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					                                                                                                                                  PIHP FY07 Medicaid Utilization and Net Cost Report                                                                                                             Page: 1




                 PIHP Name:                                                                                                        FY2009
Reporting Period: October 1, 2008 to September 30, 2009
                           A                            B        C           D                         E                                  F               G            H                  I              J              K             L               M               N                O               P
           Service Description (Chapter III &        HCPCS    Modifier    Revenue        Reporting Code Description -              Reporting Units     Unique     State Plan         State Plan   B3 Additional        B3        HSW Services   HSW Services   Total Medicaid   Total Medicaid    Aggregated
LineID




                    PIHP Contract)                    Code                 Code          See CPT/HCPCS Manuals for                                      cases    Services units    Services Total Services Units   Additional       Units        Total Costs       Units            Costs             Net
                                                                                         Details                                                       served                          Costs                        Services                                                                       Cost/Unit
                                                                                                                                                                                                                   Total Costs
   1     Local Psychiatric Hospital/IMD PT68                    PT68     0100,   0101,   All inclusive room and board plus        Day                sdsdfsdf   fdsdfsdfsf        dfdsfsdf                                                                        #VALUE!          #VALUE!          #VALUE!
                                                                         0114,   0124,   ancillaries
                                                                         0134,   0154
   2     Local Psychiatric Hospital - Acute                     PT73     0100,   0101,   All inclusive room and board             Day                                                                                                                                       0                0                0
         Community PT73                                                  0114,   0124,
                                                                         0134,   0154
   3     ECT Anesthesia                                                  0370            Anesthesia charges                                                                                                                                                                 0                0                0
   4     ECT Recovery Room                                               0710            Recovery room charge                                                                                                                                                               0                0                0
   5     Crisis Observation Care                                         0762            Outpatient extended observation beds     Hour                                                                                                                                      0                0                0
                                                                                         (23 hour)
   6     Electro-Convulsive Therapy                                      0901            Facility charges                         Encounter                                                                                                                                 0                0                0
   7     Outpatient Partial Hospitalization                              0912            Partial hospitalization-Less Intensive   Day                                                                                                                                       0                0                0
   8     Outpatient Partial Hospitalization                              0913            Partial hospitalization-More Intensive   Day                                                                                                                                       0                0                0
   9     Electro-Convulsive Therapy                   00104                              Anesthesia charges for ECT               Minutes                                                                                                                                   0                0                0
  10     Drug Screen for Methadone clients only       80100                              Methodone drug screen                    Per Screen                                                                                                                                0                0                0
  11     Alcohol Breath Test for Methadone clients    82075                              Methodone alcohol breath teast           Per Test                                                                                                                                  0                0                0
         only
  12     Medication Administration                    90772                              Only used when provided as separate      Encounter                                                                                                                                 0                0                0
                                                                                         service.
  13 Assessment-Psychiatric Assessment                90801                              Psychiatric diagnostic interview         Encounter                                                                                                                                 0                0                0
                                                                                         examination
  14 Substance Abuse: Psychiatric Evaluation          90801                              Psychiatric diagnostic interview         Encounter                                                                                                                                 0                0                0
                                                                                         examination
  15 Assessment-Psychiatric Assessment                90802                              Interactive psychiatric diagnostic       Encounter                                                                                                                                 0                0                0
                                                                                         interview examination
  16 Substance Abuse: Psychiatric Evaluation          90802                              Interactive psychiatric diagnostic       Encounter                                                                                                                                 0                0                0
                                                                                         interview examination
  17 Therapy-Individual Therapy                       90804                              Individual psychotherapy 20-30           Encounter 20-30                                                                                                                           0                0                0
                                                                                         minutes                                  Min
  18 Substance Abuse: Outpatient Care                 90804              0900,   0914,   Individual Psychotherapy                 Encounter 20-30                                                                                                                           0                0                0
                                                                         0915,   0916,                                            Min
                                                                         0919
  19 Substance Abuse: Outpatient Care                 90805              0900,   0914,   Individual Psychotherapy                 Encounter 20-30                                                                                                                           0                0                0
                                                                         0915,   0916,                                            Min
                                                                         0919
  20 Therapy-Individual Therapy                       90806                              Individual psychotherapy 45-50           Encounter 45-50                                                                                                                           0                0                0
                                                                                         minutes                                  Min
  21 Substance Abuse: Outpatient Care                 90806              0900, 0914,     Individual Psychotherapy                 Encounter 45-50                                                                                                                           0                0                0
                                                                         0915, 0916,                                              Min
                                                                         0919
  22 Therapy-Individual Therapy                       90807                               Individual psychotherapy with medical Encounter 45-50                                                                                                                             0                0                0
                                                                                         evaluation and management services     Min
  23 Substance Abuse: Outpatient Care                 90807              0900, 0914,     Individual Psychotherapy               Encounter 45-50                                                                                                                             0                0                0
                                                                         0915, 0916,                                            Min
                                                                         0919
  24 Therapy-Individual Therapy                       90808                              Individual psychotherapy 75-80           Encounter 75-80                                                                                                                           0                0                0
                                                                                         minutes                                  Min
  25 Substance Abuse: Outpatient Care                 90808              0900, 0914,     Individual Psychotherapy                 Encounter 75-80                                                                                                                           0                0                0
                                                                         0915, 0916,                                              Min
                                                                         0919
  26 Therapy-Individual Therapy                       90809                              Individual psychotherapy with medical    Encounter 75-80                                                                                                                           0                0                0
                                                                                         evaluation and management services       Min
  27 Substance Abuse: Outpatient Care                 90809              0900, 0914,     Individual Psychotherapy                 Encounter 75-80                                                                                                                           0                0                0
                                                                         0915, 0916,                                              Min
                                                                         0919
  28 Therapy-Individual Therapy                       90810                              Individual psychotherapy, interactive    Encounter 20-30                                                                                                                           0                0                0
                                                                                         20-30 minutes                            Min
  29 Substance Abuse: Outpatient Care                 90810              0900, 0914,     Individual Psychotherapy                 Encounter 20-30                                                                                                                           0                0                0
                                                                         0915, 0916,                                              Min
                                                                         0919
  30 Therapy-Individual Therapy                       90811                              Individual psychotherapy with medical    Encounter 20-30                                                                                                                           0                0                0
                                                                                         evaluation and management services       Min
  31 Substance Abuse: Outpatient Care                 90811              0900, 0914,     Individual Psychotherapy                 Encounter 20-30                                                                                                                           0                0                0
                                                                         0915, 0916,                                              Min
                                                                         0919
  32 Therapy-Individual Therapy                       90812                              Individual psychotherapy, interactive    Encounter 45-50                                                                                                                           0                0                0
                                                                                         45-50 minutes                            Min
  33 Substance Abuse: Outpatient Care                 90812              0900, 0914,     Individual Psychotherapy                 Encounter 45-50                                                                                                                           0                0                0
                                                                         0915, 0916,                                              Min
                                                                         0919
  34 Therapy-Individual Therapy                       90813                               Individual psychotherapy with medical Encounter 45-50                                                                                                                             0                0                0
                                                                                         evaluation and management services     Min
  35 Substance Abuse: Outpatient Care                 90813              0900, 0914,     Individual Psychotherapy               Encounter 45-50                                                                                                                             0                0                0
                                                                         0915, 0916,                                            Min
                                                                         0919
  36 Therapy-Individual Therapy                       90814                              Individual psychotherapy, interactive    Encounter 75-80                                                                                                                           0                0                0
                                                                                         75-80 minutes                            Min
  37 Substance Abuse: Outpatient Treatment            90814              0900, 0914,     Individual Psychotherapy                 Encounter 75-80                                                                                                                           0                0                0
                                                                         0915, 0916,                                              Min
                                                                         0919
  38 Therapy-Individual Therapy                       90815                              Individual psychotherapy with medical    Encounter 75-80                                                                                                                           0                0                0
                                                                                         evaluation and management services       Min
  39 Substance Abuse: Outpatient Care                 90815              0900, 0914,     Individual Psychotherapy                 Encounter 75-80                                                                                                                           0                0                0
                                                                         0915, 0916,                                              Min
                                                                         0919




