rate-schedule_medicaid_b_clinician_04-01-2022 by Vaya Health

Standard Rate Schedule: Medicaid 1915(b) Clinician-Based 112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant

101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist * This service had a COVID-19/PHE Rate Enhancement for MD, NP, PA license groups

Rev. 04/01/2022

Service

90785 ‐ INTERACTIVE COMPLEXITY 90785 ‐ INTERACTIVE COMPLEXITY 90791 ‐ Psychiatric Diagnostic Evaluation 90791 ‐ Psychiatric Diagnostic Evaluation 90791HI ‐ Enhanced Psychiatric Diagnostic Evaluation 90791SR ‐ In‐Home Psychiatric Diagnostic Evaluation 90791Z1 ‐ TF‐CBT Psychiatric Diagnostic Evaluation 90791Z2 ‐ PCIT Psychiatric Diagnostic Evaluation 90792 ‐ PSYCHIATRIC DIAGNOSTIC EVAL W/ MED 90792 ‐ PSYCHIATRIC DIAGNOSTIC EVAL W/ MED 90832 ‐ PSYCHOTHERAPY 30 MN 90832 ‐ PSYCHOTHERAPY 30 MN 9083222 ‐ Specialty Psychotherapy, 30 min 90832SR ‐ IN‐HOME PSYCHOTHERAPY 30 MN 90832Z1 ‐ TF‐CBT ‐ PSYCHOTHERAPY 30 MN 90832Z2 ‐ PCIT PSYCHOTHERAPY 30 MN 90833 ‐ PSYCHOTHERAPY 30 MIN ADD ON TO E&M 90833 ‐ PSYCHOTHERAPY 30 MIN ADD ON TO E&M 90834 ‐ PSYCHOTHERAPY 45 MN 90834 ‐ PSYCHOTHERAPY 45 MN 9083422 ‐ Specialty Psychotherapy, 45 min 90834SR ‐ IN‐HOME PSYCHOTHERAPY 45 MN 90834Z1 ‐ TF‐CBT ‐ PSYCHOTHERAPY 45 MN 90834Z2 ‐ PCIT PSYCHOTHERAPY 45 MN 90834Z4 ‐ Equine‐assisted Psychotherapy, 45 min 90836 ‐ PSYCHOTHERAPY 45 MIN ADD ON TO E&M 90836 ‐ PSYCHOTHERAPY 45 MIN ADD ON TO E&M 90837 ‐ PSYCHOTHERAPY 60 MN 90837 ‐ PSYCHOTHERAPY 60 MN 9083722 ‐ Specialty Psychotherapy, 60 min 90837SR ‐ IN‐HOME PSYCHOTHERAPY 60 MN 90837Z1 ‐ TF‐CBT ‐ PSYCHOTHERAPY 60 MN 90837Z2 ‐ PCIT PSYCHOTHERAPY 60 MN 90837Z3 ‐ DBT PSYCHOTHERAPY 60 MN 90837Z4 ‐ Equine‐assisted Psychotherapy, 60 min 90838 ‐ PSYCHOTHERAPY 60 MIN ADD ON TO E&M 90838 ‐ PSYCHOTHERAPY 60 MIN ADD ON TO E&M 90839 ‐ PSYCHOTHER FOR CRISIS 60 MIN 90839 ‐ PSYCHOTHER FOR CRISIS 60 MIN 90840 ‐ PSYCHOTHER FOR CRISIS ADDÆL 30 MN 90840 ‐ PSYCHOTHER FOR CRISIS ADDÆL 30 MN 90846 ‐ FAMILY THER W/O PT 90846 ‐ FAMILY THER W/O PT 9084622 ‐ Specialty Family Therapy w/o Patient 90846SR ‐ In‐home Family Ther W/O PT

Effective Date

* * * *

1/1/2022 4/1/2022 1/1/2022 4/1/2022 4/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 4/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 4/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 4/1/2022 1/1/2022

* * * *

* * * * * * * *

End Date

3/31/2022 6/30/2022 3/31/2022 6/30/2022 6/30/2022 6/30/2022 3/31/2022 3/31/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 6/30/2022 6/30/2022 3/31/2022 3/31/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 6/30/2022 6/30/2022 3/31/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 6/30/2022 6/30/2022 3/31/2022 3/31/2022 6/30/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 6/30/2022 6/30/2022

Code Notes

Replaces Z1 and Z2 Use HI mod 4/1/22+ Use HI mod 4/1/22+

Replaces Z1 and Z2 Use22 mod 4/1/22+ Use 22 mod 4/1/22+

Replaces Z1 and Z2 Use 22 mod 4/1/22+ Use 22 mod 4/1/22+

Replaces Z1, Z2 and Z3 Use 22 mod 4/1/22+ Use 22 mod 4/1/22+ Use 22 mod 4/1/22+

Replaces Z1 and Z2

101

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

4.23 4.03 147.99 140.94 175.00 137.48 146.00 146.00 166.22 158.30 63.50 60.48 75.48 68.74 60.00 60.00 37.33 35.55 95.62 91.07 80.00 103.11 80.00 80.00 86.51 60.66 57.77 119.19 113.51 145.00 137.48 125.00 125.00 125.00 126.77 97.95 93.28 133.98 127.60 112.80 107.43 92.76 88.34 145.00 136.88

