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									Array of Services Overview:

Highlighting: Each newly published Array of Services will have all changes since the previous publication highlighted in yellow.

Comments: In addition to the highlighting of current changes, a comment is added to any cell that has been modified during the FY. These comments will remain in the spreadsheet after the highlighting has been removed. Cells which contain comments are identified by a small red triangle in the upper right hand corner. To temporarily display a comment, click on or place your mouse over the cell containing the comment mark. To permanently display all comments, Select 'Comments' under the 'View' menu from the tool bar.

Workbooks: Please note that there are multiple worksheets within this spreadsheet for the various categories of population groups.

IPRS Code 90772 90801 90801:GT 90802 90804 90804:GT 90805 90805:GT 90806 90806:GT 90807 90807:GT 90808:GT 90809:GT 90810 90811 90812 90813 90814 90815

Service Description - For Target Populations Medication Administration Clinical Evaluation/Intake Clinical Evaluation/Intake - Telemedicine Interactive Evaluation Individual Therapy (20-30 min.) Individual Therapy (20-30 min.) Telemedicine Individual Therapy (20-30 min.)--MD Individual Therapy (20-30 min.)--MD Telemedicine Individual Therapy (45-50 min.) Individual Therapy (45-50 min.) Telemedicine Individual Therapy (45-50 min.)--MD Individual Therapy (45-50 min.)--MD Telemedicine Individual Therapy (75+ min.)--MD Individual Therapy (75+ min.)--MD Telemedicine Interactive Therapy (30 min.) Interactive Therapy (30 min.)--MD Interactive Therapy (50 min.) Interactive Therapy (50 min.)--MD Interactive Therapy (80 min.) Interactive Therapy (80 min.)--MD

Effective July 1, 2009

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ris C d le ab is P s D A N nd lly -S Fu ta y en SN nt m D ou C op es el ic -C r C ev rv D Se de TN y ld D or C nl hi is D -C tO S se en C bu D sm A C s e es nd es ss nc fu ic ta -A y rv bs nt O Se A Su ou D is C m ith -C ris w ra C C N ld og se hi ST Pr bu C S -C A R D e A JO nc A SS ta C -M bs y J nl Su A ld tO SM hi C en es -C s sm ili S nd es ed am SC Fu ss C rb rF y tu -A ei nt is O th D ou d SA -C lly C an C s na io an TN r ot H er es M de et ic Em C or -V rv ly is T D Se us VE is od rio M ris ho C Se C ld hi lth D C ea SE ly M lH ar C ta -E en y D M nl EC ld tO M hi C en -C sm S C es M is ss C ris -A C O s d A le M nd C ab Fu is y D nt lly ou ta -C en C m P TN op es A D e l ic N A ev rv -S D Se y lt y SN er D du nl A ov -A tO ec S en R C D sm nd A s es ta nd ss en Fu -A y em O nt ag A ou D es ng A ic -C tE en rv C en N om Se tm ST is -W A ea ris se M Tr C O ea lt se is ed du SW D lv bu A -A le A vo er e In ab ER nd ic nc SS ST ffe ta un A O -D m bs e ic Su om SS st lt r/C SD Ju du A se al U -A in g S ru rim SC D A g -C y tin nl JO ec tO SC nj A en es -I ili R sm s D am es nd SC ss rF A Fu ei y -A th nt O d ou SA an A s -C y C es an er ic er TN ov s rv et M ec es A Se R -V lln am T is le lI gr ris ab VE ta ro C M St en A tP M lth E en ea ith SR em w lH M lt ta nc A du en ha A M En lt IM ity du A un y -A m nl S C om nt O M A e -C sm EP es ss -A
AMH AMH AMH AMH AMH AMH AMH ASA ASA ASA ASA ASA ASA ASA ASA ADD x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x ADD x x ADD ADD x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x CMH CMH CMH x x x x x x x x x x x x x x x x x x x x x x x x x CMH x x x x x x x x x x x x x x x x x x x x CMH CMH CSA CSA CSA CSA x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

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Last Update: 6/292009

90816 90817 90818 90819 90822 90823 90824 90826 90827 90828 90829 90846 90847 90849 90853 90857 90862

Individual Therapy (30 min.) Inpatient/Partial Hospitalization Individual Therapy (30 min.)--MD Inpatient/Partial Hospitalization Individual Therapy (50 min.) Inpatient/Partial Hospitalization Individual Therapy (50 min.)--MD Inpatient/Partial Hospitalization Individual Therapy (80 min) -- MD Interactive Therapy (30 min.) Inpatient/Partial Hospitalization Interactive Therapy (30 min.)--MD Inpatient/Partial Hospitalization Interactive Therapy (50 min.) Inpatient/Partial Hospitalization Interactive Therapy (50 min.)--MD Inpatient/Partial Hospitalization Interactive Therapy (80 min.) Inpatient/Partial Hospitalization Interactive Therapy (80 min.)--MD Inpatient/Partial Hospitalization Family Therapy without patient Family Therapy with patient Group Therapy (Multiple Family Group) Group Therapy (non-multiple family group) Interactive Group Psychotherapy Medication Check-Individual