          December 21, 2007
                                                                                                                          PIHP FY07 Medicaid Utilization and Net Cost Report                                                                                                           Page: 2




                 PIHP Name:                                                                                                 FY2009
Reporting Period: October 1, 2008 to September 30, 2009
                           A                       B        C           D                       E                                 F               G           H                 I              J              K             L               M               N                O               P
           Service Description (Chapter III &   HCPCS    Modifier    Revenue      Reporting Code Description -             Reporting Units     Unique    State Plan        State Plan   B3 Additional        B3        HSW Services   HSW Services   Total Medicaid   Total Medicaid    Aggregated
LineID




                    PIHP Contract)               Code                 Code        See CPT/HCPCS Manuals for                                     cases   Services units   Services Total Services Units   Additional       Units        Total Costs       Units            Costs             Net
                                                                                  Details                                                      served                        Costs                        Services                                                                       Cost/Unit
                                                                                                                                                                                                         Total Costs
  40 Therapy-Individual Therapy                  90816                            Individual psychotherapy                 Encounter   20-30                                                                                                                      0                0             0
                                                                                                                           Min
  41 Therapy-Individual Therapy                  90817                            Individual psychotherapy with medical    Encounter   20-30                                                                                                                      0                0             0
                                                                                  evaluation and management services       Min
  42 Therapy-Individual Therapy                  90818                            Individual psychotherapy                 Encounter   45-50                                                                                                                      0                0             0
                                                                                                                           Min
  43 Therapy-Individual Therapy                  90819                            Individual psychotherapy with medical    Encounter   45-50                                                                                                                      0                0             0
                                                                                  evaluation and management services       Min
  44 Therapy-Individual Therapy                  90821                            Individual psychotherapy                 Encounter   75-80                                                                                                                      0                0             0
                                                                                                                           Min
  45 Therapy-Individual Therapy                  90822                            Individual psychotherapy with medical    Encounter   75-80                                                                                                                      0                0             0
                                                                                  evaluation and management services       Min
  46 Therapy-Individual Therapy                  90823                            Individual psychotherapy, interactive    Encounter   20-30                                                                                                                      0                0             0
                                                                                                                           Min
  47 Therapy-Individual Therapy                  90824                            Individual psychotherapy with medical    Encounter   20-30                                                                                                                      0                0             0
                                                                                  evaluation and management services       Min
  48 Therapy-Individual Therapy                  90826                            Individual psychotherapy, interactive    Encounter   45-50                                                                                                                      0                0             0
                                                                                                                           Min
  49 Therapy-Individual Therapy                  90827                            Individual psychotherapy with medical    Encounter   45-50                                                                                                                      0                0             0
                                                                                  evaluation and management services       Min
  50 Therapy-Individual Therapy                  90828                            Individual psychotherapy                 Encounter   75-80                                                                                                                      0                0             0
                                                                                                                           Min
  51 Therapy-Individual Therapy                  90829                            Individual psychotherapy with medical    Encounter   75-80                                                                                                                      0                0             0
                                                                                  evaluation and management services       Min
  52 Therapy-Family Therapy                      90846                            Family therapy, per session              Encounter                                                                                                                              0                0             0
  53 Therapy-Family Therapy                      90847                            Family psychotherapy (conjoint           Encounter                                                                                                                              0                0             0
                                                                                  psychotherapy) (with patient present)