110

109

111

$ $ $ $ $ $ $ $

3.96 3.96 125.39 125.39 175.00 137.48 146.00 146.00

$ $ $ $ $ $ $ $

2.97 2.97 94.04 94.04 175.00 137.48 110.00 110.00

$ $ $ $ $ $ $ $

3.37 3.37 119.80 119.80 175.00 137.48 146.00 146.00

$ $ $ $ $ $

52.24 52.24 75.48 68.74 60.00 60.00

$ $ $ $ $ $

39.18 39.18 75.48 68.74 60.00 60.00

$ $ $ $ $ $

51.41 51.41 75.48 68.74 60.00 60.00

$ 67.85 $ 50.89 $ $ 67.85 $ 50.89 $ $ 80.00 $ 80.00 $ $ 103.11 $ 103.11 $ $ 80.00 $ 80.00 $ $ 80.00 $ 80.00 $ $ 86.51 $ 86.51 $

77.41 77.41 80.00 103.11 80.00 80.00 86.51

$ $ $ $ $ $ $ $

99.42 99.42 145.00 137.48 125.00 125.00 125.00 126.77

$ $ $ $ $ $ $ $

96.48 96.48 145.00 137.48 125.00 125.00 125.00 126.77

$ $ $ $ $ $ $ $

125.28 125.28 105.47 105.47 72.24 72.24 145.00 136.88

$ 93.96 $ $ 93.96 $ $ 79.10 $ $ 79.10 $ $ 54.17 $ $ 54.17 $ $ 145.00 $ $ 136.88 $

106.49 106.49 89.65 89.65 75.09 75.09 145.00 136.88

74.57 74.57 145.00 137.48 125.00 125.00 125.00 126.77

112

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

4.23 4.03 134.10 127.71 175.00 137.48 146.00 146.00 141.29 134.56 55.86 53.20 75.48 68.74 60.00 60.00 37.33 35.55 81.28 77.41 80.00 103.11 80.00 80.00 86.51 60.66 57.77 106.33 101.26 145.00 137.48 125.00 125.00 125.00 126.77 97.95 93.28 133.98 127.60 112.80 107.43 78.84 75.09 145.00 136.88

128

129

$ $ $ $ $ $ $ $

2.97 2.97 94.04 94.04 175.00 137.48 110.00 110.00

$ $ $ $ $ $ $ $

2.97 2.97 94.04 94.04 175.00 137.48 110.00 110.00

$ $ $ $ $ $

39.18 39.18 75.48 68.74 60.00 60.00

$ $ $ $ $ $

39.18 39.18 75.48 68.74 60.00 60.00

$ 50.89 $ 50.89 $ 50.89 $ 50.89 $ 80.00 $ 80.00 $ 103.11 $ 103.11 $ 80.00 $ 80.00 $ 80.00 $ 80.00 $ 86.51 $ 86.51

$ $ $ $ $ $ $ $

74.57 74.57 145.00 137.48 125.00 125.00 125.00 126.77

$ $ $ $ $ $ $ $

74.57 74.57 145.00 137.48 125.00 125.00 125.00 126.77

$ 93.96 $ 93.96 $ 93.96 $ 93.96 $ 79.10 $ 79.10 $ 79.10 $ 79.10 $ 54.17 $ 54.17 $ 54.17 $ 54.17 $ 145.00 $ 145.00 $ 136.88 $ 136.88

210

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

3.54 3.37 125.79 119.80 175.00 137.48 146.00 146.00 141.29 134.56 53.98 51.41 75.48 68.74 60.00 60.00 31.15 29.67 81.28 77.41 80.00 103.11 80.00 80.00 86.51 50.62 48.21 101.30 96.48 145.00 137.48 125.00 125.00 125.00 126.77 81.74 77.85 133.98 127.60 112.80 107.43 78.84 75.09 145.00 136.88

Standard Rate Schedule: Medicaid 1915(b) Clinician-Based 112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant

101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist * This service had a COVID 19/PHE Rate Enhancement for MD, NP, PA license groups

