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					                                                                                                                                                                               PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                                                                         Page: 1




                  PIHP Name:                                                                                                                        FY2010 MUNC
Reporting Period: October 1, 2009 to September 30, 2010
                            A                      B         C                D                             E                                 F                  G           H                 I              J            K              L               M               N                O              P
         Service Description (Chapter III & PIHP HCPCS     Modifier      Revenue Code         Reporting Code Description -             Reporting Units        Unique     State Plan       State Plan   B3 Additional B3 Additional   HSW Services   HSW Services   Total Medicaid   Total Medicaid   Aggregated
LineID




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

   1     Local Psychiatric Hospital/IMD PT68                 PT68     0100,   0101,   0114,   All inclusive room and board plus        Day                                                                                                                                      0                0            0
                                                                      0124,   0134,   0154    ancillaries
   2     Local Psychiatric Hospital - Acute                  PT73     0100,   0101,   0114,   All inclusive room and board             Day                                                                                                                                      0                0            0
         Community PT73                                               0124,   0134,   0154
   3     HRA (Hospital Reimbursement Adjustment)             PT68     HRA                     HRA payments to IMDs during FY10.        Amount                                                                                                                                   0                0
         to IMDs PT68

   4     HRA (Hospital Reimbursement Adjustment)             PT73     HRA                     HRA payments to community hospitals      Amount                                                                                                                                   0                0
         to Acute Community Hospitals PT73                                                    during FY10


   5     ECT Anesthesia                                               0370                    Anesthesia charges                                                                                                                                                                0                0            0
   6     ECT Recovery Room                                            0710                    Recovery room charge                                                                                                                                                              0                0            0
   7     Crisis Observation Care                                      0762                    Outpatient extended observation beds     Hour                                                                                                                                     0                0            0
                                                                                              (23 hour)
   8     Electro-Convulsive Therapy                                   0901                    Facility charges                         Encounter                                                                                                                                0                0            0
   9     Substance Abuse: Outpatient                                  0906                    Intensive Outpatient Services - Chemical Day                                                                                                                                      0                0            0
                                                                                              Dependency
  10 Outpatient Partial Hospitalization                               0912                    Partial hospitalization-Less Intensive   Day                                                                                                                                      0                0            0
  11 Outpatient Partial Hospitalization                               0913                    Partial hospitalization-More Intensive   Day                                                                                                                                      0                0            0
  12 Substance Abuse: Subacute Detoxification                         1002                    Residential treatment - chemical         Day                                                                                                                                      0                0            0
                                                                                              dependency
  13     Electro-Convulsive Therapy                00104                                      Anesthesia charges for ECT               Minutes                                                                                                                                  0                0            0
  14     Drug Screen under Methadone               80100                                      Methodone drug screen                    Per Screen                                                                                                                               0                0            0
  15     Drug Screen under Methadone               80101                                      Methodone drug screen                    Per Screen                                                                                                                               0                0
  16     Assessment-Psychiatric Assessment         90801                                      Psychiatric diagnostic interview       Encounter                                                                                                                                  0                0            0
                                                                                              examination
  17 Assessment-Psychiatric Assessment             90802                                      Interactive psychiatric diagnostic     Encounter                                                                                                                                  0                0            0
                                                                                              interview examination
  18 Therapy-Individual Therapy                    90804                                      Individual psychotherapy 20-30 minutes Encounter 20-30 Min                                                                                                                        0                0            0

  19 Substance Abuse: Outpatient Care              90804              0900, 0914, 0915,       Individual Psychotherapy                 Encounter 20-30 Min                                                                                                                      0                0            0
                                                                      0916, 0919
  20 Individual Psychotherapy                      90805                                      Individual Psychotherapy                 Encounter 20-30 Min                                                                                                                      0                0            0

  21 Substance Abuse: Outpatient Care              90805              0900, 0914, 0915,       Individual Psychotherapy                 Encounter 20-30 Min                                                                                                                      0                0            0
                                                                      0916, 0919
  22 Therapy-Individual Therapy                    90806                                      Individual psychotherapy 45-50 minutes Encounter 45-50 Min                                                                                                                        0                0            0

  23 Substance Abuse: Outpatient Care              90806              0900, 0914, 0915,       Individual Psychotherapy                 Encounter 45-50 Min                                                                                                                      0                0            0
                                                                      0916, 0919
  24 Therapy-Individual Therapy                    90807                                       Individual psychotherapy with medical   Encounter 45-50 Min                                                                                                                      0                0            0
                                                                                              evaluation and management services
  25 Substance Abuse: Outpatient Care              90807              0900, 0914, 0915,       Individual Psychotherapy                 Encounter 45-50 Min                                                                                                                      0                0            0
                                                                      0916, 0919
  26 Therapy-Individual Therapy                    90808                                      Individual psychotherapy 75-80 minutes Encounter 75-80 Min                                                                                                                        0                0            0

  27 Substance Abuse: Outpatient Care              90808              0900, 0914, 0915,       Individual Psychotherapy                 Encounter 75-80 Min                                                                                                                      0                0            0
                                                                      0916, 0919
  28 Therapy-Individual Therapy                    90809                                      Individual psychotherapy with medical    Encounter 75-80 Min                                                                                                                      0                0            0
                                                                                              evaluation and management services
  29 Substance Abuse: Outpatient Care              90809              0900, 0914, 0915,       Individual Psychotherapy                 Encounter 75-80 Min                                                                                                                      0                0            0
                                                                      0916, 0919
  30 Therapy-Individual Therapy                    90810                                      Individual psychotherapy, interactive    Encounter 20-30 Min                                                                                                                      0                0            0
                                                                                              20-30 minutes
  31 Substance Abuse: Outpatient Care              90810              0900, 0914, 0915,       Individual Psychotherapy                 Encounter 20-30 Min                                                                                                                      0                0            0
                                                                      0916, 0919
  32 Therapy-Individual Therapy                    90811                                      Individual psychotherapy with medical    Encounter 20-30 Min                                                                                                                      0                0            0
                                                                                              evaluation and management services
  33 Substance Abuse: Outpatient Care              90811              0900, 0914, 0915,       Individual Psychotherapy                 Encounter 20-30 Min                                                                                                                      0                0            0
                                                                      0916, 0919
  34 Therapy-Individual Therapy                    90812                                      Individual psychotherapy, interactive 45- Encounter 45-50 Min                                                                                                                     0                0            0
                                                                                              50 minutes
  35 Substance Abuse: Outpatient Care              90812              0900, 0914, 0915,       Individual Psychotherapy                  Encounter 45-50 Min                                                                                                                     0                0            0
                                                                      0916, 0919
  36 Therapy-Individual Therapy                    90813                                       Individual psychotherapy with medical   Encounter 45-50 Min                                                                                                                      0                0            0
                                                                                              evaluation and management services
  37 Substance Abuse: Outpatient Care              90813              0900, 0914, 0915,       Individual Psychotherapy                 Encounter 45-50 Min                                                                                                                      0                0            0
                                                                      0916, 0919
  38 Therapy-Individual Therapy                    90814                                      Individual psychotherapy, interactive 75- Encounter 75-80 Min                                                                                                                     0                0            0
                                                                                              80 minutes
  39 Substance Abuse: Outpatient Treatment         90814              0900, 0914, 0915,       Individual Psychotherapy                  Encounter 75-80 Min                                                                                                                     0                0            0
                                                                      0916, 0919
  40 Therapy-Individual Therapy                    90815                                      Individual psychotherapy with medical    Encounter 75-80 Min                                                                                                                      0                0            0
                                                                                              evaluation and management services
  41 Substance Abuse: Outpatient Care              90815              0900, 0914, 0915,       Individual Psychotherapy                 Encounter 75-80 Min                                                                                                                      0                0            0
                                                                      0916, 0919
  42 Therapy-Individual Therapy                    90816                                      Individual psychotherapy                 Encounter 20-30 Min                                                                                                                      0                0            0

  43 Therapy-Individual Therapy                    90817                                      Individual psychotherapy with medical    Encounter 20-30 Min                                                                                                                      0                0            0
                                                                                              evaluation and management services
  44 Therapy-Individual Therapy                    90818                                      Individual psychotherapy                 Encounter 45-50 Min                                                                                                                      0                0            0

  45 Therapy-Individual Therapy                    90819                                      Individual psychotherapy with medical    Encounter 45-50 Min                                                                                                                      0                0            0
                                                                                              evaluation and management services
  46 Therapy-Individual Therapy                    90821                                      Individual psychotherapy                 Encounter 75-80 Min                                                                                                                      0                0            0

  47 Therapy-Individual Therapy                    90822                                      Individual psychotherapy with medical    Encounter 75-80 Min                                                                                                                      0                0            0
                                                                                              evaluation and management services




          DRAFT 12-15-2010                                                                                                                                                                                  Page 1                                                                                                Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                                                                                                PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                                                                         Page: 2




                  PIHP Name:                                                                                                                          FY2010 MUNC
Reporting Period: October 1, 2009 to September 30, 2010
                            A                      B        C                D                            E                                     F                 G           H                 I              J            K              L               M               N                O              P
         Service Description (Chapter III & PIHP HCPCS    Modifier      Revenue Code        Reporting Code Description -                 Reporting Units       Unique     State Plan       State Plan   B3 Additional B3 Additional   HSW Services   HSW Services   Total Medicaid   Total Medicaid   Aggregated
LineID




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

  48 Therapy-Individual Therapy                   90823                                     Individual psychotherapy, interactive        Encounter 20-30 Min                                                                                                                     0                0            0