  54 Substance Abuse: Outpatient Care            90847              0900, 0906,   Family psychotherapy                     Encounter                                                                                                                              0                0             0
                                                                    0914, 0915,
                                                                    0916, 0919
  55 Therapy-Family Therapy                      90849                            Family psycho-education with             Encounter                                                                                                                              0                0             0
                                                                                  consumer present (EBP only)
  56 Therapy-Family Therapy                      90849      HS                    Family psycho-education without          Encounter                                                                                                                              0                0             0
                                                                                  consumer present (EBP only)
  57 Therapy-Group Therapy                       90853                            Group therapy, adult or child, per       Encounter                                                                                                                              0                0             0
                                                                                  session
  58 Substance Abuse: Outpatient Treatment       90853              0900, 0906,   Group psychotherapy                      Encounter                                                                                                                              0                0             0
                                                                    0914, 0915,
                                                                    0916, 0919
  59 Therapy-Group Therapy                       90857                            Interactive group psychotherapy          Encounter                                                                                                                              0                0             0
  60 Substance Abuse: Outpatient Treatment       90857              0900, 0906,   Interactive group psychotherapy          Encounter                                                                                                                              0                0             0
                                                                    0914, 0915,
                                                                    0916, 0919
  61 Medication Review                           90862                            Brief assessment, dosage adjustment,     Encounter                                                                                                                              0                0             0
                                                                                  minimal psychotherapy, TD testing
  62 Substance Abuse: Medication Review          90862                            Brief assessment, dosage adjustment,     Encounter                                                                                                                              0                0             0
                                                                                  minimial psychotherapy
  63 Electroconvulsive Therapy                   90870                            Attending physician charges              Encounter                                                                                                                              0                0             0
  64 Assessments-Other                           90887                            Interpretation or explanation of results Encounter                                                                                                                              0                0             0
                                                                                  of psychiatric exams
  65     Speech & Language Therapy               92506                            Speech & language evaluation             Encounter                                                                                                                              0                0             0
  66     Speech & Language Therapy               92507                            Speech & language therapy, individual    Encounter                                                                                                                              0                0             0
  67     Speech & Language Therapy               92508                            Speech & language therapy, group         Encounter                                                                                                                              0                0             0
  68     Speech & Language Therapy               92526                            Speech & language therapy, individual    Encounter                                                                                                                              0                0             0
  69     Speech & Language Therapy               92610                            Speech & language evaluation             Encounter                                                                                                                              0                0             0
  70     Assessments - Testing                   96101                            Psychological testing                    Hour                                                                                                                                   0                0             0
  71     Assessments - Testing                   96102                            Psychological testing                    Hour                                                                                                                                   0                0             0
  72     Assessments - Testing                   96103                            Psychological testing                    Hour                                                                                                                                   0                0             0
  73     Assessments - Other                     96105                            Assessment of aphasia                    Encounter                                                                                                                              0                0             0
  74     Assessments - Other                     96110                            Developmental testing; limited           Encounter                                                                                                                              0                0             0
  75     Assessments - Other                     96111                            Developmental testing extended           Encounter                                                                                                                              0                0             0
  76     Assessments - Testing                   96116                            Neurobehavioral status exam              Hour                                                                                                                                   0                0             0
  77     Assessments - Testing                   96118                            Neuropsychological testing battery        Hour                                                                                                                                  0                0             0
                                                                                  (with doctor)
  78 Assessments - Testing                       96119                            Neuropsychological testing battery        Hour                                                                                                                                  0                0             0
                                                                                  (with qualified health care professional)

  79 Assessments - Testing                       96120                            Neuropsychological testing battery       Hour                                                                                                                                   0                0             0
                                                                                  (administered by a computer)
  80 Medication Administration                   96372                            Report using this procedure code only    Encounter
                                                                                  when provided as a separate service.
  81     Physical Therapy                        97001                            Physical therapy evaluation              Encounter                                                                                                                              0                0             0
  82     Physical Therapy                        97002                            Physical therapy re-evaluation           Encounter                                                                                                                              0                0             0
  83     Occupational Therapy                    97003                            OT evaluation                            Encounter                                                                                                                              0                0             0
  84     Occupational Therapy                    97004                            OT re-evaluation                         Encounter                                                                                                                              0                0             0
  85     Occupational or Physical Therapy        97110                            Therapeutic procedure, one or more       15 Minutes                                                                                                                             0                0             0
                                                                                  areas
  86 Occupational or Physical Therapy            97112                               neuromuscular reeducation of          15 Minutes                                                                                                                             0                0             0
                                                                                  movement




          December 21, 2007
                                                                                                                       PIHP FY07 Medicaid Utilization and Net Cost Report                                                                                                           Page: 3




                 PIHP Name:                                                                                             FY2009
Reporting Period: October 1, 2008 to September 30, 2009
                           A                       B        C          D                    E                                  F               G           H                 I              J              K             L               M               N                O               P
           Service Description (Chapter III &   HCPCS    Modifier   Revenue   Reporting Code Description -              Reporting Units     Unique    State Plan        State Plan   B3 Additional        B3        HSW Services   HSW Services   Total Medicaid   Total Medicaid    Aggregated
LineID