Rev. 04/01/2022

Service

90846Z1 ‐ TF‐CBT ‐ FAMILY THER W/O PT 90846Z2 ‐ PCIT ‐ FAMILY THER W/O PT 90847 ‐ FAMILY THER W/ PT 90847 ‐ FAMILY THER W/ PT 9084722 ‐ Specialty Family Therapy w/ Patient 90847SR ‐ In‐home Family Ther W/ PT 90847Z1 ‐ TF‐CBT ‐ FAMILY THER W/ PT 90847Z2 ‐ PCIT ‐ FAMILY THER W/ PT 90849 ‐ MULTI‐FAM GROUP 90849 ‐ MULTI‐FAM GROUP 90853 ‐ GROUP THER 90853 ‐ GROUP THER 9085322 ‐ Specialty Group Therapy 90853Z3 ‐ DBT GROUP THER 90853Z4 ‐ Equine‐assisted Group Therapy 90870 ‐ ELECTROCONVULSIVE THERAPY 90870 ‐ ELECTROCONVULSIVE THERAPY 96110 ‐ DEVEL TST LMT 96110 ‐ DEVEL TST LMT 96112 ‐ DEVEL TST EXT 96112 ‐ DEVEL TST EXT 96113 ‐ add on DEVEL TST EXT 96113 ‐ add on DEVEL TST EXT 96116 ‐ NEUROBEHAV EXAM 96116 ‐ NEUROBEHAV EXAM 96121 ‐ add on NEUROBEHAV EXAM 96121 ‐ add on NEUROBEHAV EXAM 96130 ‐ PSYCH TESTING CLINICAL PSYCH 96130 ‐ PSYCH TESTING CLINICAL PSYCH 96131 ‐ add on PSYCH TESTING CLINICAL PSYCH 96131 ‐ add on PSYCH TESTING CLINICAL PSYCH 96132 ‐ NEUROPSYCH TST‐ CLIN PSYCH 96132 ‐ NEUROPSYCH TST‐ CLIN PSYCH 96133 ‐ add on NEUROPSYCH TST‐ CLIN PSYCH 96133 ‐ add on NEUROPSYCH TST‐ CLIN PSYCH 96136 ‐ PSYCH OR NEUROPSYCH TESTING CLINICAL PSYCH TST ADMIN AND SCORING 96136 ‐ PSYCH OR NEUROPSYCH TESTING CLINICAL PSYCH TST ADMIN AND SCORING 96137 ‐ add on PSYCH OR NEUROPSYCH TESTING CLINICAL PSYCH TST ADMIN AND SCORING 96137 ‐ add on PSYCH OR NEUROPSYCH TESTING CLINICAL PSYCH TST ADMIN AND SCORING 96372 ‐ Therapeutic prophylactic or diagnostic injection 96372 ‐ Therapeutic prophylactic or diagnostic injection

Effective Date

End Date

* * * * * * * * * * * * * * * * * * * *

1/1/2022 1/1/2022 1/1/2022 4/1/2022 4/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 4/1/2022 1/1/2022 1/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022

3/31/2022 3/31/2022 3/31/2022 6/30/2022 6/30/2022 6/30/2022 3/31/2022 3/31/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022

1/1/2022

3/31/2022

4/1/2022

Code Notes

125.00 125.00 89.70 89.70 160.00 136.88 135.00 135.00 36.00 36.00 36.00 36.00 62.68 62.68 36.69

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

8.58 8.58 116.16 116.16 53.20 53.20 93.07 93.07 93.07 93.07 101.00 101.00 83.94 83.94 113.03 113.03 113.03 113.03

56.48 $

6/30/2022

1/1/2022

3/31/2022

4/1/2022

* *

1/1/2022 4/1/2022

* * * *

125.00 125.00 67.28 67.28 160.00 136.88 135.00 135.00 36.00 36.00 36.00 36.00 62.68 62.68 36.69

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $

125.00 125.00 91.70 91.70 160.00 136.88 135.00 135.00 36.00 36.00 36.00 36.00 62.68 62.68 36.69

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

6.43 6.43 87.12 87.12 39.90 39.90 69.82 69.82 69.82 69.82 75.75 75.75 62.96 62.96 84.77 84.77 84.77 84.77

41.97

31.48

53.79 $

41.97

31.48

56.48 $

41.97

31.48

6/30/2022

53.79 $

41.97

31.48

3/31/2022 6/30/2022

$ $

18.22 17.36

$ $

125.00 125.00 97.88 93.22 160.00 136.88 135.00 135.00 37.80 36.00 37.80 36.00 62.68 62.68 36.69 121.21 115.44 10.62 10.11

128

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Replaces Z3 Use 22 mod 4/1/22+

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $

112

125.00 125.00 67.28 67.28 160.00 136.88 135.00 135.00 36.00 36.00 36.00 36.00 62.68 62.68 36.69

Use 22 mod 4/1/22+ Use 22 mod 4/1/22+

125.00 125.00 113.27 107.88 160.00 136.88 135.00 135.00 37.80 36.00 37.80 36.00 62.68 62.68 36.69 121.21 115.44 10.62 10.11 139.16 132.53 69.58 66.27 124.24 118.32 124.24 118.32 112.96 107.58 112.96 107.58 147.61 140.58 147.61 140.58

111

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Replaces Z1 and Z2

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

110

109

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $

* *

Use 22 mod 4/1/22+ Use 22 mod 4/1/22+

101

18.22 17.36

129

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $

125.00 125.00 67.28 67.28 160.00 136.88 135.00 135.00 36.00 36.00 36.00 36.00 62.68 62.68 36.69

