standard-rate-schedule_medicaid-1915b-b3_clinician-based_04-01-22_rev by Vaya Health

Standard Rate Schedule: Medicaid 1915(b) and (b)(3) Clinician-Based 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LMCHC, LMFT 111 ‐ Certified Clinical Nurse Specialist

112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant Rev. 04/01/22

* This service had a COVID‐19/PHE Rate Enhancement for MD, NP, and PA license groups

Service

90785 ‐ INTERACTIVE COMPLEXITY 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 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 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 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 90839 ‐ PSYCHOTHER FOR CRISIS 60 MIN 90840 ‐ PSYCHOTHER FOR CRISIS ADDÆL 30 MN 90846 ‐ FAMILY THER W/O PT 9084622 ‐ Specialty Family Therapy w/o Patient 90846SR ‐ In‐home Family Ther W/O PT 90846Z1 ‐ TF‐CBT ‐ FAMILY THER W/O PT 90846Z2 ‐ PCIT ‐ FAMILY THER W/O PT 90847 ‐ FAMILY THER W/ PT 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

Effective Date

End Date

* *

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

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

* *

* * * *

Code Notes

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

101

4.23 147.99 175.00 137.48 146.00 146.00 166.22 63.50 75.48 68.74 60.00 60.00 37.33 95.62 80.00 103.11 80.00 80.00 86.51 60.66 119.19 145.00 137.48 125.00 125.00 125.00 126.77 97.95 133.98 112.80 92.76 145.00 136.88 125.00 125.00 113.27 160.00 136.88 135.00 135.00 37.80

109

110

111

$ $ $ $ $ $

3.96 125.39 175.00 137.48 146.00 146.00

$ $ $ $ $ $

2.97 94.04 175.00 137.48 110.00 110.00

$ $ $ $ $ $

3.37 119.80 175.00 137.48 146.00 146.00

$ $ $ $ $

52.24 75.48 68.74 60.00 60.00

$ $ $ $ $

39.18 75.48 68.74 60.00 60.00

$ $ $ $ $

51.41 75.48 68.74 60.00 60.00

$ $ $ $ $ $

67.85 80.00 103.11 80.00 80.00 86.51

$ $ $ $ $ $

50.89 80.00 103.11 80.00 80.00 86.51

$ $ $ $ $ $

77.41 80.00 103.11 80.00 80.00 86.51

$ $ $ $ $ $ $

99.42 145.00 137.48 125.00 125.00 125.00 126.77

$ $ $ $ $ $ $

74.57 145.00 137.48 125.00 125.00 125.00 126.77

$ $ $ $ $ $ $

96.48 145.00 137.48 125.00 125.00 125.00 126.77

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

125.28 105.47 72.24 145.00 136.88 125.00 125.00 89.70 160.00 136.88 135.00 135.00 36.00

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

93.96 79.10 54.17 145.00 136.88 125.00 125.00 67.28 160.00 136.88 135.00 135.00 36.00

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

106.49 89.65 75.09 145.00 136.88 125.00 125.00 91.70 160.00 136.88 135.00 135.00 36.00

112

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

4.23 134.10 175.00 137.48 146.00 146.00 141.29 55.86 75.48 68.74 60.00 60.00 37.33 81.28 80.00 103.11 80.00 80.00 86.51 60.66 106.33 145.00 137.48 125.00 125.00 125.00 126.77 97.95 133.98 112.80 78.84 145.00 136.88 125.00 125.00 97.88 160.00 136.88 135.00 135.00 37.80

128

129

$ $ $ $ $ $

2.97 94.04 175.00 137.48 110.00 110.00

$ $ $ $ $ $

2.97 94.04 175.00 137.48 110.00 110.00

$ $ $ $ $

39.18 75.48 68.74 60.00 60.00

$ $ $ $ $

39.18 75.48 68.74 60.00 60.00

$ $ $ $ $ $

50.89 80.00 103.11 80.00 80.00 86.51

$ $ $ $ $ $

50.89 80.00 103.11 80.00 80.00 86.51

$ $ $ $ $ $ $

74.57 145.00 137.48 125.00 125.00 125.00 126.77

$ $ $ $ $ $ $

74.57 145.00 137.48 125.00 125.00 125.00 126.77

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

93.96 79.10 54.17 145.00 136.88 125.00 125.00 67.28 160.00 136.88 135.00 135.00 36.00