                    PIHP Contract)               Code                Code     See CPT/HCPCS Manuals for                                      cases   Services units   Services Total Services Units   Additional       Units        Total Costs       Units            Costs             Net
                                                                              Details                                                       served                        Costs                        Services                                                                       Cost/Unit
                                                                                                                                                                                                      Total Costs
  87 Occupational or Physical Therapy            97113                            aquatic therapy with therapeutic     15 Minutes                                                                                                                              0                0             0
                                                                              exercises
  88 Occupational or Physical Therapy            97116                            gait training (includes stair        15 Minutes                                                                                                                              0                0             0
                                                                              climbing)
  89     Occupational or Physical Therapy        97124                            massage, including effleurage        15 Minutes                                                                                                                              0                0             0
  90     Occupational or Physical Therapy        97140                        Manual therapy techniques                15 Minutes                                                                                                                              0                0             0
  91     Occupational or Physical Therapy        97150                        Group, per session                       Encounter                                                                                                                               0                0             0
  92     Occupational or Physical Therapy        97530                        Therapeutic activities, direct           15 Minutes                                                                                                                              0                0             0
  93     Occupational or Physical Therapy        97532                        Development of cognitive skills to       15 Minutes                                                                                                                              0                0             0
                                                                              improve attention
  94     Occupational or Physical Therapy        97533                        Sensory integrative techniques           15 Minutes                                                                                                                              0                0             0
  95     Occupational or Physical Therapy        97535                        Self-care/home management training       15 Minutes                                                                                                                              0                0             0
  96     Occupational or Physical Therapy        97537                        Community/work reintegration training 15 Minutes                                                                                                                                 0                0             0
  97     Occupational or Physical Therapy        97542                        Wheelchair management/propulsion         15 Minutes                                                                                                                              0                0             0
                                                                              training
 98      Ocupational Therapy                     97703                        Checkout for orthotics.                  15 Minutes                                                                                                                              0                0             0
 99      Occupational Therapy                    97750                        Physical performance testing             15 Minutes                                                                                                                              0                0             0
 100     Occupational Therapy                    97755                        Assistive technology assessment          15 Minutes                                                                                                                              0                0             0
 101     Occupational Therapy                    97760                        Orthotic(s) management and training      15 Minutes                                                                                                                              0                0             0
 102     Occupational Therapy                    97762                        Checkout for orthotic/prosthetic use,    15 Minutes                                                                                                                              0                0             0
                                                                              established patient
 103 Assessment or Health Services               97802                        Medical nutrition therapy; initial       15 Minutes                                                                                                                              0                0             0
                                                                              assessment and intervention
 104 Assessment or Health Services               97803                        re-assessment and intervention,          15 Minutes                                                                                                                              0                0             0
                                                                              individual
 105     Health Services                         97804                        Nutrition Therapy-group                  30 Minutes                                                                                                                              0                0             0
 106     Additional Codes-Physician Services     99201                        E & M 10 Minutes                         Encounter                                                                                                                               0                0             0
 107     Additional Codes-Physician Services     99202                        E & M 20 Minutes                         Encounter                                                                                                                               0                0             0
 108     Additional Codes-Physician Services     99203                        E & M 30 Minutes                         Encounter                                                                                                                               0                0             0
 109     Additional Codes-Physician Services     99204                        E & M 45 Minutes                         Encounter                                                                                                                               0                0             0
 110     Additional Codes-Physician Services     99205                        E & M 60 Minutes                         Encounter                                                                                                                               0                0             0
 111     Medication Administration               99211                        Only used when provided as separate      Encounter                                                                                                                               0                0             0
                                                                              service.
 112     Additional Codes-Physician Services     99212                        Office or other outpatient visit.        Encounter                                                                                                                               0                0             0
 113     Additional Codes-Physician Services     99213                        15 Minutes                               Encounter                                                                                                                               0                0             0
 114     Additional Codes-Physician Services     99214                        25 Minutes                               Encounter                                                                                                                               0                0             0
 115     Additional Codes-Physician Services     99215                        40 Minutes                               Encounter                                                                                                                               0                0             0
 116     Additional Codes-Physician Services     99221                        Initial hospital care-30 minutes                                                                                                                                                 0                0             0
 117     Additional Codes-Physician Services     99222                        Initial hospital care-50 minutes                                                                                                                                                 0                0             0
 118     Additional Codes-Physician Services     99223                        Initial hospital care-70 minutes                                                                                                                                                 0                0             0
 119     Additional Codes-Physician Services     99231                        Subsequent hospital care-15 minutes                                                                                                                                              0                0             0
 120     Additional Codes-Physician Services     99232                        Subsequent hospital care-25 minutes                                                                                                                                              0                0             0
 121     Additional Codes-Physician Services     99233                        Subsequent hospital care-35 minutes                                                                                                                                              0                0             0
 122     Hospital Discharge Day Management       99238                        Hospital Discharge Day Management        30 minutes or less                                                                                                                      0                0             0


 123     Additional Codes-Physician Services     99241                        Office consultation, 15 minutes          Encounter                                                                                                                               0                0             0
 124     Additional Codes-Physician Services     99242                        30 Minutes                               Encounter                                                                                                                               0                0             0
 125     Additional Codes-Physician Services     99243                        40 Minutes                               Encounter                                                                                                                               0                0             0
 126     Additional Codes-Physician Services     99244                        60 Minutes                               Encounter                                                                                                                               0                0             0
 127     Additional Codes-Physician Services     99245                        80 Minutes                               Encounter                                                                                                                               0                0             0
 128     Additional Codes-Physician Services     99251                        Office consultation, 20 minutes          Encounter                                                                                                                               0                0             0
 129     Additional Codes-Physician Services     99252                        40 Minutes                               Encounter                                                                                                                               0                0             0
 130     Additional Codes-Physician Services     99253                        55 Minutes                               Encounter                                                                                                                               0                0             0
 131     Additional Codes-Physician Services     99254                        80 Minutes                               Encounter                                                                                                                               0                0             0
 132     Additional Codes-Physician Services     99255                        110 Minutes                              Encounter                                                                                                                               0                0             0
 133     Additional Codes-Physician Services     99261                        Office consultation, 10 minutes          Encounter                                                                                                                               0                0             0
 134     Additional Codes-Physician Services     99262                        20 Minutes                               Encounter                                                                                                                               0                0             0
 135     Additional Codes-Physician Services     99263                        30 Minutes                               Encounter                                                                                                                               0                0             0
 136     Additional Codes-Physician Services     99271                        Confirmatory consultation, self-limited Encounter                                                                                                                                0                0             0
                                                                              or minor
 137 Additional Codes-Physician Services         99272                        Confirmatory consultation, low severity Encounter                                                                                                                                0                0             0

 138 Additional Codes-Physician Services         99273                        Confirmatory consultation, moderate      Encounter                                                                                                                               0                0             0
                                                                              severity
 139 Additional Codes-Physician Services         99274                        Confirmatory consultation, moderate to   Encounter                                                                                                                               0                0             0
                                                                              high severity
 140 Additional Codes-Physician Services         99275                        Confirmatory consultation, moderate to   Encounter                                                                                                                               0                0             0
                                                                              high severity
 141 Medication Administration                   99506                        Only used when provided as separate      Encounter                                                                                                                               0                0             0
                                                                              service.
 142 Transportation                              A0080                        Non-emergency transportation.            Per mile                                                                                                                                0                0             0
 143 Transportation                              A0090                        Non-emergency transportation.            Per mile                                                                                                                                0                0             0




          December 21, 2007
                                                                                                                               PIHP FY07 Medicaid Utilization and Net Cost Report                                                                                                           Page: 4




                    PIHP Name:                                                                                                  FY2009
Reporting Period: October 1, 2008 to September 30, 2009
                           A                        B        C           D                         E                                   F               G           H                 I              J              K             L               M               N                O               P
           Service Description (Chapter III &    HCPCS    Modifier    Revenue        Reporting Code Description -               Reporting Units     Unique    State Plan        State Plan   B3 Additional        B3        HSW Services   HSW Services   Total Medicaid   Total Medicaid    Aggregated
LineID