210

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

125.00 125.00 97.88 93.22 160.00 136.88 135.00 135.00 37.80 36.00 37.80 36.00 62.68 62.68 36.69 121.21 115.44 10.62 10.11

$ $

18.22 17.36

Standard Rate Schedule: Medicaid 1915(b) Clinician-Based 112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant

101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist * This service had a COVID-19/PHE Rate Enhancement for MD, NP, PA license groups

Rev. 04/01/2022

Service

Effective Date

1/1/2022

3/31/2022

46.64

4/1/2022

6/30/2022

44.42

1/1/2022

3/31/2022

20.22

4/1/2022

6/30/2022

19.26

1/1/2022

6/30/2022

11.89 $

8.92 $

8.92

8.92 $

11.89

1/1/2022

6/30/2022

23.16 $

17.37 $

17.37

17.37 $

23.16

1/1/2022

6/30/2022

33.95 $

25.46 $

25.46

25.46 $

33.95

End Date

Code Notes

101

109

110

111

112

128

129

210

96374 ‐ therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug 96374 ‐ therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug 96375 ‐ therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (list separately in addition to code for primary service) 96375 ‐ therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (list separately in addition to code for primary service) 98966CR ‐ Telephone Assessment and Management Service ‐ 5‐ 10 min 98967CR ‐ Telephone Assessment and Management Service ‐ 11‐20 min 98968CR ‐ Telephone Assessment and Management Service ‐ 21‐30 min 99202 ‐ OP Visit New Pat, straightforward, 15‐29 minutes 99202 ‐ OP Visit New Pat, straightforward, 15‐29 minutes 99203 ‐ OP Visit New Pat, low level, 30‐44 minutes 99203 ‐ OP Visit New Pat, low level, 30‐44 minutes 99204 ‐ OP Visit New Pat, moderate, 45‐59 minutes 99204 ‐ OP Visit New Pat, moderate, 45‐59 minutes 99205 ‐ OP Visit New Pat, high level, 60‐74 minutes 99205 ‐ OP Visit New Pat, high level, 60‐74 minutes 99211 ‐ OP Visit Est Pat, presenting problem minimal 99211 ‐ OP Visit Est Pat, presenting problem minimal 99212 ‐ OP Visit Est Pat, straightforward, 10‐19 minutes 99212 ‐ OP Visit Est Pat, straightforward, 10‐19 minutes 99213 ‐ OP Visit Est Pat, low level, 20‐29 minutes 99213 ‐ OP Visit Est Pat, low level, 20‐29 minutes 99214 ‐ OP Visit Est Pat, moderate, 30‐39 minutes 99214 ‐ OP Visit Est Pat, moderate, 30‐39 minutes 99215 ‐ OP Visit Est Pat, high level, 40‐54 minutes 99215 ‐ OP Visit Est Pat, high level, 40‐54 minutes 99217 ‐ observation care discharge day management 99217 ‐ observation care discharge day management 99218 ‐ initial observation, per day, low complexity 99218 ‐ initial observation, per day, low complexity

* * * * * * * * * * * * * * * * * * * * * *

1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022

3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

61.53 58.60 93.83 89.36 138.24 131.66 174.76 166.44 17.99 17.14 35.83 34.13 78.75 75.00 110.25 105.00 121.91 116.11 65.58 62.45 61.85 58.91

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

61.53 58.60 89.15 84.90 138.24 131.66 174.76 166.44 17.99 17.14 35.83 34.13 66.94 63.75 93.71 89.25 121.91 116.11 65.58 62.45 61.85 58.91

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

61.53 58.60 89.15 84.90 138.24 131.66 174.76 166.44 17.99 17.14 35.83 34.13 66.94 63.75 93.71 89.25 121.91 116.11 65.58 62.45 61.85 58.91

99219 ‐ initial observation care, per day, moderate complexity

1/1/2022

3/31/2022

102.43

$ 102.43

102.43

Standard Rate Schedule: Medicaid 1915(b) Clinician-Based 112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant

101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist * This service had a COVID-19/PHE Rate Enhancement for MD, NP, PA license groups

Rev. 04/01/2022

Service

Effective Date

99219 ‐ initial observation care, per day, moderate complexity

4/1/2022

6/30/2022

97.56

99220 ‐ initial observation care, per day, high complexity 99220 ‐ initial observation care, per day, high complexity 99221 ‐ Initial Hospital Care 30 Min 99221 ‐ Initial Hospital Care 30 Min 99222 ‐ Initial Hospital Care‐Mod‐50 Min 99222 ‐ Initial Hospital Care‐Mod‐50 Min 99223 ‐ Initial Hospital Care‐70 Min 99223 ‐ Initial Hospital Care‐70 Min