Effective July 1, 2009

A M A

ris C d le ab is P s D A N nd lly -S Fu ta y en SN nt m D ou C op es el ic -C r C ev rv D Se de TN y ld D or C nl hi is D -C tO S se en C bu D sm A C s e es nd es ss nc fu ic ta -A y rv bs nt O Se A Su ou D is C m ith -C ris w ra C C N ld og se hi ST Pr bu C S -C A R D e A JO nc A SS ta C -M bs y J nl Su A ld tO SM hi C en es -C s sm ili S nd es ed am SC Fu ss C rb rF y tu -A ei nt is O th D ou d SA -C lly C an C s na io an TN r ot H er es M de et ic Em C or -V rv ly is T D Se us VE is od rio M ris ho C Se C ld hi lth D C ea SE ly M lH ar C ta -E en y D M nl EC ld tO M hi C en -C sm S C es M is ss C ris -A C O s d A le M nd C ab Fu is y D nt lly ou ta -C en C m P TN op es A D e l ic N A ev rv -S D Se y lt y SN er D du nl A ov -A tO ec S en R C D sm nd A s es ta nd ss en Fu -A y em O nt ag A ou D es ng A ic -C tE en rv C en N om Se tm ST is -W A ea ris se M Tr C O ea lt se is ed du SW D lv bu A -A le A vo er e In ab ER nd ic nc SS ST ffe ta un A O -D m bs e ic Su om SS st lt r/C SD Ju du A se al U -A in g S ru rim SC D A g -C y tin nl JO ec tO SC nj A en es -I ili R sm s D am es nd SC ss rF A Fu ei y -A th nt O d ou SA an A s -C y C es an er ic er TN ov s rv et M ec es A Se R -V lln am T is le lI gr ris ab VE ta ro C M St en A tP M lth E en ea ith SR em w lH M lt ta nc A du en ha A M En lt IM ity du A un y -A m nl S C om nt O M A e -C sm EP es ss -A
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

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Last Update: 6/292009

A M A

ris C d le ab is P s D A N nd lly -S Fu ta y en SN nt m D ou C op es el ic -C r C ev rv D Se de TN y ld D or C nl hi is D -C tO S se en C bu D sm A C s e es nd es ss nc fu ic ta -A y rv bs nt O Se A Su ou D is C m ith -C ris w ra C C N ld og se hi ST Pr bu C S -C A R D e A JO nc A SS ta C -M bs y J nl Su A ld tO SM hi C en es -C s sm ili S nd es ed am SC Fu ss C rb rF y tu -A ei nt is O th D ou d SA -C lly C an C s na io an TN r ot H er es M de et ic Em C or -V rv ly is T D Se us VE is od rio M ris ho C Se C ld hi lth D C ea SE ly M lH ar C ta -E en y D M nl EC ld tO M hi C en -C sm S C es M is ss C ris -A C O s d A le M nd C ab Fu is y D nt lly ou ta -C en C m P TN op es A D e l ic N A ev rv -S D Se y lt y SN er D du nl A ov -A tO ec S en R C D sm nd A s es ta nd ss en Fu -A y em O nt ag A ou D es ng A ic -C tE en rv C en N om Se tm ST is -W A ea ris se M Tr C O ea lt se is ed du SW D lv bu A -A le A vo er e In ab ER nd ic nc SS ST ffe ta un A O -D m bs e ic Su om SS st lt r/C SD Ju du A se al U -A in g S ru rim SC D A g -C y tin nl JO ec tO SC nj A en es -I ili R sm s D am es nd SC ss rF A Fu ei y -A th nt O d ou SA an A s -C y C es an er ic er TN ov s rv et M ec es A Se R -V lln am T is le lI gr ris ab VE ta ro C M St en A tP M lth E en ea ith SR em w lH M lt ta nc A du en ha A M En lt IM ity du A un y -A m nl S C om nt O M A e -C sm EP es ss -A
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

C M A

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90862:GT 96101 96105 96110 96111 96116 96118 96372 97001 97002 97003 97004 97110 97112 97113 97116 97124 97140 97530 97750 97761 97762 99201

Medication Check-Individual - Telemedicine Psychological Testing Aphasia Assessment Developmental Testing (Limited) Developmental Testing (Extended) Neurobehavioral Exam Neuropsychological testing battery Therapeutic, prophylactic, or diagnostic injection Physical Therapy Evaluation Physical Therapy Re-Evaluation Occupational Therapy Evaluation Occupational Therapy Re-Evaluation Physcial Therapy each 15 min. Physical Therapy (Nueromuscular reeducation) each 15 min. Aquatic Therapy Gait Training each 15 min. Massage Therapy each 15 min. Manual Therapy each 15 min. PT and OT Therapy Physical Performance Testing Prosthetic Training each 15 min. Checkout for Orthotic/Prosthetic Use Evaluation and Management-Problem Focused-New Patient

x x x x

x x x

x x x x x x x x x x x x x x x x x x

x

x

x

x

x

x

x

Effective July 1, 2009

Last Update: 6/292009

99201:GT 99202 99202:GT 99203 99203:GT 99204 99204:GT 99205 99205:GT 99211

Evaluation and Management-Problem Focused-New Patient - Telemedicine Evaluation and Management-ExpandedNew Patient Evaluation and Management-ExpandedNew Patient - Telemedicine Evaluation and Management-Detailed-New Patient Evaluation and Management-Detailed-New Patient - Telemedicine Evaluation and Management-Moderate-New Patient Evaluation and Management-Moderate-New Patient - Telemedicine Evaluation and Management-High-New Patient Evaluation and Management-High-New Patient - Telemedicine Evaluation and Management-Problem Focused-Established Patient Evaluation and Management-Problem Focused-Established Patient Telemedicine Evaluation and Management-ExpandedEstablished Patient Evaluation and Management-ExpandedEstablished Patient - Telemedicine