                    PIHP Contract)                Code                 Code          See CPT/HCPCS Manuals for                                       cases   Services units   Services Total Services Units   Additional       Units        Total Costs       Units            Costs             Net
                                                                                     Details                                                        served                        Costs                        Services                                                                       Cost/Unit
                                                                                                                                                                                                              Total Costs
 144 Transportation                               A0100                              Non-emergency transportation; taxi        Per one-way trip                                                                                                                        0                0             0
 145 Transportation                               A0110                              Non-emergency transportation and          Per one-way trip                                                                                                                        0                0             0
                                                                                     bus, intra- or interstate carrier
 146     Transportation                           A0120                              Non-emergency transportation.                                                                                                                                                     0                0             0
 147     Transportation                           A0130                              Non-emergency transportation.                                                                                                                                                     0                0             0
 148     Transportation                           A0140                              Non-emergency transportation.                                                                                                                                                     0                0             0
 149     Transportation                           A0170                              Transportation ancillary; parking fees,                                                                                                                                           0                0             0
                                                                                     tolls, other
 150     General dental services                  D0150                                                                                                                                                                                                                0                0             0
 151     Comp periodontal evaluation              D0180                              Comp periodontal Eval                     Encounter                                                                                                                               0                0             0
 152     Intraoral periapical                     D0220                              First film                                                                                                                                                                        0                0             0
 153     Intraoral periapical                     D0230                              Each additional film                                                                                                                                                              0                0             0
 154     Bitewings                                D0274                              Four films                                                                                                                                                                        0                0             0
 155     Prophylaxis Adult                        D1110                                                                                                                                                                                                                0                0             0
 156                                              D2330                                                                                                                                                                                                                0                0             0
         Resin based comp-one surface, ant
 157                                              D2331                                                                                                                                                                                                                0                0             0
         Resin based comp-two surfaces, ant
 158                                              D2332                                                                                                                                                                                                                0                0             0
         Resin based comp-three surfaces, an
 159                                              D2391                                                                                                                                                                                                                0                0             0
         Resin based comp-one surface, post
 160                                              D2392                                                                                                                                                                                                                0                0             0
         Resin based comp-two surfaces, post
 161                                              D2393                                                                                                                                                                                                                0                0             0
         Resin based comp-three surfaces, post
 162 Crown, porc, fused to high                   D2750                                                                                                                                                                                                                0                0             0
 163 Periodontal, main                            D4910                                                                                                                                                                                                                0                0             0
 164 Surgical removal of erupted tooth            D7210                              Surgical removal of erupted tooth                                                                                                                                                 0                0             0
                                                                                     requiring elevation of mucoperiosteal
                                                                                     flap of bone and/or section of tooth
 165 Alveoloplasty in conjunction with            D7310                                                                                                                                                                                                                0                0             0
         extractions, per quadrant
 166                                              D9920                                                                                                                                                                                                                0                0             0
         Behavior Management/dental, by report
 167 Enhanced Medical Equipment-Supplies          E1399                              DME, miscellaneous (single room air       Item                                                                                                                                    0
                                                                                     conditioner)
 168 Family Training/Support                      G0177                              Family Psycho-Education - educational     45 minutes or more                                                                                                                      0                0             0
                                                                                     groups
 169 Substance Abuse: Individual Assessment       H0001                              Alcohol and/or drug assessment (done      Encounter                                                                                                                               0                0             0
                                                                                     by provider)
 170 Assessment                                   H0002                              Brief screening to non-patient program    Encounter                                                                                                                               0                0             0

 171 Substance Abuse: Individual Screenings       H0002                              Screening to determine eligibility for Encounter                                                                                                                                  0                0             0
                                                                                     admission to treatment program (face-
                                                                                     to-face)
 172 Substance Abuse: Outpatient Treatment        H0004              0900,   0906,   Behavioral health counseling and       15 Minutes                                                                                                                                 0                0             0
                                                                     0914,   0915,   therapy
                                                                     0916,   0919
 173 Substance Abuse: Outpatient Care             H0005              0900,   0914,   Alcohol and/or drug services; group       Encounter                                                                                                                               0                0             0
                                                                     0915,   0916,   counseling by a clinician
                                                                     0919
 174 Substance Abuse: Sub-Acute                   H0010                              Alcohol/drug services; medically          Day                                                                                                                                     0                0             0
         Detoxification                                                              monitored (ASAM Level III.7.D)
 175 Substance Abuse: Sub-Acute                   H0012                              Alcohol and/or drug services; subacute    Day                                                                                                                                     0                0             0
         Detoxification                                                              detoxification (residential addiction
                                                                                     program outpatient)
 176 Substance Abuse: Sub-Acute                   H0014                              Alcohol/drug services; medically          Day                                                                                                                                     0                0             0
         Detoxification                                                              monitored (ASAM Level I.7.D)
 177 Substance Abuse: Outpatient Care             H0015              0900, 0906,     Alcohol and/or drug services; intensive   Day                                                                                                                                     0                0             0
                                                                     0914, 0915,     outpatient.
                                                                     0916, 0919
 178 Crisis Residential Services                  H0018                              Behavioral health; short-term             Day                                                                                                                                     0                0             0
                                                                                     residential (non-hosp resident
                                                                                     treatment program) without R&B per
                                                                                     diem. Use for both child & adult
                                                                                     services.
 179 Substance Abuse: Residential Services        H0018              1002            Alcohol and/or drug services; short       Day                                                                                                                                     0                0             0
                                                                                     term residential
 180 Substance Abuse: Residential Services        H0019              1002            Alcohol and/or drug services; long-       Day                                                                                                                                     0                0             0
                                                                                     term residential
 181 Substance Abuse: Methadone                   H0020                              Alcohol and/or drug services;             Encounter                                                                                                                               0                0             0
                                                                                     Methadone administration and/or
                                                                                     service
 182 Peer Directed and Operated Support           H0023                              Drop-in Center attendance.                Encounter                                                                                                                               0                0             0
         Services
 183 Prevention Services - Direct Model           H0025                              Behavioral health prevention education Face to Face                                                                                                                               0                0             0
                                                                                     service (delivery of services with target Contact
                                                                                     population to affect knowledge,
                                                                                     attitude, and/or behavior)
 184 Crisis Intervention                          H0030                              Michigan Center for Positive Living       Per Service
                                                                                     Supports Crisis line