* * * * * * * *

1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022

3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022

$ $ $ $ $ $ $ $

143.66 136.82 88.82 84.59 121.21 115.44 178.47 169.97

$ $ $ $ $ $ $ $

143.66 136.82 88.82 84.59 121.21 115.44 178.47 169.97

$ $ $ $ $ $ $ $

143.66 136.82 88.82 84.59 121.21 115.44 178.47 169.97

99224 ‐ subsequent observation care, per day, low complexity

1/1/2022

3/31/2022

24.91

99224 ‐ subsequent observation care, per day, low complexity

4/1/2022

6/30/2022

23.72

1/1/2022

3/31/2022

44.24

4/1/2022

6/30/2022

42.14

99226 ‐ subsequent observation care, per day, high complexity

1/1/2022

3/31/2022

66.15

99226 ‐ subsequent observation care, per day, high complexity

4/1/2022

6/30/2022

63.00

99231 ‐ Subsequent Hospital 15 Min 99231 ‐ Subsequent Hospital 15 Min 99232 ‐ Subsequent Hospital 25 Min 99232 ‐ Subsequent Hospital 25 Min 99233 ‐ Subsequent Hospital 35 Min 99233 ‐ Subsequent Hospital 35 Min 99234 ‐ Observation/Inpat Low 99234 ‐ Observation/Inpat Low 99235 ‐ Hosp/Obs 1‐Day Mod Sev 99235 ‐ Hosp/Obs 1‐Day Mod Sev 99236 ‐ Hosp/Obs 1‐Day High Sev 99236 ‐ Hosp/Obs 1‐Day High Sev 99238 ‐ Hospital Discharge 30 99238 ‐ Hospital Discharge 30 99239 ‐ Hospital Discharge > 30 Min 99239 ‐ Hospital Discharge > 30 Min 99241 ‐ outpt. consult, minor‐ phys time approx 15 min. 99241 ‐ outpt. consult, minor‐ phys time approx 15 min. 99241U4 ‐ Physician Consult ‐ Brief 99241U4 ‐ Physician Consult ‐ Brief

* * * * * * * * * * * * * * * * * * * *

1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022

3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

36.68 34.93 66.11 62.96 94.67 90.16 125.30 119.33 164.59 156.75 204.57 194.83 65.36 62.24 94.98 90.46 42.75 40.72 57.75 55.00

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

36.68 34.93 66.11 62.96 94.67 90.16 125.30 119.33 164.59 156.75 204.57 194.83 65.36 62.24 94.98 90.46 42.75 40.72

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

36.68 34.93 66.11 62.96 94.67 90.16 125.30 119.33 164.59 156.75 204.57 194.83 65.36 62.24 94.98 90.46 42.75 40.72

99242 ‐ outpt. consult, moderate‐ phys time approx 30 min.

1/1/2022

3/31/2022

80.10

99225 ‐ subsequent observation care, per day, moderate complexity 99225 ‐ subsequent observation care, per day, moderate complexity

End Date

Code Notes

101

109

110

111

112

128

129

210

Standard Rate Schedule: Medicaid 1915(b) Clinician-Based 112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant

101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist * This service had a COVID-19/PHE Rate Enhancement for MD, NP, PA license groups

Rev. 04/01/2022

Service

Effective Date

99242 ‐ outpt. consult, moderate‐ phys time approx 30 min.

4/1/2022

6/30/2022

76.28

99242U4 ‐ Physician Consult ‐ Intermediate 99242U4 ‐ Physician Consult ‐ Intermediate 99243 ‐ outpt. consult, severe‐ phys time approx 40 min. 99243 ‐ outpt. consult, severe‐ phys time approx 40 min. 99244 ‐ outpt. consult, severe‐ phys time approx 60 min. 99244 ‐ outpt. consult, severe‐ phys time approx 60 min. 99244U4 ‐ Physician Consult ‐ Extensive 99244U4 ‐ Physician Consult ‐ Extensive 99245 ‐ outpt. consult, severe‐ phys time approx 80 min. 99245 ‐ outpt. consult, severe‐ phys time approx 80 min. 99251 ‐ initial inpt consult‐ phys time approx 20 min. 99251 ‐ initial inpt consult‐ phys time approx 20 min. 99252 ‐ initial inpt consult‐ phys time approx 40 min. 99252 ‐ initial inpt consult‐ phys time approx 40 min. 99253 ‐ initial inpt consult‐ phys time approx 55 min. 99253 ‐ initial inpt consult‐ phys time approx 55 min. 99254 ‐ initial inpt consult‐ phys time approx 80 min. 99254 ‐ initial inpt consult‐ phys time approx 80 min. 99255 ‐ initial inpt consult‐ phys time approx 110 min. 99255 ‐ initial inpt consult‐ phys time approx 110 min. 99281 ‐ er visit, minor 99281 ‐ er visit, minor 99282 ‐ er visit, low severity 99282 ‐ er visit, low severity 99283 ‐ er visit, moderate severity 99283 ‐ er visit, moderate severity 99284 ‐ er visit, high severity 99284 ‐ er visit, high severity 99285 ‐ emergency department visit for the evaluation and management of a patient, 99285 ‐ emergency department visit for the evaluation and management of a patient, 99291 ‐ critical care, evaluation and management of the critically ill or critically 99291 ‐ critical care, evaluation and management of the critically ill or critically 99292 ‐ critical care, 30‐74 min Add 30 Min 99292 ‐ critical care, 30‐74 min Add 30 Min 99304 ‐ initial nursing facility care, per day, for the evaluation and management of 99304 ‐ initial nursing facility care, per day, for the evaluation and management of 99305 ‐ Init Nursing Fac Care 35 Min