A M A

ris C d le ab is P s D A N nd lly -S Fu ta y en SN nt m D ou C op es el ic -C r C ev rv D Se de TN y ld D or C nl hi is D -C tO S se en C bu D sm A C s e es nd es ss nc fu ic ta -A y rv bs nt O Se A Su ou D is C m ith -C ris w ra C C N ld og se hi ST Pr bu C S -C A R D e A JO nc A SS ta C -M bs y J nl Su A ld tO SM hi C en es -C s sm ili S nd es ed am SC Fu ss C rb rF y tu -A ei nt is O th D ou d SA -C lly C an C s na io an TN r ot H er es M de et ic Em C or -V rv ly is T D Se us VE is od rio M ris ho C Se C ld hi lth D C ea SE ly M lH ar C ta -E en y D M nl EC ld tO M hi C en -C sm S C es M is ss C ris -A C O s d A le M nd C ab Fu is y D nt lly ou ta -C en C m P TN op es A D e l ic N A ev rv -S D Se y lt y SN er D du nl A ov -A tO ec S en R C D sm nd A s es ta nd ss en Fu -A y em O nt ag A ou D es ng A ic -C tE en rv C en N om Se tm ST is -W A ea ris se M Tr C O ea lt se is ed du SW D lv bu A -A le A vo er e In ab ER nd ic nc SS ST ffe ta un A O -D m bs e ic Su om SS st lt r/C SD Ju du A se al U -A in g S ru rim SC D A g -C y tin nl JO ec tO SC nj A en es -I ili R sm s D am es nd SC ss rF A Fu ei y -A th nt O d ou SA an A s -C y C es an er ic er TN ov s rv et M ec es A Se R -V lln am T is le lI gr ris ab VE ta ro C M St en A tP M lth E en ea ith SR em w lH M lt ta nc A du en ha A M En lt IM ity du A un y -A m nl S C om nt O M A e -C sm EP es ss -A
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

C M A

O

99211:GT 99212 99212:GT

Effective July 1, 2009

Last Update: 6/292009

99213 99213:GT 99214 99214:GT 99215 99215:GT 99221 99222 99223 99231 99232 99233 99234 99235 99236 99238 99239 99241

Evaluation and Management-DetailedEstablished Patient Evaluation and Management-DetailedEstablished Patient - Telemedicine Evaluation and Management-ModerateEstablished Patient Evaluation and Management-ModerateEstablished Patient - Telemedicine Evaluation and Management-HighEstablished Patient Evaluation and Management-HighEstablished Patient - Telemedicine Initial Hospital Care Low Severity Initial Hospital Care Mod Severity Initial Hospital Care High Severity Subsequent Hospital Care per Day Subsequent Hospital Care per Day Subsequent Hospital Care per Day Observation or Inpatient Hospital Care, Low Complexity Observation or Inpatient Hospital Care, Moderate Complexity Observation or Inpatient Hospital Care, High Complexity Hospital Discharge Day 30 min or less Hospital Discharge Day more than 30 min Office Consultation

Effective July 1, 2009

A M A

ris C d le ab is P s D A N nd lly -S Fu ta y en SN nt m D ou C op es el ic -C r C ev rv D Se de TN y ld D or C nl hi is D -C tO S se en C bu D sm A C s e es nd es ss nc fu ic ta -A y rv bs nt O Se A Su ou D is C m ith -C ris w ra C C N ld og se hi ST Pr bu C S -C A R D e A JO nc A SS ta C -M bs y J nl Su A ld tO SM hi C en es -C s sm ili S nd es ed am SC Fu ss C rb rF y tu -A ei nt is O th D ou d SA -C lly C an C s na io an TN r ot H er es M de et ic Em C or -V rv ly is T D Se us VE is od rio M ris ho C Se C ld hi lth D C ea SE ly M lH ar C ta -E en y D M nl EC ld tO M hi C en -C sm S C es M is ss C ris -A C O s d A le M nd C ab Fu is y D nt lly ou ta -C en C m P TN op es A D e l ic N A ev rv -S D Se y lt y SN er D du nl A ov -A tO ec S en R C D sm nd A s es ta nd ss en Fu -A y em O nt ag A ou D es ng A ic -C tE en rv C en N om Se tm ST is -W A ea ris se M Tr C O ea lt se is ed du SW D lv bu A -A le A vo er e In ab ER nd ic nc SS ST ffe ta un A O -D m bs e ic Su om SS st lt r/C SD Ju du A se al U -A in g S ru rim SC D A g -C y tin nl JO ec tO SC nj A en es -I ili R sm s D am es nd SC ss rF A Fu ei y -A th nt O d ou SA an A s -C y C es an er ic er TN ov s rv et M ec es A Se R -V lln am T is le lI gr ris ab VE ta ro C M St en A tP M lth E en ea ith SR em w lH M lt ta nc A du en ha A M En lt IM ity du A un y -A m nl S C om nt O M A e -C sm EP es ss -A
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

