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VBH-PA Covered Services Grid
VBH-PA HIPAA X_Walk Covered Services Grid TPL Exempt Unit Dx Class PROMISe Specialty Code Auth Req? Prov PROMISe Provider Mod 3 Type Claim Type Prov Mod 2 Type Code Prov Mod 1 Level of Service Description Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class POS Timely Filing (Date of Service or Date of Discharge) Inpatient Psychiatric Services per diem per diem per diem per diem per diem per diem per diem per diem per diem I I I I I I I I I I I I I I I I I I PP PP PP PG PG PG PP PP PP IP IP IP IG IG IG IP IP IP Y Y Y Y Y Y Y Y Y 21 21 21 01 010 011 022 010 011 022 010 011 022 01 010 011 022 per diem per diem per diem I I I I I I UI UI UI IF IF IF 010 per diem I I D 019 per diem I I D 441 per diem I I 010 per diem I 019 per diem 01 441 IPA Acute 0124 01 Specialized 0114 01 IPP IPW Extended Acute Care 0120 21 21 21 PSY PSY PSY PSY PSY PSY PSY PSY PSY N N N N N N N N N DOD DOD DOD DOD DOD DOD DOD DOD DOD Y Y Y 21 21 21 PSY, SUB N PSY, SUB N PSY, SUB N DOD DOD DOD DT Y 21 SUB N DOD DT Y 21 SUB N DOD D DT Y 21 SUB N DOD I SR RE Y 21 SUB N DOD I I SR RE Y 21 SUB N DOD per diem I I SR RE Y 21 SUB N DOD 21 21 21 Inpatient Dual Diagnosis IPD Other (Dual) 0929 Inpatient Drug & Alcohol Services IDD Acute Detox (4A) 0126 01 IDR Acute Rehab (4B) 0128 H0013 H0018 H0018 T2048 H2034 HF U4 HF 11 11 11 11 11 132 133 133 134 131 per diem per diem per diem per diem per diem R R R R R R R R R R SD SR SR SR SA DT RE RE RE DA Y Y Y Y Y 99 99 99 99 99 SUB SUB SUB SUB SUB Y Y Y Y Y DOD DOD DOD DOD DOD H2034 H0018 T2048 U3 SC SC 11 11 11 131 133 134 per diem per diem per diem R R R R R R SA SD SR DA NA NA Y Y Y 99 99 99 SUB SUB SUB Y Y Y DOD DOD DOD H0018 U5 U9 11 133 per diem R R SR RE Y 99 SUB Y DOD T2048 H0018 UB U9 U9 STR Detox (3A) Short term Rehab (3B) Enhanced Residential Long term Rehab (3C) Halfway House (2B) Halfway House for Women with Children (2B) Short Term Rehab 3.5 Long Term Rehab 3.1 Adolescent Male Rehab YES Program Non-Hosp Adol Rehab Long Term (3.1) Short Term Rehab (3B) 3.5 11 11 134 133 per diem per diem R R R R SR SR RE RE Y Y 99 99 SUB SUB Y Y DOD DOD NHA Adult Res/Dual H0018 HE 11 110 per diem R R UD DD Y 99 PSY, SUB Y DOD Transitional RTF JCAHO 0949 01 013 per diem R R Y 56 PSY N DOD JCAHO Transitional RTF JCAHO/Reserve Bed Day 0154 01 013 per diem R R 0919 01 013 per diem R R JCAHO/Reserve Bed Day Non-JCAHO/Comp (R&B) Non-JCAHO TX Only Non-JCAHO/Reserve Bed Day Comp (R&B) Non-JCAHO/Reserve Bed Day Tx Only Accredited Diversion and Stabilization Unit Long Term Structured Residential Treatment Long Term Structured Residential Room & Board Non hospital residential treatment program 0134 T2048 H0019 U7 SC 01 56 56 013 560 560 per diem per diem per diem R R R T2048 U3 56 560 per diem H0019 U4 56 560 per diem 01 013 per diem Non-Hospital Drug & Alcohol NHD NHS NHL NHH ST3 AR3 YES AR2 Non-Hospital Dual Residential Treatment Facility RF1 RF2 RF3 RF4 RF5 RF6 DAS LTR LTB RTF 0911 H0037 T2048 H0018 HE DT, RE, D, SR, P NA DT, RE, D, SR, P NA Y 56 PSY N DOD Y 56 PSY N DOD R R R D, SR, P NA DT, RE, D, SR, P NA P, SA NA, DA P, SA NA, DA Y Y Y 56 56 56 PSY PSY PSY N N N DOD DOD DOD R R P, SA NA, DA Y 56 PSY N DOD R R P, SA NA, DA Y 56 PSY N DOD R R D,SR, P NA Y 56 PSY Y DOD 11 110 per diem R R P, SA NA, DA Y 56 PSY Y DOD 11 110 per diem R R P, SA NA Y 56 PSY Y DOD 08 340 per diem R P P NA Y 12, 99 PSY Y DOD Page 1 of 23 VBH-PA HIPAA X_Walk Covered Services Grid TPL Exempt Dx Class Auth Req? PROMISe Specialty Code Claim Type Prov PROMISe Provider Mod 3 Type Type Code Prov Mod 2 Level of Service Prov Mod 1 Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class Timely Filing (Date of Service or Date of Discharge) Description Provider Service Code New Patient/Focused Examination 99201 31 339 per event I I P, SA NA, DA N 21 PSY, SUB N DOD New Patient/Expanded Examination Office or Other Outpatient Visit for the New Patient/Comprehensive Examination Established Patient/Evaluation Established Patient/Focused Examination Established Patient/Expanded Examination Office or Other Outpatient Visit for the Eval Initial Hosp Eval/Low Initial Hosp Eval/Mod Initial Hosp Eval/High Inpt Consult Inpt Consult Inpt Consult Inpt Consult Inpt Consult Inpt Fu (15 min) Inpt Fu (25 min) Inpt Fu (35 min) Home Visit EM of New Patient, Problem Low Home Visit EM of New Patient, Problem Moderate Home Visit EM of New Patient, Problem High 99202 31 339 per event I I P, SA NA, DA N 21 PSY, SUB N DOD 99203 31 339 per event I I P, SA NA, DA N 21 PSY, SUB N DOD 99204 99211 31 31 339 339 per event per event I I I I P, SA P, SA NA, DA NA, DA N N 21 21 PSY, SUB N PSY, SUB N DOD DOD 99212 31 339 per event I I P, SA NA, DA N 21 PSY, SUB N DOD 99213 31 339 per event I I P, SA NA, DA N 21 PSY, SUB N DOD 99214 99221 99222 99223 99251 99252 99253 99254 99255 99231 99232 99233 31 31 31 31 31 31 31 31 31 31 31 31 339 339 339 339 339 339 339 339 339 339 339 339 per event 30 min 50 min 70 min 20 min 40 min 55 min 80 min 110 min 15 min 25 min 35 min I I I I I I I I I I I I I I I I I I I I I I I I P, SA P, SA P, SA P, SA P, SA P, SA P, SA P, SA P, SA P, SA P, SA P, SA NA, DA NA NA NA NA, DA NA, DA NA, DA NA, DA NA, DA NA, DA NA, DA NA, DA N N N N N N N N N N N N 21 21 21 21 21 21 21 21 21 21 21 21 PSY, SUB PSY, SUB PSY, SUB PSY, SUB PSY, SUB PSY, SUB PSY, SUB PSY, SUB PSY, SUB PSY, SUB PSY, SUB PSY, SUB N N N N N N N N N N N N DOD DOD DOD DOD DOS DOS DOS DOS DOS DOS DOS DOS 99341 31 339 20 min I I P,SA NA N 12 PSY, SUB N DOD 99342 31 339 30 min I I P,SA NA N 12 PSY, SUB N DOD 99343 31 339 45 min I I P,SA NA N 12 PSY, SUB N DOD 99304 31 339 visit I I P,SA NA N 31, 32 PSY, SUB N DOD 31 339 visit I I P,SA NA N 31, 32 PSY, SUB N DOD 31 339 visit I I P,SA NA N 31, 32 PSY, SUB N DOD 31 339 visit I I P,SA NA N 31, 32 PSY, SUB N DOD 31 339 visit I I P,SA NA N 31, 32 PSY, SUB N DOD 99309 31 339 visit I I P,SA NA N 31, 32 PSY, SUB N DOD 99310 31 339 visit I I P,SA NA N 31, 32 PSY, SUB N DOD Initial Hosp Eval/Low Initial Hosp Eval/Mod Initial Hosp Eval/High Sub Hosp (15 min) Sub Hosp (25 min) Sub Hosp (35 min) Discharge 99221 99222 99223 99231 99232 99233 99238 31 31 31 31 31 31 31 339 339 339 339 339 339 339 30 min 50 min 70 min 15 min 25 min 35 min vst I I I I I I I I I I I I I I P, SA P, SA P, SA P, SA P, SA P, SA P, SA NA, DA NA, DA NA, DA NA, DA NA, DA NA, DA NA, DA Y Y Y Y Y Y Y 21 21 21 21 21 21 21 PSY, SUB PSY, SUB PSY, SUB PSY, SUB PSY, SUB PSY, SUB PSY, SUB N N N N N N N DOD DOD DOD DOD DOD DOD DOD Site Based Autism H0046 SC 08 11 340 340 H0046 HA 08 11 340 340 O O O O O O O O P, SA P, SA P P NA, DA NA, DA NA NA Y Y Y Y 12, 99 12, 99 Site Based Autism (Plus) 15 min 15 min 15 min 15 min PSY, SUB PSY, SUB PSY, SUB PSY, SUB Y Y Y Y DOS DOS DOS DOS Unit POS Consultations CNS** Initial nursing Facility care, per day EM of patient with three key components (low complexity) U1 U1 U1 U1 U1 U1 Initial nursing Facility care, per day EM of patient with three key components (moderate complexity) 99305 Initial nursing Facility care, per day EM of patient with three key components (high complexity) 99306 Subsequent nursing facility care, per day 99307 Subsequent nursing facility care, per day low complexity 99308 Subsequent nursing facility care, per day, moderate complexity Subsequent nursing facility care, per day , high complexity Inpatient Physicians Services BED** Outpatient Professional Services TXC Page 2 of 23 12, 99 12, 99 VBH-PA HIPAA X_Walk Covered Services Grid TI1** Family Psychotherapy (without the patient present) Peer Support Services Peer Support Services- Group Peer Support Out of County 90846 U1 31 08 19 90846 H0038 Peer Support/Interactive Telecom Services Forensic Peer Support H0038 H0038 P, SA P, SA P, SA NA, DA NA, DA NA, DA Y Y Y 08 15 min O O P NA N 11 15 min O O P NA N 15 min O O P NA N 08 15 min O O P NA N 11 15 min O O P NA N 15 min O O P NA N 08 15 min O O P NA N 11 15 min O O P NA N 15 min O O P NA N 08 15 min O O P NA N 11 15 min O O P NA N U5 076 076 076 15 min O O P NA N 08 15 min O O P NA N 11 15 min O O P NA N 21 15 min O O P NA N 15 min O O P NA N 15 min O O P NA N 15 min O O P NA N 08 15 min O O P NA N 11 15 min O O P NA N 21 GT 076 Forensic Peer Support/Interactive Telecommunication system H0038 U8 Assess & Assist TSS worker less than 6 months exp. H2014 HA 12,49 11 12, 21, 23, 49, 99 11, 12, 21, 52, 99 TPL Exempt Dx Class PSY, SUB Y PSY, SUB Y PSY, SUB Y DOS DOS DOS PSY Y DOS PSY Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS Y DOS 12,21,31,32,9 9 PSY 12, 21, 23, 49, 99 PSY 11, 12, 21, 52, 99 PSY 12,21,31,32,9 9 PSY 12, 21, 23, 49, 99 PSY 