Standard Rate Schedule: Medicaid 1915(b) 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/29/21
Service 90785 ‐ INTERACTIVE COMPLEXITY 90791 ‐ Psychiatric Diagnostic Evaluation 90791SR ‐ In‐Home Psychiatric Diagnostic Evaluation 90791Z1 ‐ TF‐CBT Psychiatric Diagnostic Evaluation 90791Z2 ‐ PCIT Psychiatric Diagnostic Evaluation 90792 ‐ PSYCHIATRIC DIAGNOSTIC EVAL W/ MED 90832 ‐ PSYCHOTHERAPY 30 MN 90832SR ‐ IN‐HOME PSYCHOTHERAPY 30 MN 90832Z1 ‐ TF‐CBT ‐ PSYCHOTHERAPY 30 MN 90832Z2 ‐ PCIT PSYCHOTHERAPY 30 MN 90833 ‐ PSYCHOTHERAPY 30 MIN ADD ON TO E&M 90834 ‐ PSYCHOTHERAPY 45 MN 90834SR ‐ IN‐HOME PSYCHOTHERAPY 45 MN 90834Z1 ‐ TF‐CBT ‐ PSYCHOTHERAPY 45 MN 90834Z2 ‐ PCIT PSYCHOTHERAPY 45 MN 90834Z4 ‐ Equine‐assisted Psychotherapy, 45 min 90836 ‐ PSYCHOTHERAPY 45 MIN ADD ON TO E&M 90837 ‐ PSYCHOTHERAPY 60 MN 90837SR ‐ IN‐HOME PSYCHOTHERAPY 60 MN 90837Z1 ‐ TF‐CBT ‐ PSYCHOTHERAPY 60 MN 90837Z2 ‐ PCIT PSYCHOTHERAPY 60 MN 90837Z3 ‐ DBT PSYCHOTHERAPY 60 MN 90837Z4 ‐ Equine‐assisted Psychotherapy, 60 min 90838 ‐ PSYCHOTHERAPY 60 MIN ADD ON TO E&M 90839 ‐ PSYCHOTHER FOR CRISIS 60 MIN 90840 ‐ PSYCHOTHER FOR CRISIS ADDÆL 30 MN 90846 ‐ FAMILY THER W/O PT 90846SR ‐ In‐home Family Ther W/O PT 90846Z1 ‐ TF‐CBT ‐ FAMILY THER W/O PT 90846Z2 ‐ PCIT ‐ FAMILY THER W/O PT 90847 ‐ FAMILY THER W/ PT 90847SR ‐ In‐home Family Ther W/ PT 90847Z1 ‐ TF‐CBT ‐ FAMILY THER W/ PT 90847Z2 ‐ PCIT ‐ FAMILY THER W/ PT 90849 ‐ MULTI‐FAM GROUP 90853 ‐ GROUP THER 90853Z3 ‐ DBT GROUP THER 90853Z4 ‐ Equine‐assisted Group Therapy 90870 ‐ ELECTROCONVULSIVE THERAPY 96110 ‐ DEVEL TST LMT
* * *
* *
* *
* *
* * * *
*
* *
* *
Effective Date 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant LQASP ‐ Licensed Qualified Autism Services Practitioner
* This service is subject to a COVID‐19/PHE Rate Enhancement.
End Date 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
ALL
101 $ 4.03 $ 140.94 $ 137.48 $ 146.00 $ 146.00 $ 158.30 $ 60.48 $ 68.74 $ 60.00 $ 60.00 $ 35.55 $ 91.07 $ 103.11 $ 80.00 $ 80.00 $ 86.51 $ 57.77 $ 113.51 $ 137.48 $ 125.00 $ 125.00 $ 125.00 $ 126.77 $ 93.28 $ 127.60 $ 107.43 $ 88.34 $ 136.88 $ 125.00 $ 125.00 $ 107.88 $ 136.88 $ 135.00 $ 135.00 $ 36.00 $ 36.00 $ 62.68 $ 36.69 $ 115.44 $ 10.11
109 $ 3.96 $ 125.39 $ 137.48 $ 146.00 $ 146.00
110 $ 2.97 $ 94.04 $ 137.48 $ 110.00 $ 110.00
111 $ 3.37 $ 119.80 $ 137.48 $ 146.00 $ 146.00
