chromatographic method, each procedure 1 N/A
81000 Urinalysis, by dip stick or tablet reagent, non-automated, with microscopy 1 N/A
83840 Methadone chemistry (quantitative analysis) 1 N/A
90782 Therapeutic or diagnostic injection; subcutaneous or intramuscular 1 N/A
90783 Therapeutic or diagnostic injection; intra-arterial 1 N/A
90784 Therapeutic or diagnostic injection; intravenous 1 N/A
908XX Psychotherapy codes 4 N/A
99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician.(Typically 5 minutes) 1 N/A
99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: problem focused history; problem focused examination; straightforward medical decision making (Typically 10 minutes face-to-face) 1 N/A
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: expanded problem focused history; expanded problem focused examination; medical decision making of low complexity. (Typically 15 minutes face-to-face) 1 N/A
99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: detailed history; detailed examination; medical decision making of moderate complexity (Typically 25 minutes face-to-face) 1 N/A
99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: comprehensive history; comprehensive examination; medical decision making of high complexity (Typically 40 minutes face-to-face) 1 N/A
All others   1 N/A
Code Psychiatrist (MD or DO) Coverage BHP Fee
90801 Diagnostic Interview 2 $156.67
90802 Interactive Diagnostic Interview 2 $157.52
90804 Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $63.21
90805 Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $69.28
90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $91.53
90807 Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $99.14
90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $135.38
90809 Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $142.20
90810 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $67.27
90811 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $76.72
90812 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $99.07
90813 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $106.69
90814 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $142.49
90815 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $148.88
90816 Individual Psychotherapy-Facility Based (20-30 min) 2 $60.95
90817 90816 with medical evaluation and management 2 $67.60
90818 Individual psychotherapy, insight oriented 45-50 minutes 2 $91.97
90819 90818 with medical evaluation and management 2 $96.18
90821 Individual Psychotherapy-Facility Based (75-80 min) 2 $135.60
90822 Individual Psychotherapy-Facility Based (75-80 min) with med management 2 $139.79
90823 Interactive Individual Psychotherapy-Facility Based (20-30 min) 2 $65.54
90824 Interactive Individual Psychotherapy-Facility Based (20-30 min) med management 2 $71.89
90826 Interactive Individual Psychotherapy-Facility Based (45-50 min) 2 $97.08
90827 Interactive Individual Psychotherapy-Facility Based (45-50 min) med management 2 $100.68
90828 Interactive Individual Psychotherapy-Facility Based (75-80 min) 2 $140.66
90829 Interactive Individual Psychotherapy-Facility Based (75-80 min) med management 2 $144.48
90846 Family Psychotherapy (without the patient present) 2 $89.10
90847 Family Psychotherapy (conjoint) 2 $109.72
90849 Multi-group family psychotherapy 2 $32.26
90853 Group Psychotherapy 2 $36.64
90857 Interactive Group psychotherapy 2 $41.93
90862 Pharmacological management, including prescription, use, and review of medication with no more than minimal medical psychotherapy 2 $54.54
90865 Narcosynthesis for Psychiatric Diagnostic and Therapeutic purposes 2 $154.82
90870 Electroconvulsive therapy (including necessary monitoring); single seizure 2 $145.87
90875 Individual psychophysiological therapy incorporating biofeedback training (20-30 min) 2 $77.43
90876 Individual psychophysiological therapy incorporating biofeedback training (45-50 min) 2 $112.04
90880 Hypnotherapy 2 $114.04