  49 Therapy-Individual Therapy                   90824                                     Individual psychotherapy with medical        Encounter 20-30 Min                                                                                                                     0                0            0
                                                                                            evaluation and management services
  50 Therapy-Individual Therapy                   90826                                     Individual psychotherapy, interactive        Encounter 45-50 Min                                                                                                                     0                0            0

  51 Substance Abuse: Individual Therapy          90826                                     Individual psychotherapy, interactive        Encounter 45-50 Min                                                                                                                     0                0

  52 Therapy-Individual Therapy                   90827                                     Individual psychotherapy with medical        Encounter 45-50 Min                                                                                                                     0                0            0
                                                                                            evaluation and management services
  53 Therapy-Individual Therapy                   90828                                     Individual psychotherapy                     Encounter 75-80 Min                                                                                                                     0                0            0

  54 Therapy-Individual Therapy                   90829                                     Individual psychotherapy with medical        Encounter 75-80 Min                                                                                                                     0                0            0
                                                                                            evaluation and management services
  55 Therapy-Family Therapy                       90846                                     Family therapy, per session                  Encounter                                                                                                                               0                0            0
  56 Substance Abuse: Psychotherapy (group)       90846                                      Psychotherapy (group)
                                                                     0900, 0914, 0915, 0916, 0919                                        Encounter                                                                                                                               0                0
  57 Therapy-Family Therapy                       90847                                     Family psychotherapy (conjoint               Encounter                                                                                                                               0                0            0
                                                                                            psychotherapy) (with patient present)

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

  83 Assessments - Testing                        96120                                     Neuropsychological testing battery           Hour                                                                                                                                    0                0            0
                                                                                            (administered by a computer)
  84 Medication Administration                    96372                                     Report using this procedure code only        Encounter                                                                                                                               0                0            0
                                                                                            when provided as a separate service.
  85     Physical Therapy                         97001                                     Physical therapy evaluation                  Encounter                                                                                                                               0                0            0
  86     Physical Therapy                         97002                                     Physical therapy re-evaluation               Encounter                                                                                                                               0                0            0
  87     Occupational Therapy                     97003                                     OT evaluation                                Encounter                                                                                                                               0                0            0
  88     Occupational Therapy                     97004                                     OT re-evaluation                             Encounter                                                                                                                               0                0            0
  89     Occupational or Physical Therapy         97110                                     Therapeutic procedure, one or more           15 Minutes                                                                                                                              0                0            0
                                                                                            areas
  90 Occupational or Physical Therapy             97112                                        neuromuscular reeducation of              15 Minutes                                                                                                                              0                0            0
                                                                                            movement
  91 Occupational or Physical Therapy             97113                                        aquatic therapy with therapeutic          15 Minutes                                                                                                                              0                0            0
                                                                                            exercises
  92 Occupational or Physical Therapy             97116                                        gait training (includes stair climbing)   15 Minutes                                                                                                                              0                0            0

  93     Occupational or Physical Therapy         97124                                         massage, including effleurage            15 Minutes                                                                                                                              0                0            0
  94     Occupational or Physical Therapy         97140                                     Manual therapy techniques                    15 Minutes                                                                                                                              0                0            0
  95     Occupational or Physical Therapy         97150                                     Group, per session                           Encounter                                                                                                                               0                0            0
  96     Occupational or Physical Therapy         97530                                     Therapeutic activities, direct               15 Minutes                                                                                                                              0                0            0
  97     Occupational or Physical Therapy         97532                                     Development of cognitive skills to           15 Minutes                                                                                                                              0                0            0
                                                                                            improve attention
  98     Occupational or Physical Therapy         97533                                     Sensory integrative techniques               15 Minutes                                                                                                                              0                0            0
  99     Occupational or Physical Therapy         97535                                     Self-care/home management training           15 Minutes                                                                                                                              0                0            0
 100     Occupational or Physical Therapy         97537                                     Community/work reintegration training        15 Minutes                                                                                                                              0                0            0
 101     Occupational or Physical Therapy         97542                                     Wheelchair management/propulsion             15 Minutes                                                                                                                              0                0            0
                                                                                            training




          DRAFT 12-15-2010                                                                                                                                                                                   Page 2                                                                                                Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                                                                                  PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                                                                         Page: 3




                   PIHP Name:                                                                                                              FY2010 MUNC
Reporting Period: October 1, 2009 to September 30, 2010
                            A                      B        C             D                       E                                  F              G           H                 I              J            K              L               M               N                O              P
         Service Description (Chapter III & PIHP HCPCS    Modifier   Revenue Code   Reporting Code Description -              Reporting Units    Unique     State Plan       State Plan   B3 Additional B3 Additional   HSW Services   HSW Services   Total Medicaid   Total Medicaid   Aggregated
LineID




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

 102     Occupational Therapy                     97750                             Physical performance testing              15 Minutes                                                                                                                           0                0            0
 103     Occupational Therapy                     97755                             Assistive technology assessment           15 Minutes                                                                                                                           0                0            0
 104     Occupational Therapy                     97760                             Orthotic(s) management and training       15 Minutes                                                                                                                           0                0            0
 105     Occupational Therapy                     97762                             Checkout for orthotic/prosthetic use,     15 Minutes                                                                                                                           0                0            0
                                                                                    established patient
 106 Assessment or Health Services                97802                             Medical nutrition therapy; initial        15 Minutes                                                                                                                           0                0            0
                                                                                    assessment and intervention
 107 Assessment or Health Services                97803                             re-assessment and intervention,           15 Minutes                                                                                                                           0                0            0
                                                                                    individual
 108     Health Services                          97804                             Nutrition Therapy-group                   30 Minutes                                                                                                                           0                0            0
 109     Additional Codes-Physician Services      99201                             E & M 10 Minutes                          Encounter                                                                                                                            0                0            0
 110     Additional Codes-Physician Services      99202                             E & M 20 Minutes                          Encounter                                                                                                                            0                0            0
 111     Additional Codes-Physician Services      99203                             E & M 30 Minutes                          Encounter                                                                                                                            0                0            0
 112     Substance Abuse: Physician               99203                             30 mins face-to-face                      30 Minutes                                                                                                                           0                0
         Evaluation/Exam Under methodone
 113 Additional Codes-Physician Services          99204                             E & M 45 Minutes                          Encounter                                                                                                                            0                0            0
 114 Substance Abuse: Physician                   99204                             45 mins face-to-face                      45 Minutes                                                                                                                           0                0
         Evaluation/Exam Under methodone

 115 Additional Codes-Physician Services          99205                             E & M 60 Minutes                          Encounter                                                                                                                            0                0            0
 116 Substance Abuse: Physician                   99205                             60 mins face-to-face                      60 Minutes                                                                                                                           0                0
         Evaluation/Exam Under methodone
 117 Medication Administration                    99211                             Only used when provided as separate       Encounter                                                                                                                            0                0            0
                                                                                    service.
 118     Additional Codes-Physician Services      99212                             Office or other outpatient visit.         Encounter                                                                                                                            0                0            0
 119     Additional Codes-Physician Services      99213                             15 Minutes                                Encounter                                                                                                                            0                0            0
 120     Additional Codes-Physician Services      99214                             25 Minutes                                Encounter                                                                                                                            0                0            0
 121     Additional Codes-Physician Services      99215                             40 Minutes                                Encounter                                                                                                                            0                0            0
 122     Additional Codes-Physician Services      99221                             Initial hospital care-30 minutes                                                                                                                                               0                0            0
 123     Additional Codes-Physician Services      99222                             Initial hospital care-50 minutes                                                                                                                                               0                0            0
 124     Additional Codes-Physician Services      99223                             Initial hospital care-70 minutes                                                                                                                                               0                0            0
 125     Additional Codes-Physician Services      99231                             Subsequent hospital care-15 minutes                                                                                                                                            0                0            0
 126     Additional Codes-Physician Services      99232                             Subsequent hospital care-25 minutes                                                                                                                                            0                0            0
 127     Additional Codes-Physician Services      99233                             Subsequent hospital care-35 minutes                                                                                                                                            0                0            0
 128     Additional Codes-Physician Services      99241                             Office consultation, 15 minutes           Encounter                                                                                                                            0                0            0
 129     Additional Codes-Physician Services      99242                             30 Minutes                                Encounter                                                                                                                            0                0            0
 130     Additional Codes-Physician Services      99243                             40 Minutes                                Encounter                                                                                                                            0                0            0
 131     Additional Codes-Physician Services      99244                             60 Minutes                                Encounter                                                                                                                            0                0            0
 132     Additional Codes-Physician Services      99245                             80 Minutes                                Encounter                                                                                                                            0                0            0
 133     Additional Codes-Physician Services      99251                             Office consultation, 20 minutes           Encounter                                                                                                                            0                0            0
 134     Additional Codes-Physician Services      99252                             40 Minutes                                Encounter                                                                                                                            0                0            0
 135     Additional Codes-Physician Services      99253                             55 Minutes                                Encounter                                                                                                                            0                0            0
 136     Additional Codes-Physician Services      99254                             80 Minutes                                Encounter                                                                                                                            0                0            0
 137     Additional Codes-Physician Services      99255                             110 Minutes                               Encounter                                                                                                                            0                0            0
 138     Additional Codes-Physician Services      99261                             Office consultation, 10 minutes           Encounter                                                                                                                            0                0            0
 139     Additional Codes-Physician Services      99262                             20 Minutes                                Encounter                                                                                                                            0                0            0
 140     Additional Codes-Physician Services      99263                             30 Minutes                                Encounter                                                                                                                            0                0            0
 141     Additional Codes-Physician Services      99271                             Confirmatory consultation, self-limited   Encounter                                                                                                                            0                0            0
                                                                                    or minor
 142 Additional Codes-Physician Services          99272                             Confirmatory consultation, low severity   Encounter                                                                                                                            0                0            0