11, 12, 21, 52, 99 PSY 12,21,31,32,9 9 PSY 12, 21, 23, 49, 99 PSY 11, 12, 21, 52, 99 PSY 12,21,31,32,9 9 PSY 12, 21, 23, 49, 99 PSY 11, 12, 21, 52, 99 PSY 076 15 min O O P NA N 31 548 15 min O W P NA N 12,99 PSY Y DOS 19 548 15 min O W P NA N 12, 99 PSY Y DOS 08 808 15 min O W P NA N 12, 99 PSY Y DOS 08 800 or 804 15 min O W P NA N 12, 99 PSY Y DOS 21 U7 11 21 076 11 H0038 POS Timely Filing (Date of Service or Date of Discharge) 12,21,31,32,9 9 PSY 12, 21, 23, 49, 99 PSY 11, 12, 21, 52, 99 PSY 12,21,31,32,9 9 PSY 12, 21, 23, 49, 99 PSY 11, 12, 21, 52, 99 PSY 12,21,31,32,9 9 PSY 08 Forensic Peer Support Group Auth Req? O O O 21 U4 PSS 339 110 190 Unit O O O 21 U3 PROMISe Specialty Code 15 min 15 min 15 min 21 H0038 H0038 Prov PROMISe Provider Mod 3 Type Claim Type Prov Mod 2 Type Code Prov Mod 1 Level of Service Description Family Psychotherapy (without the patient present) Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class 076 Assessment & Assistance Assess & Assist TSS worker less than 6 months exp. H2014 U1 HA AAT* Page 3 of 23 VBH-PA HIPAA X_Walk Covered Services Grid 09 11 Assess & Assist TSS worker more than 6 months exp. Assess & Assist TSS worker more than 6 months exp. H2014 U1 31 19 08 H2014 11 08 09 548 548, 442, 446, or 450 548 548 808 548, 442, 446, or 450 800 or 804 548 TPL Exempt Unit Dx Class PROMISe Specialty Code Auth Req? Prov PROMISe Provider Mod 3 Type Claim Type Prov Mod 2 Type Code HA Prov Mod 1 Level of Service Description H2014 Provider Service Code Auth Type Assess & Assist TSS worker less than 6 months exp. Service Class AAT* 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class POS Timely Filing (Date of Service or Date of Discharge) 15 min O W P NA N 12, 99 PSY Y DOS 15 min O W P NA N 12, 99 PSY Y DOS 15 min 15 min 15 min O O O W W W P P P NA NA NA N N N 12, 99 12, 99 12, 99 PSY PSY PSY Y Y Y DOS DOS DOS 15 min 15 min 15 min O O O W W W P P P NA NA NA N N N 12, 99 12, 99 12, 99 PSY PSY PSY Y Y Y DOS DOS DOS PSY Y DOS PSY Y DOS PSY Y DOS PSY Y DOS PSY Y DOS PSY Y DOS PSY Y DOS PSY Y DOS PSY Y DOS PSY Y DOS PSY Y DOS PSY Y DOS PSY Y DOS PSY Family Based Services FB1** Team member w/Consumer Team member w/ Family of Consumer H0004 HE 11 115 15 min O W P NA Y H0004 UK 11 115 15 min O W P NA Y Team member w/Consumer Team member w/Family of Consumer Enhanced Family Based Team Member w/Consumer Team member w/Family and/or Consumer Enhanced Family Based Team Member w/Family Enhanced Family Based Team Member w/Family Enhanced Family Based Team w/Consumer Enhanced Family Based Team Member w/Collateral Enhanced Family Based Team w/Collateral H0004 U3 HE 11 115 15 min O W P NA Y H0004 U2 UK 11 115 15 min O W P NA Y H0004 UA 11 115 15 min O W P NA Y H0004 U5 HT 11 115 15 min O W P NA Y H0004 U6 U4 11 115 15 min O W P NA Y H0004 HA 11 115 15 min O W P NA Y H0004 UB 11 115 15 min O W P NA Y T1016 U4 11 115 15 min O W P NA Y T1016 U8 U4 11 115 15 min O W P NA Y Team member w/ Collateral T1016 UB UK 11 115 15 min O W P NA Y Team w/consumer &/or Family H0004 HT 11 115 15 min O W P NA Y Team w/ Collateral FAMILY BASED- CRISIS TEAM MEMBER W/ CONSUMER T1016 HT 11 115 15 min O W P NA Y Y DOS H0004 ET 11 115 15 min O W P NA Y 12,21,31,32,9 9 12,21,31,32,9 9 12,21,31,32,9 9 12,21,31,32,9 9 12,21,31,32,9 9 12,21,31,32,9 9 12,21,31,32,9 9 12,21,31,32,9 9 12,21,31,32,9 9 12,21,31,32,9 9 12,21,31,32,9 9 12,21,31,32,9 9 12,21,31,32,9 9 12,21,31,32,9 9 12,21,31,32,9 9 PSY Y DOS H0004 TJ 11 115 15 min O W P NA Y 12,21,31,32,9 9 PSY Y DOS Y 12,21,31,32,9 9 PSY Y DOS Y 12,21,31,32,9 9 PSY Y DOS Y DOS FAMILY BASED -CRISIS TEAM MEMBER/ FAMILY OF CONSUMBER FBC FAMILY BASED CRISIS TEAM MEMBER W/ COLLATERAL FAMILY BASED CRISIS TEAM W/CONSUMER &/OR FAMILY T1016 H0004 HS HR U4 11 11 115 115 15 min 15 min O O W W P P NA NA FAMILY BASED CRISIS TEAM W/ COLLATERAL T1016 TJ 11 115 15 min O W P NA Y 12,21,31,32,9 9 PSY BSP DXA BSU Diagnostic Assessment BSU Diagnostic Assessment 90791 H0031 U7 08 11 110 110 per event 15 min O O O O P P NA NA N N 11,12,99 99 PSY PSY Y Y DOS DOS SPA SCA Service Plan Assessment H0001 U5 11 184 15 min O O P, SA NA, DA N 99 SUB Y DOS 11 184 15 min O O P, SA NA, DA N 99 SUB Y DOS 11 184 15 min O O P, SA NA N 99 SUB Y DOS Base Service Unit Plan Assessments DAA Diagnostic Assessment - Level of Care Assessment Diagnostic Assessment-Level of Care Assessment (mobile) H0001 H0001 U4 Page 4 of 23 VBH-PA HIPAA X_Walk Covered Services Grid TPL Exempt Unit Dx Class PROMISe Specialty Code Auth Req? Prov PROMISe Provider Mod 3 Type Claim Type Prov Mod 2 Type Code Prov Mod 1 Level of Service Description Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class POS Timely Filing (Date of Service or Date of Discharge) Medication Mgt. OV/OP Visit for Evaluation & Management of New Patient, Problem Self Ltd or Minor, face to face with patient and/or family CoOccurring OV/OP Visit for Evaluation & Management of New Patient, Problem Low to Moderate, face to face w/ patient and/or family CoOccurring 99201 99202 OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate, face to face w/ patient and/or family Co-Occurring 99203 OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family CoOccurring OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family CoOccurring 99204 99205 OV/OP Visit for Evaluation & Management of Established Patient, Problem Self Ltd or Minor, face to face w/ patient and/or family Co-Occurring 99212 OV/OP Visit for Evaluation & Management of Established Patient, Problem Low to Moderate, face to face w/ patient and/or family Co-Occurring 99213 OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family Co-Occurring 99214 TG TG TG TG TG TG TG TG 08 110 10 min O O P NA Y 49 PSY N DOS 08 184 10 min O O SA NA Y 57 SUB N DOS 08 110 20 min O O P NA Y 49 PSY N DOS 08 184 20 min O O SA NA Y 57 SUB N DOS 08 110 30 min O O P NA Y 49 PSY N DOS 08 184 30 min O O SA NA Y 57 SUB N DOS 08 110 45 min O O P NA Y 49 PSY N DOS 08 184 45 min O O SA NA Y 57 SUB N DOS 08 110 60 min O O P NA Y 49 PSY N DOS 08 184 60 min O O SA NA Y 57 SUB N DOS 08 110 10 min O O P NA Y 49 PSY N DOS 08 184 10 min O O SA NA Y 57 SUB N DOS 08 110 15 min O O P NA Y 49 PSY N DOS 08 184 15 min O O SA NA Y 57 SUB N DOS 08 110 25 min O O P NA Y 49 PSY N DOS 08 184 25 min O O SA NA Y 57 SUB N DOS 08 110 40 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family Co-Occurring 99215 TG 08 184 40 min O O SA NA Y 57 SUB N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Self Ltd or Minor, face to face with patient and/or familyBuprenorphine Patient Only 99201 U6 08 184 10 min O O P, SA NA Y 57 PSY, SUB N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Self Ltd or Minor, face to face with patient and/or family Buprenorphine Patient Only 99202 U6 08 184 20 min O O P, SA NA Y 57 PSY, SUB N DOS Page 5 of 23 VBH-PA HIPAA X_Walk Covered Services Grid TPL Exempt Dx Class Auth Req? Timely Filing (Date of Service or Date of Discharge) Description Provider Service Code OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate, face to face w/ patient and/or family Buprenorphine Patient Only 99203 U6 08 184 30 min O O P, SA NA Y 57 PSY, SUB N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family Buprenorphine Patient Only 99204 U6 08 184 45 min O O P, SA NA Y 57 PSY, SUB N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family Buprenorphine Patient Only 99205 U6 08 184 60 min O O P, SA NA Y 57 PSY, SUB N DOS OV/OP Visit for Evaluation & Management of Established Patient, Problem Self Ltd or Minor, face to face w/ patient and/or family 99212 Buprenorphine Patient Only U6 08 184 10 min O O P, SA NA Y 57 PSY, SUB N DOS OV/OP Visit for Evaluation & Management of Established Patient, Problem Low to Moderate, face to face w/ patient and/or family 99213 Buprenorphine Patient Only U6 08 184 15 min O O P, SA NA Y 57 PSY, SUB N DOS OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family 99214 Buprenorphine Patient Only U6 08 184 25 min O O P, SA NA Y 57 PSY, SUB N DOS OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family 99215 Buprenorphine Patient Only U6 08 184 40 min O O P, SA NA Y 57 PSY, SUB N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Self Ltd or Minor, face to face with patient and/or family (signing psychiatrist) 99201 U5 08 110 10 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Low to Moderate, face to face w/ patient and/or family (signing psychiatrist) 99202 U5 08 110 20 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate, face to face w/ patient and/or family (signing psychiatrist) 99203 U5 08 110 30 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family (signing psychiatrist) 