$ 52.24 $ 68.74 $ 60.00 $ 60.00
$ 39.18 $ 68.74 $ 60.00 $ 60.00
$ 51.41 $ 68.74 $ 60.00 $ 60.00
$ 67.85 $ 103.11 $ 80.00 $ 80.00 $ 86.51
$ 50.89 $ 103.11 $ 80.00 $ 80.00 $ 86.51
$ 77.41 $ 103.11 $ 80.00 $ 80.00 $ 86.51
$ 99.42 $ 137.48 $ 125.00 $ 125.00 $ 125.00 $ 126.77
$ 74.57 $ 137.48 $ 125.00 $ 125.00 $ 125.00 $ 126.77
$ 96.48 $ 137.48 $ 125.00 $ 125.00 $ 125.00 $ 126.77
$ 125.28 $ 105.47 $ 72.24 $ 136.88 $ 125.00 $ 125.00 $ 89.70 $ 136.88 $ 135.00 $ 135.00 $ 36.00 $ 36.00 $ 62.68 $ 36.69
$ 93.96 $ 79.10 $ 54.17 $ 136.88 $ 125.00 $ 125.00 $ 67.28 $ 136.88 $ 135.00 $ 135.00 $ 36.00 $ 36.00 $ 62.68 $ 36.69
$ 106.49 $ 89.65 $ 75.09 $ 136.88 $ 125.00 $ 125.00 $ 91.70 $ 136.88 $ 135.00 $ 135.00 $ 36.00 $ 36.00 $ 62.68 $ 36.69
$ 8.58
112 $ 4.03 $ 127.71 $ 137.48 $ 146.00 $ 146.00 $ 134.56 $ 53.20 $ 68.74 $ 60.00 $ 60.00 $ 35.55 $ 77.41 $ 103.11 $ 80.00 $ 80.00 $ 86.51 $ 57.77 $ 101.26 $ 137.48 $ 125.00 $ 125.00 $ 125.00 $ 126.77 $ 93.28 $ 127.60 $ 107.43 $ 75.09 $ 136.88 $ 125.00 $ 125.00 $ 93.22 $ 136.88 $ 135.00 $ 135.00 $ 36.00 $ 36.00 $ 62.68 $ 36.69 $ 115.44 $ 10.11
128 $ 2.97 $ 94.04 $ 137.48 $ 110.00 $ 110.00
129 $ 2.97 $ 94.04 $ 137.48 $ 110.00 $ 110.00
$ 39.18 $ 68.74 $ 60.00 $ 60.00
$ 39.18 $ 68.74 $ 60.00 $ 60.00
$ 50.89 $ 103.11 $ 80.00 $ 80.00 $ 86.51
$ 50.89 $ 103.11 $ 80.00 $ 80.00 $ 86.51
$ 74.57 $ 137.48 $ 125.00 $ 125.00 $ 125.00 $ 126.77
$ 74.57 $ 137.48 $ 125.00 $ 125.00 $ 125.00 $ 126.77
$ 93.96 $ 79.10 $ 54.17 $ 136.88 $ 125.00 $ 125.00 $ 67.28 $ 136.88 $ 135.00 $ 135.00 $ 36.00 $ 36.00 $ 62.68 $ 36.69
$ 93.96 $ 79.10 $ 54.17 $ 136.88 $ 125.00 $ 125.00 $ 67.28 $ 136.88 $ 135.00 $ 135.00 $ 36.00 $ 36.00 $ 62.68 $ 36.69
$ 6.43
210 $ 3.37 $ 119.80 $ 137.48 $ 146.00 $ 146.00 $ 134.56 $ 51.41 $ 68.74 $ 60.00 $ 60.00 $ 29.67 $ 77.41 $ 103.11 $ 80.00 $ 80.00 $ 86.51 $ 48.21 $ 96.48 $ 137.48 $ 125.00 $ 125.00 $ 125.00 $ 126.77 $ 77.85 $ 127.60 $ 107.43 $ 75.09 $ 136.88 $ 125.00 $ 125.00 $ 93.22 $ 136.88 $ 135.00 $ 135.00 $ 36.00 $ 36.00 $ 62.68 $ 36.69 $ 115.44 $ 10.11
LQASP
Standard Rate Schedule: Medicaid 1915(b) 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/29/21
Service
* * * * * * * * *
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant LQASP ‐ Licensed Qualified Autism Services Practitioner
* This service is subject to a COVID‐19/PHE Rate Enhancement.