          December 21, 2007
                                                                                                                           PIHP FY07 Medicaid Utilization and Net Cost Report                                                                                                           Page: 5




                    PIHP Name:                                                                                              FY2009
Reporting Period: October 1, 2008 to September 30, 2009
                           A                       B        C           D                       E                                  F               G           H                 I              J              K             L               M               N                O               P
           Service Description (Chapter III &   HCPCS    Modifier    Revenue      Reporting Code Description -              Reporting Units     Unique    State Plan        State Plan   B3 Additional        B3        HSW Services   HSW Services   Total Medicaid   Total Medicaid    Aggregated
LineID




                    PIHP Contract)               Code                 Code        See CPT/HCPCS Manuals for                                      cases   Services units   Services Total Services Units   Additional       Units        Total Costs       Units            Costs             Net
                                                                                  Details                                                       served                        Costs                        Services                                                                       Cost/Unit
                                                                                                                                                                                                          Total Costs
 185 Assessment                                  H0031                            Mental health assessment, by non-      Encounter                                                                                                                                 0                0             0
                                                                                  physician
 186 Substance Abuse: Assessment                 H0031                            Mental health assessment, by non-      Encounter                                                                                                                                 0                0             0
                                                                                  physician
 187 Treatment Planning                          H0032                            Mental health service plan development Encounter                                                                                                                                 0                0             0
                                                                                  by non-physician
 188 Monitoring of Treatment-Physician           H0032      TS                                                           Encounter                                                                                                                                 0                0             0


 189 Substance Abuse: Pharmalogical Support -    H0033              1002          Oral medication administration, direct   Encounter                                                                                                                               0                0             0
         Suboxane                                                                 observation.
 190 Health Services                             H0034                            Medication training and support          15 Minutes                                                                                                                              0                0             0
 191 Home Based Services                         H0036                            Community psychiatric supportive         15 Minutes                                                                                                                              0                0             0
                                                                                  treatment, face-to-face
 192 Home Based Services                         H0036      ST                    Modifier ST when providing Trauma-       15 Minutes
                                                                                  focused Cognitive Behavioral Therapy
                                                                                  when pre-approved by MDCH
 193 Peer Directed and Operated Support          H0038                            Peer-speciailist                         15 Minutes                                                                                                                              0                0             0
         Services
 194 Peer Directed and Operated Support            NA                             Drop-in centers                                                                                                                                                                                   0
         Services
 195 Assertive Community Treatment (ACT)         H0039                            ACT face-to-face                         15 Minutes                                                                                                                              0                0             0
 196 Community Living Supports in                H0043                            CLS per diem                             Per diem                                                                                                                                0                0             0
         Independent living/own home
 197 Community Living Supports in                H0043      TT                    Additional Patient                       Per diem                                                                                                                                0                0             0
         Independent living/own home
 198 Respite Care                                H0045                            Respite out-of-home                      Per Diem                                                                                                                                0                0             0
 199 Substance Abuse: Individual Assessment      H0049                            AMS alcohol/drug screening               Encounter                                                                                                                               0                0             0
 200 Behavior Management Treatment Plan          H2000                            Comprehensive multidisciplinary          Encounter                                                                                                                               0                0             0
     Review                                                                       evaluation
 201 Monitoring Activities                       H2000      TS                    Modifier TS for monitoring activities    Encounter                                                                                                                               0                0             0
                                                                                  associated with a behavior treatment
                                                                                  plan
 202 Medication Review                           H2010                            Medication Algorithm EBP                 15 Minutes                                                                                                                              0                0             0
 203 Crisis Intervention                         H2011                            Crisis intervention service.             15 Minutes                                                                                                                              0                0             0
 204 Skill-Building and Out of Home Non          H2014                            Skills training and development          15 minutes                                                                                                                              0                0             0
     Vocational Habilitation
 205 Skill-Building and Out of Home Non          H2014      TT                    Additional Patient                       15 minutes                                                                                                                              0                0             0
     Vocational Habilitation
 206 Community Living Supports (15 Minutes)      H2015                            Comprehensive Community Support          15 Minutes                                                                                                                              0                0             0
                                                                                  Services
 207 Community Living Supports (15 Minutes)      H2015      TT                    Additional Patient                       15 Minutes                                                                                                                              0                0             0

 208 Community Living Supports (Daily)           H2016                            No modifier - Low Level of Supports      Per Diem                                                                                                                                0                0             0
 209 Community Living Supports (Daily)           H2016      TF                    TF Modifier - Medium Level of Supports Per Diem                                                                                                                                  0                0             0

 210 Community Living Supports (Daily)           H2016      TG                    TG Modifier - High Level of Supports     Per Diem                                                                                                                                0                0             0
                                                                                  Therapeutic Behavioral Services: Use
 211 Mental Health Therapy                       H2019                                                                     15 Minutes
                                                                                  for individual Dialectical Behavior
                                                                                  Therapy (DBT) provided by staff
                                                                                  trained and certified by MDCH.
 212 Mental Health Therapy                       H2019      TT                                                             15 Minutes
                                                                                  Therapeutic Behavioral Services: TT
                                                                                  modifier for group skills training
 213 Crisis Intervention                         H2020                            Michigan Center for Positive Living      Day
                                                                                  Supports Transition Home
 214     Wraparound Services                     H2021                            Specialize Wraparound Faciliation        15 Minutes                                                                                                                              0                0             0
 215     Supported Employment Services           H2023                            Supported employment                     15 Minutes                                                                                                                              0                0             0
 216     Supported Employment Services           H2023      TT                    Additional Patient                       15 Minutes                                                                                                                              0                0             0
 217 Clubhouse Psychosocial Rehabilitation       H2030                            Mental Health Clubhouse                  15 Minutes                                                                                                                              0                0             0
     Programs
 218 Home Based Services                         H2033                            Multi-systemic therapy (MST) for         15 Minutes
                                                                                  juveniles provided in home-based
                                                                                  program
 219 Substance Abuse Outpatient                  H2035              0900, 0906,   Outpatient alcohol/other drug            Hour                                                                                                                                    0                0             0
                                                                    0914, 0915,   treatment services.Referral, linking and
                                                                    0916, 0919    coordinating
 220 Substance Abuse: Outpatient Care            H2036                            Alcohol/other drug treatment.            Per Diem                                                                                                                                0                0             0
                                                                                  Referral, linking and coordinating
 221 Medication Review                           M0064                            Brief assessment, med monitoring or      Encounter Face-to-                                                                                                                      0                0             0
                                                                                  change                                   Face
 222 Transportation                              S0209                            Wheelchair van mileage                   Per Mile                                                                                                                                0                0             0
 223 Transportation                              S0215                            Non-emergency transportation mileage Per Mile                                                                                                                                    0                0             0