99204 U5 08 110 45 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family (signing psychiatrist) 99205 U5 08 110 60 min O O P NA Y 49 PSY N DOS RXM Page 6 of 23 PROMISe Specialty Code Claim Type Prov PROMISe Provider Mod 3 Type Type Code Prov Mod 2 Level of Service Prov Mod 1 Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class Unit POS VBH-PA HIPAA X_Walk Covered Services Grid RXM TPL Exempt Unit Dx Class PROMISe Specialty Code Auth Req? Prov PROMISe Provider Mod 3 Type Claim Type Prov Mod 2 Type Code Prov Mod 1 Level of Service Description Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class POS Timely Filing (Date of Service or Date of Discharge) OV/OP Visit for Evaluation & Management of Established Patient, Problem Self Ltd or Minor, face to face w/ patient and/or family 99212 (signing Psychiatrist) U5 08 110 10 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of Established Patient, Problem Low to Moderate, face to face w/ patient and/or family 99213 (signing Psychiatrist) U5 08 110 15 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family 99214 (signing Psychiatrist) U5 08 110 25 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family 99215 (signing Psychiatrist) U5 08 31 110 339 40 min O O O O P P NA NA Y Y 49 10 min 11 PSY N PSY, SUB N DOS DOS 08 110 10 min O O P NA Y 49 PSY N DOS 08 184 10 min O O SA NA Y 57 SUB N DOS 31 339 20 min O O P NA Y 11 PSY, SUB N DOS 08 110 20 min O O P NA Y 49 PSY N DOS 08 184 20 min O O SA NA Y 57 SUB N DOS 31 339 30 min O O P NA Y 11 PSY, SUB N DOS 08 110 30 min O O P NA Y 49 PSY N DOS 08 184 30 min O O SA NA Y 57 SUB N DOS 31 339 45 min O O P NA Y 11 PSY, SUB N DOS 08 110 O O P NA Y 49 PSY N DOS 08 184 45 min O O SA NA Y 57 SUB N DOS 31 339 60 min O O P NA Y 11 PSY, SUB N DOS 08 08 110 184 60 min O O O O P SA NA NA Y Y 49 57 PSY SUB N N DOS DOS 31 339 15 min O O P NA Y 11 PSY, SUB N DOS 08 110 15 min O O P NA Y 49 PSY N DOS 08 184 15 min O O SA NA Y 57 SUB N DOS 31 339 25 min O O P NA Y 11 PSY, SUB N DOS 08 110 25 min O O P NA Y 49 PSY N DOS 08 184 25 min O O SA NA Y 57 SUB N DOS 31 339 40 min O O P NA Y 11 PSY, SUB N DOS 08 110 40 min O O P NA Y 49 PSY N DOS 08 184 40 min O O SA NA Y 57 SUB N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Self Ltd or Minor, face to face with patient and/or family OV/OP Visit for Evaluation & Management of New Patient, Problem Low to Moderate, face to face w/ patient and/or family OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate, face to face w/ patient and/or family OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family 99201 99202 99203 99204 99205 OV/OP Visit for Evaluation & Management of Established Patient, Problem Low to Moderate, face to face w/ patient and/or family 99213 OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family 99214 OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family 99215 UB UB UB UB UB UB UB UB Page 7 of 23 VBH-PA HIPAA X_Walk Covered Services Grid OV/OP Visit for Evaluation & Management of Established Patient, Problem Self Ltd or Minor, face to face w/ patient and/or family 99212 Telepsychiatry OV/OP Visit for Evaluation & Management of Established Patient, Problem Self Ltd or Minor, face to face w/ patient and/or family 99212 Telepsychiatry OV/OP Visit for Evaluation & Management of Established Patient, Problem Low to Moderate, face to face w/ patient and/or family 99213 Telepsychiatry OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family Telepsychiatry OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family Telepsychiatry OV/OP Visit for Evaluation & Management of New Patient, Problem Self Ltd or Minor, face to face with patient and/or family 99214 99215 99201 Telepsychiatry OV/OP Visit for Evaluation & Management of New Patient, Problem Low to Moderate, face to face w/ patient and/or family 99202 Telepsychiatry OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate, face to face w/ patient and/or family 99203 Telepsychiatry OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family 99204 Telepsychiatry OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family 99205 Office or other OP Visit for the EM of an Established Patient 99211 Office Visit Established Patient (Nurse Medication Management) Telepsychiatry Office Visit Established Patient (Nurse Medication Management) UB GT GT GT GT GT GT GT GT TPL Exempt Dx Class POS 339 10 min O O P NA Y 11 PSY, SUB N DOS 08 110 10 min O O P NA Y 49 PSY N DOS 08 184 10 min O O SA NA Y 57 SUB N DOS 08 110 10 min O O P NA Y 49 PSY N DOS 08 184 10 min O O SA NA Y 57 SUB N DOS 08 110 15 min O O P NA Y 49 PSY N DOS 08 184 15 min O O SA NA Y 57 SUB N DOS PSY N DOS O O P NA Y 49 25 min O O SA NA Y 57 SUB N DOS 40 min O O P NA Y 49 PSY N DOS 184 40 min O O SA NA Y 57 SUB N DOS 110 10 min O O P NA Y 49 PSY N DOS 08 184 10 min O O SA NA Y 57 SUB N DOS 08 110 20 min O O P NA Y 49 PSY N DOS 08 08 184 110 20 min O O O O SA P NA NA Y Y 57 SUB PSY N N DOS DOS 08 08 184 110 30 min O O O O SA P NA NA Y Y 57 SUB PSY N N DOS DOS 08 08 184 110 45 min O O O O SA P, SA NA NA Y Y 57 SUB PSY N N DOS DOS 184 110 184 339 110 184 60 min O O O o O O P, SA P, SA P, SA P, SA P, SA P, SA NA NA NA NA NA NA Y Y Y Y Y Y 57 15 min 15 min 15 min O O O O O O 11 49 57 SUB PSY SUB PSY, SUB PSY SUB N N N N N N DOS DOS DOS DOS DOS DOS 110 15 min O O P, DA NA Y 49 PSY N DOS 08 110 08 184 08 110 08 08 99211 UB 99211 GT 08 HE Unit Timely Filing (Date of Service or Date of Discharge) 31 08 08 08 31 08 08 GT PROMISe Specialty Code Auth Req? Prov PROMISe Provider Mod 3 Type Claim Type Prov Mod 2 Type Code Prov Mod 1 Level of Service Description Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class Page 8 of 23 30 min 45 min 60 min Per Event per event 49 49 49 49 57 VBH-PA HIPAA X_Walk Covered Services Grid TPL Exempt Dx Class Auth Req? Unit Claim Type PROMISe Specialty Code Type Code Prov PROMISe Provider Mod 3 Type Level of Service Prov Mod 2 Timely Filing (Date of Service or Date of Discharge) Description Provider Service Code OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate, face to face w/ patient and/or family (Eating disorder/Merck Unit) 99203 TU 08 110 30 minutes O O P NA Y 49 Psy Sub N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family 99204 (Eating disorder/Merck Unit) TU 08 110 45 minutes O O P NA Y 49 Psy Sub N DOS 99205 TU 08 110 60 minutes O O P NA Y 49 Psy Sub N DOS 99213 TU 08 110 10 minutes O O P NA Y 49 Psy Sub N DOS 99214 TU 08 110 15 minutes O O P NA Y 49 Psy Sub N DOS 99215 TU 08 110 25 minutes O O P NA Y 49 Psy Sub N DOS 99212 TU 08 110 40 minutes O O P NA Y 49 Psy Sub N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family (Eating disorder/Merck Unit) OV/OP Visit for Evaluation & Management of Established Patient, Problem Self Ltd or Minor, face to face w/ patient and/or family (Eating disorder/Merck Unit) OV/OP Visit for Evaluation & Management of Established Patient, Problem Low to Moderate, face to face w/ patient and/or family (Eating disorder/Merck Unit) OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family (Eating disorder/Merck Unit) OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family (Eating disorder/Merck Unit) Prov Mod 1 Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class POS OV/OP Visit for Evaluation & Management of New Patient, Problem Self Ltd or Minor, face to face with patient and/or family Forensic 99201 HZ 08 110 10 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Low to Moderate, face to face w/ patient and/or family Forensic 99202 HZ 08 110 20 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate, face to face w/ patient and/or family Forensic 99203 HZ 08 110 30 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family Forensic 99204 HZ 08 110 45 min O O P NA Y 49 PSY N DOS RXF Page 9 of 23 VBH-PA HIPAA X_Walk Covered Services Grid RXF TPL Exempt Unit Dx Class PROMISe Specialty Code Auth Req? Prov PROMISe Provider Mod 3 Type Claim Type Prov Mod 2 Type Code OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family Forensic Prov Mod 1 Level of Service Description Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class POS Timely Filing (Date of Service or Date of Discharge) 99205 HZ 08 110 60 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of Established Patient, Problem Self Ltd or Minor, face to face w/ patient and/or family 99212 Forensic HZ 08 110 10 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of Established Patient, Problem Low to Moderate, face to face w/ patient and/or family 99213 Forensic HZ 08 110 15 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family 99214 Forensic HZ 08 110 25 