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Last Update: 6/292009

99241:GT 99242 99242:GT 99243 99243:GT 99244 99244:GT 99245 99245:GT 99251 99251:GT 99252 99252:GT 99253 99253:GT 99254 99254:GT 99255 99255:GT H0001 H0004 H0004-HQ

Office Consultation - Telemedicine Office Consultation Office Consultation - Telemedicine Office Consultation Office Consultation - Telemedicine Office Consultation Office Consultation - Telemedicine Office Consultation Office Consultation - Telemedicine Initial Inpatient Consultation Initial Inpatient Consultation - Telemedicine Initial Inpatient Consultation Initial Inpatient Consultation - Telemedicine Initial Inpatient Consultation Initial Inpatient Consultation - Telemedicine Initial Inpatient Consultation Initial Inpatient Consultation - Telemedicine Initial Inpatient Consultation Initial Inpatient Consultation - Telemedicine Alcohol and/or Drug Assessment Behavioral Health Counseling Behavioral Health Counseling - Group Therapy

Effective July 1, 2009

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ris C d le ab is P s D A N nd lly -S Fu ta y en SN nt m D ou C op es el ic -C r C ev rv D Se de TN y ld D or C nl hi is D -C tO S se en C bu D sm A C s e es nd es ss nc fu ic ta -A y rv bs nt O Se A Su ou D is C m ith -C ris w ra C C N ld og se hi ST Pr bu C S -C A R D e A JO nc A SS ta C -M bs y J nl Su A ld tO SM hi C en es -C s sm ili S nd es ed am SC Fu ss C rb rF y tu -A ei nt is O th D ou d SA -C lly C an C s na io an TN r ot H er es M de et ic Em C or -V rv ly is T D Se us VE is od rio M ris ho C Se C ld hi lth D C ea SE ly M lH ar C ta -E en y D M nl EC ld tO M hi C en -C sm S C es M is ss C ris -A C O s d A le M nd C ab Fu is y D nt lly ou ta -C en C m P TN op es A D e l ic N A ev rv -S D Se y lt y SN er D du nl A ov -A tO ec S en R C D sm nd A s es ta nd ss en Fu -A y em O nt ag A ou D es ng A ic -C tE en rv C en N om Se tm ST is -W A ea ris se M Tr C O ea lt se is ed du SW D lv bu A -A le A vo er e In ab ER nd ic nc SS ST ffe ta un A O -D m bs e ic Su om SS st lt r/C SD Ju du A se al U -A in g S ru rim SC D A g -C y tin nl JO ec tO SC nj A en es -I ili R sm s D am es nd SC ss rF A Fu ei y -A th nt O d ou SA an A s -C y C es an er ic er TN ov s rv et M ec es A Se R -V lln am T is le lI gr ris ab VE ta ro C M St en A tP M lth E en ea ith SR em w lH M lt ta nc A du en ha A M En lt IM ity du A un y -A m nl S C om nt O M A e -C sm EP es ss -A
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

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Last Update: 6/292009

H0004-HR H0004-HS H0005 H0010 H0012:HB H0013 H0014 H0015 H0019 H0020 H0031 H0035 H0036:HA H0036:HB H0036:HQ H0040 H2011 H2012-HA H2014 H2014-HM

Behavioral Health Counseling - Family Therapy with Client Behavioral Health Counseling - Family Therapy without Client Alcohol and/or Drug Group Counseling Non-Hospital Medical Detox SA Non-Medical Community Residential Treatment - Adult SA Medically Monitored Community Residential Treatment Ambulatory Detox SA Intensive Outpatient Program Behavorial Health - Long Term Residential Opioid Treatment Mental Health Assessment Mental Health - Partial Hospitalization Community Support: Individual Child Community Support: Individual Adult Community Support: Group Assertive Community Treatment Program Mobile Crisis Management Mental Health - Day Treatment - Child Developmental Therapy Service Professional Developmental Therapy Service Paraprofessional

Effective July 1, 2009

A M A

ris C d le ab is P s D A N nd lly -S Fu ta y en SN nt m D ou C op es el ic -C r C ev rv D Se de TN y ld D or C nl hi is D -C tO S se en C bu D sm A C s e es nd es ss nc fu ic ta -A y rv bs nt O Se A Su ou D is C m ith -C ris w ra C C N ld og se hi ST Pr bu C S -C A R D e A JO nc A SS ta C -M bs y J nl Su A ld tO SM hi C en es -C s sm ili S nd es ed am SC Fu ss C rb rF y tu -A ei nt is O th D ou d SA -C lly C an C s na io an TN r ot H er es M de et ic Em C or -V rv ly is T D Se us VE is od rio M ris ho C Se C ld hi lth D C ea SE ly M lH ar C ta -E en y D M nl EC ld tO M hi C en -C sm S C es M is ss C ris -A C O s d A le M nd C ab Fu is y D nt lly ou ta -C en C m P TN op es A D e l ic N A ev rv -S D Se y lt y SN er D du nl A ov -A tO ec S en R C D sm nd A s es ta nd ss en Fu -A y em O nt ag A ou D es ng A ic -C tE en rv C en N om Se tm ST is -W A ea ris se M Tr C O ea lt se is ed du SW D lv bu A -A le A vo er e In ab ER nd ic nc SS ST ffe ta un A O -D m bs e ic Su om SS st lt r/C SD Ju du A se al U -A in g S ru rim SC D A g -C y tin nl JO ec tO SC nj A en es -I ili R sm s D am es nd SC ss rF A Fu ei y -A th nt O d ou SA an A s -C y C es an er ic er TN ov s rv et M ec es A Se R -V lln am T is le lI gr ris ab VE ta ro C M St en A tP M lth E en ea ith SR em w lH M lt ta nc A du en ha A M En lt IM ity du A un y -A m nl S C om nt O M A e -C sm EP es ss -A
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