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

93.96 79.10 54.17 145.00 136.88 125.00 125.00 67.28 160.00 136.88 135.00 135.00 36.00

210

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

3.54 125.79 175.00 137.48 146.00 146.00 141.29 53.98 75.48 68.74 60.00 60.00 31.15 81.28 80.00 103.11 80.00 80.00 86.51 50.62 101.30 145.00 137.48 125.00 125.00 125.00 126.77 81.74 133.98 112.80 78.84 145.00 136.88 125.00 125.00 97.88 160.00 136.88 135.00 135.00 37.80

Standard Rate Schedule: Medicaid 1915(b) and (b)(3) Clinician-Based 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LMCHC, LMFT 111 ‐ Certified Clinical Nurse Specialist

112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant Rev. 04/01/22

* This service had a COVID‐19/PHE Rate Enhancement for MD, NP, and PA license groups

Service

Effective Date

End Date

90853 ‐ GROUP THER 90853 ‐ GROUP THER 9085322 ‐ Specialty Group Therapy 90853Z3 ‐ DBT GROUP THER 90853Z4 ‐ Equine‐assisted Group Therapy 90870 ‐ ELECTROCONVULSIVE THERAPY 96110 ‐ DEVEL TST LMT 96112 ‐ DEVEL TST EXT 96113 ‐ add on DEVEL TST EXT 96116 ‐ NEUROBEHAV EXAM 96121 ‐ add on NEUROBEHAV EXAM 96130 ‐ PSYCH TESTING CLINICAL PSYCH 96131 ‐ add on PSYCH TESTING CLINICAL PSYCH 96132 ‐ NEUROPSYCH TST‐ CLIN PSYCH 96133 ‐ add on NEUROPSYCH TST‐ CLIN PSYCH 96136 ‐ PSYCH OR NEUROPSYCH TESTING CLINICAL PSYCH TST ADMIN AND SCORING 96137 ‐ add on PSYCH OR NEUROPSYCH TESTING CLINICAL PSYCH TST ADMIN AND SCORING 96372 ‐ Therapeutic prophylactic or diagnostic injection 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) 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 99203 ‐ OP Visit New Pat, low level, 30‐44 minutes 99204 ‐ OP Visit New Pat, moderate, 45‐59 minutes 99205 ‐ OP Visit New Pat, high level, 60‐74 minutes 99211 ‐ OP Visit Est Pat, presenting problem minimal 99212 ‐ OP Visit Est Pat, straightforward, 10‐19 minutes 99213 ‐ OP Visit Est Pat, low level, 20‐29 minutes 99214 ‐ OP Visit Est Pat, moderate, 30‐39 minutes

* *

* * * * * * * * * *

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 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022

6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022

1/1/2022

6/30/2022

56.48 $ 41.97

$ 31.48

1/1/2022

6/30/2022

56.48 $ 41.97

$ 31.48

1/1/2022

6/30/2022

18.22

$ 18.22

1/1/2022

6/30/2022

46.64

$ 46.64

1/1/2022

6/30/2022

20.22

$ 20.22

1/1/2022

6/30/2022

$ 11.89 $

8.92 $

8.92

1/1/2022

6/30/2022

$ 23.16 $ 17.37 $

17.37

$ 17.37 $ 17.37 $ 23.16

1/1/2022

6/30/2022

$ 33.95 $ 25.46 $

25.46

$ 25.46 $ 25.46 $ 33.95

1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022

6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022

* * * * * * * *

Code Notes

Replaces Z3 Use 22 mod 4/1/22+

101

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

37.80 36.00 62.68 62.68 36.69 121.21 10.62 139.16 69.58 124.24 124.24 112.96 112.96 147.61 147.61