min O O P NA Y 49 PSY N DOS OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family 99215 Forensic HZ 08 110 40 min O O P NA Y 49 PSY N DOS 31 08 08 08 08 19 339 110 184 110 184 190 per occurrence O O O O O O P, SA P, SA P, SA P, SA P, SA P, SA NA NA NA NA NA NA Y Y Y Y Y Y 11 per occurrence O O O O O O 11,12,99 12 11,12,99 PSY, SUB PSY, SUB PSY, SUB PSY, SUB PSY, SUB PSY, SUB N N N N N N DOS DOS DOS DOS DOS DOS 08 110 per occurrence O O P NA Y 11,12,99 PSY N DOS 08 110 per occurrence O O P NA Y 11,12,99 PSY N DOS 19 190 per occurrence O O P NA Y 11 PSY N DOS 11 112 per occurrence O O P NA Y 99 PSY N DOS 11 112 per occurrence O O P NA Y 99 PSY N DOS O O P NA Y 11,12,21,99 PSY N DOS O O SA NA Y 12 SUB N DOS PSY N DOS Evaluation Psychiatric diagnostic Evaluation with Medical Services EXM** 90792 Psychiatric Diagnostic Evaluation without Medical Services 90791 Telepsych Diagnostic Interview Therapist 90791 GT Telepsych Diagnostic Interview 90791 U1 Psychological Evaluation-Sex Offender Treatment 90791 AJ Victim Evaluation MD/DO Diagnostic Evaluation for Buprenorphine patients only Diagnostic Interview (Masters Level) EXF 90792 Psychiatric diagnostic Evaluation with Medical Services GT per occurrence 90791 ST 19 190 per occurrence 90791 HB 08 184 per occurrence 12, 49 12, 57 H0031 AJ 11 112 15 min O O P NA Y 99 Psychiatric Diagnostic Evaluation without Medical Services (Eating Disorder/Merck Unit) 90791 TU 08 110 per occurrence O O P NA Y 49 Psy, Sub N DOS Psychiatric diagnostic Evaluation with Medical Services (Eating disorder/Merck Unit) 90792 TU 08 110 per occurrence O O P NA Y 49 Psy, Sub N DOS 90791 HY 08 110 per occurrence O O P NA Y 12,49 PSY N DOS 90791 HZ 08 110 per occurrence O O P NA Y 12,49 PSY N DOS 080 visit O O P NA Y 12,21,31,32,5 0,72,99 PSY N DOS FORENSIC DIAGNOSTIC EVALUATION THERAPIST FORENSIC DIAGNOSTIC EVALUATION MD/DO Therapy Clinic Visit/Encounter, All-Inclusive HE 08 Page 10 of 23 VBH-PA HIPAA X_Walk Covered Services Grid TPL Exempt Dx Class Timely Filing (Date of Service or Date of Discharge) Clinic Visit/Encounter, All-Inclusive Individual Activity Therapy (Music Therapy) Group Activity Therapy (Music Therapy) T1015 HE 08 081 visit O O P NA Y N DOS G0176 UB 17 175 1 hour O O P NA Y 11 PSY Y DOS G0176 U3 90832 17 08 19 175 110 190 15 min 30 min 30 min O O O O O O P P P NA NA NA Y Y Y 11 Individual Psychotherapy PSY PSY PSY Y N N DOS DOS DOS Individual Psychotherapy (Trauma Focused Services) 90832 O O O O O O O O P P P P NA NA NA NA Y Y Y Y 11 99 90834 190 112 110 190 30 min 30 min Individual Psychotherapy 19 11 08 19 PSY PSY PSY PSY N N N N DOS DOS DOS DOS Individual Psychotherapy (Trauma Focused Services) 90834 60 min 60 min O O O O O O O O P P P P NA NA NA NA Y Y Y Y 11 99 90837 190 112 110 190 45 min 45 min Individual Psychotherapy 19 11 08 19 12, 49 11 PSY PSY PSY PSY N N N N DOS DOS DOS DOS ST ST Unit Auth Req? PROMISe Specialty Code Claim Type Prov PROMISe Provider Mod 3 Type Type Code Prov Mod 2 POS 12,21,31,32,5 0,72,99 PSY Individual Psychotherapy (Trauma Focused Services) Telepsych Individual Psychotherapy Telepsych Individual Psychotherapy Telepsych Individual Psychotherapy Individual Therapy Individual Therapy Individual Therapy Mobile Mental Health Treatment (MMHT) Individual Mobile Mental Health Treatment (MMHT) Individual Individual Psychotherapy, Interpreter Individual Psychotherapy, Interpreter Individual Psychotherapy, Interpreter OUT** Prov Mod 1 Level of Service Description Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class 45 min 45 min 12,49 11 12,49 11 90837 ST 19 11 190 112 60 min 60 min O O O O P P NA NA Y Y 11 99 PSY PSY N N DOS DOS 90832 GT 08 110 30 min O O P, SA NA Y 12,49 PSY N DOS 90834 GT 08 110 45 min O O P, SA NA Y 12,49 PSY N DOS O O O O O O O O P, SA P, SA P, SA P, SA NA NA, DA NA, DA NA, DA Y Y Y Y 12,49 12, 49 12, 49 12, 49 PSY PSY PSY PSY N N N N DOS DOS DOS DOS 90837 90832 90834 90837 GT U5 U5 U5 08 08 08 08 110 110 110 110 60 min 30 min 45 min 60 min 90832 U4 08 110 30 min O O P, SA NA Y 12, 49 PSY N DOS 90834 U4 08 110 45 min O O P, SA NA Y 12, 49 PSY N DOS O O P, SA NA, DA Y 12, 49 PSY N DOS O O P, SA NA, DA Y 12, 49 PSY N DOS 90832 U3 08 110 30 min 90834 U3 08 110 45 min 90837 U3 08 110 60 min O O P, SA NA, DA Y 12, 49 PSY N DOS Group Psychotherapy, Interpreter 90853 U4 UB 08 110 15 min O O P, SA NA, DA Y 49 PSY N DOS Family Psychotherapy, Interpreter UB 08 110 15 min O O P, SA NA, DA Y 12,49 PSY N DOS 90847 U4 Individual Psychotherapy, Interpreter, not covered by Medicare 90832 GX 08 110 30 min O O P, SA NA Y 12,49 PSY N DOS Individual Psychotherapy, Interpreter, not covered by Medicare 90834 GX 08 110 45 min O O P, SA NA Y 12,49 PSY N DOS Individual Psychotherapy, Interpreter, not covered by Medicare 90837 GX 08 110 60 min O O P, SA NA Y 12,49 PSY N DOS Group Psychotherapy, Interpreter, not covered by Medicare 90853 GX 08 110 15 min O O P, SA NA Y 49 PSY N DOS 90847 90832 90834 90837 GX U1 U1 U1 08 31 31 31 110 339 339 339 15 min 30 min 45 min 60 min O O O O O O O O P, SA P P P NA NA NA NA Y Y Y Y 12,49 11 11 11 PSY PSY PSY PSY N N N N DOS DOS DOS DOS 90832 AJ 11 112 30 min O O P, SA NA Y 99 PSY N DOS 90834 AJ 11 112 45 min O O P, SA NA Y 99 PSY N DOS 90837 AJ 11 112 60 min O O P, SA NA Y 99 PSY N DOS Family Psychotherapy, Interpreter, not covered by Medicare Individual Therapy MD Individual Therapy MD Individual Therapy MD Individual Psychotherapy (Masters Level) Individual Psychotherapy (Masters Level) Individual Psychotherapy (Masters Level) Page 11 of 23 VBH-PA HIPAA X_Walk Covered Services Grid Group Psychotherapy Group Therapy (Masters Level) 90853 90853 AJ Group Psychotherapy (Trauma Focused Services) Family Psychotherapy 90853 90847 ST U1 Family Psychotherapy 90847 Family Psychotherapy Family Psychotherapy (Masters Level) OPR 08 19 110 190 PSY PSY PSY PSY PSY PSY PSY N N N N N N N Y Y 11,12,15,49,9 9 PSY 11 PSY N N DOS DOS Y 11,12,15,49,9 9 PSY N DOS 15 min 15 min 15 min O O O O O O O O O O O O O O P, SA P P P, SA P, SA P P, SA NA NA NA NA NA NA NA Y Y Y Y Y Y Y 15 min 15 min O O O O P P NA NA 15 min 15 min 15 min 90847 08 080 15 min 112 15 min O O P NA TPL Exempt Unit 15 min Timely Filing (Date of Service or Date of Discharge) DOS DOS DOS DOS DOS DOS DOS POS 11 49 11 99 11 99 11 Dx Class PROMISe Specialty Code 339 110 190 112 190 112 339 Auth Req? Prov PROMISe Provider Mod 3 Type 31 08 19 11 19 11 31 Claim Type Prov Mod 2 Type Code Prov Mod 1 U1 Level of Service Description Group Psychotherapy Provider Service Code 90853 Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class 90847 AJ 11 Family Psychotherapy (Trauma Focused Services) 90847 ST 19 11 190 112 15 min 15 min O O O O O O P, SA P, SA P NA NA NA Y Y Y 99 11 99 PSY PSY PSY N N N DOS DOS DOS Individual Psychotherapy (Eating disorder/Merck Unit) 90832 TU 08 110 30 min O O P NA Y 12, 49 PSY N DOS Individual Psychotherapy (Eating disorder/Merck Unit) 90834 TU 08 110 45 min O O P NA Y 12, 49 PSY N DOS Individual Psychotherapy (Eating disorder/Merck Unit) 90837 TU 08 110 60 min O O P NA Y 12, 49 PSY N DOS Group Psychotherapy (Eating disorder/Merck Unit) 90853 TU 08 110 15 min O O P NA Y 12, 49 PSY N DOS Family Psychotherapy (Eating disorder/Merck Unit) 90847 TU 08 110 15 min O O P NA Y 12, 49 PSY N DOS DA Individual Psychotherapy 90832 HF 30 min 30 min 90834 HF DA Individual Psychotherapy 90837 HF 15 min 15 min O O O O O O O O O O O O O O O O O O O O SA SA SA SA SA SA SA SA SA SA NA NA NA NA NA NA NA NA NA NA Y Y Y Y Y Y Y Y Y Y 11 12.57 DA Individual Psychotherapy 339 184 339 184 339 184 339 184 339 184 11 12.57 SUB SUB SUB SUB SUB SUB SUB SUB SUB SUB N N N N N N N N N N DOS DOS DOS DOS DOS DOS DOS DOS DOS DOS DA Group Psychotherapy 90853 HF DA Family Psychotherapy Evaluation Drug & Alcohol Intervention Services Drug & Alcohol Intervention Services Nurse Coordination with PCP 90847 HF 31 08 31 08 31 08 31 08 31 08 H0022 U5 11 184 Per Event O O SA NA Y 99 SUB Y DOS H0022 H0047 U4 U4 11 11 184 184 Per Event 15 min O O O O SA SA NA NA Y Y 99 12.57 SUB SUB Y Y DOS DOS 90792 U8 08 110 Per Occ O O P NA N 49 Psy, Sub N DOS 99201 U8 08 110 10 min O O P NA N 49 Psy N DOS U8 08 110 20 min O O P NA N 49 Psy N DOS Urgent Care Psychiatric Diagnostic Evaluation with Medical Services Urgent Care OV/OP Visit for Evaluation & Management of New Patient, Problem Self Ltd or Minor, face to face with patient and/or family Urgent Care OV/OP Visit for Evaluation & Management of New Patient, Problem Low to Moderate, face to face w/ patient and/or family 99202 Page 12 of 23 45 min 45 min 60 min 60 min 15 min 15 min 11 12.57 11 12.57 11 12.57 VBH-PA HIPAA X_Walk Covered Services