90887 Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons. 2 $84.10
96101 Psychological testing, per hour 2 $88.47
96110 Developmental testing with report 2 $14.75
96111 Developmental testing, extended 2 $133.69
96118 Neuropsychological testing battery, per hour 2 $120.90
99201 Office or other outpatient visit, 10 minutes, new patient 2 $40.22
99202 Office or other outpatient visit, 20 minutes, new patient 2 $64.88
99203 Office or other outpatient visit, 30 minutes, new patient 2 $95.77
99204 Office or other outpatient visit, 45 minutes, new patient 2 $144.48
99205 Office or other outpatient visit, 60 minutes, new patient 2 $180.79
99211 Office or other outpatient visit, 5 minutes, established patient 2 $21.54
99212 Office or other outpatient visit, 10 minutes, established patient 2 $38.69
99213 Office or other outpatient visit, 15 minutes, established patient 2 $61.93
99214 Office or other outpatient visit, 25 minutes, established patient 2 $93.74
99215 Office or other outpatient visit, 40 minutes, established patient 2 $126.36
99217 Observation care discharge 2 $67.25
99218 Initial observation care, low severity 2 $63.03
99219 Initial observation care, moderate severity 2 $104.05
99220 Initial observation care, high severity 2 $146.77
99221 Inpatient hospital care, 30 minutes 2 $85.64
99222 Inpatient hospital care, 50 minutes 2 $120.37
99223 Inpatient hospital care, 70 minutes 2 $175.51
99231 Subsequent hospital care, 15 minutes 2 $56.59
99232 Subsequent hospital care, 25 minutes 2 $64.45
99233 Subsequent hospital care, 35 minutes 2 $91.97
99234 Observation of inpatient hospital care, low severity 2 $126.81
99235 Observation of inpatient hospital care, moderate severity 2 $167.09
99236 Observation of inpatient hospital care, high severity 2 $208.26
99238 Hospital discharge day management 30 minutes or less 2 $66.94
99239 Hospital discharge day management more than 30 minutes 2 $96.52
99241 Office consultation for a new or established patient, approximately 15 minutes 2 $50.69
99242 Office consultation for a new or established patient, approximately 30 minutes 2 $92.71
99243 Office consultation for a new or established patient, approximately 40 minutes 2 $126.80
99244 Office consultation for a new or established patient, approximately 60 minutes 2 $185.23
99245 Office consultation for a new or established patient, approximately 80 minutes 2 $229.59
99251 Initial inpatient consultation, 20 minutes 2 $46.20
99252 Initial inpatient consultation, 40 minutes 2 $74.42
99253 Initial inpatient consultation, 55 minutes 2 $110.12
99254 Initial inpatient consultation, 80 minutes 2 $158.65
99255 Initial inpatient consultation, 110 minutes 2 $198.08
99271 Confirmatory consultation, limited or minor 2 $37.94
99272 Confirmatory consultation, low severity 2 $62.77
99273 Confirmatory consultation, moderate severity 2 $85.98
99274 Confirmatory consultation, moderate to high severity 2 $115.65
99275 Confirmatory consultation, high severity 2 $146.85
99281 Emergency department visit, minor severity 2 $19.38
99282 Emergency department visit, low to moderate severity 2 $37.13
99283 Emergency department visit, moderate severity 2 $60.75
99284 Emergency department visit, high severity 2 $110.25
99285 Emergency department visit, high severity with significant threat 2 $165.10
J1630 Injection, Haloperidol, up to 5 mg 2 $2.12
J1631 Injection, Haloperidol decanoate, per 50 mg 2 $5.25
J2680 Injection, Fluphenazine decanoate, up to 25 mg 2 $1.49
M0064 Brief office visit for the sole purpose of monitoring or changing prescriptions used in the treatment of mental psychoneurotic or personality disorders 2 $32.91
T1016 Case Management - Coordination of health care services - each 15 min. 2 $15.00
All others   4 N/A
Code Psychiatric APRN Coverage BHP Fee
90801 Diagnostic Interview 2 $141.00
90802 Interactive Diagnostic Interview 2 $141.77
90804 Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $56.89
90805 Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $62.36