$ 61.53 $ 93.83 $ 138.24 $ 174.76 $ 17.99 $ 35.83 $ 78.75 $ 110.25

109

$ $ $ $ $

36.00 36.00 62.68 62.68 36.69

$ $ $ $ $ $ $ $ $

8.58 116.16 53.20 93.07 93.07 101.00 83.94 113.03 113.03

110

$ $ $ $ $

36.00 36.00 62.68 62.68 36.69

111

$ $ $ $ $

36.00 36.00 62.68 62.68 36.69

112

$ $ $ $ $ $ $

37.80 36.00 62.68 62.68 36.69 121.21 10.62

128

$ $ $ $ $

36.00 36.00 62.68 62.68 36.69

$ $ $ $ $ $ $ $ $

6.43 87.12 39.90 69.82 69.82 75.75 62.96 84.77 84.77

$ $ $ $ $ $ $ $

61.53 89.15 138.24 174.76 17.99 35.83 66.94 93.71

129

$ $ $ $ $

8.92 $

36.00 36.00 62.68 62.68 36.69

210

$ $ $ $ $ $ $

37.80 36.00 62.68 62.68 36.69 121.21 10.62

8.92 $ 11.89

$ $ $ $ $ $ $ $

61.53 89.15 138.24 174.76 17.99 35.83 66.94 93.71

Standard Rate Schedule: Medicaid 1915(b) and (b)(3) Clinician-Based 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LMCHC, LMFT 111 ‐ Certified Clinical Nurse Specialist

112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant Rev. 04/01/22

* This service had a COVID‐19/PHE Rate Enhancement for MD, NP, and PA license groups

Service

99215 ‐ OP Visit Est Pat, high level, 40‐54 minutes 99217 ‐ observation care discharge day management 99218 ‐ initial observation, per day, low complexity 99219 ‐ initial observation care, per day, moderate complexity 99220 ‐ initial observation care, per day, high complexity 99221 ‐ Initial Hospital Care 30 Min 99222 ‐ Initial Hospital Care‐Mod‐50 Min 99223 ‐ Initial Hospital Care‐70 Min 99224 ‐ subsequent observation care, per day, low complexity 99225 ‐ subsequent observation care, per day, moderate complexity 99226 ‐ subsequent observation care, per day, high complexity 99231 ‐ Subsequent Hospital 15 Min 99232 ‐ Subsequent Hospital 25 Min 99233 ‐ Subsequent Hospital 35 Min 99234 ‐ Observation/Inpat Low 99235 ‐ Hosp/Obs 1‐Day Mod Sev 99236 ‐ Hosp/Obs 1‐Day High Sev 99238 ‐ Hospital Discharge 30 99239 ‐ Hospital Discharge > 30 Min 99241 ‐ outpt. consult, minor‐ phys time approx 15 min. 99241U4 ‐ Physician Consult ‐ Brief 99242 ‐ outpt. consult, moderate‐ phys time approx 30 min. 99242U4 ‐ Physician Consult ‐ Intermediate 99243 ‐ outpt. consult, severe‐ phys time approx 40 min. 99244 ‐ outpt. consult, severe‐ phys time approx 60 min. 99244U4 ‐ Physician Consult ‐ Extensive 99245 ‐ outpt. consult, severe‐ phys time approx 80 min. 99251 ‐ initial inpt consult‐ phys time approx 20 min. 99252 ‐ initial inpt consult‐ phys time approx 40 min. 99253 ‐ initial inpt consult‐ phys time approx 55 min. 99254 ‐ initial inpt consult‐ phys time approx 80 min. 99255 ‐ initial inpt consult‐ phys time approx 110 min. 99281 ‐ er visit, minor 99282 ‐ er visit, low severity 99283 ‐ er visit, moderate severity 99284 ‐ er visit, high severity

Effective Date

End Date

Code Notes

101

109

110

111

112

* * *

1/1/2022 1/1/2022 1/1/2022

6/30/2022 6/30/2022 6/30/2022

$ 121.91 $ 65.58 $ 61.85

1/1/2022

6/30/2022

$ 102.43

* * * *

1/1/2022 1/1/2022 1/1/2022 1/1/2022

6/30/2022 6/30/2022 6/30/2022 6/30/2022

$ 143.66 $ 88.82 $ 121.21 $ 178.47

$ $ $ $

1/1/2022

6/30/2022

24.91

$ 24.91

1/1/2022

6/30/2022

44.24

$ 44.24

1/1/2022

6/30/2022

66.15

$ 66.15

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

1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022

6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022 6/30/2022

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

36.68 66.11 94.67 125.30 164.59 204.57 65.36 94.98 42.75 57.75 80.10 94.50 110.15 163.61 176.40 201.08 43.66 67.64 102.69 148.53 180.98 18.21 35.43 54.92 102.82