 143 Additional Codes-Physician Services          99273                             Confirmatory consultation, moderate    Encounter                                                                                                                               0                0            0
                                                                                    severity
 144 Additional Codes-Physician Services          99274                             Confirmatory consultation, moderate to Encounter                                                                                                                               0                0            0
                                                                                    high severity
 145 Additional Codes-Physician Services          99275                             Confirmatory consultation, moderate to Encounter                                                                                                                               0                0            0
                                                                                    high severity
 146 Medication Administration                    99506                             Home visit for intramusular injection  Encounter                                                                                                                               0                0            0

 147 Medication Management                        99605                             Medication therapy management             15 Minutes                                                                                                                           0                0            0
                                                                                    service(s) provided by a pharmacist
 148     Transportation                           A0080                             Non-emergency transportation.             Per mile                                                                                                                             0                0            0
 149     Transportation                           A0090                             Non-emergency transportation.             Per mile                                                                                                                             0                0            0
 150     Transportation                           A0100                             Non-emergency transportation; taxi        Per one-way trip                                                                                                                     0                0            0
 151     Transportation                           A0110                             Non-emergency transportation and bus, Per one-way trip                                                                                                                         0                0            0
                                                                                    intra- or interstate carrier
 152     Transportation                           A0120                             Non-emergency transportation.                                                                                                                                                  0                0            0
 153     Transportation                           A0130                             Non-emergency transportation.                                                                                                                                                  0                0            0
 154     Transportation                           A0140                             Non-emergency transportation.                                                                                                                                                  0                0            0
 155     Transportation                           A0170                             Transportation ancillary; parking fees,                                                                                                                                        0                0            0
                                                                                    tolls, other
 156     General dental services                 D0150                                                                                                                                                                                                             0                0            0
 157     Comp periodontal evaluation             D0180                              Comp periodontal Eval                     Encounter                                                                                                                            0                0            0
 158     Intraoral periapical                    D0220                              First film                                                                                                                                                                     0                0            0
 159     Intraoral periapical                    D0230                              Each additional film                                                                                                                                                           0                0            0
 160     Bitewings                               D0274                              Four films                                                                                                                                                                     0                0            0




          DRAFT 12-15-2010                                                                                                                                                                     Page 3                                                                                                Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                                                                                             PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                                                                         Page: 4




                    PIHP Name:                                                                                                                       FY2010 MUNC
Reporting Period: October 1, 2009 to September 30, 2010
                            A                      B        C               D                            E                                    F                G           H                 I              J            K              L               M               N                O              P
         Service Description (Chapter III & PIHP HCPCS    Modifier     Revenue Code        Reporting Code Description -                Reporting Units      Unique     State Plan       State Plan   B3 Additional B3 Additional   HSW Services   HSW Services   Total Medicaid   Total Medicaid   Aggregated
LineID




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

 161 Prophylaxis Adult                           D1110                                                                                                                                                                                                                        0                0            0
 162                                             D2330                                                                                                                                                                                                                        0                0            0
         Resin based comp-one surface, ant
 163                                             D2331                                                                                                                                                                                                                        0                0            0
         Resin based comp-two surfaces, ant
 164                                             D2332                                                                                                                                                                                                                        0                0            0
         Resin based comp-three surfaces, an
 165                                             D2391                                                                                                                                                                                                                        0                0            0
         Resin based comp-one surface, post
 166                                             D2392                                                                                                                                                                                                                        0                0            0
         Resin based comp-two surfaces, post
 167                                             D2393                                                                                                                                                                                                                        0                0            0
         Resin based comp-three surfaces, post
 168 Crown, porc, fused to high                  D2750                                                                                                                                                                                                                        0                0            0
 169 Periodontal, main                           D4910                                                                                                                                                                                                                        0                0            0
 170 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
 171 Alveoloplasty in conjunction with           D7310                                                                                                                                                                                                                        0                0            0
         extractions, per quadrant
 172                                             D9920                                                                                                                                                                                                                        0                0            0
         Behavior Management/dental, by report
 173 Enhanced Medical Equipment-Supplies          E1399                                    DME, miscellaneous (single room air         Item                                                                                                                                   0                0
                                                                                           conditioner)
 174 Family Training/Support                     G0177                                     Family Psycho-Education - educational       45 minutes or more                                                                                                                     0                0            0
                                                                                           groups
 175 Substance Abuse: Individual Assessment      H0001                                     Alcohol and/or drug assessment (done        Encounter                                                                                                                              0                0            0
                                                                                           by provider)
 176 Assessment                                  H0002                                     Brief screening to non-patient program      Encounter                                                                                                                              0                0            0

 177 Substance Abuse: Outpatient Treatment       H0004               0900,   0906, 0914,   Behavioral health counseling and            15 Minutes                                                                                                                             0                0            0
                                                                     0915,   0916, 0919    therapy
 178 Substance Abuse: Outpatient Care            H0005               0900,   0914, 0915,   Alcohol and/or drug services; group         Encounter                                                                                                                              0                0            0
                                                                     0916,   0919          counseling by a clinician
 179 Substance Abuse: Sub-Acute Detoxification   H0010                                     Alcohol/drug services; medically            Day                                                                                                                                    0                0            0
                                                                                           monitored (ASAM Level III.7.D)
 180 Substance Abuse: Sub-Acute Detoxification   H0012                                     Alcohol and/or drug services; subacute      Day                                                                                                                                    0                0            0
                                                                                           detoxification (residential addiction
                                                                                           program outpatient)
 181 Substance Abuse: Sub-Acute Detoxification   H0014                                     Alcohol/drug services; medically            Day                                                                                                                                    0                0            0
                                                                                           monitored (ASAM Level I.7.D)
 182 Substance Abuse: Outpatient Care            H0015                                     Alcohol and/or drug services; intensive     Day                                                                                                                                    0                0            0
                                                                                           outpatient.
 183 Crisis Residential Services                 H0018                                     Behavioral health; short-term residential   Day                                                                                                                                    0                0            0
                                                                                           (non-hosp resident treatment program)
                                                                                           without R&B per diem. Use for both
                                                                                           child & adult services.

 184 Substance Abuse: Residential Services       H0018               1002                  Alcohol and/or drug services; short term    Day                                                                                                                                    0                0            0
                                                                                           residential
 185 Substance Abuse: Residential Services       H0019               1002                  Alcohol and/or drug services; long-term     Day                                                                                                                                    0                0            0
                                                                                           residential
 186 Substance Abuse: Methadone                  H0020                                     Alcohol and/or drug services;               Encounter                                                                                                                              0                0            0
                                                                                           Methadone administration and/or
                                                                                           service
 187 Substance Abuse: Early Intervention         H0022                                     Alcohol and/or drug services;               Encounter                                                                                                                              0                0
                                                                                           Intervention Service (Early
                                                                                           Intervention).
 188 Peer Directed and Operated Support          H0023                                     Drop-in Center attendance.                  Encounter                                                                                                                              0                0            0
         Services
 189 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)
 190 Crisis Intervention                         H0030                                     Michigan Center for Positive Living         Per Service                                                                                                                            0                0            0
                                                                                           Supports Crisis line
 191 Assessment                                  H0031                                     Mental health assessment, by non-      Encounter                                                                                                                                   0                0            0
                                                                                           physician
 192 Treatment Planning                          H0032                                     Mental health service plan development Encounter                                                                                                                                   0                0            0
                                                                                           by non-physician
 193 Monitoring of Treatment-Physician           H0032       TS                                                                   Encounter                                                                                                                                   0                0            0


 194 Substance Abuse: Pharmalogical Support -    H0033               1002                  Oral medication administration, direct      Encounter                                                                                                                              0                0            0
         Suboxane                                                                          observation.
 195 Health Services                             H0034                                     Medication training and support             15 Minutes                                                                                                                             0                0            0
 196 Home Based Services                         H0036                                     Community psychiatric supportive            15 Minutes                                                                                                                             0                0            0
                                                                                           treatment, face-to-face
 197 Home Based Services                         H0036       ST                            Modifier ST when providing Trauma-          15 Minutes                                                                                                                             0                0            0
                                                                                           focused Cognitive Behavioral Therapy
                                                                                           when pre-approved by MDCH
 198 Peer Directed and Operated Support          H0038                                     Peer-speciailist services                   15 Minutes                                                                                                                             0                0            0
         Services
 199 Substance Abuse: Peer Services              H0038                                     Peer-speciailist services                   15 Minutes                                                                                                                             0                0
 200 Peer Directed and Operated Support             NA                                     Drop-in centers                                                                                                                                                                    0                0
         Services
 201 Assertive Community Treatment (ACT)         H0039                                     ACT face-to-face                            15 Minutes                                                                                                                             0                0            0




          DRAFT 12-15-2010                                                                                                                                                                                Page 4                                                                                                Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                                                                                             PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                                                                         Page: 5




                  PIHP Name:                                                                                                                        FY2010 MUNC
Reporting Period: October 1, 2009 to September 30, 2010
                            A                      B        C                D                             E                                  F                G           H                 I              J            K              L               M               N                O              P
         Service Description (Chapter III & PIHP HCPCS    Modifier      Revenue Code         Reporting Code Description -              Reporting Units      Unique     State Plan       State Plan   B3 Additional B3 Additional   HSW Services   HSW Services   Total Medicaid   Total Medicaid   Aggregated
LineID




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

 202 Community Living Supports in Independent    H0043                                       CLS per diem                              Per diem                                                                                                                               0                0            0
         living/own home
 203 Respite Care                                H0045                                       Respite out-of-home                       Per Diem                                                                                                                               0                0            0
 204 Substance Abuse: Individual Assessment      H0049                                       AMS alcohol/drug screening                Encounter                                                                                                                              0                0            0