Effective Date 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
End Date 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
1/1/2022
6/30/2022
$ 53.79 $ 41.97
$ 31.48
1/1/2022
6/30/2022
$ 53.79 $ 41.97
$ 31.48
1/1/2022
6/30/2022 $ 32.64
1/1/2022
6/30/2022 $ 32.64
1/1/2022
6/30/2022 $ 1.74
*
1/1/2022
6/30/2022
$ 17.36
$ 17.36
$ 17.36
*
1/1/2022
6/30/2022
$ 44.42
$ 44.42
$ 44.42
96375 ‐ therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (list separately in * addition to code for primary service) 97151 ‐ Behavior identification assessment
1/1/2022 1/1/2022
6/30/2022 6/30/2022
$ 19.26
$ 19.26
$ 19.26
1/1/2022 1/1/2022
6/30/2022 6/30/2022
$ 53.65 $ 20.00
1/1/2022
6/30/2022
$ 10.00
1/1/2022 1/1/2022
6/30/2022 6/30/2022
$ 28.00 $ 30.00
1/1/2022
6/30/2022
$ 10.00
96112 ‐ DEVEL TST EXT 96113 ‐ add on DEVEL TST EXT 96116 ‐ NEUROBEHAV EXAM 96121 ‐ add on NEUROBEHAV EXAM 96130 ‐ PSYCH TESTING CLINICAL PSYCH 96131 ‐ add on PSYCH TESTING CLINICAL PSYCH 96132 ‐ NEUROPSYCH TST‐ CLIN PSYCH 96133 ‐ add on NEUROPSYCH TST‐ CLIN PSYCH 96136 ‐ PSYCH OR NEUROPSYCH TESTING CLINICAL PSYCH TST ADMIN AND SCORING * 96137 ‐ add on PSYCH OR NEUROPSYCH TESTING CLINICAL PSYCH TST ADMIN AND SCORING * 96138 ‐ PSYCH OR NEUROPSYCH TESTING TECH TST ADMIN AND SCORING 96139 ‐ add on PSYCH OR NEUROPSYCH TESTING TECH TST ADMIN AND SCORING 96146 ‐ PSYCH OR NEUROPSYCH AUTOMATED TESTING AND RESULT 96372 ‐ Therapeutic prophylactic or diagnostic injection 96374 ‐ therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
97152 ‐ Behavior identification supporting assessment, tech 97153 ‐ Adaptive behavior treatment by protocol, tech 97154 ‐ Group adaptive behavior treatment by protocol, tech 97155 ‐ Adaptive behavior treatment with protocol modification, QHP 97156 ‐ Family adaptive behavior treatment guidance 97157 ‐ Multiple‐family group adaptive behavior treatment guidance
ALL
101 $ 132.53 $ 66.27 $ 118.32 $ 118.32 $ 107.58 $ 107.58 $ 140.58 $ 140.58
109 $ 116.16 $ 53.20 $ 93.07 $ 93.07 $ 101.00 $ 83.94 $ 113.03 $ 113.03
110
111
112 $ 132.53 $ 66.27
128 $ 87.12 $ 39.90 $ 69.82 $ 69.82 $ 75.75 $ 62.96 $ 84.77 $ 84.77
129
210 $ 132.53 $ 66.27
LQASP
$ 31.25
Standard Rate Schedule: Medicaid 1915(b) 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/29/21
Service * 98966CR ‐ Telephone Assessment and Management Service ‐ 5‐10 min 98967CR ‐ Telephone Assessment and Management Service ‐ 11‐20 min 98968CR ‐ Telephone Assessment and Management Service ‐ 21‐30 min
Effective Date
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant LQASP ‐ Licensed Qualified Autism Services Practitioner
* This service is subject to a COVID‐19/PHE Rate Enhancement.
End Date
ALL
101
109
110
111
112
128
129
210
1/1/2022
6/30/2022
$ 11.89 $ 8.92 $ 8.92
$ 8.92 $ 8.92 $ 11.89
1/1/2022
6/30/2022
$ 23.16 $ 17.37 $ 17.37
$ 17.37 $ 17.37 $ 23.16
1/1/2022
6/30/2022
$ 33.95 $ 25.46 $ 25.46
$ 25.46 $ 25.46 $ 33.95
99202 ‐ OP Visit New Pat, straightforward, 15‐29 minutes 99203 ‐ OP Visit New Pat, low level, 30‐44 minutes 99204 ‐ OP Visit New Pat, moderate, 45‐59 minutes 99205 ‐ OP Visit New Pat, high level, 60‐74 minutes 99211 ‐ OP Visit Est Pat, presenting problem minimal
* * * * *
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ 58.60 $ 89.36 $ 131.66 $ 166.44 $ 17.14
$ 58.60 $ 84.90 $ 131.66 $ 166.44 $ 17.14
$ 58.60 $ 84.90 $ 131.66 $ 166.44 $ 17.14
99212 ‐ OP Visit Est Pat, straightforward, 10‐19 minutes 99213 ‐ OP Visit Est Pat, low level, 20‐29 minutes 99214 ‐ OP Visit Est Pat, moderate, 30‐39 minutes 99215 ‐ OP Visit Est Pat, high level, 40‐54 minutes 99217 ‐ observation care discharge day management 99218 ‐ initial observation, per day, low complexity 99219 ‐ initial observation care, per day, moderate complexity
* * * * * *
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ 34.13 $ 75.00 $ 105.00 $ 116.11 $ 62.45 $ 58.91
$ 34.13 $ 63.75 $ 89.25 $ 116.11 $ 62.45 $ 58.91
$ 34.13 $ 63.75 $ 89.25 $ 116.11 $ 62.45 $ 58.91
*
1/1/2022
6/30/2022
$ 97.56
$ 97.56
$ 97.56