$ $ $ $ $ $ $ $ $

143.66 88.82 121.21 178.47

36.68 66.11 94.67 125.30 164.59 204.57 65.36 94.98 42.75

128

129

210

143.66 88.82 121.21 178.47

36.68 66.11 94.67 125.30 164.59 204.57 65.36 94.98 42.75

$ 80.10

$ 110.15 $ 163.61

$ $ $ $ $ $ $ $ $ $

201.08 43.66 67.64 102.69 148.53 180.98 18.21 35.43 54.92 102.82

Standard Rate Schedule: Medicaid 1915(b) and (b)(3) Clinician-Based 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LMCHC, LMFT 111 ‐ Certified Clinical Nurse Specialist

112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant Rev. 04/01/22

* This service had a COVID‐19/PHE Rate Enhancement for MD, NP, and PA license groups

Service

99285 ‐ emergency department visit for the evaluation and management of a patient, 99291 ‐ critical care, evaluation and management of the critically ill or critically 99292 ‐ critical care, 30‐74 min Add 30 Min 99304 ‐ initial nursing facility care, per day, for the evaluation and management of 99305 ‐ Init Nursing Fac Care 35 Min 99306 ‐ initial nursing facility care, per day, for the evaluation and management of a 99307 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99308 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99309 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99310 ‐ subsequent nursing facility care, per day, for the evaluation and management of 99315 ‐ nursing facility discharge day management; 30 minutes or less 99316 ‐ nursing facility discharge day management; 30 minutes or less more than 30 99318 ‐ evaluation and management of a patient involving an annual nursing facility 99324 ‐ domiciliary or rest home visit for the evaluation and management of a new 99325 ‐ domiciliary or rest home visit for the evaluation and management of a new 99326 ‐ domiciliary or rest home visit for the evaluation and management of a new 99327 ‐ domiciliary or rest home visit for the evaluation and management of a new 99328 ‐ domiciliary or rest home visit for the evaluation and management of a new 99334 ‐ domiciliary or rest home visit for the evaluation and management of an 99335 ‐ domiciliary or rest home visit for the evaluation and management of an 99336 ‐ domiciliary or rest home visit for the evaluation and management of an

Effective Date

End Date

Code Notes

101

109

110

111

112

128

129

210

1/1/2022

6/30/2022

$ 152.85

1/1/2022

6/30/2022

$ 248.74

1/1/2022

6/30/2022

$ 112.80

1/1/2022

6/30/2022

79.14

$ 79.14

1/1/2022

6/30/2022

$ 110.65

1/1/2022

6/30/2022

$ 142.18

1/1/2022

6/30/2022

39.05

$ 39.05

1/1/2022

6/30/2022

59.71

$ 59.71

1/1/2022

6/30/2022

79.20

$ 79.20

1/1/2022

6/30/2022

$ 117.11

1/1/2022

6/30/2022

57.14

$ 57.14

1/1/2022

6/30/2022

74.66

$ 74.66

1/1/2022

6/30/2022

82.80

$ 82.80

1/1/2022

6/30/2022

53.09

$ 53.09

1/1/2022

6/30/2022

77.32

$ 77.32

1/1/2022

6/30/2022

$ 127.83

1/1/2022

6/30/2022

$ 166.74

1/1/2022

6/30/2022

$ 196.29

1/1/2022

6/30/2022

54.72

$ 54.72

1/1/2022

6/30/2022

84.75

$ 84.75

1/1/2022

6/30/2022

$ 119.35

Standard Rate Schedule: Medicaid 1915(b) and (b)(3) Clinician-Based 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LMCHC, LMFT 111 ‐ Certified Clinical Nurse Specialist

112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant Rev. 04/01/22

* This service had a COVID‐19/PHE Rate Enhancement for MD, NP, and PA license groups