 205 Substance Abuse: Individual Treatment       H0050                                       Outpatient alcohol/other drug treatment 15 Minutes                                                                                                                               0                0
                                                                                             services (brief intervention)
 206 Behavior Treatment Plan Review              H2000                                       Comprehensive multidisciplinary         Encounter                                                                                                                                0                0            0
                                                                                             evaluation
 207 Monitoring Activities                       H2000       TS                              Modifier TS for monitoring activities   Encounter                                                                                                                                0                0            0
                                                                                             associated with a behavior treatment
                                                                                             plan
 208 Medication Review                           H2010                                       Medication Algorithm EBP                  15 Minutes                                                                                                                             0                0            0
 209 Crisis Intervention                         H2011                                       Crisis intervention service.              15 Minutes                                                                                                                             0                0            0
 210 Skill-Building and Out of Home Non          H2014                                       Skills training and development           15 minutes                                                                                                                             0                0            0
     Vocational Habilitation
 211 Community Living Supports (15 Minutes)      H2015                                       Comprehensive Community Support           15 Minutes                                                                                                                             0                0            0
                                                                                             Services
 212 Community Living Supports (Daily)           H2016                                       No modifier - Low Level of Supports       Per Diem                                                                                                                               0                0            0
 213 Community Living Supports (Daily)           H2016       TF                              TF Modifier - Medium Level of Supports Per Diem                                                                                                                                  0                0            0

 214 Community Living Supports (Daily)           H2016       TG                              TG Modifier - High Level of Supports    Per Diem                                                                                                                                 0                0            0
                                                                                             Therapeutic Behavioral Services: Use
 215 Mental Health Therapy                       H2019                                                                               15 Minutes                                                                                                                               0                0            0
                                                                                             for individual Dialectical Behavior
                                                                                             Therapy (DBT) provided by staff trained
                                                                                             and certified by MDCH.
 216 Mental Health Therapy                       H2019       TT                                                                        15 Minutes                                                                                                                             0                0            0
                                                                                             Therapeutic Behavioral Services: TT
                                                                                             modifier for group skills training
 217 Crisis Intervention                         H2020                                       Michigan Center for Positive Living       Day                                                                                                                                    0                0            0
                                                                                             Supports Transition Home
 218     Wraparound Services                     H2021                                       Specialize Wraparound Faciliation         15 Minutes                                                                                                                             0                0            0
 219     Supported Employment Services           H2023                                       Supported employment                      15 Minutes                                                                                                                             0                0            0
 220     Supported Employment Services           H2023       TT                              Additional Patient                        15 Minutes                                                                                                                             0                0            0
 221     Substance Abuse Outpatient: Didactics   H2027                                       Didactics
                                                                     0900, 0914, 0915, 0916, 0919                                      15 Minutes                                                                                                                             0                0
 222 Clubhouse Psychosocial Rehabilitation       H2030                                       Mental Health Clubhouse                   15 Minutes                                                                                                                             0                0            0
     Programs
 223 Home Based Services                         H2033                                       Multi-systemic therapy (MST) for          15 Minutes                                                                                                                             0                0            0
                                                                                             juveniles provided in home-based
                                                                                             program
 224 Substance Abuse Outpatient                  H2035               0900, 0906, 0914,       Outpatient alcohol/other drug treatment Hour                                                                                                                                     0                0            0
                                                                     0915, 0916, 0919        services.Referral, linking and
                                                                                             coordinating
 225 Substance Abuse: Outpatient Care            H2036                                       Alcohol/other drug treatment. Referral, Per Diem
                                                                     0900, 0914, 0915, 0916, 0919                                                                                                                                                                             0                0            0
                                                                                             linking and coordinating
 226 Medication Review                           M0064                                       Brief assessment, med monitoring or       Encounter Face-to-                                                                                                                     0                0            0
                                                                                             change                                    Face
 227 Transportation                               S0209                                      Wheelchair van mileage                    Per Mile                                                                                                                               0                0            0
 228 Transportation                               S0215                                      Non-emergency transportation mileage      Per Mile                                                                                                                               0                0            0

 229 Family Training                              S5110                                      Family psycho-education: skills           15 Minutes                                                                                                                             0                0            0
                                                                                             workshop
 230     Family Training                          S5111                                      Home care training, family per session    Encounter                                                                                                                              0                0            0
 231     Chore Services                           S5120                                      Chore services                            15 Minutes                                                                                                                             0                0            0
 232     Respite Care                             S5151                                      Respite care in-home                      Per Diem                                                                                                                               0                0            0
 233 Personal Emergency Response System           S5160                                      Emergency response system;                Encounter                                                                                                                              0                0
     (PERS)                                                                                  installation and testing
 234 Personal Emergency Response System           S5161                                      PERS Service fee, per month (excludes     Month                                                                                                                                  0                0
     (PERS)                                                                                  installation and testing).
 235 Environmental Modification                   S5165                                      Home modifications, per service.          Service                                                                                                                                0                0
 236 Enhanced Medical Equipment-Supplies          S5199                                      Personal care item, NOS. (assistive       Item                                                                                                                                   0                0
                                                                                             technology)
 237 Occupational or Physical Therapy             S8990                                      Physical or manipulative therapy          Encounter                                                                                                                              0                0            0
                                                                                             performed for maintenance rather than
                                                                                             restoration
 238 Private Duty Nursing                         S9123              0582                    Private duty nursing, habilitation        Hour                                                                                                                                   0                0            0
                                                                                             supports waiver (individual nurse only)
                                                                                             21 years and over ONLY
 239 Private Duty Nursing                         S9123                                      Private duty nursing, habilitation        Hour                                                                                                                                   0                0            0
                                                                                             supports waiver (individual nurse only)
                                                                                             21 years and over ONLY
 240 Private Duty Nursing                         S9123      TT                              Additional Patient                        Hour                                                                                                                                   0                0            0
 241 Private Duty Nursing                         S9124              0582                    Nursing care, in the home, by licensed    Hour                                                                                                                                   0                0            0
                                                                                             practical nurse
 242 Private Duty Nursing                         S9124                                      Nursing care, in the home, by licensed    Hour                                                                                                                                   0                0            0
                                                                                             practical nurse
 243 Private Duty Nursing                         S9124      TT                              Additional Patient                        Hour                                                                                                                                   0                0            0
 244 Health Services                              S9445                                      Pt education NOC nonphysician indiv       Encounter                                                                                                                              0                0            0
                                                                                             per session
 245 Health Services                              S9446                                      Pt education NOC nonphysician group,      Encounter                                                                                                                              0                0            0
                                                                                             per session
 246 Health Services                              S9470                                      Nutritional counseling dietician visit    Encounter                                                                                                                              0                0            0
 247 Intensive Crisis Stabilization               S9484                                      Crisis intervention mental health         Hour                                                                                                                                   0                0            0
                                                                                             services approved programs only




          DRAFT 12-15-2010                                                                                                                                                                                Page 5                                                                                                Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                                                                                 PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                                                                         Page: 6




                  PIHP Name:                                                                                                              FY2010 MUNC
Reporting Period: October 1, 2009 to September 30, 2010
                            A                      B        C             D                       E                                 F              G           H                 I              J            K              L               M               N                O              P
         Service Description (Chapter III & PIHP HCPCS    Modifier   Revenue Code   Reporting Code Description -             Reporting Units    Unique     State Plan       State Plan   B3 Additional B3 Additional   HSW Services   HSW Services   Total Medicaid   Total Medicaid   Aggregated
LineID




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

 248 Private Duty Nursing                         T1000                             Private duty nursing, habilitation       Up to 15 min                                                                                                                         0                0            0
                                                                                    supports waiver, private
                                                                                    duty/independent nursing service(s),
                                                                                    licensed.
 249 Assessment                                   T1001                             Nursing/Nutrition Assessment             Encounter                                                                                                                            0                0            0
 250 Health Services                              T1002                             RN services                              Up to 15 min                                                                                                                         0                0            0
 251 Respite Care                                 T1005                             Respite care services. No modifier = all 15 minutes                                                                                                                           0                0            0
                                                                                    providers except RN & LPN. TD
                                                                                    modifier = RN only. TE modifier = LPN
                                                                                    only.
 252 Substance Abuse: Recovery Supports           T1012                             Recovery Supports                        Encounter                                                                                                                            0                0            0
 253 Family Training                              T1015                             Family psycho-education: joining         Encounter                                                                                                                            0                0            0
 254 Supports Coordination                        T1016                             Case management                          15 minutes                                                                                                                           0                0            0
 255 Targeted Case Management                     T1017                             Targeted Case management (face to        15 minutes                                                                                                                           0                0            0
                                                                                    face)
 256 Nursing Facility Mental Health Monitoring    T1017      SE                     Targeted Case management (face to        15 minutes                                                                                                                           0                0            0
                                                                                    face)
 257 Personal Care in Licensed Specialized        T1020                             No modifier - Low Level of Supports      Day                                                                                                                                  0                0            0
         Residential Setting
 258 Personal Care in Licensed Specialized        T1020      TF                     TF Modifier - Medium Level of Supports Day                                                                                                                                    0                0            0
         Residential Setting
 259 Personal Care in Licensed Specialized        T1020      TG                     TG Modifier - High Level of Supports     Day                                                                                                                                  0                0            0
         Residential Setting
 260 Assessments                                  T1023                             Screening for inpatient programs         Encounter                                                                                                                            0                0            0
 261 Enhanced Pharmacy                            T1999                             Miscellaneous therapeutic items and       Item                                                                                                                                0                0
                                                                                    supplies, retail purchases, not otherwise
                                                                                    classified; identify product in “remarks”