* * * * * * * * * * * * * * * * * * * * * * * * * * * *

1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

94.50 90.00 110.15 104.91 163.61 155.82 176.40 168.00 201.08 191.51 43.66 41.58 67.64 64.42 102.69 97.80 148.53 141.46 180.98 172.36 18.21 17.35 35.43 33.75 54.92 52.30 102.82 97.92

1/1/2022

3/31/2022

4/1/2022

6/30/2022

1/1/2022

3/31/2022

End Date

Code Notes

101

109

110

111

112

128

129

210

76.28

$ $ $ $

110.15 104.91 163.61 155.82

$ $ $ $

110.15 104.91 163.61 155.82

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

201.08 191.51 43.66 41.58 67.64 64.42 102.69 97.80 148.53 141.46 180.98 172.36 18.21 17.35 35.43 33.75 54.92 52.30 102.82 97.92

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

201.08 191.51 43.66 41.58 67.64 64.42 102.69 97.80 148.53 141.46 180.98 172.36 18.21 17.35 35.43 33.75 54.92 52.30 102.82 97.92

152.85

$ 152.85

152.85

145.57

$ 145.57

145.57

248.74

$ 248.74

248.74

4/1/2022

6/30/2022

236.89

$ 236.89

236.89

* *

1/1/2022 4/1/2022

3/31/2022 6/30/2022

$ $

112.80 107.43

$ 112.80 $ 107.43

$ $

112.80 107.43

1/1/2022

3/31/2022

79.14

75.37

$ 110.65

110.65

4/1/2022

6/30/2022

75.37

1/1/2022

3/31/2022

110.65

Standard Rate Schedule: Medicaid 1915(b) Clinician-Based 112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant

101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist * This service had a COVID-19/PHE Rate Enhancement for MD, NP, PA license groups

Rev. 04/01/2022

Service

99305 ‐ Init Nursing Fac Care 35 Min 99306 ‐ initial nursing facility care, per day, for the evaluation and management of a 99306 ‐ initial nursing facility care, per day, for the evaluation and management of a 99307 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99307 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99308 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99308 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99309 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99309 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99310 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99310 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99315 ‐ nursing facility discharge day management; 30 minutes or less 99315 ‐ nursing facility discharge day management; 30 minutes or less 99316 ‐ nursing facility discharge day management; 30 minutes or less more than 30 99316 ‐ nursing facility discharge day management; 30 minutes or less more than 30 99318 ‐ evaluation and management of a patient involving an annual nursing facility 99318 ‐ evaluation and management of a patient involving an annual nursing facility 99324 ‐ domiciliary or rest home visit for the evaluation and management of a new 99324 ‐ domiciliary or rest home visit for the evaluation and management of a new 99325 ‐ domiciliary or rest home visit for the evaluation and management of a new 99325 ‐ domiciliary or rest home visit for the evaluation and management of a new 99326 ‐ domiciliary or rest home visit for the evaluation and management of a new 99326 ‐ domiciliary or rest home visit for the evaluation and management of a new

Effective Date

4/1/2022

6/30/2022

105.38

$ 105.38

105.38

1/1/2022

3/31/2022

142.18

$ 142.18

142.18

4/1/2022

6/30/2022

135.41

$ 135.41

135.41

1/1/2022

3/31/2022

39.05

4/1/2022

6/30/2022

37.19

1/1/2022

3/31/2022

59.71

4/1/2022

6/30/2022

56.87

1/1/2022

3/31/2022

79.20

4/1/2022

6/30/2022

75.43

1/1/2022

3/31/2022

117.11

$ 117.11

117.11

4/1/2022

6/30/2022

111.53

$ 111.53

111.53

1/1/2022

3/31/2022

57.14

4/1/2022

6/30/2022

54.42

1/1/2022

3/31/2022

74.66

4/1/2022

6/30/2022

71.11

1/1/2022

3/31/2022

82.80

4/1/2022

6/30/2022

78.86

1/1/2022

3/31/2022

53.09

4/1/2022

6/30/2022

50.56

1/1/2022

3/31/2022

77.32

4/1/2022

6/30/2022

73.64

1/1/2022

3/31/2022

127.83

$ 127.83

127.83

4/1/2022

6/30/2022

121.75

$ 121.75

121.75

End Date

Code Notes

101

109

110

111

112

128

129

210

Standard Rate Schedule: Medicaid 1915(b) Clinician-Based 112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant

101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist * This service had a COVID-19/PHE Rate Enhancement for MD, NP, PA license groups

Rev. 04/01/2022

Service

99327 ‐ domiciliary or rest home visit for the evaluation and management of a new 99327 ‐ domiciliary or rest home visit for the evaluation and management of a new 99328 ‐ domiciliary or rest home visit for the evaluation and management of a new 99328 ‐ domiciliary or rest home visit for the evaluation and management of a new 99334 ‐ domiciliary or rest home visit for the evaluation and management of an 99334 ‐ domiciliary or rest home visit for the evaluation and management of an 99335 ‐ domiciliary or rest home visit for the evaluation and management of an 99335 ‐ domiciliary or rest home visit for the evaluation and management of an 99336 ‐ domiciliary or rest home visit for the evaluation and management of an 99336 ‐ domiciliary or rest home visit for the evaluation and management of an 99337 ‐ domiciliary or rest home visit for the evaluation and management of an 99337 ‐ domiciliary or rest home visit for the evaluation and management of an 99341 ‐ home visit for the evaluation and management of a new patient, which requires 99341 ‐ home visit for the evaluation and management of a new patient, which requires 99342 ‐ home visit for the evaluation and management of a new patient, which requires 99342 ‐ home visit for the evaluation and management of a new patient, which requires 99343 ‐ home visit for the evaluation and management of a new patient, which requires 99343 ‐ home visit for the evaluation and management of a new patient, which requires 99344 ‐ home visit for the evaluation and management of a new patient, which requires 99344 ‐ home visit for the evaluation and management of a new patient, which requires 99345 ‐ home visit for the evaluation and management of a new patient, which requires 99345 ‐ home visit for the evaluation and management of a new patient, which requires

Effective Date

1/1/2022

3/31/2022

166.74

$ 166.74

166.74

4/1/2022

6/30/2022

158.80

$ 158.80

158.80

1/1/2022

3/31/2022

196.29

$ 196.29

196.29

4/1/2022

6/30/2022

186.94

$ 186.94

186.94

1/1/2022

3/31/2022

54.72

4/1/2022

6/30/2022

52.11

1/1/2022

3/31/2022

84.75

4/1/2022

6/30/2022

80.71

1/1/2022

3/31/2022

119.35

$ 119.35

119.35

4/1/2022

6/30/2022

113.66

$ 113.66

113.66

1/1/2022

3/31/2022

171.48

$ 171.48

171.48

4/1/2022

6/30/2022

163.32

$ 163.32

163.32

1/1/2022

3/31/2022

53.09

4/1/2022

6/30/2022

50.56

1/1/2022

3/31/2022

77.32

4/1/2022

6/30/2022

73.64

1/1/2022

3/31/2022

124.52

$ 124.52

124.52

4/1/2022

6/30/2022

118.59

$ 118.59

118.59

1/1/2022

3/31/2022

163.47

$ 163.47

163.47

4/1/2022

6/30/2022

155.68

$ 155.68

155.68

1/1/2022

3/31/2022

196.62

$ 196.62

196.62

4/1/2022

6/30/2022

187.26

$ 187.26

187.26

End Date

Code Notes

101

109

110

111

112

128

129

210

Standard Rate Schedule: Medicaid 1915(b) Clinician-Based 112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant

101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist * This service had a COVID-19/PHE Rate Enhancement for MD, NP, PA license groups