90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $82.38
90807 Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $89.23
90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $121.84
90809 Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $127.98
90810 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $60.54
90811 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services 2 $69.05
90812 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $89.16
90813 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services 2 $96.02
90814 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $128.24
90815 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services 2 $134.00
90816 Individual Psychotherapy-Facility Based (20-30 min) 2 $54.86
90817 90816 with medical evaluation and management 2 $60.84
90818 Individual psychotherapy, insight oriented 45-50 minutes 2 $82.77
90819 90818 with medical evaluation and management 2 $86.56
90821 Individual Psychotherapy-Facility Based (75-80 min) 2 $122.04
90822 Individual Psychotherapy-Facility Based (75-80 min) with med management 2 $125.81
90823 Interactive Individual Psychotherapy-Facility Based (20-30 min) 2 $58.99
90824 Interactive Individual Psychotherapy-Facility Based (20-30 min) med management 2 $64.70
90826 Interactive Individual Psychotherapy-Facility Based (45-50 min) 2 $87.37
90827 Interactive Individual Psychotherapy-Facility Based (45-50 min) med management 2 $90.61
90828 Interactive Individual Psychotherapy-Facility Based (75-80 min) 2 $126.59
90829 Interactive Individual Psychotherapy-Facility Based (75-80 min) med management 2 $130.03
90846 Family Psychotherapy (without the patient present) 2 $80.19
90847 Family Psychotherapy (conjoint) 2 $98.74
90849 Multi-group family psychotherapy 2 $29.04
90853 Group Psychotherapy 2 $32.98
90857 Interactive Group psychotherapy 2 $37.73
90862 Pharmacological management, including prescription, use, and review of medication with no more than minimal medical psychotherapy 2 $49.09
90865 Narcosynthesis for Psychiatric Diagnostic and Therapeutic purposes 2 $139.34
90870 Electroconvulsive therapy (including necessary monitoring); single seizure 2 $131.29
90875 Individual psychophysiological therapy incorporating biofeedback training (20-30 min) 2 $69.69
90876 Individual psychophysiological therapy incorporating biofeedback training (45-50 min) 2 $100.84
90880 Hypnotherapy 2 $102.63
90887 Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons. 2 $75.69
96101 Psychological testing, per hour 2 $79.63
96110 Developmental testing with report 2 $13.27
96111 Developmental testing, extended 2 $120.32
96118 Neuropsychological testing battery, per hour 2 $108.81
99201 Office or other outpatient visit, 10 minutes, new patient 2 $36.20
99202 Office or other outpatient visit, 20 minutes, new patient 2 $58.39
99203 Office or other outpatient visit, 30 minutes, new patient 2 $86.19
99204 Office or other outpatient visit, 45 minutes, new patient 2 $130.03
99205 Office or other outpatient visit, 60 minutes, new patient 2 $162.72
99211 Office or other outpatient visit, 5 minutes, established patient 2 $19.38
99212 Office or other outpatient visit, 10 minutes, established patient 2 $34.82
99213 Office or other outpatient visit, 15 minutes, established patient 2 $55.74
99214 Office or other outpatient visit, 25 minutes, established patient 2 $84.36
99215 Office or other outpatient visit, 40 minutes, established patient 2 $113.72
99217 Observation care discharge 2 $60.53
99218 Initial observation care, low severity 2 $56.73
99219 Initial observation care, moderate severity 2 $93.65
99220 Initial observation care, high severity 2 $132.09
99221 Inpatient hospital care, 30 minutes 2 $77.08
99222 Inpatient hospital care, 50 minutes 2 $108.33
99223 Inpatient hospital care, 70 minutes 2 $157.96
99231 Subsequent hospital care, 15 minutes 2 $50.93
99232 Subsequent hospital care, 25 minutes 2 $58.00
99233 Subsequent hospital care, 35 minutes 2 $82.77