 262 Transportation                               T2001                             Non-emergency transportation; patient                                                                                                                                         0                0            0
                                                                                    attendant / escort
 263 Transportation                               T2002                             Non-emergency transportation             Per Diem                                                                                                                             0                0            0
 264 Transportation                               T2003                             Non-emergency transportation             Encounter / Trip                                                                                                                     0                0            0
 265 Transportation                               T2004                             Non-emergency transport; commercial                                                                                                                                           0                0            0
                                                                                    carrier, multi-pass
 266 Transportation                               T2005                             Non-emergency transportation; non-                                                                                                                                            0                0            0
                                                                                    ambulatory stretcher van
 267 Out of Home Prevocational Service            T2015                             Habilitation, prevocational, waiver      Hour                                                                                                                                 0                0            0

 268 Fiscal Intermediary Services                 T2025                             Use for services performed by a fiscal   Per Month                                                                                                                            0                0            0
                                                                                    intermediary.
 269 Enhanced Medical Equipment-Supplies          T2028                             Specialized supply, not otherwise        Item                                                                                                                                 0                0
                                                                                    specified, waiver (allergy control
                                                                                    supplies)
 270 Enhanced Medical Equipment-Supplies          T2029                             Specialized medical equipment, not       Item                                                                                                                                 0                0
                                                                                    otherwise specified, waiver.
                                                                                    (environmental safety & control devices)

 271 Crisis Intervention                          T2034                             Michigan Center for Positive Living      Day                                                                                                                                  0                0            0
                                                                                    Supports Mobile Crisis/Training Team
 272 Community Living Supports/Respite Care-      T2036                             Therapeutic camping overnight.(one       Encounter / Trip                                                                                                                     0                0            0
         Therapeutic Camping                                                        night = one session)
 273 Community Living Supports/Respite Care-      T2037                             Therapeutic camping overnight. (one      Encounter / Trip                                                                                                                     0                0            0
         Therapeutic Camping                                                        day/partial day = one session)
 274 Housing Assistance                           T2038                             Community transition, waiver, per        Month                                                                                                                                0                0
                                                                                    service
 275 Enhanced Medical Equipment-Supplies          T2039                             Van lifts & wheelchair tie down system   Item                                                                                                                                 0                0



         TOTAL MEDICAID CASES AND
II       COSTS (MH/DD/SA)                                                                                                                                                             0                           0                              0                                 0


         TOTAL MEDICAID MH/DD CASES
III      AND COSTS                                                                                                                                                                    0                           0                              0                                 0
                                                                                                                                                                                                                                                     PLUS
         MEDICAID MANAGED CARE
IV       ADMINISTRATION MH/DD


V        TOTAL MEDICAID MH/DD COSTS                                                                                                                                                                                                                  EQUALS =                      0


         MEDICAID SUBSTANCE ABUSE
VI       CASES & COSTS                                                                                                                                                                0                           0                                                                0


  a.         Administration by PIHP                                                                                                                                                                                                                  PLUS



  b.         Administration by CA                                                                                                                                                                                                                    PLUS


VII TOTAL SA MEDICAID COSTS                                                                                                                                                                                                                          EQUALS =                      0




          DRAFT 12-15-2010                                                                                                                                                                    Page 6                                                                                                Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                                                                     PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                                                                         Page: 7




                   PIHP Name:                                                                                            FY2010 MUNC
Reporting Period: October 1, 2009 to September 30, 2010
                            A                      B       C             D                       E                       F             G           H                 I              J            K              L               M               N                O              P
         Service Description (Chapter III & PIHP HCPCS   Modifier   Revenue Code   Reporting Code Description -   Reporting Units   Unique     State Plan       State Plan   B3 Additional B3 Additional   HSW Services   HSW Services   Total Medicaid   Total Medicaid   Aggregated
LineID




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



     TOTAL MEDICAID COSTS
VIII (MH/DD/SA) (Sum of V & VII)                                                                                                                                                                                                                                       0
IX SPEND-DOWN
              EMBEDDED IN ABOVE (amt of GF
   a. expenditures for spend-down to be deducted)                                                                                                                                                                                        DEDUCT:

             NOT EMBEDDED IN ABOVE (amt of GF
         expenditures for spend-down already
  b. deducted)
     MEDICAID MH/DD/SA NET
X    EXPENSES                                                                                                                                                                                                                            EQUALS =                      0


XI       RECONCILING ITEMS TO FSR
a.         Payments into the ISF
b.       Use Tax
c.         Prior year adjustments in the FSR
d.         OTHER - specify type




e.       Total Reconciling items                                                                                                                                                                                                                                       0


XII Adjusted MUNC report Medicaid costs                                                                                                                                                                                                                                0




XIII FSR
          TOTAL MEDICAID EXPENDITURES (FSR row
a.       A290)
         Difference between XII and XIIIa                                                                                                                                                                                                                              0




          DRAFT 12-15-2010                                                                                                                                                        Page 7                                                                                                Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                                        PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                        Page: 8




                   PIHP Name:                                                                                                               FY2010 ABW MUNC
Reporting Period: May 1, 2010 to September 30, 2010
                            A                       B        C              D                              E                                 F                G          H               I             J
         Service Description (Chapter III & PIHP HCPCS    Modifier     Revenue Code          Reporting Code Description -             Reporting Units      Unique   ABW Services   ABW Services   Aggregated
LineID




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

   1     Local Psychiatric Hospital/IMD PT68                PT68     0100,   0101,   0114,   All inclusive room and board plus        Day                                                                  0
                                                                     0124,   0134,   0154    ancillaries
   2     Local Psychiatric Hospital - Acute                 PT73     0100,   0101,   0114,   All inclusive room and board             Day                                                                  0
         Community PT73                                              0124,   0134,   0154

   3
   4
   5     ECT Anesthesia                                              0370                    Anesthesia charges                                                                                            0
   6     ECT Recovery Room                                           0710                    Recovery room charge                                                                                          0
   7     Crisis Observation Care                                     0762                    Outpatient extended observation beds     Hour                                                                 0
                                                                                             (23 hour)
   8     Electro-Convulsive Therapy                                  0901                    Facility charges                         Encounter                                                            0
   9     Substance Abuse: Outpatient                                 0906                    Intensive Outpatient Services -          Day
                                                                                             Chemical Dependency
  10 Outpatient Partial Hospitalization                              0912                    Partial hospitalization-Less Intensive   Day                                                                  0
  11 Outpatient Partial Hospitalization                              0913                    Partial hospitalization-More Intensive   Day                                                                  0
  12 Substance Abuse: Subacute Detoxification                        1002                    Residential treatment - chemical         Day
                                                                                             dependency
  13     Electro-Convulsive Therapy               00104                                      Anesthesia charges for ECT               Minutes                                                              0
  14     Drug Screen under Methadone              80100                                      Methodone drug screen                    Per Screen                                                           0
  15     Drug Screen under Methadone              80101                                      Methodone drug screen                    Per Screen                                                           0
  16     Assessment-Psychiatric Assessment        90801                                      Psychiatric diagnostic interview         Encounter                                                            0
                                                                                             examination
  17 Assessment-Psychiatric Assessment            90802                                      Interactive psychiatric diagnostic       Encounter                                                            0
                                                                                             interview examination
  18 Therapy-Individual Therapy                   90804                                      Individual psychotherapy 20-30         Encounter      20-30                                                   0
                                                                                             minutes                                Min
  19 Substance Abuse: Outpatient Care             90804              0900, 0914, 0915,       Individual Psychotherapy               Encounter      20-30                                                   0
                                                                     0916, 0919                                                     Min
  20 Individual Psychotherapy                     90805                                      Individual Psychotherapy               Encounter      20-30                                                   0
                                                                                                                                    Min
  21 Substance Abuse: Outpatient Care             90805              0900, 0914, 0915,       Individual Psychotherapy               Encounter      20-30                                                   0
                                                                     0916, 0919                                                     Min
  22 Therapy-Individual Therapy                   90806                                      Individual psychotherapy 45-50         Encounter      45-50                                                   0
                                                                                             minutes                                Min
  23 Substance Abuse: Outpatient Care             90806              0900, 0914, 0915,       Individual Psychotherapy               Encounter      45-50                                                   0
                                                                     0916, 0919                                                     Min
  24 Therapy-Individual Therapy                   90807                                       Individual psychotherapy with medical Encounter      45-50                                                   0
                                                                                             evaluation and management services     Min
  25 Substance Abuse: Outpatient Care             90807              0900, 0914, 0915,       Individual Psychotherapy               Encounter      45-50                                                   0
                                                                     0916, 0919                                                     Min
  26 Therapy-Individual Therapy                   90808                                      Individual psychotherapy 75-80         Encounter      75-80                                                   0
                                                                                             minutes                                Min
  27 Substance Abuse: Outpatient Care             90808              0900, 0914, 0915,       Individual Psychotherapy               Encounter      75-80                                                   0
                                                                     0916, 0919                                                     Min
  28 Therapy-Individual Therapy                   90809                                      Individual psychotherapy with medical Encounter       75-80                                                   0
                                                                                             evaluation and management services     Min
  29 Substance Abuse: Outpatient Care             90809              0900, 0914, 0915,       Individual Psychotherapy               Encounter      75-80                                                   0
                                                                     0916, 0919                                                     Min
  30 Therapy-Individual Therapy                   90810                                      Individual psychotherapy, interactive  Encounter      20-30                                                   0
                                                                                             20-30 minutes                          Min
  31 Substance Abuse: Outpatient Care             90810              0900, 0914, 0915,       Individual Psychotherapy               Encounter      20-30                                                   0
                                                                     0916, 0919                                                     Min
  32 Therapy-Individual Therapy                   90811                                      Individual psychotherapy with medical Encounter       20-30                                                   0
                                                                                             evaluation and management services     Min
  33 Substance Abuse: Outpatient Care             90811              0900, 0914, 0915,       Individual Psychotherapy               Encounter      20-30                                                   0
                                                                     0916, 0919                                                     Min
  34 Therapy-Individual Therapy                   90812                                      Individual psychotherapy, interactive  Encounter      45-50                                                   0
                                                                                             45-50 minutes                          Min
  35 Substance Abuse: Outpatient Care             90812              0900, 0914, 0915,       Individual Psychotherapy               Encounter      45-50                                                   0
                                                                     0916, 0919                                                     Min
  36 Therapy-Individual Therapy                   90813                                       Individual psychotherapy with medical Encounter      45-50                                                   0
                                                                                             evaluation and management services     Min
  37 Substance Abuse: Outpatient Care             90813              0900, 0914, 0915,       Individual Psychotherapy               Encounter      45-50                                                   0
                                                                     0916, 0919                                                     Min
  38 Therapy-Individual Therapy                   90814                                      Individual psychotherapy, interactive  Encounter      75-80                                                   0
                                                                                             75-80 minutes                          Min
  39 Substance Abuse: Outpatient Treatment        90814              0900, 0914, 0915,       Individual Psychotherapy               Encounter      75-80                                                   0
                                                                     0916, 0919                                                     Min
  40 Therapy-Individual Therapy                   90815                                      Individual psychotherapy with medical Encounter       75-80                                                   0
                                                                                             evaluation and management services     Min
  41 Substance Abuse: Outpatient Care             90815              0900, 0914, 0915,       Individual Psychotherapy               Encounter      75-80                                                   0
                                                                     0916, 0919                                                     Min
  42 Therapy-Individual Therapy                   90816                                      Individual psychotherapy               Encounter      20-30                                                   0
                                                                                                                                    Min
  43 Therapy-Individual Therapy                   90817                                      Individual psychotherapy with medical Encounter       20-30                                                   0
                                                                                             evaluation and management services     Min
  44 Therapy-Individual Therapy                   90818                                      Individual psychotherapy               Encounter      45-50                                                   0
                                                                                                                                    Min
  45 Therapy-Individual Therapy                   90819                                      Individual psychotherapy with medical Encounter       45-50                                                   0
                                                                                             evaluation and management services     Min
  46 Therapy-Individual Therapy                   90821                                      Individual psychotherapy               Encounter      75-80                                                   0
                                                                                                                                    Min