C M A

O

Last Update: 6/292009

H2014-HQ H2014-U1 H2015:HT H2017

Developmental Therapy Service Professional - Group Developmental Therapy Service Paraprofessional - Group Community Support Team Psychosocial Rehab Services Residential Treatment - Level II - Program Type (Therapeutic Behavioral Service) Intensive In-Home Services Multisystemic Therapy SA Halfway House SA Comprehensive Outpatient Treatment Program Medically Supervised or ADATC Detox Residential Treatment - Level II - Family Type (Foster Care Therapeutic Child) Facility Based Crisis Service Targeted Case Management Developmental Disability Diagnostic Assessment Diagnostic Assessment - telemedicine Telehealth originating site facility fee Hourly Respite Community Respite Psychiatric Residential Treatment Facility Room and Board - Level III (1-4 Beds) Room and Board - Level III (5+ Beds)

A M A

ris C d le ab is P s D A N nd lly -S Fu ta y en SN nt m D ou C op es el ic -C r C ev rv D Se de TN y ld D or C nl hi is D -C tO S se en C bu D sm A C s e es nd es ss nc fu ic ta -A y rv bs nt O Se A Su ou D is C m ith -C ris w ra C C N ld og se hi ST Pr bu C S -C A R D e A JO nc A SS ta C -M bs y J nl Su A ld tO SM hi C en es -C s sm ili S nd es ed am SC Fu ss C rb rF y tu -A ei nt is O th D ou d SA -C lly C an C s na io an TN r ot H er es M de et ic Em C or -V rv ly is T D Se us VE is od rio M ris ho C Se C ld hi lth D C ea SE ly M lH ar C ta -E en y D M nl EC ld tO M hi C en -C sm S C es M is ss C ris -A C O s d A le M nd C ab Fu is y D nt lly ou ta -C en C m P TN op es A D e l ic N A ev rv -S D Se y lt y SN er D du nl A ov -A tO ec S en R C D sm nd A s es ta nd ss en Fu -A y em O nt ag A ou D es ng A ic -C tE en rv C en N om Se tm ST is -W A ea ris se M Tr C O ea lt se is ed du SW D lv bu A -A le A vo er e In ab ER nd ic nc SS ST ffe ta un A O -D m bs e ic Su om SS st lt r/C SD Ju du A se al U -A in g S ru rim SC D A g -C y tin nl JO ec tO SC nj A en es -I ili R sm s D am es nd SC ss rF A Fu ei y -A th nt O d ou SA an A s -C y C es an er ic er TN ov s rv et M ec es A Se R -V lln am T is le lI gr ris ab VE ta ro C M St en A tP M lth E en ea ith SR em w lH M lt ta nc A du en ha A M En lt IM ity du A un y -A m nl S C om nt O M A e -C sm EP es ss -A
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

C M A

O

H2020 H2022 H2033 H2034 H2035 H2036 S5145 S9484 T1017-HI T1023 T1023:GT Q3014:GT YA125 YA213 YA230 YA232 YA233

x x x

x x x x

x x x

x x x

x x x

x x x

x x x

Effective July 1, 2009

Last Update: 6/292009

YA234 YA235 YA236 YA237 YA238 YA241 YA254 YA255 YA256 YA257 YA258 YA259 YA263 YA264 YA265 YA266

Room and Board - Level II (Age 5 or less) Room and Board - Level II (Age 6-12) Room and Board - Level II (Age 13+) Room and Board - Level IV (1-4 Beds) Room and Board - Level IV (5+ Beds) Wilderness Camp Therapeutic Leave - Resid Level II Therapeutic Foster Care Therapeutic Leave - Residential Level II/Program Type Therapeutic Leave - Residential Level III (14 Beds) Therapeutic Leave - Residential Level III (5+ Beds) Therapeutic Leave - Residential Level IV (14 Beds) Therapeutic Leave - Residential Level IV (5+ Beds) Therapeutic Leave Room and Board - Level III (1-4 Beds) Therapeutic Leave Room and Board - Level III (5+ Beds) Therapeutic Leave Room and Board - Level II (Age 5 or less) Therapeutic Leave Room and Board - Level II (Age 6-12)