 224 Family Training                             S5110                            Family psycho-education: skills          15 Minutes                                                                                                                              0                0             0
                                                                                  workshop
 225     Family Training                         S5111                            Home care training, family per session   Encounter                                                                                                                               0                0             0
 226     Chore Services                          S5120                            Chore services                           15 Minutes                                                                                                                              0                0             0
 227     Respite Care                            S5151                            Respite care in-home                     Per Diem                                                                                                                                0                0             0
 228     Personal Emergency Response System      S5160                            Emergency response system;               Encounter                                                                                                                               0                0
         (PERS)                                                                   installation and testing




          December 21, 2007
                                                                                                                        PIHP FY07 Medicaid Utilization and Net Cost Report                                                                                                         Page: 6




                  PIHP Name:                                                                                             FY2009
Reporting Period: October 1, 2008 to September 30, 2009
                          A                       B        C           D                    E                                   F             G           H                 I              J              K             L               M               N                O               P
          Service Description (Chapter III &   HCPCS    Modifier    Revenue   Reporting Code Description -               Reporting Units   Unique    State Plan        State Plan   B3 Additional        B3        HSW Services   HSW Services   Total Medicaid   Total Medicaid    Aggregated
LineID




                   PIHP Contract)               Code                 Code     See CPT/HCPCS Manuals for                                     cases   Services units   Services Total Services Units   Additional       Units        Total Costs       Units            Costs             Net
                                                                              Details                                                      served                        Costs                        Services                                                                       Cost/Unit
                                                                                                                                                                                                     Total Costs
 229 Personal Emergency Response System         S5161                         PERS Service fee, per month (excludes Month                                                                                                                                     0                0
         (PERS)                                                               installation and testing).
 230 Environmental Modification                 S5165                         Home modifications, per service.      Service                                                                                                                                   0                0
 231 Enhanced Medical Equipment-Supplies        S5199                         Personal care item, NOS. (assistive       Item                                                                                                                                  0                0
                                                                              technology)
 232 Occupational or Physical Therapy           S8990                         Physical or manipulative therapy          Encounter                                                                                                                             0                0             0
                                                                              performed for maintenance rather than
                                                                              restoration
 233 Private Duty Nursing                       S9123              0582       Private duty nursing, habilitation        Hour                                                                                                                                  0                0             0
                                                                              supports waiver (individual nurse only)
                                                                              21 years and over ONLY
 234 Private Duty Nursing                       S9123                         Private duty nursing, habilitation        Hour                                                                                                                                  0                0             0
                                                                              supports waiver (individual nurse only)
                                                                              21 years and over ONLY
 235 Private Duty Nursing                       S9123      TT                 Additional Patient                        Hour                                                                                                                                  0                0             0




          December 21, 2007
                                                                                                                         PIHP FY07 Medicaid Utilization and Net Cost Report                                                                                                         Page: 7




                 PIHP Name:                                                                                               FY2009
Reporting Period: October 1, 2008 to September 30, 2009
                           A                        B        C           D                    E                                  F             G           H                 I              J              K             L               M               N                O               P
           Service Description (Chapter III &    HCPCS    Modifier    Revenue   Reporting Code Description -              Reporting Units   Unique    State Plan        State Plan   B3 Additional        B3        HSW Services   HSW Services   Total Medicaid   Total Medicaid    Aggregated
LineID




                    PIHP Contract)                Code                 Code     See CPT/HCPCS Manuals for                                    cases   Services units   Services Total Services Units   Additional       Units        Total Costs       Units            Costs             Net
                                                                                Details                                                     served                        Costs                        Services                                                                       Cost/Unit
                                                                                                                                                                                                      Total Costs
 236 Private Duty Nursing                         S9124              0582       Nursing care, in the home, by licensed   Hour                                                                                                                                  0                0             0
                                                                                practical nurse
 237 Private Duty Nursing                         S9124                         Nursing care, in the home, by licensed   Hour                                                                                                                                  0                0             0
                                                                                practical nurse
 238 Private Duty Nursing                         S9124      TT                 Additional Patient                       Hour                                                                                                                                  0                0             0
 239 Health Services                              S9445                         Pt education NOC nonphysician indiv      Encounter                                                                                                                             0                0             0
                                                                                per session
 240 Health Services                              S9446                         Pt education NOC nonphysician group,     Encounter                                                                                                                             0                0             0
                                                                                per session
 241 Health Services                              S9470                         Nutritional counseling dietician visit   Encounter                                                                                                                             0                0             0
 242 Intensive Crisis Stabilization               S9484                         Crisis intervention mental health        Hour                                                                                                                                  0                0             0
                                                                                services approved programs only
 243 Private Duty Nursing                         T1000                         Private duty nursing, habilitation       Up to 15 min                                                                                                                          0                0             0
                                                                                supports waiver, private
                                                                                duty/independent nursing service(s),
                                                                                licensed.
 244 Assessment                                   T1001                         Nursing/Nutrition Assessment             Encounter                                                                                                                             0                0             0
 245 Health Services                              T1002                         RN services                              Up to 15 min                                                                                                                          0                0             0
 246 Respite Care                                 T1005                         Respite care services. No modifier =  15 minutes                                                                                                                               0                0             0
                                                                                all providers except RN & LPN. TD
                                                                                modifier = RN only. TE modifier = LPN
                                                                                only.
 247     Peer Recovery                            T1012                         Recovery Supports                     Encounter                                                                                                                                0                0             0
 248     Family Training                          T1015                         Family psycho-education: joining      Encounter                                                                                                                                0                0             0
 249     Supports Coordination                    T1016                         Case management                          15 minutes                                                                                                                            0                0             0
 250     Targeted Case Management                 T1017                         Targeted Case management (face to        15 minutes                                                                                                                            0                0             0
                                                                                face)
 251 Nursing Facility Mental Health Monitoring    T1017      SE                 Targeted Case management (face to        15 minutes                                                                                                                            0                0             0
                                                                                face)
 252 Personal Care in Licensed Specialized        T1020                         No modifier - Low Level of Supports      Day                                                                                                                                   0                0             0
         Residential Setting
 253 Personal Care in Licensed Specialized        T1020      TF                 TF Modifier - Medium Level of Supports Day                                                                                                                                     0                0             0
         Residential Setting
 254 Personal Care in Licensed Specialized        T1020      TG                 TG Modifier - High Level of Supports     Day                                                                                                                                   0                0             0
         Residential Setting
 255 Assessments                                  T1023                         Screening for inpatient programs         Encounter                                                                                                                             0                0             0
 256 Enhanced Pharmacy                            T1999                         Miscellaneous therapeutic items and       Item                                                                                                                                 0                0
                                                                                supplies, retail purchases, not
                                                                                otherwise classified; identify product in
                                                                                “remarks”
 257 Transportation                               T2001                         Non-emergency transportation; patient                                                                                                                                          0                0             0
                                                                                attendant / escort
 258 Transportation                               T2002                         Non-emergency transportation              Per Diem                                                                                                                             0                0             0
 259 Transportation                               T2003                         Non-emergency transportation             Encounter / Trip                                                                                                                      0                0             0
 260 Transportation                               T2004                         Non-emergency transport; commercial                                                                                                                                            0                0             0
                                                                                carrier, multi-pass
 261 Transportation                               T2005                         Non-emergency transportation; non-                                                                                                                                             0                0             0
                                                                                ambulatory stretcher van
 262 Out of Home Prevocational Service            T2015                         Habilitation, prevocational, waiver      Hour                                                                                                                                  0                0             0