          DRAFT 12-15-2010                                                                                                                                 Page 8                                         Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                                        PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                      Page: 9




                  PIHP Name:                                                                                                             FY2010 ABW MUNC
Reporting Period: May 1, 2010 to September 30, 2010
                            A                       B        C              D                             E                                 F               G          H               I             J
         Service Description (Chapter III & PIHP HCPCS    Modifier     Revenue Code         Reporting Code Description -             Reporting Units     Unique   ABW Services   ABW Services   Aggregated
LineID




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

  47 Therapy-Individual Therapy                   90822                                     Individual psychotherapy with medical    Encounter   75-80                                                   0
                                                                                            evaluation and management services       Min
  48 Therapy-Individual Therapy                   90823                                     Individual psychotherapy, interactive    Encounter   20-30                                                   0
                                                                                                                                     Min
  49 Therapy-Individual Therapy                   90824                                     Individual psychotherapy with medical    Encounter   20-30                                                   0
                                                                                            evaluation and management services       Min
  50 Therapy-Individual Therapy                   90826                                     Individual psychotherapy, interactive    Encounter   45-50                                                   0
                                                                                                                                     Min
  51 Substance Abuse: Individual Therapy          90826                                     Individual psychotherapy, interactive    Encounter   45-50                                                   0
                                                                                                                                     Min
  52 Therapy-Individual Therapy                   90827                                     Individual psychotherapy with medical    Encounter   45-50                                                   0
                                                                                            evaluation and management services       Min
  53 Therapy-Individual Therapy                   90828                                     Individual psychotherapy                 Encounter   75-80                                                   0
                                                                                                                                     Min
  54 Therapy-Individual Therapy                   90829                                     Individual psychotherapy with medical    Encounter   75-80                                                   0
                                                                                            evaluation and management services       Min
  55 Therapy-Family Therapy                       90846                                     Family therapy, per session              Encounter                                                           0
  56 Substance Abuse: Psychotherapy (group)       90846              0900, 0914, 0915, 0916, Psychotherapy (group)
                                                                                             0919                                    Encounter                                                           0
  57 Therapy-Family Therapy                       90847                                     Family psychotherapy (conjoint           Encounter                                                           0
                                                                                            psychotherapy) (with patient present)

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

  83 Assessments - Testing                        96120                                     Neuropsychological testing battery       Hour                                                                0
                                                                                            (administered by a computer)
  84 Medication Administration                    96372                                     Report using this procedure code only    Encounter                                                           0
                                                                                            when provided as a separate service.
  85     Physical Therapy                         97001                                     Physical therapy evaluation              Encounter                                                           0
  86     Physical Therapy                         97002                                     Physical therapy re-evaluation           Encounter                                                           0
  87     Occupational Therapy                     97003                                     OT evaluation                            Encounter                                                           0
  88     Occupational Therapy                     97004                                     OT re-evaluation                         Encounter                                                           0
  89     Occupational or Physical Therapy         97110                                     Therapeutic procedure, one or more       15 Minutes                                                          0
                                                                                            areas
  90 Occupational or Physical Therapy             97112                                         neuromuscular reeducation of         15 Minutes                                                          0
                                                                                            movement
  91 Occupational or Physical Therapy             97113                                         aquatic therapy with therapeutic     15 Minutes                                                          0
                                                                                            exercises
  92 Occupational or Physical Therapy             97116                                         gait training (includes stair        15 Minutes                                                          0
                                                                                            climbing)
  93     Occupational or Physical Therapy         97124                                         massage, including effleurage        15 Minutes                                                          0
  94     Occupational or Physical Therapy         97140                                     Manual therapy techniques                15 Minutes                                                          0
  95     Occupational or Physical Therapy         97150                                     Group, per session                       Encounter                                                           0
  96     Occupational or Physical Therapy         97530                                     Therapeutic activities, direct           15 Minutes                                                          0




          DRAFT 12-15-2010                                                                                                                               Page 9                                         Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                               PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                     Page: 10




                  PIHP Name:                                                                                                    FY2010 ABW MUNC
Reporting Period: May 1, 2010 to September 30, 2010
                            A                       B        C            D                       E                                F               G          H               I             J
         Service Description (Chapter III & PIHP HCPCS    Modifier   Revenue Code   Reporting Code Description -            Reporting Units     Unique   ABW Services   ABW Services   Aggregated
LineID




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

  97 Occupational or Physical Therapy             97532                             Development of cognitive skills to      15 Minutes                                                          0
                                                                                    improve attention
 98      Occupational or Physical Therapy         97533                             Sensory integrative techniques          15 Minutes                                                          0
 99      Occupational or Physical Therapy         97535                             Self-care/home management training      15 Minutes                                                          0
 100     Occupational or Physical Therapy         97537                             Community/work reintegration training 15 Minutes                                                            0
 101     Occupational or Physical Therapy         97542                             Wheelchair management/propulsion        15 Minutes                                                          0
                                                                                    training
 102     Occupational Therapy                     97750                             Physical performance testing            15 Minutes                                                          0
 103     Occupational Therapy                     97755                             Assistive technology assessment         15 Minutes                                                          0
 104     Occupational Therapy                     97760                             Orthotic(s) management and training     15 Minutes                                                          0
 105     Occupational Therapy                     97762                             Checkout for orthotic/prosthetic use,   15 Minutes                                                          0
                                                                                    established patient
 106 Assessment or Health Services                97802                             Medical nutrition therapy; initial      15 Minutes                                                          0
                                                                                    assessment and intervention
 107 Assessment or Health Services                97803                             re-assessment and intervention,         15 Minutes                                                          0
                                                                                    individual
 108     Health Services                          97804                             Nutrition Therapy-group                 30 Minutes                                                          0
 109     Additional Codes-Physician Services      99201                             E & M 10 Minutes                        Encounter                                                           0
 110     Additional Codes-Physician Services      99202                             E & M 20 Minutes                        Encounter                                                           0
 111     Additional Codes-Physician Services      99203                             E & M 30 Minutes                        Encounter                                                           0
 112     Substance Abuse: Physician               99203                             30 mins face-to-face                    30 Minutes                                                          0
         Evaluation/Exam Under methodone
 113 Additional Codes-Physician Services          99204                             E & M 45 Minutes                        Encounter                                                           0
 114 Substance Abuse: Physician                   99204                             45 mins face-to-face                    45 Minutes                                                          0
         Evaluation/Exam Under methodone