Grid EMC DAL TPL Exempt Dx Class Auth Req? Unit Claim Type PROMISe Specialty Code POS Timely Filing (Date of Service or Date of Discharge) 99203 U8 08 110 30 min O O P NA N 49 Psy N DOS Urgent Care OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family 99204 U8 08 110 45 min O O P NA N 49 Psy N DOS Urgent Care OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate to High, face to face w/ patient and/or family 99205 U8 08 110 60 min O O P NA N 49 Psy N DOS Urgent Care OV/OP Visit for Evaluation & Management of Established Patient, Problem Low to Moderate, face to face w/ patient and/or family 99213 U8 08 110 15 min O O P NA N 49 Psy N DOS Urgent Care OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family 99214 U8 08 110 25 min O O P NA N 49 Psy N DOS Urgent Care OV/OP Visit for Evaluation & Management of Established Patient, Problem Moderate to High, face to face w/ patient and/or family 99215 U8 08 110 40 min O O P NA N 49 Psy n DOS H0047 HA 11 184 15 min O O SA NA Y 03, 99 SUB Y DOS H0047 U5 11 184 15 min O O SA NA Y 03, 99 SUB Y DOS DA OP in an Alternative Setting Individual DA OP in an Alternative Setting Group Co-Occurring Individual Therapy 90832 90834 TG TG 08 110 08 184 08 110 08 184 08 COT Co-Occurring Individual Therapy Co-Occurring Group Therapy DRS Prov PROMISe Provider Mod 3 Type Urgent Care OV/OP Visit for Evaluation & Management of New Patient, Problem Moderate, face to face w/ patient and/or family Co-Occurring Individual Therapy PAS Prov Mod 2 Type Code Prov Mod 1 Level of Service Description Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class Co-Occurring Family Therapy PASS Program week 1 & 2 PASS Program DA Recovery Specialist 90837 90853 90847 H0004 H0004 H0047 TG TG TG UC AJ U6 45 min 110 08 184 08 110 08 184 08 110 08 11 11 11 184 112 112 184 Page 13 of 23 30 min 60 min 15 min 15 min 15 min 15 min 15 min O O P, SA NA Y O O P, SA NA Y O O P, SA NA Y O O P, SA NA Y O O P, SA NA Y O O P, SA NA Y O O P, SA NA Y O O P, SA NA Y O O P, SA NA Y O O O O O O O O P, SA P P SA NA NA NA NA Y Y Y N 11,12,15,49,5 9,99 PSY, SUB N 11,12,15,49,5 9,99 PSY, SUB N 11,12,15,49,5 9,99 PSY, SUB N 11,12,15,49,5 9,99 PSY, SUB N 11,12,15,49,5 9,99 PSY, SUB N 11,12,15,49,5 9,99 PSY, SUB N 11,12,15,49,5 9,99 PSY, SUB N 11,12,15,49,5 9,99 PSY, SUB N 11,12,15,49,5 9,99 PSY, SUB 11,12,15,49,5 9,99 PSY, SUB 99 PSY 99 PSY 99 SUB DOS DOS DOS DOS DOS DOS DOS DOS N DOS N Y Y Y DOS DOS DOS DOS VBH-PA HIPAA X_Walk Covered Services Grid DCC MMH PCT OS1 MDF OS2 OPM OPF TPL Exempt O O SA SA NA NA N N POS 99 99 SUB SUB Y Y Dx Class O O Timely Filing (Date of Service or Date of Discharge) DOS DOS 90791 HW 08 110 per occurrence O O P NA Y 15 PSY Y DOS 90832 HW 08 110 30 min O O P NA Y 15 PSY Y DOS 90834 HW 08 110 45 min O O P NA Y 15 PSY Y DOS 08 08 110 110 60 min PSY PSY Y N DOS DOS 190 110 190 110 190 110 190 110 190 30 min N N N N N N N N N DOS DOS DOS DOS DOS DOS DOS DOS DOS 90837 HW INDIVIDUAL THERAPY PARENTCHILD INTERACTION THERAPY (PCIT) INDIVIDUAL THERAPY PARENT- 90832 HR CHILD INTERACTION THERAPY (PCIT) INDIVIDUAL THERAPY PARENT- 90834 HR CHILD INTERACTION THERAPY (PCIT) THERAPY PARENTFAMILY 90837 HR CHILD INTERACTION THERAPY (PCIT) THERAPY PARENTGROUP 90847 HR 90853 HR 19 08 19 08 19 08 19 08 19 CHILD INTERACTION THERAPY (PCIT) INDIVIDUAL THERAPY PARENTCHILD INTERACTION THERAPY (PCIT) PROMISe Specialty Code Unit 184 15 min 184 15 min Auth Req? Prov PROMISe Provider Mod 3 Type 11 11 Claim Type Prov Mod 2 Type Code Prov Mod 1 HQ U7 Level of Service Description DA Recovery Group DA Case Coordination Mobile Mental Health Diagnostic Interview Mobile Mental Health Individual Therapy Mobile Mental Health Individual Therapy Mobile Mental Health Individual Therapy Provider Service Code H0047 H0047 Auth Type Service Class DRS 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class O O O O P P NA NA Y N 15 O O O O O O O O O P P P P P P P P P NA NA NA NA NA NA NA NA NA N N N N N N N N N 11,49 15 MIN O O O O O O O O O 12,49 11,49 PSY PSY PSY PSY PSY PSY PSY PSY PSY 30 min 45 min 60 min 15 MIN 12,49 12,49 11,49 12,49 11,49 12,49 11,49 90832 HR 11 112 30 min O O P NA N 99 PSY N DOS INDIVIDUAL THERAPY PARENTCHILD INTERACTION THERAPY (PCIT) 90834 HR 11 112 45 min O O P NA N 99 PSY N DOS INDIVIDUAL THERAPY PARENTCHILD INTERACTION THERAPY (PCIT) 90837 HR 11 112 60 min O O P NA N 99 PSY N DOS FAMILY THERAPY PARENTCHILD INTERACTION THERAPY (PCIT) 90847 HR 11 112 15 MIN O O P NA N 99 PSY N DOS 90853 HR 11 112 15 MIN O O P NA N 99 PSY N DOS 90847 UB 08 184 15 min O O SA NA, DA N 99 SUB N DOS H0047 HW 11 184 15 min O O SA NA Y 99 SUB Y DOS H0047 U3 11 184 Weekly O O SA NA, DA Y 99 SUB N DOS 90791 HE 08 110 per occurrence O O P NA Y 11,15 PSY Y DOS 90791 TS 08 110 per occurrence O O P NA Y 11,15 PSY Y DOS 90832 HE 08 110 30 min O O P NA Y 11,15 PSY Y DOS 90834 HE 08 110 45 min O O P NA Y 11,15 PSY Y DOS 90837 HE 08 110 60 min O O P NA Y 11,15 PSY Y DOS Forensic Individual Therapy 90832 HZ 08 110 30 min O O P NA Y 11, 12, 49, 99 PSY N DOS Forensic Individual Therapy 90834 HZ 08 110 45 min O O P NA Y 11, 12, 49, 99 PSY N DOS Forensic Individual Therapy 90837 HZ 08 110 60 min O O P NA Y 11, 12, 49, 99 PSY N DOS Forensic Group Therapy 90835 HZ 08 110 15 MIN O O P NA Y 11, 12, 49, 99 PSY N DOS Forensic Family Therapy 90847 HZ 08 110 15 MIN O O P NA Y 11, 12, 49, 99 PSY N DOS 19 190 per occurrence O O P NA N 11,12,21,99 PSY N DOS SE 11 112 per occurrence SE 190 112 30 min 30 min O O O P P P NA NA NA N N N 99 19 11 O O O PSY PSY PSY N N N DOS DOS DOS GROUP THERAPY PARENTCHILD INTERACTION THERAPY (PCIT) Alcohol and/or other drug abuse service, not otherwise specified Mobile Drug & Alcohol Family Therapy Alcohol and/or other drug abuse service, not otherwise specified Expedited Evaluation - MD (Mobile Adult Outpatient) Intake Evaluation (Mobile Adult Outpatient) Individual Therapy (Mobile Adult Outpatient) Individual Therapy (Mobile Adult Outpatient) Individual Therapy (Mobile Adult Outpatient) Psychological Evaluation (Sex Offender Assessment, including Testing & Clinical Interview) Individual Therapy- Sex Offender Treatment 90791 90832 SXE Page 14 of 23 11 99 VBH-PA HIPAA X_Walk Covered Services Grid SXE Individual Therapy- Sex Offender Treatment Individual Therapy- Sex Offender Treatment 90834 90837 SE SE 19 11 190 112 60 min 60 min 19 11 190 112 15 min 15 min 19 11 190 112 15 min 15 min 19 190 08 110 Group Therapy- Sex Offender Treatment 90853 SE Family Therapy- Sex Offender Treatment Psych Testing 90847 96101 SE SE Clozaril Monitor & Eval H0034 HK O O O O P P NA NA N N 11 99 TPL Exempt POS 11 99 PSY PSY N N Timely Filing (Date of Service or Date of Discharge) DOS DOS PSY PSY PSY N N N DOS DOS DOS PSY PSY N N DOS DOS Dx Class PROMISe Specialty Code Unit 190 30 min 112 30 min Auth Req? Prov PROMISe Provider Mod 3 Type 19 11 Claim Type Prov Mod 2 Type Code Prov Mod 1 Level of Service Description Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class O O O O O O P P P NA NA NA N N N 30 min O O O O P P NA NA N N 15 min O O P NA Y 11, 12, 22, 50,72, 99, 49 PSY Y DOS Y DOS 11 99 11 99 11,12,21,99 Clozapine Support CME Clozaril Monitor & Eval by MD/DO H0034 U1 08 110 15 min O O P NA Y 11, 12, 22, 50,72, 99, 49 PSY Clozapine Support Serv H2010 U1 31 339 15 min O O P NA Y 11, 12, 22, 50,72, 99, 49 PSY Y DOS Clozapine Support Serv Clozapine Support H2010 H2010 HK U4 08, 11 08 110, 113/114 110 15 min 15 min O P O O P P NA NA Y Y 11, 12, 22, 50,72, 99, 49 PSY 52, 99 PSY Y Y DOS DOD 08 110 30 min O O P NA Y 12,49 PSY N DOS Psychological Testing 96101 19 190 30 min O O P NA Y 11,12,21 PSY N DOS Psychological Testing 96101 31 08 339 110 30 min O O P NA Y 11,21 PSY N DOS 19 31 190 30 min 30 min O O O O P P NA NA Y Y 11,12,21 339 11, 21 PSY PSY N N DOS DOS 01 08 010 110 1x 1tx O O O O P, SA P, SA NA, DA NA, DA Y Y 22 49 PSY, SUB N PSY, SUB N DOS DOS 31 1 tx occur occur occur O I I I O O I I I O P, SA PP PP PP P, SA NA, DA IP IP IP NA, DA Y Y Y Y N 11,21,99 01 31 339 010 011 022 339 11,21,99 PSY, SUB PSY PSY PSY PSY, SUB N N N N N DOS DOD DOD DOD DOS 08 110 per occurrence O W P, SA NA Y 11,12,99, PSY N DOS 19 190 per occurrence O W P, SA NA Y 11,12,21,99 PSY N DOS 11 113 per occurrence O W P, SA NA Y 11,12,99 PSY N DOS 11 114 per occurrence O W P, SA NA Y 11,12,99 PSY N DOS 08 19 15 min 15 min O O W W P, SA P, SA NA, DA NA, DA Y Y 12,23,99 12,23,99 PSY PSY Y Y DOS DOS 11 09 800, 804, or 808 548 548,442, 446,450 548 15 min 15 min O O W W P, SA P, SA NA, DA NA, DA Y Y 12,23,99 12,23,99 PSY PSY Y Y DOS DOS 31 548 PSY Y DOS PSY Y DOS CS1 CS2 PRC Testing TS1 Neuropsychological Testing Neuropsychological Testing 96118 96118 ECT