99234 Observation of inpatient hospital care, low severity 2 $114.13
99235 Observation of inpatient hospital care, moderate severity 2 $150.38
99236 Observation of inpatient hospital care, high severity 2 $187.43
99238 Hospital discharge day management 30 minutes or less 2 $60.24
99239 Hospital discharge day management more than 30 minutes 2 $86.87
99241 Office consultation for a new or established patient, approximately 15 minutes 2 $45.62
99242 Office consultation for a new or established patient, approximately 30 minutes 2 $83.44
99243 Office consultation for a new or established patient, approximately 40 minutes 2 $114.12
99244 Office consultation for a new or established patient, approximately 60 minutes 2 $166.71
99245 Office consultation for a new or established patient, approximately 80 minutes 2 $206.63
99251 Initial inpatient consultation, 20 minutes 2 $41.58
99252 Initial inpatient consultation, 40 minutes 2 $66.98
99253 Initial inpatient consultation, 55 minutes 2 $99.11
99254 Initial inpatient consultation, 80 minutes 2 $142.79
99255 Initial inpatient consultation, 110 minutes 2 $178.28
99271 Confirmatory consultation, limited or minor 2 $34.14
99272 Confirmatory consultation, low severity 2 $56.49
99273 Confirmatory consultation, moderate severity 2 $77.38
99274 Confirmatory consultation, moderate to high severity 2 $104.08
99275 Confirmatory consultation, high severity 2 $132.17
99281 Emergency department visit, minor severity 2 $17.44
99282 Emergency department visit, low to moderate severity 2 $33.41
99283 Emergency department visit, moderate severity 2 $54.68
99284 Emergency department visit, high severity 2 $99.22
99285 Emergency department visit, high severity with significant threat 2 $148.59
J1630 Injection, Haloperidol, up to 5 mg 2 $1.90
J1631 Injection, Haloperidol decanoate, per 50 mg 2 $4.73
J2680 Injection, Fluphenazine decanoate, up to 25 mg 2 $1.34
M0064 Brief office visit for the sole purpose of monitoring or changing prescriptions used in the treatment of mental psychoneurotic or personality disorders 2 $29.62
T1016 Case Management - Coordination of health care services - each 15 min. 2 $13.50
All others   4 N/A
Code Psychologist and Psychologist Group Coverage BHP Fee
90801 Diagnostic Interview 2 $133.17
90802 Interactive Diagnostic Interview 2 $133.89
90804 Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $53.73
90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $77.80
90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $115.07
90810 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $57.18
90812 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $84.21
90814 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $121.12
90816 Individual Psychotherapy-Facility Based (20-30 min) 2 $51.81
90818 Individual psychotherapy, insight oriented 45-50 minutes 2 $78.18
90821 Individual Psychotherapy-Facility Based (75-80 min) 2 $115.26
90823 Interactive Individual Psychotherapy-Facility Based (20-30 min) 2 $55.71
90826 Interactive Individual Psychotherapy-Facility Based (45-50 min) 2 $82.52
90828 Interactive Individual Psychotherapy-Facility Based (75-80 min) 2 $119.56
90846 Family Psychotherapy (without the patient present) 2 $75.74
90847 Family Psychotherapy (conjoint) 2 $93.26
90849 Multi-group family psychotherapy 2 $27.42
90853 Group Psychotherapy 2 $31.15
90857 Interactive Group psychotherapy 2 $35.64
90875 Individual psychophysiological therapy incorporating biofeedback training (20-30 min) 2 $65.82
90876 Individual psychophysiological therapy incorporating biofeedback training (45-50 min) 2 $95.24
90880 Hypnotherapy 2 $96.93
90887 Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons. . 2 $84.10
96101 Psychological testing, per hour 2 $75.20
96110 Developmental testing with report 2 $12.53
96111 Developmental testing, extended 2 $113.64
96118 Neuropsychological testing battery, per hour 2 $102.76
T1016 Case Management - Coordination of health care services - each 15 min. 2 $12.75