 263 Fiscal Intermediary Services                 T2025                         Use for services performed by a fiscal   Per Month                                                                                                                             0                0             0
                                                                                intermediary.
 264 Enhanced Medical Equipment-Supplies          T2028                         Specialized supply, not otherwise        Item                                                                                                                                  0                0
                                                                                specified, waiver (allergy control
                                                                                supplies)
 265 Enhanced Medical Equipment-Supplies          T2029                         Specialized medical equipment, not       Item                                                                                                                                  0                0
                                                                                otherwise specified, waiver.
                                                                                (environmental safety & control
                                                                                devices)
 266 Crisis Intervention                          T2034                         Michigan Center for Positive Living      Day
                                                                                Supports Mobile Crisis/Training Team
 267 Community Living Supports/Respite Care-      T2036                         Therapeutic camping overnight.(one       Encounter / Trip                                                                                                                      0                0             0
         Therapeutic Camping                                                    night = one session)
 268 Community Living Supports/Respite Care-      T2037                         Therapeutic camping overnight. (one      Encounter / Trip                                                                                                                      0                0             0
         Therapeutic Camping                                                    day/partial day = one session)
 269 Housing Assistance                           T2038                         Community transition, waiver, per        Month                                                                                                                                 0                0
                                                                                service
 270 Enhanced Medical Equipment-Supplies          T2039                         Van lifts & wheelchair tie down system   Item                                                                                                                                  0                0




          December 21, 2007
                                                                                                            PIHP FY07 Medicaid Utilization and Net Cost Report                                                                                                          Page: 8




                 PIHP Name:                                                                                  FY2009
Reporting Period: October 1, 2008 to September 30, 2009
                           A                       B       C          D                    E                        F             G           H                 I              J              K             L                M               N                O               P
           Service Description (Chapter III &   HCPCS   Modifier   Revenue   Reporting Code Description -    Reporting Units   Unique    State Plan        State Plan   B3 Additional        B3        HSW Services    HSW Services   Total Medicaid   Total Medicaid    Aggregated
LineID




                    PIHP Contract)               Code               Code     See CPT/HCPCS Manuals for                          cases   Services units   Services Total Services Units   Additional       Units         Total Costs       Units            Costs             Net
                                                                             Details                                           served                        Costs                        Services                                                                        Cost/Unit
                                                                                                                                                                                         Total Costs


         TOTAL MEDICAID CASES AND
II       COSTS (MH/DD/SA)                                                                                                                                                                                                                                #VALUE!


         TOTAL MEDICAID MH/DD
III      CASES AND COSTS                                                                                                                                                                                                                                  #VALUE!
                                                                                                                                                                                                                                      PLUS
         MEDICAID MANAGED CARE
IV       ADMINISTRATION MH/DD

         TOTAL MEDICAID MH/DD
V        COSTS                                                                                                                                                                                                                        EQUALS =


         MEDICAID SUBSTANCE ABUSE
VI       CASES & COSTS

    a.       Administration by PIHP                                                                                                                                                                                                   PLUS



  b.         Administration by CA                                                                                                                                                                                                     PLUS


VII TOTAL SA MEDICAID COSTS                                                                                                                                                                                                           EQUALS =

     TOTAL MEDICAID COSTS
VIII (MH/DD/SA) (Sum of V & VII)
IX SPEND-DOWN
             EMBEDDED IN ABOVE (amt of GF
         expenditures for spend-down to be
    a. deducted)                                                                                                                                                                                                                      DEDUCT:

           NOT EMBEDDED IN ABOVE (amt of GF
       expenditures for spend-down already
    b. deducted)                                                                                                                                                                                                      INFO ONLY:

         MEDICAID MH/DD/SA NET
X        EXPENSES                                                                                                                                                                                                                     EQUALS =


XI       RECONCILING ITEMS TO FSR
a.         Payments into the ISF
b.         Charged to GF but not in FSR costs
c.         QAAP/Use Tax
d.         Prior year adjustments in the FSR
e.         SSI & other Reimbursements
f.         OTHER - specifiy type




g.       Total Reconciling items


XII Adjusted MUNC report Medicaid costs



XIII FSR
          PRIOR YEAR SAVINGS EXPENSES MH/DD
a.       (FSR row G. 2)
b.        USE OF MEDICAID ISF (FSR row G.3a)
c.        MEDICAID EXPENSES (FSR row K)




          December 21, 2007

				
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