Therapy/single seizure ECT Therapy/single seizure/physician services 90870 U1 U1 30 min 12,49 Electroconvulsive Therapy EC1** EC2** IET ANE ECT/Inpt Anesthesia 90870 0901 00104 AM U1 21 21 21 Behavioral Health Rehabilitative Services (BHRS) Physician Wraparound Y96** CCASBE Psychological or Psychiatric Re-Evaluation (child/adolescent) YT1** TSS TSS 90791 H2021 H2021 UC EP EP U1 08 TSS, Interpreter U5 Page 15 of 23 15 min O W P, SA NA, DA Y 12,23,99 800, 804, or 808 15 min O W P, SA NA, DA Y 12,23,99 VBH-PA HIPAA X_Walk Covered Services Grid 091416 19 TSS, Interpreter YT2 H2021 11 09 U5 YT3 YT5 YT6 548 548,442, 446,450 548 TPL Exempt Unit POS Timely Filing (Date of Service or Date of Discharge) 15 min O W P, SA NA, DA Y 12,23,99 PSY Y DOS 15 min 15 min O O W W P, SA P, SA NA, DA NA, DA Y Y 12,23,99 12,23,99 PSY PSY Y Y DOS DOS 800, 804, or 808 15 min O W P, SA NA, DA Y 03 PSY Y DOS Physician Wraparound-TSS (Authorization purposes only) 08 YT4 PROMISe Specialty Code Dx Class Prov PROMISe Provider Mod 3 Type Auth Req? Description Prov Mod 2 Claim Type Service Class Prov Mod 1 Type Code Auth Type YT1** Provider Service Code Level of Service >=2013 Billed by Provider ** Codes interchangeable within the service class TSS in School TSS in School (Authorization purposes only) School - Act 62 (Authorization purposes only) Home & Community - Act 62 (Authorization purposes only) H2021 U3 19 548 15 min O W P, SA NA, DA Y 03 PSY Y DOS 11 548,442, 446,450 15 min O W P, SA NA, DA Y 03 PSY Y DOS 09 548 15 min O W P, SA NA, DA Y 03 PSY Y DOS 08 110 per occurrence O W P,SA NA, DA Y 11,12,99 PSY Y DOS 19 190 per occurrence O W P,SA NA, DA Y 11,12,21,99 PSY Y DOS 11 113 per occurrence O W P,SA NA, DA Y 11,12,99 PSY Y DOS 11 114 per occurrence O W P, SA NA, DA Y 11,12,99 PSY Y DOS ITM Interagency Service Planning Team Mtg 98966 TXS AEV CMP CCASBE Psychological or Psychiatric Evaluation (Child/Adolecent) (Independent Evaluator) 90791 U4 19 190 per occurrence O W P, SA NA, DA Y 11,12,21,99 PSY N DOS CCASBE Psychological or Psychiatric Evaluation in the school (Child/Adolescent) Independent Evalautor 90791 AH 19 190 per occurrence O W P, SA NA, DA Y 11,12,21,99 PSY N DOS CCASBE Addenudum to Evaluation 90791 U5 08 08 11 08 11 110 803 or 807, 811 445,449,or 453 per occurrence 803 or 807, 811 445,449,or 453 O O O O O W W W W W P, SA P,SA P, SA P,SA P, SA NA, DA NA NA NA NA Y Y Y Y Y 11,12,99 15 min 15 min 15 min 15 min PSY PSY, SUB PSY, SUB PSY, SUB PSY, SUB Y Y Y Y Y DOD DOS DOS DOS DOS 08 11 08 11 08 11 340 340 340 340 340 340 Weekly Weekly 15 min 15 min 15 min 15 min O O O O O O W W W W O O P P P P P P NA NA NA NA NA NA N N Y Y Y Y 12,99 12,99 PSY PSY PSY PSY PSY PSY Y Y Y Y Y (S8) Y (S8) DOS DOS DOS DOS DOS DOS 31 08 08 19 559 802 or 806 810 559 559,444,448. or 452 559 15 min 15 min 15 min 15 min O O O O W W W W P, SA P, SA P, SA P, SA NA, DA NA, DA NA, DA NA, DA Y Y Y Y 11,12,23,99 PSY PSY PSY PSY Y Y Y Y DOS DOS DOS DOS 15 min 15 min 15 min 15 min 15 min O O O O O W W W W W P, SA P, SA P, SA P, SA P, SA NA, DA NA, DA NA, DA NA, DA NA, DA Y Y Y Y Y 11,12,23,99 11,12,23,99 12,23,50,99 11,12,23,99 11,12,23,99 PSY PSY PSY PSY PSY Y Y Y Y Y DOS DOS DOS DOS DOS 15 min 15 min O O W W P, SA P, SA NA, DA NA, DA Y Y 11,12,23,99 11,12,23,99 PSY PSY Y Y DOS DOS Summer Therapeutic Activities Program (STAP) H2015 U4 Summer Therapeutic Activities Program (STAP) H2015 HA Multi-Systemic Therapy H2033 U4 Multi-Systemic Therapy H2033 U5 Multi-Systemic Therapy H2033 Behavioral Specialist Consultant (Doctoral Level) H0032 99 99 99 99 MST MS1 MS2 MS5 12,99 12,99 12, 99 12, 99 BHRS Services Behavioral Specialist Consultant (Doctoral Level) H0032 HP HP U1 11 09 08 08 19 Behavioral Specialist Consultant, (Doctoral Level) Interpreter H0032 U5 11 09 BS1** Page 16 of 23 802 or 806 810 559 559,444,448. or 452 559 12,23,50,99 11,12,23,99 11,12,23,99 VBH-PA HIPAA X_Walk Covered Services Grid BS1** Behavioral Specialist Consultant (Master's Level) Behavior Specialist Consultant for Children with Autism Spectrum Disorder BSC-ASD-Doctoral level Behavior Specialist Consultant for children with Autism Spectrum Disorder BSC-ASD-Masters Level ExACT (Doctoral Level) H0032 H0032 H0046 H0046 H0032 HO H0032 15 min 15 min O O O O O O W W W W W W P, SA P, SA P, SA P, SA P, SA P, SA NA, DA NA, DA NA, DA NA, DA NA, DA NA, DA Y Y Y Y 11,12,23,99 Y Y 11,12,23,99 11,12,23,99 11,12,23,50,7 2,99 11,12,23,99 11,12,23,99 11,12,23,99 12,23,72,99 11,12,23,99 11,12,23,99 TPL Exempt PSY PSY Y Y DOS DOS PSY Y DOS PSY PSY Y Y DOS DOS PSY PSY PSY PSY Y Y Y Y DOS DOS DOS DOS PSY PSY PSY PSY PSY PSY PSY Y Y Y Y Y Y Y DOS DOS DOS DOS DOS DOS DOS PSY PSY PSY Y Y Y DOS DOS DOS PSY Y DOS HP 15 min 15 min 15 min 15 min O O O O W W W W P, SA P, SA P, SA P, SA NA, DA NA, DA NA, DA NA, DA Y Y Y Y HO 08 19 11 31 558 558 558 558 08 08 19 802 or 806 810 559 559,444,448. or 452 559 15 min 15 min 15 min 15 min 15 min 15 min 15 min O O O O O O O W W W W W W W P, SA P, SA P, SA P, SA P, SA P, SA P, SA NA, DA NA, DA NA, DA NA, DA NA, DA NA, DA NA, DA Y Y Y Y Y Y Y 15 min 15 min 15 min 15 min 15 min O O O O O W W W W W P, SA P, SA P, SA P, SA P, SA NA, DA NA, DA NA, DA NA, DA NA, DA Y Y Y Y Y 11,12,23,99 11,12,23,99 15 min 15 min O O W W P, SA P, SA NA, DA NA, DA Y Y 11,12,23,99 11,12,23,99 PSY PSY Y Y DOS DOS 15 min 15 min 15 min O O O W W W P, SA P, SA P, SA NA, DA NA, DA NA, DA Y Y Y 12,23,50,99 11,12,23,99 11,12,23,99 PSY PSY PSY Y Y Y DOS DOS DOS 11 09 802 or 806 810 559 559,444,448. or 452 559 15 min 15 min O O W W P, SA P, SA NA, DA NA, DA Y Y 11,12,23,99 11,12,23,99 PSY PSY Y Y DOS DOS 31 08 08 559 802 or 806 810 15 min 15 min 15 min O O O W W W P, SA P, SA P, SA NA, DA NA, DA NA, DA Y Y Y 11,12,23,99 PSY PSY Y Y DOS DOS 19 559 15 min O W P, SA NA, DA Y 11,12,23,99 PSY Y DOS 15 min 15 min O O W W P, SA P, SA NA, DA NA, DA Y Y 11,12,23,99 11,12,23,99 PSY PSY Y Y DOS DOS U7 11 09 U8 11 09 802 or 806 810 559 559,444,448. or 452 559 11,12,23,50,7 2,99 11,12,23,99 11,12,23,99 11,12,23,99 12,23,50,99 11,12,23,99 11,12,23,99 12,23,72,99 11,12,23,99 11,12,23,99 BHRS Services - BSC 08 08 19 Functional Behavioral Assessment (FBA) BSC Doctoral Level H0032 U4 Functional Behavioral Assessment (FBA) BSC Doctoral level H0032 U4 FBA ASX 15 min 15 min 15 min 15 min 558 558 558 558 08 08 19 ExACT (Masters Level) BS2 11 09 559 802 or 806 810 559 559,444,448. or 452 559 POS Timely Filing (Date of Service or Date of Discharge) 08 19 11 31 EAC auth place holder 31 08 08 19 Unit Dx Class U1 PROMISe Specialty Code Auth Req? HO Prov PROMISe Provider Mod 3 Type Claim Type Prov Mod 2 Type Code Prov Mod 1 Level of Service Description Behavioral Specialist Consultant (Master's Level) Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class 12,23,72,99 11,12,23,99 Functional Behavioral Assessment (FBA) BSC Masters Level H0032 U6 11 09 559,444,448. or 452 559 Functional Behavioral Assessment (FBA) BSC Masters level H0032 U6 31 559 340 15 min 15 min O O W W P, SA P NA NA Y Y 11,12,23,99 08 12,99 PSY PSY Y Y DOS DOS 11 340 15 min O W P NA Y 12,99 PSY Y DOS 31 08 19 549 801,805, or 809 549 549,443,447, or 451 559 15 min 15 min 15 min O O O W W W P, SA P, SA P, SA NA, DA NA, DA NA, DA Y Y Y 12,99 PSY PSY PSY Y Y Y DOS DOS DOS 15 min 15 min 801,805, or 809 15 min 549 15 min O O O O W W W W P, SA P, SA P, SA P, SA NA, DA NA, DA NA, DA NA, DA Y Y Y Y 12,99 12,99 PSY PSY PSY PSY Y Y Y Y DOS DOS DOS DOS Comprehensive Community Support Svcs (After School Program) H2015 Therapeutic Behavioral Services MT (Licensed) H2019 Mobile BHRS Services Therapeutic Behavioral Svcs MT (Licensed) U1 11 09 H2019 08 19 MT1** Therapeutic Behavioral Svcs MT, Interpreter U5 Page 17 of 23 12,99 12,99 12,99 12,99 VBH-PA HIPAA X_Walk Covered Services Grid Therapeutic Behavioral Svcs MT, Interpreter Therapeutic Behavioral Svcs MT (Non-licensed) Therapeutic Behavioral Svcs MT (Non-licensed) auth purposes only MT2 H2019 U5 H2019 U4 H2019 11 09 U1 31 08 19 11 09 U4 Targeted/Enhanced Non Licensed Masters Level MT H2019 11 09 HO 08 19 Targeted/Enhanced Licensed Masters Level MT H2019 11 09 UB 08 19 TPL Exempt Dx Class P, SA P, SA NA, DA NA, DA Y Y 12,99 12,99 PSY PSY Y Y DOS DOS 549 801,805, or 809 549 549,443,447, or 451 559 15 min 15 min 15 min O O O W W W P, SA P, SA P, SA NA, DA NA, DA NA, DA Y Y Y 12,99 12,99 12,99 PSY PSY PSY Y Y Y DOS DOS DOS 15 min 15 min O O W W P, SA P, SA NA, DA NA, DA Y Y 12,99 12,99 PSY PSY Y Y DOS DOS 801,805, or 809 549 549,443,447, or 451 559 15 min 15 min O O W W P, SA P, SA NA, DA NA, DA Y Y 12,99 12,99 PSY PSY Y Y DOS DOS DOS 15 min 15 min 801,805, or 809 15 min 549 15 min 549,443,447, or 451 15 min 559 15 min 