Rev. 04/01/2022

Service

Effective Date

1/1/2022

3/31/2022

51.81

4/1/2022

6/30/2022

49.34

1/1/2022

3/31/2022

78.22

4/1/2022

6/30/2022

74.50

1/1/2022

3/31/2022

113.90

$ 113.90

113.90

4/1/2022

6/30/2022

108.48

$ 108.48

108.48

1/1/2022

3/31/2022

158.80

$ 158.80

158.80

4/1/2022

6/30/2022

151.24

$ 151.24

151.24

* * * * * * * *

1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022

3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022

$ $ $ $ $ $ $ $

90.44 86.13 89.53 85.27 82.59 78.66 83.16 79.20

$ $ $ $ $ $ $ $

90.44 86.13 89.53 85.27 82.59 78.66 83.16 79.20

$ $ $ $ $ $ $ $

90.44 86.13 89.53 85.27 82.59 78.66 83.16 79.20

99406 ‐ smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes

1/1/2022

3/31/2022

12.76

99406 ‐ smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes

4/1/2022

6/30/2022

12.15

1/1/2022

3/31/2022

24.65

4/1/2022

6/30/2022

23.48

1/1/2022

3/31/2022

32.87

4/1/2022

6/30/2022

31.30

1/1/2022

3/31/2022

64.61

99347 ‐ home visit for the evaluation and management of an established patient, which 99347 ‐ home visit for the evaluation and management of an established patient, which 99348 ‐ home visit for the evaluation and management of an established patient, which 99348 ‐ home visit for the evaluation and management of an established patient, which 99349 ‐ home visit for the evaluation and management of an established patient, which 99349 ‐ home visit for the evaluation and management of an established patient, which 99350 ‐ home visit for the evaluation and management of an established patient, which 99350 ‐ home visit for the evaluation and management of an established patient, which 99354 ‐ Prolonged MD Serv except Office(60 min) 99354 ‐ Prolonged MD Serv except Office(60 min) 99355 ‐ Prolng MD Serv except Office(Add 30min) 99355 ‐ Prolng MD Serv except Office(Add 30min) 99356 ‐ Prolng MD Serv IP or observ (60min) 99356 ‐ Prolng MD Serv IP or observ (60min) 99357 ‐ Prolng MD Serv IP or observ (Add 30min) 99357 ‐ Prolng MD Serv IP or observ (Add 30min)

99407 ‐ smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes 99407 ‐ smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes 99408 ‐ alcohol and/or substance (other than tobacco) abuse structured screening (eg. audit, dast) and brief intervention (sbi) services; 15‐ 30 minutes 99408 ‐ alcohol and/or substance (other than tobacco) abuse structured screening (eg. audit, dast) and brief intervention (sbi) services; 15‐ 30 minutes 99409 ‐ alcohol and/or substance (other than tobacco) abuse structured screening (eg. audit, dast) and brief intervention (sbi) services; greater than 30 minutes

End Date

Code Notes

101

109

110

111

112

128

129

210

Standard Rate Schedule: Medicaid 1915(b) Clinician-Based 112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant

101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LCMHC, LMFT 111 ‐ Certified Clinical Nurse Specialist * This service had a COVID-19/PHE Rate Enhancement for MD, NP, PA license groups

Rev. 04/01/2022

Service

99409 ‐ alcohol and/or substance (other than tobacco) abuse structured screening (eg. audit, dast) and brief intervention (sbi) services; greater than 30 minutes 99417 ‐ Prolonged Office or other OP (15 min) 99417 ‐ Prolonged Office or other OP (15 min) 99421 ‐ Online Digital E/M Service, 5‐10 min 99421 ‐ Online Digital E/M Service, 5‐10 min 99422 ‐ Online Digital E/M Service, 11‐20 min 99422 ‐ Online Digital E/M Service, 11‐20 min 99423 ‐ Online Digital E/M Service, 21 or more min 99423 ‐ Online Digital E/M Service, 21 or more min 99441 ‐ Telephone Evaluation and Management Service ‐ 5‐10 min 99441 ‐ Telephone Evaluation and Management Service ‐ 5‐10 min 99442 ‐ Telephone Evaluation and Management Service ‐ 11‐20 min 99442 ‐ Telephone Evaluation and Management Service ‐ 11‐20 min 99443 ‐ Telephone Evaluation and Management Service ‐ 21‐30 min 99443 ‐ Telephone Evaluation and Management Service ‐ 21‐30 min 99446 ‐ Interprofessional Tele/Internet/EHR Consultation, 5‐10 min 99446 ‐ Interprofessional Tele/Internet/EHR Consultation, 5‐10 min 99447 ‐ Interprofessional Tele/Internet/EHR Consultation, 11‐ 20 min 99447 ‐ Interprofessional Tele/Internet/EHR Consultation, 11‐ 20 min 99448 ‐ Interprofessional Tele/Internet/EHR Consultation, 21‐ 30 min 99448 ‐ Interprofessional Tele/Internet/EHR Consultation, 21‐ 30 min 99449 ‐ Interprofessional Tele/Internet/EHR Consultation, 31 or more min 99449 ‐ Interprofessional Tele/Internet/EHR Consultation, 31 or more min G2012CR ‐ Brief Virtual Check‐in by Prescriber, 5‐10 minutes

Effective Date

4/1/2022

6/30/2022

61.53

* * * * * * * *

1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022 1/1/2022 4/1/2022

3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022 3/31/2022 6/30/2022

$ $ $ $ $ $ $ $

86.13 82.03 27.30 26.00 45.58 43.41 68.68 65.41

$ $ $ $ $ $ $ $

86.13 82.03 27.30 26.00 45.58 43.41 68.68 65.41

$ $ $ $ $ $ $ $

86.13 82.03 27.30 26.00 45.58 43.41 68.68 65.41

1/1/2022

3/31/2022

27.30

4/1/2022

6/30/2022

26.00

1/1/2022

3/31/2022

45.58

4/1/2022

6/30/2022

43.41

1/1/2022

3/31/2022

68.68

4/1/2022

6/30/2022

65.41

1/1/2022

3/31/2022

16.76

4/1/2022

6/30/2022

15.96

1/1/2022

3/31/2022

33.84

4/1/2022

6/30/2022

32.22

1/1/2022

3/31/2022

50.59

4/1/2022

6/30/2022

48.18

1/1/2022

3/31/2022

67.42

4/1/2022

6/30/2022

64.21

1/1/2022

6/30/2022

12.19

End Date

Code Notes

101

109

110

111

112

128

129

210