| 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 |