99220 ‐ initial observation care, per day, high complexity 99221 ‐ Initial Hospital Care 30 Min 99222 ‐ Initial Hospital Care‐Mod‐50 Min 99223 ‐ Initial Hospital Care‐70 Min 99224 ‐ subsequent observation care, per day, low complexity 99225 ‐ subsequent observation care, per day, moderate complexity 99226 ‐ subsequent observation care, per day, high complexity 99231 ‐ Subsequent Hospital 15 Min 99232 ‐ Subsequent Hospital 25 Min 99233 ‐ Subsequent Hospital 35 Min 99234 ‐ Observation/Inpat Low 99235 ‐ Hosp/Obs 1‐Day Mod Sev 99236 ‐ Hosp/Obs 1‐Day High Sev 99238 ‐ Hospital Discharge 30 99239 ‐ Hospital Discharge > 30 Min
* * * *
1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ 136.82 $ 84.59 $ 115.44 $ 169.97
$ 136.82 $ 84.59 $ 115.44 $ 169.97
$ 136.82 $ 84.59 $ 115.44 $ 169.97
*
1/1/2022
6/30/2022
$ 23.72
$ 23.72
$ 23.72
*
1/1/2022
6/30/2022
$ 42.14
$ 42.14
$ 42.14
* * * * * * * * *
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ 63.00 $ 34.93 $ 62.96 $ 90.16 $ 119.33 $ 156.75 $ 194.83 $ 62.24 $ 90.46
$ 63.00 $ 34.93 $ 62.96 $ 90.16 $ 119.33 $ 156.75 $ 194.83 $ 62.24 $ 90.46
$ 63.00 $ 34.93 $ 62.96 $ 90.16 $ 119.33 $ 156.75 $ 194.83 $ 62.24 $ 90.46
LQASP
Standard Rate Schedule: Medicaid 1915(b) 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/29/21
Service
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant LQASP ‐ Licensed Qualified Autism Services Practitioner
* This service is subject to a COVID‐19/PHE Rate Enhancement.
*
Effective Date
End Date
ALL
101
109
110
111
112
128
129
210
99241 ‐ outpt. consult, minor‐ phys time approx 15 min. 99241U4 ‐ Physician Consult ‐ Brief
* *
1/1/2022 1/1/2022
6/30/2022 6/30/2022
$ 40.72 $ 55.00
$ 40.72
$ 40.72
99242 ‐ outpt. consult, moderate‐ phys time approx 30 min. 99242U4 ‐ Physician Consult ‐ Intermediate
* *
1/1/2022 1/1/2022
6/30/2022 6/30/2022
$ 76.28 $ 90.00
$ 76.28
$ 76.28
99243 ‐ outpt. consult, severe‐ phys time approx 40 min.
*
1/1/2022
6/30/2022
$ 104.91
$ 104.91
$ 104.91
99244 ‐ outpt. consult, severe‐ phys time approx 60 min. 99244U4 ‐ Physician Consult ‐ Extensive
* *
1/1/2022 1/1/2022
6/30/2022 6/30/2022
$ 155.82 $ 168.00
$ 155.82
$ 155.82
99245 ‐ outpt. consult, severe‐ phys time approx 80 min. 99251 ‐ initial inpt consult‐ phys time approx 20 min. 99252 ‐ initial inpt consult‐ phys time approx 40 min. 99253 ‐ initial inpt consult‐ phys time approx 55 min. 99254 ‐ initial inpt consult‐ phys time approx 80 min. 99255 ‐ initial inpt consult‐ phys time approx 110 min. 99281 ‐ er visit, minor 99282 ‐ er visit, low severity 99283 ‐ er visit, moderate severity 99284 ‐ er visit, high severity 99285 ‐ emergency department visit for the evaluation and management of a patient, 99291 ‐ critical care, evaluation and management of the critically ill or critically 99292 ‐ critical care, 30‐74 min Add 30 Min 99304 ‐ initial nursing facility care, per day, for the evaluation and management of 99305 ‐ Init Nursing Fac Care 35 Min 99306 ‐ initial nursing facility care, per day, for the evaluation and management of a 99307 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99308 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99309 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99310 ‐ subsequent nursing facility care, per day, for the evaluation and management of
* * * * * * * * * *
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ 191.51 $ 41.58 $ 64.42 $ 97.80 $ 141.46 $ 172.36 $ 17.35 $ 33.75 $ 52.30 $ 97.92
$ 191.51 $ 41.58 $ 64.42 $ 97.80 $ 141.46 $ 172.36 $ 17.35 $ 33.75 $ 52.30 $ 97.92
$ 191.51 $ 41.58 $ 64.42 $ 97.80 $ 141.46 $ 172.36 $ 17.35 $ 33.75 $ 52.30 $ 97.92
*
1/1/2022
6/30/2022
$ 145.57
$ 145.57
$ 145.57
* *
1/1/2022 1/1/2022
6/30/2022 6/30/2022
$ 236.89 $ 107.43
$ 244.22 $ 107.43
$ 244.22 $ 107.43
* *
1/1/2022 1/1/2022
6/30/2022 6/30/2022
$ 75.37 $ 105.38
$ 75.37 $ 105.38
$ 75.37 $ 105.38
*
1/1/2022
6/30/2022
$ 135.41
$ 135.41
$ 135.41
*
1/1/2022
6/30/2022
$ 37.19
$ 37.19
$ 37.19
*
1/1/2022
6/30/2022
$ 56.87
$ 56.87
$ 56.87
*
1/1/2022
6/30/2022
$ 75.43
$ 75.43
$ 75.43
*
1/1/2022
6/30/2022
$ 111.53
$ 111.53
$ 111.53
LQASP
Standard Rate Schedule: Medicaid 1915(b) 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/29/21