Effective July 1, 2009

A M A

ris C d le ab is P s D A N nd lly -S Fu ta y en SN nt m D ou C op es el ic -C r C ev rv D Se de TN y ld D or C nl hi is D -C tO S se en C bu D sm A C s e es nd es ss nc fu ic ta -A y rv bs nt O Se A Su ou D is C m ith -C ris w ra C C N ld og se hi ST Pr bu C S -C A R D e A JO nc A SS ta C -M bs y J nl Su A ld tO SM hi C en es -C s sm ili S nd es ed am SC Fu ss C rb rF y tu -A ei nt is O th D ou d SA -C lly C an C s na io an TN r ot H er es M de et ic Em C or -V rv ly is T D Se us VE is od rio M ris ho C Se C ld hi lth D C ea SE ly M lH ar C ta -E en y D M nl EC ld tO M hi C en -C sm S C es M is ss C ris -A C O s d A le M nd C ab Fu is y D nt lly ou ta -C en C m P TN op es A D e l ic N A ev rv -S D Se y lt y SN er D du nl A ov -A tO ec S en R C D sm nd A s es ta nd ss en Fu -A y em O nt ag A ou D es ng A ic -C tE en rv C en N om Se tm ST is -W A ea ris se M Tr C O ea lt se is ed du SW D lv bu A -A le A vo er e In ab ER nd ic nc SS ST ffe ta un A O -D m bs e ic Su om SS st lt r/C SD Ju du A se al U -A in g S ru rim SC D A g -C y tin nl JO ec tO SC nj A en es -I ili R sm s D am es nd SC ss rF A Fu ei y -A th nt O d ou SA an A s -C y C es an er ic er TN ov s rv et M ec es A Se R -V lln am T is le lI gr ris ab VE ta ro C M St en A tP M lth E en ea ith SR em w lH M lt ta nc A du en ha A M En lt IM ity du A un y -A m nl S C om nt O M A e -C sm EP es ss -A
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

C M A

O

Last Update: 6/292009

YA267 YA268 YA269 YM050 YM580 YM600 YM645 YM686 YM700 YM716 YM725 YM755 YM811 YM812 YM813 YM814 YM815 YM816 YM850 YP010 YP011 YP020 YP118 YP230

Therapeutic Leave Room and Board - Level II (Age 13+) Therapeutic Leave Room and Board - Level IV (1-4 Beds) Therapeutic Leave Room and Board - Level IV (5+ Beds) Personal Care Day Supports Financial Support Services Long Term Support Guardianship Independent Living-MR/MI Individual Supports Sup Liv – High Family Living – High Supervised Living – 1 Resident Supervised Living – 2 Resident Supervised Living – 3 Resident Supervised Living – 4 Resident Supervised Living – 5 Resident Supervised Living – 6 Resident Residential Supports Hourly Respite – Individ Hourly Respite – Group Per Asst – Individ Disaster/Emergency Services Assert Outreach

Effective July 1, 2009

A M A

ris C d le ab is P s D A N nd lly -S Fu ta y en SN nt m D ou C op es el ic -C r C ev rv D Se de TN y ld D or C nl hi is D -C tO S se en C bu D sm A C s e es nd es ss nc fu ic ta -A y rv bs nt O Se A Su ou D is C m ith -C ris w ra C C N ld og se hi ST Pr bu C S -C A R D e A JO nc A SS ta C -M bs y J nl Su A ld tO SM hi C en es -C s sm ili S nd es ed am SC Fu ss C rb rF y tu -A ei nt is O th D ou d SA -C lly C an C s na io an TN r ot H er es M de et ic Em C or -V rv ly is T D Se us VE is od rio M ris ho C Se C ld hi lth D C ea SE ly M lH ar C ta -E en y D M nl EC ld tO M hi C en -C sm S C es M is ss C ris -A C O s d A le M nd C ab Fu is y D nt lly ou ta -C en C m P TN op es A D e l ic N A ev rv -S D Se y lt y SN er D du nl A ov -A tO ec S en R C D sm nd A s es ta nd ss en Fu -A y em O nt ag A ou D es ng A ic -C tE en rv C en N om Se tm ST is -W A ea ris se M Tr C O ea lt se is ed du SW D lv bu A -A le A vo er e In ab ER nd ic nc SS ST ffe ta un A O -D m bs e ic Su om SS st lt r/C SD Ju du A se al U -A in g S ru rim SC D A g -C y tin nl JO ec tO SC nj A en es -I ili R sm s D am es nd SC ss rF A Fu ei y -A th nt O d ou SA an A s -C y C es an er ic er TN ov s rv et M ec es A Se R -V lln am T is le lI gr ris ab VE ta ro C M St en A tP M lth E en ea ith SR em w lH M lt ta nc A du en ha A M En lt IM ity du A un y -A m nl S C om nt O M A e -C sm EP es ss -A
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

C M A

O

Last Update: 6/292009

YP485 YP610 YP620 YP630 YP640 YP650 YP660 YP690 YP692 YP710 YP720 YP730 YP740 YP750 YP760 YP770 YP780 YP790 YP820 YP821 YP830 YP831 YP832

Facility Based Crisis Program - NonMedicaid Dev Day ADVP Sup Emp – Ind Sup Emp – Group Community Rehabilitation Program (Sheltered Workshop) Day Activity Drop In – Attend Drop In – Cover Sup Liv – Low Sup Liv – Mod. Comm Respite Family Living – Low Familiy Living – Mod GP Liv – Low GP Liv – Mod GP Liv – Hi Detox – Soc Set Inpat Hosp 3-Way Contract - IPU Bed Alcohol and/or Drug Assessment - nonlicensed provider Behavioral Health Counseling - nonlicensed provider Behavioral Health Counseling - Group Therapy - non-licensed provider