801,805, or 809 15 min 549 15 min 549,443,447, or 451 15 min 559 15 min O O O O W W W W P, SA P, SA P, SA P, SA NA, DA NA, DA NA, DA NA, DA Y Y Y Y 12,99 12,99 PSY PSY PSY PSY Y Y Y Y DOS DOS DOS DOS O O O O W W W W P, SA P, SA P, SA P, SA NA, DA NA, DA NA, DA NA, DA Y Y Y Y 12,99 12,99 12,99 12,99 PSY PSY PSY PSY Y Y Y Y DOS DOS DOS DOS O O W W P, SA P, SA NA, DA NA, DA Y Y 12,99 12,99 PSY PSY Y Y DOS DOS 12, 99 12, 99 PSY PSY Y Y DOS DOS 11 09 After School Program for Youth with ASD H2015 SC 08 11 340 340 15 min 15 min O O W W P P NA NA Y Y Therapeutic Behavioral Services (SBBH-Master's Level Individual Therapy) SC 08 11 08 340 340 340 15 min 15 min 15 min O O O P P P NA NA NA NA NA NA Y Y 11 08 340 340 15 min 15 min O O P P NA NA NA NA Y 11 08 340 340 15 min 15 min O O P P NA NA NA NA Y 11 340 15 min O P NA 08 340 15 min O P 11 340 15 min O 08 340 15 min HQ 11 340 52 Therapeutic Behavioral Services (SBBH-Master's Level Group Therapy) Community-based Wraparound Svcs (SBBH- Bachelor's Level Individual Svcs) PEP W W UA H2019 H2019 H2021 Community Baed Wraparound Svcs (SBBH-Bachelor's Level Group Svcs) H2021 School Based Program Individual H0046 TJ HA SC TJ TJ School Based Program Group H0046 GRC Group Home R &B H0019 U3 GRT Tx Services Chd & Adol/Group Home -- -- Host Home Therapeutic Foster Care (TX only) Licensed Adult Psych Partial Hosp/Adult Licensed Adult Psych Partial Hosp/Child Psych Partial/Non-covered Medicare/Adult Enhanced School Based Partial Level 1 H0019 U5 H0035 HQ Timely Filing (Date of Service or Date of Discharge) O O H2019 Targeted/Enhanced Licensed Psychologist Level MT ASC POS BHRS Services - Mobile Therapy 08 19 TMT PROMISe Specialty Code Unit 549,443,447, or 451 15 min 559 15 min Auth Req? Prov PROMISe Provider Mod 3 Type Claim Type Prov Mod 2 Type Code Prov Mod 1 Level of Service Description Provider Service Code Auth Type Service Class MT1** 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class 12,99 12,99 99 PSY 99 PSY 99 PSY Y Y Y DOS DOS DOS 99 PSY 99 PSY Y Y DOS DOS Y 99 PSY 99 PSY Y Y DOS DOS NA Y 99 PSY Y DOS NA NA Y 99 PSY Y DOS P NA NA Y 99 PSY Y DOS O P NA NA Y 99 PSY Y DOS 15 min O P NA NA Y 99 PSY Y DOS 523 per diem O W P, SA NA Y 12, 99, 49 PSY Y DOS 52 523 per diem O W P, SA NA, DA Y 12, 99, 49 PSY Y DOS 11 114 1 hour P O P NA Y 52 PSY N DOS O P NA Y 52 Y Y H0035 HA 11 114 1 hour P PSY N DOS H0035 U2 11 114 1 hour P O P NA Y 52 PSY Y DOS H0035 U7 11 113 1 hour P O P NA Y 52 PSY Y DOS PRT** Page 18 of 23 VBH-PA HIPAA X_Walk Covered Services Grid PRT** APH NPH COO APD DAP TPL Exempt Unit Dx Class PROMISe Specialty Code Auth Req? Prov PROMISe Provider Mod 3 Type Claim Type Prov Mod 2 Type Code Prov Mod 1 Level of Service Description Enhanced School Based Partial Level 2 Psych Partial/Non-covered Medicare/Child (0-14) Licensed Child Psych Partial Hosp/Adult Licensed Child Psych Partial Hosp/Child Licensed Child Psych Partial Hosp/Child (15 to 20 yrs) Adult Acute Partial Adult Acute Partial (Non-covered Medicare) Child/Adol Acute Partial (Noncovered Medicare) Sleep Over Partial Acute Partial Non-Covered Acute Partial Acute Partial Hospitalization CoOccurring Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class POS Timely Filing (Date of Service or Date of Discharge) H0035 U8 11 113 1 hour P O P NA Y 52 PSY, SUB Y DOS H0035 U4 11 113 1 hour P O P NA Y 52 PSY Y DOS H0035 HB UA 11 113 1 hour P O P NA Y 52 PSY N DOS H0035 UB UA 11 113 1 hour P O P NA Y 52 PSY N DOS H0035 H0035 UA U5 11 11 113 114 1 hour 1 hour P P O P P P NA NA Y Y 52 52 PSY PSY N N DOS DOS H0035 U3 11 114 1 hour P P P NA Y 52 PSY Y DOS H0035 H0035 H0035 H0035 HE HK U6 GX 11 11 11 11 113 114 114 114 1 hour 1 hour 1 hour 1 hour P P P P P P P P P P P P NA NA NA NA Y Y Y Y 52 52 52 50 PSY PSY PSY PSY Y N N Y DOS DOS DOS DOS H0035 TG 11 114 1 hour P P P NA Y 52 PSY, SUB N DOS Adult Acute Partial Hospitalization D & A Partial Enhanced D & A Partial H0035 H2035 H2035 UC 11 11 11 114 129 129 per hour per hour per hour P P P P O O P SP SP NS PD PD N Y Y 52 99 99 PSY SUB SUB N Y Y DOS DOS DOS Crisis Block Payment - Not for use by providers W9700 11 118 O O P NA N 11, 15 PSY Y Blended Case Management Block Payment - Not for use by providers W9701 21 222 O O P NA N 11, 12, 21, 31, 32, 99 PSY Y 11 11 184 118 O O O O S P NA N 99 11 Sub PSY Y Y DOS N N N N N 11 11 11 15 15 PSY PSY PSY PSY PSY Y Y Y Y Y DOS DOS DOS DOS DOS U4 Crisis Intervention claims payment only CR0 claims payment only CBP claims payment only CR1 CR2 CR3 CR4 CR5 CR6 CR7 CR8 DA Case Management Block Payment- Not for use by provider Telephone Crisis Child Urgent Response Telephone Crisis Walk-In Crisis Child Urgent Response Walk In Mobile/Individual Delivered Mobile Crisis Follow-Up Child Urgent Response Mobile Crisis- Individual Mobile/Team Delivered Child Urgent Response Mobile Crisis- Team Crisis In-Home Support Medical Mobile/Team Crisis Residential Residential Treatment Facility Adult (RTFA) W9702 H0030 15 min H0030 H2011 H2011 H2011 H2011 U4 HE U7 11 11 11 11 11 118 118 118 118 118 15 min 15 min 15 min 15 min 15 min O O O O O O O O O O P P P P O NA NA NA NA NA H2011 H2011 U5 HT 11 11 118 118 15 min 15 min O O O O P P NA NA N N 15 15 PSY PSY Y Y DOS DOS H2011 S9484 H2011 S9485 U6 11 11 11 11 118 118 118 118 15 min per hour 15 min per diem O O O O O O O O P P P P NA NA NA NA N N N N 15 12,99 15 12 PSY PSY PSY PSY, SUB Y Y Y Y DOS DOS DOS DOS 11 110 per diem O O P NA N 99 PSY, SUB Y DOS Y 12 PSY, SUB Y DOS H0019 U4 HK HB Crisis Residential S9485 U3 11 118 per diem O O P NA Methadone Maintenance Methadone Maintenance Methadone Maintenance (clinic encounter) Methadone Maintenance (clinic encounter) H0020 H0020 UB U3 08 08 084 084 daily daily O O O O SA SA DA DA Y Y 57 57 SUB SUB Y Y DOS DOS T1015 HG 08 084 weekly O O SA DA Y 57 SUB Y DOS Methadone Maintenance T1015 U3 08 084 weekly O O SA DA Y 57 SUB Y DOS METHADONE-RECOVERY INITIATION & STABLIZATION PHASE 1 T1015 U4 08 084 weekly O O SA NA Y 57 SUB Y DOS METHADONE-RECOVERY INITIATION & STABLIZATION PHASE 1 H0020 U4 08 084 daily O O SA NA Y 57 SUB Y DOS MM1 Page 19 of 23 VBH-PA HIPAA X_Walk Covered Services Grid MM1 METHADONE-EARLY RECOVERY & REHABILITATION PHASE 2 T2015 METHADONE-EARLY RECOVERY & REHABILITATION PHASE 2 H0020 METHADONE-RECOVERY MAINTENANCE- PHASE 3 T1015 METHADONE-RECOVERY MAINTENANCE- PHASE 3 H0020 METHADONE-LONG TERM SUSTAINED RECOVERY- PHASE 4 T1015 METHADONE-LONG TERM SUSTAINED RECOVERY- PHASE 4 H0020 Methadone-Women who are pregnant T1015 Methadone-Women who are pregnant H0020 TPL Exempt Unit Dx Class PROMISe Specialty Code Auth Req? Prov PROMISe Provider Mod 3 Type Claim Type Prov Mod 2 Type Code Prov Mod 1 Level of Service Description Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class POS Timely Filing (Date of Service or Date of Discharge) U5 08 084 weekly O O SA NA Y 57 SUB Y DOS U5 08 084 daily O O SA NA Y 57 SUB Y DOS U6 08 084 weekly O O SA NA Y 57 SUB Y DOS U6 08 084 daily O O SA NA Y 57 SUB Y DOS U7 08 084 weekly O O SA NA Y 57 SUB Y DOS U7 08 084 daily O O SA NA Y 57 SUB Y DOS TH 08 084 weekly O O SA NA Y 57 SUB Y DOS TH 08 084 daily O O SA NA Y 57 SUB Y DOS 08 340 per diem R R UD RE Y 12 PSY Y DOD 11 52 340 523 per diem per diem R R R R UD UD RE RE Y Y 12 12 PSY PSY Y Y DOD DOD 08 11 52 11 08 340 340 523 128 110 per diem per diem per diem 15 min per hour R R R N N R R R O O UD UD UD SA P RE RE RE DA NA Y Y Y Y Y 12 12 99 PSY PSY PSY SUB PSY Y Y Y Y Y DOD DOD DOD DOS DOS Other Adolescent Diversion & Acute Stabilization Unit (Includes Partial Hospitalization Programming) H0019 HA RSP IND INP SMK PRS PRM CLB CRR CTA CTT W.H.O - CRR, All other providers - Mobile Meds CMM Adolescent Diversion & Acute Stabilization Unit (without partial hospitalization) Intensive outpt D & A Intensive outpt Psych Smoking Cessation - Individual therapy Smoking Cessation - Group Therapy Psych Rehab-Site Based Transition Site Based Psych Rehab Psych Rehab Site Based Group Psych Rehab-Mobile Psych Rehab Mobile Group Psych Rehab-Mobile by ASL Cert. Signing Therapist Psych Rehab Clubhouse Psych Rehab Clubhouse Group Community Res Rehab CTT Assessment Community Tx Teams Assertive Community Tx Team (ACT) Group Transitions Program Community Mental Health/Other (Mobile Meds) H0019 H0015 H2012 U7 37 370 15 min N O P, SA NA N G0437 H0036 HQ 37 11 370 123 15 min 15 min N O O O P, SA P NA NA N Y 99 49 11,12,31,32,9 9 PSY, SUB N 11,12,31,32,9 9 PSY, SUB N 15,99 PSY Y H0036 H0036 H0036 H0036 U4 HQ HB U5 11 11 11 11 123 123 123 123 15 min 15 min 15 min 15 min O O O O O O O O P P P P NA NA NA NA Y Y Y Y 15,99 15, 99 15, 99 15, 99 PSY PSY PSY PSY Y Y Y Y DOS DOS DOS DOS H0036 H2030 H2030 