Service 99315 ‐ nursing facility discharge day management; 30 minutes or less 99316 ‐ nursing facility discharge day management; 30 minutes or less more than 30 99318 ‐ evaluation and management of a patient involving an annual nursing facility 99324 ‐ domiciliary or rest home visit for the evaluation and management of a new 99325 ‐ domiciliary or rest home visit for the evaluation and management of a new 99326 ‐ domiciliary or rest home visit for the evaluation and management of a new 99327 ‐ domiciliary or rest home visit for the evaluation and management of a new 99328 ‐ domiciliary or rest home visit for the evaluation and management of a new 99334 ‐ domiciliary or rest home visit for the evaluation and management of an 99335 ‐ domiciliary or rest home visit for the evaluation and management of an 99336 ‐ domiciliary or rest home visit for the evaluation and management of an 99337 ‐ domiciliary or rest home visit for the evaluation and management of an 99341 ‐ home visit for the evaluation and management of a new patient, which requires 99342 ‐ home visit for the evaluation and management of a new patient, which requires 99343 ‐ home visit for the evaluation and management of a new patient, which requires 99344 ‐ home visit for the evaluation and management of a new patient, which requires 99345 ‐ home visit for the evaluation and management of a new patient, which requires 99347 ‐ home visit for the evaluation and management of an established patient, which 99348 ‐ home visit for the evaluation and management of an established patient, which 99349 ‐ home visit for the evaluation and management of an established patient, which
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant LQASP ‐ Licensed Qualified Autism Services Practitioner
* This service is subject to a COVID‐19/PHE Rate Enhancement.
*
Effective Date
End Date
ALL
101
109
110
111
112
128
129
210
*
1/1/2022
6/30/2022
$ 54.42
$ 54.42
$ 54.42
*
1/1/2022
6/30/2022
$ 71.11
$ 71.11
$ 71.11
*
1/1/2022
6/30/2022
$ 78.86
$ 78.86
$ 78.86
*
1/1/2022
6/30/2022
$ 50.56
$ 50.56
$ 50.56
*
1/1/2022
6/30/2022
$ 73.64
$ 73.64
$ 73.64
*
1/1/2022
6/30/2022
$ 121.75
$ 121.75
$ 121.75
*
1/1/2022
6/30/2022
$ 158.80
$ 158.80
$ 158.80
*
1/1/2022
6/30/2022
$ 186.94
$ 186.94
$ 186.94
*
1/1/2022
6/30/2022
$ 52.11
$ 52.11
$ 52.11
*
1/1/2022
6/30/2022
$ 80.71
$ 80.71
$ 80.71
*
1/1/2022
6/30/2022
$ 113.66
$ 113.66
$ 113.66
*
1/1/2022
6/30/2022
$ 163.32
$ 163.32
$ 163.32
*
1/1/2022
6/30/2022
$ 50.56
$ 50.56
$ 50.56
*
1/1/2022
6/30/2022
$ 73.64
$ 73.64
$ 73.64
*
1/1/2022
6/30/2022
$ 118.59
$ 118.59
$ 118.59
*
1/1/2022
6/30/2022
$ 155.68
$ 155.68
$ 155.68
*
1/1/2022
6/30/2022
$ 187.26
$ 187.26
$ 187.26
*
1/1/2022
6/30/2022
$ 49.34
$ 49.34
$ 49.34
*
1/1/2022
6/30/2022
$ 74.50
$ 74.50
$ 74.50
*
1/1/2022
6/30/2022
$ 108.48
$ 108.48
$ 108.48
LQASP
Standard Rate Schedule: Medicaid 1915(b) 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/29/21
Service 99350 ‐ home visit for the evaluation and management of an established patient, which 99354 ‐ Prolonged MD Serv except Office(60 min) 99355 ‐ Prolng MD Serv except Office(Add 30min) 99356 ‐ Prolng MD Serv IP or observ (60min) 99357 ‐ Prolng MD Serv IP or observ (Add 30min) 99406 ‐ smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes 99407 ‐ smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes 99408 ‐ alcohol and/or substance (other than tobacco) abuse structured screening (eg. audit, dast) and brief intervention (sbi) services; 15‐ 30 minutes 99409 ‐ alcohol and/or substance (other than tobacco) abuse structured screening (eg. audit, dast) and brief intervention (sbi) services; greater than 30 minutes 99417 ‐ Prolonged Office or other OP (15 min) 99421 ‐ Online Digital E/M Service, 5‐10 min 99422 ‐ Online Digital E/M Service, 11‐20 min 99423 ‐ Online Digital E/M Service, 21 or more min 99441 ‐ Telephone Evaluation and Management Service ‐ 5‐ 10 min 99442 ‐ Telephone Evaluation and Management Service ‐ 11‐ 20 min 99443 ‐ Telephone Evaluation and Management Service ‐ 21‐ 30 min 99446 ‐ Interprofessional Tele/Internet/EHR Consultation, 5‐ 10 min 99447 ‐ Interprofessional Tele/Internet/EHR Consultation, 11‐20 min 99448 ‐ Interprofessional Tele/Internet/EHR Consultation, 21‐30 min 99449 ‐ Interprofessional Tele/Internet/EHR Consultation, 31 or more min G2012CR ‐ Brief Virtual Check‐in by Prescriber, 5‐10 minutes H0010 ‐ DETOX‐NON‐HSP‐MED H0012HB ‐ Community Residential Tx‐Adult H0013 ‐ SA Med Mon Community Residential Tx
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant LQASP ‐ Licensed Qualified Autism Services Practitioner
* This service is subject to a COVID‐19/PHE Rate Enhancement.