Effective July 1, 2009

A M A

ris C d le ab is P s D A N nd lly -S Fu ta y en SN nt m D ou C op es el ic -C r C ev rv D Se de TN y ld D or C nl hi is D -C tO S se en C bu D sm A C s e es nd es ss nc fu ic ta -A y rv bs nt O Se A Su ou D is C m ith -C ris w ra C C N ld og se hi ST Pr bu C S -C A R D e A JO nc A SS ta C -M bs y J nl Su A ld tO SM hi C en es -C s sm ili S nd es ed am SC Fu ss C rb rF y tu -A ei nt is O th D ou d SA -C lly C an C s na io an TN r ot H er es M de et ic Em C or -V rv ly is T D Se us VE is od rio M ris ho C Se C ld hi lth D C ea SE ly M lH ar C ta -E en y D M nl EC ld tO M hi C en -C sm S C es M is ss C ris -A C O s d A le M nd C ab Fu is y D nt lly ou ta -C en C m P TN op es A D e l ic N A ev rv -S D Se y lt y SN er D du nl A ov -A tO ec S en R C D sm nd A s es ta nd ss en Fu -A y em O nt ag A ou D es ng A ic -C tE en rv C en N om Se tm ST is -W A ea ris se M Tr C O ea lt se is ed du SW D lv bu A -A le A vo er e In ab ER nd ic nc SS ST ffe ta un A O -D m bs e ic Su om SS st lt r/C SD Ju du A se al U -A in g S ru rim SC D A g -C y tin nl JO ec tO SC nj A en es -I ili R sm s D am es nd SC ss rF A Fu ei y -A th nt O d ou SA an A s -C y C es an er ic er TN ov s rv et M ec es A Se R -V lln am T is le lI gr ris ab VE ta ro C M St en A tP M lth E en ea ith SR em w lH M lt ta nc A du en ha A M En lt IM ity du A un y -A m nl S C om nt O M A e -C sm EP es ss -A
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

C M A

O

Last Update: 6/292009

Public Psychiatry - Administrative Functions Public Psychiatry - Consultation and Service Functions

Behavioral Health Counseling - Family Therapy with Client - non-licensed provider

Behavioral Health Counseling - Family Therapy without Client - non-licensed provider Alcohol and/or Drug Group Counseling non-licensed provider Mental Health Assessment - non-licensed provider

C M A A M A O

YP833

YP834

YP835

YP851

YP836

YP852

Effective July 1, 2009

ris C d le ab is P s D A N nd lly -S Fu ta y en SN nt m D ou C op es el ic -C r C ev rv D Se de TN y ld D or C nl hi is D -C tO S se en C bu D sm A C s e es nd es ss nc fu ic ta -A y rv bs nt O Se A Su ou D is C m ith -C ris w ra C C N ld og se hi ST Pr bu C S -C A R D e A JO nc A SS ta C -M bs y J nl Su A ld tO SM hi C en es -C s sm ili S nd es ed am SC Fu ss C rb rF y tu -A ei nt is O th D ou d SA -C lly C an C s na io an TN r ot H er es M de et ic Em C or -V rv ly is T D Se us VE is od rio M ris ho C Se C ld hi lth D C ea SE ly M lH ar C ta -E en y D M nl EC ld tO M hi C en -C sm S C es M is ss C ris -A C O s d A le M nd C ab Fu is y D nt lly ou ta -C en C m P TN op es A D e l ic N A ev rv -S D Se y lt y SN er D du nl A ov -A tO ec S en R C D sm nd A s es ta nd ss en Fu -A y em O nt ag A ou D es ng A ic -C tE en rv C en N om Se tm ST is -W A ea ris se M Tr C O ea lt se is ed du SW D lv bu A -A le A vo er e In ab ER nd ic nc SS ST ffe ta un A O -D m bs e ic Su om SS st lt r/C SD Ju du A se al U -A in g S ru rim SC D A g -C y tin nl JO ec tO SC nj A en es -I ili R sm s D am es nd SC ss rF A Fu ei y -A th nt O d ou SA an A s -C y C es an er ic er TN ov s rv et M ec es A Se R -V lln am T is le lI gr ris ab VE ta ro C M St en A tP M lth E en ea ith SR em w lH M lt ta nc A du en ha A M En lt IM ity du A un y -A m nl S C om nt O M A e -C sm EP es ss -A
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

Last Update: 6/292009

x

x

x x x

x

x

x x

x

SN N -S P A nd s l ab is D
CSA CDD x x x x x x x x x x x x x x x x x x x x x x x

y nt Fu

lly ta en ed is ris C
CDD x x CDD x x x x x x x x x x x x x x x x x x x x x x x x x x x CDD x x x x x x x x x x x x