H0018 H0039 H0039 U3 HQ HB HK HB 11 11 11 11 11 11 123 123 123 110 111 111 15 min 15 min 15 min per diem Event 15 min O O O O O O O O O R O O O P P P P P NA NA NA NA NA NA Y Y Y Y N Y 15, 99 99 99 99 99 99 PSY PSY PSY PSY PSY PSY Y Y Y Y Y Y DOS DOS DOS DOS DOS DOS H0039 H0046 U3 HE 11 11 111 119 15 min 15 min O O O O P P NA NA Y Y 99 99 PSY PSY Y Y DOS DOS H0046 HW 11 119 15 min O O P, SA NA, DA Y 99 PSY Y DOS SC G0437 Page 20 of 23 DOS DOS DOS VBH-PA HIPAA X_Walk Covered Services Grid MMF INS FFA FDP FDE TPL Exempt Unit 15 min 15 min 15 min 15 min O O O O O O O O P, SA P, SA P, SA P, SA NA NA NA DA Y Y N Y POS 99 99 99 99 PSY PSY PSY PSY, SUB Y Y Y Y Timely Filing (Date of Service or Date of Discharge) DOS DOS DOS DOS Dx Class PROMISe Specialty Code 119 119 119 119 Auth Req? Prov PROMISe Provider Mod 3 Type 11 11 11 11 Claim Type Prov Mod 2 Type Code Prov Mod 1 U4 HK U5 UB Level of Service Description Mobile Meds Travel Mobile Meds Nurse Extender Mobile Meds Follow Up Interpreter Services All Ages Adult Family Focused Solutions Based Services- Individual Adult Family Focused Solutions Based Services- Team Provider Service Code H0046 H0046 H0046 H0046 Auth Type Service Class CMM 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class H0046 HB 11 119 O W P NA Y 99 PSY Y DOS H0046 U6 11 119 O W P NA Y 99 PSY Y DOS Forensic Diversion Program (APA) H2033 Forensic Diversion Encounter Data (APA) H2033 HB 11 119 Weekly O O P, SA NA Y 99 PSY, SUB Y DOS U7 11 08 11 08 119 340 340 340 15 min 15 min 15 min 15 min O O O O O W W W P, SA P P P NA NA NA NA N Y Y Y 99 PSY, SUB PSY PSY PSY Y Y Y Y DOS DOS DOS DOS 11 08 340 340 15 min 15 min O O W O P P NA NA Y Y 12,99 12, 99 PSY PSY Y Y DOS DOS 11 340 15 min O O P NA Y 12,99 PSY Y (S8) DOS 08 340 15 min O O P NA Y 12,99 PSY Y DOS PSY Y (S8) DOS Y Y Y Y DOS DOS DOS DOS Child Family Focused Solutions Based Services- Individual H0046 U2 U9 FFS Child Family Focused Solutions Based Services- Team Functional Family Therapy H0046 H2019 U3 HA U9 U9 12,99 12, 99 12,99 FF1 Functional Family Therapy Collateral H2019 U6 11 340 15 min O O P NA Y 12, 99 T1 TG HX TS 11 11 11 11 119 119 119 119 15 min 15 min 15 min 15 min O O O O O O O O P P P P NA NA NA NA Y Y Y Y 99 Project Transitions Level 1 Project Transitions Level 2 Project Transitions Level 3 H0046 H0046 H0046 H0046 99 99 99 PSY PSY PSY PSY MH/MR Case Management (ICM) T1017 UB 21 222 15 min O O P NA Y 11, 12,99 PSY Y DOS MH Services During Psych Inpatient Admission (ICM) T1017 HK 21 222 15 min I O P NA Y 99 PSY Y DOS 21 222 15 min I O P NA Y 21,,31,,32 PT1 Project Transitions 24/7 Program PT2 U9 Case Management CM1* MH Services During Non-Psych Inpatient Admission (ICM) MH Intensive Case Management Svc. CMF TM1 RC1* RC2 DCM T1017 HE PSY Y DOS T1017 UC 21 222 15 min O O P NA Y 11, 12,99 PSY Y DOS Forensic Case Management T1017 HZ 21 222 15 min O O P NA Y 11, 12,99 PSY Y DOS Blended Case Management Encounter T1017 UD 21 222 15 min O O P NA N 11, 12,99 PSY Y DOS TCM Auto-Payment T1017 U7 21 222 15 min O O P NA N 11, 12,99 PSY Y DOS Advanced MH-BCM T1017 HO 21 222 15 min O O P NA N 11, 12,99 PSY Y DOS MDFT Case Management Resource Coordination MH Services During Psych Inpatient Admission (RC) MH Services During Non-Psych Inpatient Admission (RC) Resource Coordination D & A D &A ICM D &A ICM H0047 T1017 TF 11 21 184 221 15 min 15 min O O O O SA PM NA MN N N 99 11, 12,99 SUB PSY Y Y DOS DOS T1017 TS 21 221 15 min I O PM MN N 21 PSY Y DOS T1017 H0006 H0006 T1017 ST TF 21 21 21 21 221 138 138 138 15 min 15 min 15 min 15 min I O O O O O O O PM SA SA SA MN DA DA DA N N N N 21,31,32 99 99 99 PSY SUB SUB SUB Y Y Y Y DOS DOS DOS DOS HF HK Page 21 of 23 VBH-PA HIPAA X_Walk Covered Services Grid POS TPL Exempt Unit Dx Class PROMISe Specialty Code Auth Req? Prov PROMISe Provider Mod 3 Type Claim Type 99283 Prov Mod 2 Type Code 2nd vst/24 hours Prov Mod 1 Level of Service Description Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class Timely Filing (Date of Service or Date of Discharge) ER2 N/A N/A P, SA NA, DA N 23 PSY, SUB N DOS 010, 019/441, 082, 280, 339 N/A N/A P, SA NA N 22 PSY, SUB DOS 01, 01, 08, 28, 31 010, 019/441, 082, 280, 339 N/A N/A P, SA NA N 22 PSY, SUB DOS 01, 01, 08, 28, 31 010, 019/441, 082, 280, 339 N/A N/A P, SA NA N 22, 81 PSY, SUB DOS 31 339 01, 01, 08, 28, 31 visit Radiology Labs RAD Labs Laboratory LAB POS Medicare Lab Codes (lab codes beginning with 803 were eliminated for dates of service 01/01/15 forward) 80048 - 89365 Place of Service Description POS Place of Service Description 03 School 49 Independent Clinic 11 Office 50 Federally Qualified Health Ctr 12 Home 52 Psychiatric Facility - PH 15 Mobile Unit 54 ICF/MR 21 22 Inpatient Hospital Outpatient Hospital 56 57 Psychiatric RTF Non-Residential 23 Emergency Room - Hospital 65 End-Stage Renal Disease Treatment Facility 24 Ambulatory Surgical Center 72 Rural Health Clinic 31 Skilled Nursing Facility 81 Independent Laboratory 32 Nursing Facility 99 Other POS Provider Type Provider Type Description 01 Inpatient Facility Provider Specialty 010 011 013 018 019 022 183 370 441 074 076 080 081 082 084 110 184 340 370 Provider Type Provider Type Description Provider Specialty Description Acute Care Hospital Private Psych Hosp RTF (JCAHO Certified) Extended Acute Psych Inpatient Unit D&A Rehab Hosp Private Psych Unit Hospital Based Medical Clinic Tobacco Cessation D&A Rehab Unit Mobile Mental Health Treatment Peer Specialist Federally Qualified Health Center Rural Health Clinic Independent Medical/Surgical Clinic Methadone Maintenance Psychiatric Outpatient D&A Outpatient Program Exception Tobacco Cessation Page 22 of 23 Provider Specialty 119 123 127 128 129 131 132 133 134 184 340 442 443 444 445 446 447 448 449 Provider Specialty Description MH - OMHSAS Psychiatric Rehabilitation D&A Outpatient D&A Intensive Outpatient D&A Partial Hospitalization D&A Halfway House D&A Medically Monitored Detox D&A Medically Monitored D&A Medically Monitored Outpatient D&A Program Exception Partial Psych Hosp Children Partial Psych Hosp Children Mobile Partial Psych Hosp Children Partial Psych Hosp Children Partial Psych Hosp Adult Partial Psych Hosp Adult Mobile Partial Psych Hosp Adult Behavioral Partial Psych Hosp Adult Summer VBH-PA HIPAA X_Walk Covered Services Grid 08 Clinic 09 CRNP 11 110 111 112 Psychiatric Outpatient Community Mental Health Outpatient Practitioner - MH 37 Partial Psych Hosp - Children Partial Psych Hosp - Adult Family Based Mental Health Licensed Clinical Social Worker Licensed Social Worker Mental Health Crisis Intervention 56 11 21 28 31 52 Page 23 of 23 Unit 450 451 452 453 548 Mental Health/Substa 549 558 nce Abuse continued 559 076 138 212 221 Case Manager 222 Laboratory 280 316 339 370 548 549 558 Physician 559 Tobacco Cessation 370 Community 520 Residential Rehab 523 Residential Treatment Facility 560 POS Family Based MH Therapeutic Staff Family Based MH Mobile Therapy Family Based MH Behavioral Family Based MH Summer Therapeutic Staff Support Mobile Therapy Behavior Specialist for Children with Behavioral Specialist Consultant Peer Specialist D&A Targeted Case Management MA Case Management for under 21 MH TCM - Resource Coordination MH TCM - Intensive Independent Laboratory Family Practice Psychiatry Tobacco Cessation Therapeutic Staff Support Mobile Therapy Behavior Specialist for Children with Behavioral Specialist Consultant Tobacco Cessation Children & Youth Licensed Group Host Home/Children RTF (Non-JCAHO certified) TPL Exempt Behavior Specialist for Children with FQHC Therapeutic Staff Support FQHC Mobile Therapy FQHC Behavioral Specialist Consultant FQHC Summer Therapeutic Activity RHC Therapeutic Staff Support RHC Mobile Therapy RHC Behavioral Specialist Consultant RHC Summer Therapeutic Activity Psychiatric Outpatient Therapeutic Staff Psychiatric Outpatient Mobile Therapy Psychiatric Outpatient Behavioral Psychiatric Outpatient Summer CRNP Family and Adult Psychiatric Mental Tobacco Cessation Therapeutic Staff Support Mobile Therapy Behavior Specialist for Children with Behavioral Specialist Consultant Peer Specialist Dx Class PROMISe Specialty Code Auth Req? Prov PROMISe Provider Mod 3 Type Claim Type Prov Mod 2 Type Code 558 800 801 802 803 804 805 806 807 808 809 810 811 093 103 370 548 549 558 559 076 113 114 115 116 Mental Health/Substance 117 Abuse 118 Prov Mod 1 Level of Service Description Provider Service Code Auth Type Service Class 091416 >=2013 Billed by Provider ** Codes interchangeable within the service class Timely Filing (Date of Service or Date of Discharge)
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