*
Effective Date
End Date
ALL
101
109
110
111
112
128
129
210
* * * * *
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ 151.24 $ 86.13 $ 85.27 $ 78.66 $ 79.20
$ 151.24 $ 86.13 $ 85.27 $ 78.66 $ 79.20
$ 151.24 $ 86.13 $ 85.27 $ 78.66 $ 79.20
*
1/1/2022
6/30/2022
$ 12.15
$ 12.15
$ 12.15
*
1/1/2022
6/30/2022
$ 23.48
$ 23.48
$ 23.48
*
1/1/2022
6/30/2022
$ 31.30
$ 31.30
$ 31.30
* * * * *
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ 61.53 $ 82.03 $ 26.00 $ 43.41 $ 65.41
$ 61.53 $ 82.03 $ 26.00 $ 43.41 $ 65.41
$ 61.53 $ 82.03 $ 26.00 $ 43.41 $ 65.41
*
1/1/2022
6/30/2022
$ 26.00
$ 26.00
$ 26.00
*
1/1/2022
6/30/2022
$ 43.41
$ 43.41
$ 43.41
*
1/1/2022
6/30/2022
$ 65.41
$ 65.41
$ 65.41
*
1/1/2022
6/30/2022
$ 15.96
*
1/1/2022
6/30/2022
$ 32.22
*
1/1/2022
6/30/2022
$ 48.18
*
1/1/2022
6/30/2022
$ 64.21 $ 12.19
$ 12.19
$ 12.19
1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 $ 325.58 6/30/2022 $ 155.81 6/30/2022 $ 241.81
LQASP
Standard Rate Schedule: Medicaid 1915(b) 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/29/21
Service H0014 ‐ AMBULATORY DETOX H0015 ‐ SA IOP H0019HK ‐ HRI L4, BH LT Res H0019HQ ‐ HRI L3, <=4 beds, BH LT Res H0019TJ ‐ HRI L3, 5+ beds, BH LT Res H0019UR ‐ Residential Level IV (5+ Beds) H0020 ‐ Outpatient Opioid Treatment H0035 ‐ MH PARTIAL HOSP, < 24 HR H0038 ‐ Peer Support Services (PSS) ‐ individual H0038HQ ‐ Peer Support Services (PSS) ‐ group H0040 ‐ ACTT H004022 ‐ ACTT > 4 events per month H0045HQU4HA ‐ (B3) Child Group Respite H0045HQU4HB ‐ (B3) Adult Group Respite H0045U4HA ‐ (B3) Child Individual Respite H0045U4HB ‐ (B3) Adult Individual Respite H0046 ‐ High Risk Res L1 H2011 ‐ CRISIS SERVICES H2011U4HI ‐ DI Crisis Intervention and Stabilization Supports with Technical Amendment H2012HA ‐ DAY TREATMENT CHILD
*
H2015HQU4 ‐ AWC ‐ DI Community Networking ‐ Group H2015HQU4 ‐ DI Community Networking ‐ Group H2015HTHF ‐ CST ‐ SA Professional ‐ Community Support Team H2015HTHM ‐ CST ‐ Paraprofessional ‐ Community Support Team H2015HTHN ‐ CST ‐ QP/AP ‐ Community Support Team
* * * *
* * * * * * * * *
Effective Date 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant LQASP ‐ Licensed Qualified Autism Services Practitioner
* This service is subject to a COVID‐19/PHE Rate Enhancement.