Code Independent Practice Behavioral Health Professional (LCSW, LMFT, LPC, LADC) Coverage BHP Fee
90801 Diagnostic Interview 2 $109.67
90802 Interactive Diagnostic Interview 2 $110.26
90804 Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $44.25
90806 Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $64.07
90808 Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $94.76
90810 Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) 2 $47.09
90812 Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) 2 $69.35
90814 Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) 2 $99.74
90816 Individual Psychotherapy-Facility Based (20-30 min) 2 $42.67
90818 Individual psychotherapy, insight oriented 45-50 minutes 2 $64.38
90821 Individual Psychotherapy-Facility Based (75-80 min) 2 $94.92
90823 Interactive Individual Psychotherapy-Facility Based (20-30 min) 2 $45.88
90826 Interactive Individual Psychotherapy-Facility Based (45-50 min) 2 $67.96
90828 Interactive Individual Psychotherapy-Facility Based (75-80 min) 2 $98.46
90846 Family Psychotherapy (without the patient present) 2 $62.37
90847 Family Psychotherapy (conjoint) 2 $76.80
90849 Multi-group family psychotherapy 2 $22.58
90853 Group Psychotherapy 2 $25.65
90857 Interactive Group psychotherapy 2 $29.35
90875 Individual psychophysiological therapy incorporating biofeedback training (20-30 min) 2 $54.20
90876 Individual psychophysiological therapy incorporating biofeedback training (45-50 min) 2 $78.43
90880 Hypnotherapy 2 $79.83
90887 Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons. 2 $58.87
96110 Developmental testing with report 2 $10.32
96111 Developmental testing, extended 2 $93.59
T1016 Case Management - Coordination of health care services - each 15 min. 2 $10.50
Code Home Health Care Agencies* Coverage BHP Fee
RCC/HCPC  
421 Physical Therapy 1 N/A
424 Physical Therapy Evaluation 1 N/A
431 Occupational Therapy 1 N/A
434 Occupational Therapy Evaluation 1 N/A
441 Speech Therapy 1 N/A
444 Speech Therapy Evaluation 1 N/A
570/T1004 Services of a qualified nursing aide, up to 15 minutes 3 $5.25
580/S9123 Nursing care, in the home by an RN, per hour 3 $86.20
580/S9124 Nursing Care, in the home by an LPN, per hour 3 $86.20
580/T1001 Nursing Assessment/Evaluation 3 $93.15
580/T1002 RN Services, up to 15 minutes 3 $21.55
580/T1003 LPN/LVN services, up to 15 minutes 3 $21.55
580/T1502 Administration of oral, intramuscular and/or subcutaneous medication by health care agency/professional, per visit 3 $59.81
*BHP covers home health services for children with autism including when autism is co-morbid with mental retardation.
Code Independent Occupational Therapist Coverage BHP Fee
All codes   1 N/A
Code Independent Physical Therapist Coverage BHP Fee
All codes   1 N/A
Code Medical Transportation Coverage BHP Fee
All codes   1 N/A
Code Emergency Medical Transportation Coverage BHP Fee
All codes   1 N/A
Code Independent Laboratory Services Coverage BHP Fee
80100 Drug screen, qualitative, chromatographic method, each procedure 1 N/A
81000 Urinalysis, by dip stick or tablet reagent, non-automated, with microscopy 1 N/A
83840 Methadone chemistry (quantitative analysis) 1 N/A
All other codes   1 N/A
Code Pharmacy Coverage BHP Fee
All codes   1 N/A
Code Other Community Services Coverage BHP Fee
H2017 Psychosocial Rehabilitation services, per 15 minutes 2*** PSR
H2019 Therapeutic Behavioral Services, per 15 minutes (IICAPS, MST, MDFT, FFT, FST, HBV) (Clients under 21 only) 2*** $18.62
T1017 Case management - home/community, each 15 minutes (part of home-based services only - IICAPS, MST, MDFT, FFT, FST, HVS) (Clients under 21 only) 2*** $18.62
H2032 Activity Therapy, per 15 minutes (Therapeutic Mentoring/Behavioral Management Service) (Clients under 21 only) 2*** TBD
***Coverage restricted to providers certified by DCF to provide this service
****Coverage restricted to providers licensed by DCF to provide this service
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