 115 Additional Codes-Physician Services          99205                             E & M 60 Minutes                        Encounter                                                           0
 116 Substance Abuse: Physician                   99205                             60 mins face-to-face                    60 Minutes                                                          0
         Evaluation/Exam Under methodone
 117 Medication Administration                    99211                             Only used when provided as separate     Encounter                                                           0
                                                                                    service.
 118     Additional Codes-Physician Services      99212                             Office or other outpatient visit.       Encounter                                                           0
 119     Additional Codes-Physician Services      99213                             15 Minutes                              Encounter                                                           0
 120     Additional Codes-Physician Services      99214                             25 Minutes                              Encounter                                                           0
 121     Additional Codes-Physician Services      99215                             40 Minutes                              Encounter                                                           0
 122     Additional Codes-Physician Services      99221                             Initial hospital care-30 minutes                                                                            0
 123     Additional Codes-Physician Services      99222                             Initial hospital care-50 minutes                                                                            0
 124     Additional Codes-Physician Services      99223                             Initial hospital care-70 minutes                                                                            0
 125     Additional Codes-Physician Services      99231                             Subsequent hospital care-15 minutes                                                                         0
 126     Additional Codes-Physician Services      99232                             Subsequent hospital care-25 minutes                                                                         0
 127     Additional Codes-Physician Services      99233                             Subsequent hospital care-35 minutes                                                                         0
 128     Additional Codes-Physician Services      99241                             Office consultation, 15 minutes         Encounter                                                           0
 129     Additional Codes-Physician Services      99242                             30 Minutes                              Encounter                                                           0
 130     Additional Codes-Physician Services      99243                             40 Minutes                              Encounter                                                           0
 131     Additional Codes-Physician Services      99244                             60 Minutes                              Encounter                                                           0
 132     Additional Codes-Physician Services      99245                             80 Minutes                              Encounter                                                           0
 133     Additional Codes-Physician Services      99251                             Office consultation, 20 minutes         Encounter                                                           0
 134     Additional Codes-Physician Services      99252                             40 Minutes                              Encounter                                                           0
 135     Additional Codes-Physician Services      99253                             55 Minutes                              Encounter                                                           0
 136     Additional Codes-Physician Services      99254                             80 Minutes                              Encounter                                                           0
 137     Additional Codes-Physician Services      99255                             110 Minutes                             Encounter                                                           0
 138     Additional Codes-Physician Services      99261                             Office consultation, 10 minutes         Encounter                                                           0
 139     Additional Codes-Physician Services      99262                             20 Minutes                              Encounter                                                           0
 140     Additional Codes-Physician Services      99263                             30 Minutes                              Encounter                                                           0
 141     Additional Codes-Physician Services      99271                             Confirmatory consultation, self-limited Encounter                                                           0
                                                                                    or minor
 142 Additional Codes-Physician Services          99272                             Confirmatory consultation, low severity Encounter                                                           0

 143 Additional Codes-Physician Services          99273                             Confirmatory consultation, moderate    Encounter                                                            0
                                                                                    severity
 144 Additional Codes-Physician Services          99274                             Confirmatory consultation, moderate to Encounter                                                            0
                                                                                    high severity
 145 Additional Codes-Physician Services          99275                             Confirmatory consultation, moderate to Encounter                                                            0
                                                                                    high severity
 146 Medication Administration                    99506                             Home visit for intramusular injection  Encounter                                                            0

 147 Medication Management                        99605                             Medication therapy management           15 Minutes                                                          0
                                                                                    service(s) provided by a pharmacist
 148 Transportation                               A0080                             Non-emergency transportation.           Per mile                                                            0
 149 Transportation                               A0090                             Non-emergency transportation.           Per mile                                                            0
 150 Transportation                               A0100                             Non-emergency transportation; taxi      Per one-way trip                                                    0
 151 Transportation                               A0110                             Non-emergency transportation and        Per one-way trip                                                    0
                                                                                    bus, intra- or interstate carrier




          DRAFT 12-15-2010                                                                                                                     Page 10                                         Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                                      PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                           Page: 11




                    PIHP Name:                                                                                                               FY2010 ABW MUNC
Reporting Period: May 1, 2010 to September 30, 2010
                            A                       B        C              D                            E                                    F                 G          H               I             J
         Service Description (Chapter III & PIHP HCPCS    Modifier     Revenue Code        Reporting Code Description -                Reporting Units       Unique   ABW Services   ABW Services   Aggregated
LineID




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

 152     Transportation                           A0120                                    Non-emergency transportation.                                                                                     0
 153     Transportation                           A0130                                    Non-emergency transportation.                                                                                     0
 154     Transportation                           A0140                                    Non-emergency transportation.                                                                                     0
 155     Transportation                           A0170                                    Transportation ancillary; parking fees,                                                                           0
                                                                                           tolls, other
 156     General dental services                 D0150                                                                                                                                                       0
 157     Comp periodontal evaluation             D0180                                     Comp periodontal Eval                       Encounter                                                             0
 158     Intraoral periapical                    D0220                                     First film                                                                                                        0
 159     Intraoral periapical                    D0230                                     Each additional film                                                                                              0
 160     Bitewings                               D0274                                     Four films                                                                                                        0
 161     Prophylaxis Adult                       D1110                                                                                                                                                       0
 162                                             D2330                                                                                                                                                       0
         Resin based comp-one surface, ant
 163                                             D2331                                                                                                                                                       0
         Resin based comp-two surfaces, ant
 164                                             D2332                                                                                                                                                       0
         Resin based comp-three surfaces, an
 165                                             D2391                                                                                                                                                       0
         Resin based comp-one surface, post
 166                                             D2392                                                                                                                                                       0
         Resin based comp-two surfaces, post
 167                                             D2393                                                                                                                                                       0
         Resin based comp-three surfaces, post
 168 Crown, porc, fused to high                  D2750                                                                                                                                                       0
 169 Periodontal, main                           D4910                                                                                                                                                       0
 170 Surgical removal of erupted tooth           D7210                                     Surgical removal of erupted tooth                                                                                 0
                                                                                           requiring elevation of mucoperiosteal
                                                                                           flap of bone and/or section of tooth
 171 Alveoloplasty in conjunction with           D7310                                                                                                                                                       0
         extractions, per quadrant
 172                                             D9920                                                                                                                                                       0
         Behavior Management/dental, by report
 173 Enhanced Medical Equipment-Supplies          E1399                                    DME, miscellaneous (single room air         Item                                                                  0
                                                                                           conditioner)
 174 Family Training/Support                     G0177                                     Family Psycho-Education - educational       45 minutes or more                                                    0
                                                                                           groups
 175 Substance Abuse: Individual Assessment      H0001                                     Alcohol and/or drug assessment (done        Encounter                                                             0
                                                                                           by provider)
 176 Assessment                                  H0002                                     Brief screening to non-patient program      Encounter                                                             0

 177 Substance Abuse: Outpatient Treatment       H0004               0900,   0906, 0914,   Behavioral health counseling and            15 Minutes                                                            0
                                                                     0915,   0916, 0919    therapy
 178 Substance Abuse: Outpatient Care            H0005               0900,   0914, 0915,   Alcohol and/or drug services; group         Encounter                                                             0
                                                                     0916,   0919          counseling by a clinician
 179 Substance Abuse: Sub-Acute Detoxification   H0010                                     Alcohol/drug services; medically            Day                                                                   0
                                                                                           monitored (ASAM Level III.7.D)
 180 Substance Abuse: Sub-Acute Detoxification   H0012                                     Alcohol and/or drug services; subacute      Day                                                                   0
                                                                                           detoxification (residential addiction
                                                                                           program outpatient)
 181 Substance Abuse: Sub-Acute Detoxification   H0014                                     Alcohol/drug services; medically            Day                                                                   0
                                                                                           monitored (ASAM Level I.7.D)
 182 Substance Abuse: Outpatient Care            H0015                                     Alcohol and/or drug services; intensive     Day                                                                   0
                                                                                           outpatient.
 183 Crisis Residential Services                 H0018                                     Behavioral health; short-term               Day                                                                   0
                                                                                           residential (non-hosp resident
                                                                                           treatment program) without R&B per
                                                                                           diem. Use for both child & adult
                                                                                           services.
 184 Substance Abuse: Residential Services       H0018               1002                  Alcohol and/or drug services; short         Day                                                                   0
                                                                                           term residential
 185 Substance Abuse: Residential Services       H0019               1002                  Alcohol and/or drug services; long-         Day                                                                   0
                                                                                           term residential
 186 Substance Abuse: Methadone                  H0020                                     Alcohol and/or drug services;               Encounter                                                             0
                                                                                           Methadone administration and/or
                                                                                           service
 187 Substance Abuse: Early Intervention         H0022                                     Alcohol and/or drug services;               Encounter                                                             0
                                                                                           Intervention Service (Early
                                                                                           Intervention).
 188 Peer Directed and Operated Support          H0023                                     Drop-in Center attendance.                  Encounter                                                             0
         Services
 189 Prevention Services - Direct Model          H0025                                     Behavioral health prevention education      Face to Face                                                          0
                                                                                           service (delivery of services with target   Contact
                                                                                           population to affect knowledge,
                                                                                           attitude, and/or behavior)
 190 Crisis Intervention                         H0030                                     Michigan Center for Positive Living         Per Service                                                           0
                                                                                           Supports Crisis line
 191 Assessment                                  H0031                                     Mental health assessment, by non-           Encounter                                                             0
                                                                                           physician
 192 Treatment Planning                          H0032                                     Mental health service plan development      Encounter                                                             0
                                                                                           by non-physician
 193 Monitoring of Treatment-Physician           H0032       TS                                                                        Encounter                                                             0




          DRAFT 12-15-2010                                                                                                                                  Page 11                                         Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                                            PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                     Page: 12




                    PIHP Name:                                                                                                               FY2010 ABW MUNC
Reporting Period: May 1, 2010 to September 30, 2010
                            A                       B        C               D                             E                                  F                 G          H               I             J
         Service Description (Chapter III & PIHP HCPCS    Modifier      Revenue Code         Reporting Code Description -              Reporting Units       Unique   ABW Services   ABW Services   Aggregated
LineID