End Date 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
ALL $ 21.25 $ 131.56 $ 342.15 $ 232.88 $ 189.75 $ 342.15 $ 16.60 $ 132.32 $ 12.00 $ 2.88 $ 304.18 $ 0.01 $ 3.67 $ 3.67 $ 4.75 $ 4.75 $ 75.00 $ 90.00
1/1/2022 1/1/2022
6/30/2022 $ 9.00 6/30/2022 $ 31.41
* *
1/1/2022 1/1/2022
6/30/2022 $ 3.10 6/30/2022 $ 3.10
*
1/1/2022
6/30/2022 $ 25.91
* *
1/1/2022 1/1/2022
6/30/2022 $ 25.91 6/30/2022 $ 25.91
H2015HTHO ‐ CST ‐ Team Lead ‐ Community Support Team H2015HTU1 ‐ CST ‐ PSS ‐ Community Support Team
* *
1/1/2022 1/1/2022
6/30/2022 $ 25.91 6/30/2022 $ 25.91
H2015U4 ‐ AWC ‐ DI Community Networking ‐ Individual H2015U4 ‐ DI Community Networking ‐ Individual H2016HIU4 ‐ DI Level 4‐Residential Supports H2016HIU4U2 ‐ DI Level 4 AFL‐Residential Supports H2016U4 ‐ DI Level 1‐Residential Supports H2016U4U2 ‐ DI Level 1 AFL Residential Supports H2017 ‐ PSYCHOSOCIAL REHAB
* * * * * * *
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ 5.74 $ 5.74 $ 170.54 $ 170.54 $ 105.25 $ 110.25 $ 2.69
101
109
110
111
112
128
129
210
LQASP
Standard Rate Schedule: Medicaid 1915(b) 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/29/21
* This service is subject to a COVID‐19/PHE Rate Enhancement.
Service H2020 ‐ Child Residential Level II – Program Type H2021 ‐ Outpatient Plus H2021HQ ‐ Group Outpatient Plus H2022 ‐ INTENSIVE‐IN‐HOME H2023HQU4 ‐ IDD non‐DI Initial Group Supported Employment H2023U4 ‐ IDD non‐DI Initial Individual Supported Employment
* *
Effective Date 1/1/2022 1/1/2022 1/1/2022 1/1/2022
*
1/1/2022
6/30/2022 $ 2.53
*
1/1/2022
6/30/2022 $ 11.21
H2025HQU4 ‐ AWC ‐ DI Group ‐ Supported Employment H2025HQU4 ‐ DI Group ‐ Supported Employment H2025TSHQU4 ‐ AWC ‐ DI Supported Employment – Long Term Follow‐up ‐ Group H2025TSHQU4 ‐ DI Supported Employment – Long Term Follow‐up ‐ Group H2025TSU4 ‐ AWC ‐ DI Supported Employment – Long Term Follow‐up H2025TSU4 ‐ DI Supported Employment – Long Term Follow‐ up H2025U4 ‐ AWC ‐ DI Individual Supported Employment H2025U4 ‐ DI Individual Supported Employment H2026HQU4 ‐ IDD non‐DI Maint Group Supported Employment H2026U4 ‐ IDD non‐DI Maint Individual Supported Employment H2033 ‐ MULTI‐SYSTEMIC‐THER H2035 ‐ SA Comprehensive Outpatient Trt Prog Q3014GT ‐ TELEHEALTH ORIG SITE FEE S5110U4 ‐ DI Natural Supports Education ‐ Individual S5145 ‐ CTSP Residential II S5145HA ‐ CTSP FAM TYPE RES II IAFT S5145HK ‐ Enh Rate Therapeutic Foster Care S5145U5 ‐ Enhanced Therapeutic Foster Care S5150HQU4 ‐ AWC ‐ DI Respite ‐ Group S5150HQU4 ‐ DI Respite ‐ Group S5150U4 ‐ AWC ‐ DI Respite ‐ Individual S5150U4 ‐ DI Respite ‐ Individual S5150USU4 ‐ DI Respite ‐ Facility S9484 ‐ FAC BASED CRISIS HR S9484HA ‐ FAC BASED CRISIS HR ‐ Child & Adol
* *
1/1/2022 1/1/2022
6/30/2022 $ 2.69 6/30/2022 $ 2.69
*
1/1/2022
6/30/2022 $ 2.53
*
1/1/2022
6/30/2022 $ 2.53
*
1/1/2022
6/30/2022 $ 7.39
* * *
1/1/2022 1/1/2022 1/1/2022
6/30/2022 $ 7.39 6/30/2022 $ 7.62 6/30/2022 $ 7.62
*
1/1/2022
6/30/2022 $ 2.53
*
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
* * * * * * * * * * *
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant LQASP ‐ Licensed Qualified Autism Services Practitioner
End Date 6/30/2022 6/30/2022 6/30/2022 6/30/2022
ALL $ 126.31 $ 13.67 $ 7.49 $ 258.20
$ 11.21 $ 37.32 $ 45.35 $ 21.25 $ 8.53 $ 88.58 $ 231.12 $ 88.58 $ 88.58 $ 2.90 $ 2.90 $ 4.00 $ 4.00 $ 240.00 $ 30.00 $ 30.00
101
109
110
111
112
128
129
210
LQASP
Standard Rate Schedule: Medicaid 1915(b) 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/29/21