Effective July 1, 2009

Last Update: 6/292009

SN N -S P A nd s l ab is D ed is ris C
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

y nt Fu

lly ta en

Effective July 1, 2009

Last Update: 6/292009

SN N -S P A nd s l ab is D ed is ris C
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

y nt Fu

lly ta en

Effective July 1, 2009

Last Update: 6/292009

SN N -S P A nd s l ab is D ed is ris C
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

y nt Fu

lly ta en

Effective July 1, 2009

Last Update: 6/292009

SN N -S P A nd s l ab is D ed is ris C
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

y nt Fu

lly ta en

Effective July 1, 2009

Last Update: 6/292009

SN N -S P A nd s l ab is D ed is ris C
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

y nt Fu

lly ta en

Effective July 1, 2009

Last Update: 6/292009

SN N -S P A nd s l ab is D ed is ris C
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

y nt Fu

lly ta en

Effective July 1, 2009

Last Update: 6/292009

SN N -S P A nd s l ab is D ed is ris C
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

y nt Fu

lly ta en

Effective July 1, 2009

Last Update: 6/292009

SN N -S P A nd s l ab is D ed is ris C
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

y nt Fu

lly ta en

Effective July 1, 2009

Last Update: 6/292009

SN N -S P A nd s l ab is D ed is ris C
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

y nt Fu

lly ta en

Effective July 1, 2009

Last Update: 6/292009

SN N -S P A nd s l ab is D ed is ris C
x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

y nt Fu

lly ta en

Effective July 1, 2009

Last Update: 6/292009

SN N -S P A nd s l ab is D ed is ris C
x x x x x x x x x x x x

y nt Fu

lly ta en

Effective July 1, 2009

Last Update: 6/292009

State Plan IPRS Covered Services (FY08-09)

HCPCS Code H0004 H0004 H0004 H2012 T1017 H0012 H2015 H2014 H2014 H2014 90801 90804 90805 90806 90807 90862 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99241 99242 99243 99244 99245

Modifier

Description

Tracking-Only Code YP955 YP954 YP972 YP951 YP962 YP965 YP968 YP969 YP970 YP971 YP973 YP974 YP975 YP976 YP977 YP978 YP979 YP980 YP981 YP982 YP983 YP984 YP985 YP986 YP987 YP988 YP989 YP990 YP991 YP992 YP993

HQ HR HS HA HI HB HT HM HQ U1 GT GT GT GT GT GT GT GT GT GT GT GT GT GT GT GT GT GT GT GT GT

Behavioral Health Counseling - Group Therapy Behavioral Health Counseling - Family Therapy with Client Behavioral Health Counseling - Family Therapy without Client Mental Health - Day Treatment - Child Targeted Case Management - Develop Disabil SA Non-Medical Community Residential Treatment - Adult Community Support Team Developmental Therapy Service Paraprofessional Developmental Therapy Service Professional - Group Developmental Therapy Service Para professional - Group Clinical Intake - Telemedicine Individual Therapy (20-30 min.) Individual Therapy (20-30 min.)--MD Individual Therapy (45-50 min.) Individual Therapy (45-50 min.)--MD Medication Check-Individual Evaluation and Management-Problem Focused-New Patient Evaluation and Management-ExpandedNew Patient Evaluation and Management-DetailedNew Patient Evaluation and Management-ModerateNew Patient Evaluation and Management-High-New Patient Evaluation and Management-Problem Focused-Established Patient Evaluation and Management-ExpandedEstablished Patient Evaluation and Management-DetailedEstablished Patient Evaluation and Management-ModerateEstablished Patient Evaluation and Management-HighEstablished Patient Office Consultation Office Consultation Office Consultation Office Consultation Office Consultation

Last Updated 1/15/2009

Page 26

State Plan IPRS Covered Services (FY08-09)

99251 99252 99253 99254 99255 T1023 Q3014 H0036 H0036 H0036 H0036 H0036 H0036 90808 90809 H0036 H0036 H0036 H0036 H0036 H0036 H0036 H0036 H0036 H0036 H0036 H0036

GT GT GT GT GT GT GT HA, U3 HA, U4 HB, U3 HB, U4 HQ, U3 HQ, U4 GT GT HA, HP HA, HO HA, HN HA, UB HB, HP HB, HO HB, HN HB, UB HQ, U8 HQ, U7 HQ, U6 HQ, U5

Initial Inpatient Consultation Initial Inpatient Consultation Initial Inpatient Consultation Initial Inpatient Consultation Initial Inpatient Consultation Diagnostic Assessment Telehealth originating site Community Support: Individual Child Qualified Professional Community Support: Individual Child Non-Qualified Professional Community Support: Individual Adult Qualified Professional Community Support: Individual Adult Non-Qualified Professional Community Support: Group - Qualified Professional Community Support: Group - NonQualified Professional Individual Therapy (75+ minutes) Telemedicine Individual Therapy (75+ minutes) - MD Telemedicine Community Support: Individual Child Licensed Community Support: Individual Child Unlicensed Community Support: Individual Child Associate Professional Community Support: Individual Child Paraprofessional Community Support: Individual Adult Licensed Community Support: Individual Adult Unlicensed Community Support: Individual Adult Associate Professional Community Support: Individual Adult Paraprofessional Community Support: Group - Licensed Community Support: Group - Unlicensed Community Support: Group - Associate Professional Community Support: Group Paraprofessional

YP994 YP995 YP996 YP997 YP998 YP999 YP900 YP901 YP902 YP903 YP904 YP905 YP906 YP907 YP908 YP909 YP910 YP911 YP912 YP913 YP914 YP915 YP916 YP917 YP918 YP919 YP920

Last Updated 1/15/2009

Page 27


								
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