Service

99337 ‐ domiciliary or rest home visit for the evaluation and management of an 99341 ‐ home visit for the evaluation and management of a new patient, which requires 99342 ‐ home visit for the evaluation and management of a new patient, which requires 99343 ‐ home visit for the evaluation and management of a new patient, which requires 99344 ‐ home visit for the evaluation and management of a new patient, which requires 99345 ‐ home visit for the evaluation and management of a new patient, which requires 99347 ‐ home visit for the evaluation and management of an established patient, which 99348 ‐ home visit for the evaluation and management of an established patient, which 99349 ‐ home visit for the evaluation and management of an established patient, which 99350 ‐ home visit for the evaluation and management of an established patient, which 99354 ‐ Prolonged MD Serv except Office(60 min) 99355 ‐ Prolng MD Serv except Office(Add 30min) 99356 ‐ Prolng MD Serv IP or observ (60min) 99357 ‐ Prolng MD Serv IP or observ (Add 30min) 99406 ‐ smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes 99407 ‐ smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes 99408 ‐ alcohol and/or substance (other than tobacco) abuse structured screening (eg. audit, dast) and brief intervention (sbi) services; 15‐ 30 minutes 99409 ‐ alcohol and/or substance (other than tobacco) abuse structured screening (eg. audit, dast) and brief intervention (sbi) services; greater than 30 minutes 99417 ‐ Prolonged Office or other OP (15 min) 99421 ‐ Online Digital E/M Service, 5‐10 min 99422 ‐ Online Digital E/M Service, 11‐20 min 99423 ‐ Online Digital E/M Service, 21 or more min 99441 ‐ Telephone Evaluation and Management Service ‐ 5‐ 10 min

Effective Date

End Date

Code Notes

101

109

110

111

112

1/1/2022

6/30/2022

$ 171.48

1/1/2022

6/30/2022

53.09

$ 53.09

1/1/2022

6/30/2022

77.32

$ 77.32

1/1/2022

6/30/2022

$ 124.52

1/1/2022

6/30/2022

$ 163.47

1/1/2022

6/30/2022

$ 196.62

1/1/2022

6/30/2022

51.81

$ 51.81

1/1/2022

6/30/2022

78.22

$ 78.22

1/1/2022

6/30/2022

$ 113.90

1/1/2022

6/30/2022

$ 158.80

* * * *

1/1/2022 1/1/2022 1/1/2022 1/1/2022

6/30/2022 6/30/2022 6/30/2022 6/30/2022

$ $ $ $

90.44 89.53 82.59 83.16

$ $ $ $

1/1/2022

6/30/2022

12.76

$ 12.76

1/1/2022

6/30/2022

24.65

$ 24.65

1/1/2022

6/30/2022

32.87

$ 32.87

1/1/2022

6/30/2022

64.61

$ 64.61

* * * *

1/1/2022 1/1/2022 1/1/2022 1/1/2022

6/30/2022 6/30/2022 6/30/2022 6/30/2022

$ $ $ $

86.13 27.30 45.58 68.68

$ $ $ $

1/1/2022

6/30/2022

27.30

$ 27.30

90.44 89.53 82.59 83.16

86.13 27.30 45.58 68.68

128

129

210

90.44 89.53 82.59 83.16

86.13 27.30 45.58 68.68

$ 27.30

Standard Rate Schedule: Medicaid 1915(b) and (b)(3) Clinician-Based 101 ‐ Physician 109 ‐ Licensed Psychologist 110 ‐ LCSW, LMCHC, LMFT 111 ‐ Certified Clinical Nurse Specialist

112 ‐ Certified Nurse Practitioner 128 ‐ Licensed Psychological Associate 129 ‐ LCAS, CCS 210 ‐ Physician Assistant Rev. 04/01/22

* This service had a COVID‐19/PHE Rate Enhancement for MD, NP, and PA license groups

Service

99442 ‐ Telephone Evaluation and Management Service ‐ 11‐ 20 min 99443 ‐ Telephone Evaluation and Management Service ‐ 21‐ 30 min 99446 ‐ Interprofessional Tele/Internet/EHR Consultation, 5‐ 10 min 99447 ‐ Interprofessional Tele/Internet/EHR Consultation, 11‐ 20 min 99448 ‐ Interprofessional Tele/Internet/EHR Consultation, 21‐ 30 min 99449 ‐ Interprofessional Tele/Internet/EHR Consultation, 31 or more min G2012CR ‐ Brief Virtual Check‐in by Prescriber, 5‐10 minutes

Effective Date

End Date

Code Notes

101

109

110

111

112

128

129

210

1/1/2022

6/30/2022

45.58

$ 45.58

1/1/2022

6/30/2022

68.68

$ 68.68

1/1/2022

6/30/2022

16.76

1/1/2022

6/30/2022

33.84

1/1/2022

6/30/2022

50.59

1/1/2022

6/30/2022

67.42

1/1/2022

6/30/2022

12.19

$ 12.19