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

 194 Substance Abuse: Pharmalogical Support -    H0033               1002                    Oral medication administration, direct    Encounter                                                             0
         Suboxane                                                                            observation.
 195 Health Services                             H0034                                       Medication training and support           15 Minutes                                                            0
 196 Home Based Services                         H0036                                       Community psychiatric supportive          15 Minutes                                                            0
                                                                                             treatment, face-to-face
 197 Home Based Services                         H0036       ST                              Modifier ST when providing Trauma-        15 Minutes                                                            0
                                                                                             focused Cognitive Behavioral Therapy
                                                                                             when pre-approved by MDCH
 198 Peer Directed and Operated Support          H0038                                       Peer-speciailist services                 15 Minutes                                                            0
         Services
 199 Substance Abuse: Peer Services              H0038                                       Peer-speciailist services                 15 Minutes                                                            0
 200 Peer Directed and Operated Support             NA                                       Drop-in centers                                                                                                 0
     Services
 201 Assertive Community Treatment (ACT)         H0039                                       ACT face-to-face                          15 Minutes                                                            0
 202 Community Living Supports in Independent    H0043                                       CLS per diem                              Per diem                                                              0
     living/own home
 203 Respite Care                                H0045                                       Respite out-of-home                       Per Diem                                                              0
 204 Substance Abuse: Individual Assessment      H0049                                       AMS alcohol/drug screening                Encounter                                                             0


 205 Substance Abuse: Individual Treatment       H0050                                       Outpatient alcohol/other drug             15 Minutes                                                            0
                                                                                             treatment services (brief intervention)
 206 Behavior Treatment Plan Review              H2000                                       Comprehensive multidisciplinary           Encounter                                                             0
                                                                                             evaluation
 207 Monitoring Activities                       H2000       TS                              Modifier TS for monitoring activities     Encounter                                                             0
                                                                                             associated with a behavior treatment
                                                                                             plan
 208 Medication Review                           H2010                                       Medication Algorithm EBP                  15 Minutes                                                            0
 209 Crisis Intervention                         H2011                                       Crisis intervention service.              15 Minutes                                                            0
 210 Skill-Building and Out of Home Non          H2014                                       Skills training and development           15 minutes                                                            0
     Vocational Habilitation
 211 Community Living Supports (15 Minutes)      H2015                                       Comprehensive Community Support           15 Minutes                                                            0
                                                                                             Services
 212 Community Living Supports (Daily)           H2016                                       No modifier - Low Level of Supports       Per Diem                                                              0
 213 Community Living Supports (Daily)           H2016       TF                              TF Modifier - Medium Level of Supports Per Diem                                                                 0

 214 Community Living Supports (Daily)           H2016       TG                              TG Modifier - High Level of Supports      Per Diem                                                              0
                                                                                             Therapeutic Behavioral Services: Use
 215 Mental Health Therapy                       H2019                                                                                 15 Minutes                                                            0
                                                                                             for individual Dialectical Behavior
                                                                                             Therapy (DBT) provided by staff
                                                                                             trained and certified by MDCH.
 216 Mental Health Therapy                       H2019       TT                                                                        15 Minutes                                                            0
                                                                                             Therapeutic Behavioral Services: TT
                                                                                             modifier for group skills training
 217 Crisis Intervention                         H2020                                       Michigan Center for Positive Living       Day                                                                   0
                                                                                             Supports Transition Home
 218     Wraparound Services                     H2021                                       Specialize Wraparound Faciliation         15 Minutes                                                            0
 219     Supported Employment Services           H2023                                       Supported employment                      15 Minutes                                                            0
 220     Supported Employment Services           H2023       TT                              Additional Patient                        15 Minutes                                                            0
 221     Substance Abuse Outpatient: Didactics   H2027               0900, 0914, 0915, 0916, Didactics
                                                                                             0919                                      15 Minutes                                                            0
 222 Clubhouse Psychosocial Rehabilitation       H2030                                       Mental Health Clubhouse                   15 Minutes                                                            0
     Programs
 223 Home Based Services                         H2033                                       Multi-systemic therapy (MST) for          15 Minutes                                                            0
                                                                                             juveniles provided in home-based
                                                                                             program
 224 Substance Abuse Outpatient                  H2035               0900, 0906, 0914,       Outpatient alcohol/other drug            Hour                                                                   0
                                                                     0915, 0916, 0919        treatment services.Referral, linking and
                                                                                             coordinating
 225 Substance Abuse: Outpatient Care            H2036               0900, 0914, 0915, 0916, Alcohol/other drug treatment.
                                                                                             0919                                     Per Diem                                                               0
                                                                                             Referral, linking and coordinating
 226 Medication Review                           M0064                                       Brief assessment, med monitoring or       Encounter Face-to-                                                    0
                                                                                             change                                    Face
 227 Transportation                               S0209                                      Wheelchair van mileage                    Per Mile                                                              0
 228 Transportation                               S0215                                      Non-emergency transportation mileage Per Mile                                                                   0

 229 Family Training                              S5110                                      Family psycho-education: skills           15 Minutes                                                            0
                                                                                             workshop
 230     Family Training                          S5111                                      Home care training, family per session    Encounter                                                             0
 231     Chore Services                           S5120                                      Chore services                            15 Minutes                                                            0
 232     Respite Care                             S5151                                      Respite care in-home                      Per Diem                                                              0
 233 Personal Emergency Response System           S5160                                      Emergency response system;            Encounter                                                                 0
     (PERS)                                                                                  installation and testing
 234 Personal Emergency Response System           S5161                                      PERS Service fee, per month (excludes Month                                                                     0
     (PERS)                                                                                  installation and testing).
 235 Environmental Modification                   S5165                                      Home modifications, per service.      Service                                                                   0
 236 Enhanced Medical Equipment-Supplies          S5199                                      Personal care item, NOS. (assistive   Item                                                                      0
                                                                                             technology)
 237 Occupational or Physical Therapy             S8990                                      Physical or manipulative therapy      Encounter                                                                 0
                                                                                             performed for maintenance rather than
                                                                                             restoration




          DRAFT 12-15-2010                                                                                                                                  Page 12                                         Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                               PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                     Page: 13




                 PIHP Name:                                                                                                      FY2010 ABW MUNC
Reporting Period: May 1, 2010 to September 30, 2010
                            A                       B        C              D                       E                               F              G          H               I             J
         Service Description (Chapter III & PIHP HCPCS    Modifier     Revenue Code   Reporting Code Description -           Reporting Units    Unique   ABW Services   ABW Services   Aggregated
LineID




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

 238 Private Duty Nursing                         S9123              0582             Private duty nursing, habilitation      Hour                                                              0
                                                                                      supports waiver (individual nurse only)
                                                                                      21 years and over ONLY
 239 Private Duty Nursing                         S9123                               Private duty nursing, habilitation      Hour                                                              0
                                                                                      supports waiver (individual nurse only)
                                                                                      21 years and over ONLY
 240 Private Duty Nursing                         S9123      TT                       Additional Patient                      Hour                                                              0




          DRAFT 12-15-2010                                                                                                                     Page 13                                         Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                                PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                       Page: 14




                  PIHP Name:                                                                                                         FY2010 ABW MUNC
Reporting Period: May 1, 2010 to September 30, 2010
                            A                       B        C              D                       E                                 F               G          H               I             J
         Service Description (Chapter III & PIHP HCPCS    Modifier     Revenue Code   Reporting Code Description -             Reporting Units     Unique   ABW Services   ABW Services   Aggregated
LineID




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

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

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




          DRAFT 12-15-2010                                                                                                                        Page 14                                         Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls
                                                                                                       PIHP FY09 Medicaid Utilization and Net Cost Report                                                                                   Page: 15




                   PIHP Name:                                                                                       FY2010 ABW MUNC
Reporting Period: May 1, 2010 to September 30, 2010
                            A                       B       C            D                       E                       F              G           H               I             J
         Service Description (Chapter III & PIHP HCPCS   Modifier   Revenue Code   Reporting Code Description -   Reporting Units    Unique    ABW Services   ABW Services   Aggregated
LineID




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



         TOTAL ABW MEDICAID CASES
II       AND COSTS (MH/DD/SA)                                                                                                                                            0


         TOTAL ABW MEDICAID MH/DD
III      CASES AND COSTS                                                                                                                                                 0



         ABW MEDICAID MANAGED CARE
IV       ADMINISTRATION MH/DD                                                                                                                 PLUS

         TOTAL ABW MEDICAID MH/DD
V        COSTS                                                                                                                                EQUALS =                   0


         ABW MEDICAID SUBSTANCE
VI       ABUSE CASES & COSTS                                                                                                                                             0


    a.       Administration by PIHP                                                                                                           PLUS



  b.         Administration by CA                                                                                                             PLUS

    TOTAL ABW MEDICAID SA
VII COSTS                                                                                                                                     EQUALS =                   0

     TOTAL ABW MEDICAID COSTS
VIII (MH/DD/SA) (Sum of V & VII)                                                                                                                                         0



         ABW expenditures amount from line C290 in
IX       the FSR
         RECONCILING ITEMS TO FSR
         CMHSP ABW Expenditures for
a.       October-December 2009                                                                                                                DEDUCT:
         CMHSP ABW Expenditures for
b.       January-April 2010                                                                                                                   DEDUCT:
c.       Use Tax                                                                                                                              DEDUCT:
d.       Prior year adjustments in the FSR                                                                                                    DEDUCT:
e        OTHER - specify type                                                                                                                 DEDUCT:




f.       Total Reconciling items                                                                                                                                         0


X        Adjusted FSR ABW Expenditures                                                                                                                                   0




          DRAFT 12-15-2010                                                                                                          Page 15                                          Modified_-__FY10_MUNC_Report_Template_Rev_12_15_10__RBB_KMH.xls

				
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