Service T1005TDU4 ‐ AWC ‐ DI Respite ‐ Nursing RN T1005TDU4 ‐ DI Respite ‐ Nursing RN T1005TEU4 ‐ AWC ‐ DI Respite ‐ Nursing LPN T1005TEU4 ‐ DI Respite ‐ Nursing LPN T1016CR ‐ Case Support ‐ Special Situation T1019U4 ‐ Individual Support T1019U4TS ‐ Individual Support ‐ Non‐EVV, only in the community T1023 ‐ DIAGNOSTIC‐ASSESSMENT T2012HQU4 ‐ DI Community Living and Supports ‐ Group, only in the community T2012GCHQU4 ‐ DI Community Living and Supports ‐ Group, relative as provider lives in home T2012U4 ‐ DI Community Living and Supports, only in the community T2012GCU4 ‐ DI Community Living and Supports, relative as provider lives in home T2013U4 ‐ B3 non‐DI In Home Skill Building T2013TFHQU4 ‐ AWC ‐ DI Community Living and Supports‐ Group
* * * * *
T2013TFHQU4 ‐ DI Community Living and Supports‐ Group T2013TFU4 ‐ AWC ‐ DI Community Living and Supports T2013TFU4 ‐ DI Community Living and Supports T2014U4 ‐ DI Level 2 ‐ Residential Supports T2014U4U2 ‐ DI Level 2 AFL ‐ Residential Supports T2016U5 ‐ Behavioral Health Crisis Risk Assessment and Intervention (BH‐CAI) T2016U5U1 ‐ L1 Long‐term Community Supports T2016U5U2 ‐ L2 Long‐term Community Supports T2016U5U3 ‐ L3 Long‐term Community Supports T2016U5U4 ‐ L4 Long‐term Community Supports T2016U5U5 ‐ L5 Long‐term Community Supports T2020U4 ‐ DI Level 3 ‐ Residential Supports T2020U4U2 ‐ DI Level 3 AFL ‐ Residential Supports T2021HQU4 ‐ DI Day Supports ‐ Group T2021U4 ‐ DI Day Supports ‐ Individual T2025HOU4 ‐ DI Specialized Consultative Services ‐ BCBA T2025U3U4 ‐ DI Crisis Services: Crisis Consultation
Effective Date 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
* This service is subject to a COVID‐19/PHE Rate Enhancement.
End Date 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
ALL $ 9.90 $ 9.90 $ 9.90 $ 9.90 $ 15.00 $ 12.00
1/1/2022 1/1/2022
6/30/2022 $ 12.00 6/30/2022 $ 231.30
*
1/1/2022
6/30/2022 $ 5.00
*
1/1/2022
6/30/2022 $ 5.00
*
1/1/2022
6/30/2022 $ 14.00
*
1/1/2022 1/1/2022
6/30/2022 $ 14.00 6/30/2022 $ 11.45
*
1/1/2022
6/30/2022 $ 3.37
* * * * *
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ 3.37 $ 5.12 $ 5.12 $ 126.53 $ 131.44
1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
$ 450.00 $ 84.00 $ 108.00 $ 118.00 $ 128.00 $ 138.21 $ 148.54 $ 150.88 $ 15.84 $ 25.88
1/1/2022 1/1/2022
6/30/2022 $ 26.56 6/30/2022 $ 19.92
* *
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant LQASP ‐ Licensed Qualified Autism Services Practitioner
101
109
110
111
112
128
129
210
LQASP
Standard Rate Schedule: Medicaid 1915(b) 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist rev. 11/29/21
Service T2025U4 ‐ DI Specialized Consultative Services T2027U4 ‐ DI Developmental Day T2033HIU4 ‐ AWC ‐ DI Supported Living – Level 2 T2033HIU4 ‐ DI Supported Living – Level 2 T2033TFU4 ‐ AWC ‐ DI Supported Living – Level 3 T2033TFU4 ‐ DI Supported Living – Level 3 T2033U1U4 ‐ AWC ‐ DI Supported Living ‐ Periodic T2033U1U4 ‐ DI Supported Living ‐ Periodic T2033U2U4 ‐ DI Supported Living ‐ Transition T2033U4 ‐ AWC ‐ DI Supported Living – Level 1 T2033U4 ‐ DI Supported Living – Level 1 T2034U4 ‐ DI Crisis Services ‐ Out of Home T2041 U1 U4 Community Navigator for Agency with Choice AWC B3 T2041U1U4 ‐ B‐3 DI Community Navigator ‐ Periodic and Start up Training T2041U4U5 ‐ B‐3 Community Guide ‐ Monthly
*
* * * * * * * * *
Effective Date 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022
* This service is subject to a COVID‐19/PHE Rate Enhancement.
End Date 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022
ALL $ 38.00 $ 24.52 $ 184.09 $ 184.09 $ 215.17 $ 215.17 $ 5.52 $ 5.52 $ 5.52 $ 152.47 $ 152.47 $ 235.00 $ 620.00
1/1/2022 1/1/2022 1/1/2022
112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant LQASP ‐ Licensed Qualified Autism Services Practitioner
6/30/2022 $ 150.00 6/30/2022 $ 150.00
101
109
110
111
112
128
129
210
LQASP