PART I - Department of Behavioral Health and Developmental ...

Individual CounselingTransactionCodeIndividualPsychotherapy,insightoriented,behaviormodifyingand/orsupportiveface-to-facew/ patientIndividualpsychotherapy,interactive,(using playequipment,physical devices,languageinterpreter, or othermechanisms ofnon-verbalcommunication,face-to-facew/ patient~20-30 minutes~45-50 minutes~75-80 minutes~20-30 minutes~45-50 minutes~75-80 minutesCode Detail Code Mod Mod Mod Mod Rate Code Detail Code Mod Mod Mod Mod Rate1 2 3 41 2 3 4Practitioner Level 2, In-Clinic 90804 U2 U6 64.95 Practitioner Level 2, Out-of-Clinic 90804 U2 U7 77.93Practitioner Level 3, In-Clinic 90804 U3 U6 50.02 Practitioner Level 3, Out-of-Clinic 90804 U3 U7 61.13Practitioner Level 4, In-Clinic 90804 U4 U6 33.83 Practitioner Level 4, Out-of-Clinic 90804 U4 U7 40.59Practitioner Level 5, In-Clinic 90804 U5 U6 25.21 Practitioner Level 5, Out-of-Clinic 90804 U5 U7 30.25Practitioner Level 2, In-Clinic 90806 U2 U6 116.90 Practitioner Level 2, Out-of-Clinic 90806 U2 U7 140.28Practitioner Level 3, In-Clinic 90806 U3 U6 90.03 Practitioner Level 3, Out-of-Clinic 90806 U3 U7 110.04Practitioner Level 4, In-Clinic 90806 U4 U6 60.89 Practitioner Level 4, Out-of-Clinic 90806 U4 U7 73.07Practitioner Level 5, In-Clinic 90806 U5 U6 45.38 Practitioner Level 5, Out-of-Clinic 90806 U5 U7 54.46Practitioner Level 2, In-Clinic 90808 U2 U6 194.84 Practitioner Level 2, Out-of-Clinic 90808 U2 U7 233.80Practitioner Level 3, In-Clinic 90808 U3 U6 150.05 Practitioner Level 3, Out-of-Clinic 90808 U3 U7 183.39Practitioner Level 4, In-Clinic 90808 U4 U6 101.48 Practitioner Level 4, Out-of-Clinic 90808 U4 U7 121.78Practitioner Level 5, In-Clinic 90808 U5 U6 75.64 Practitioner Level 5, Out-of-Clinic 90808 U5 U7 90.76Practitioner Level 2, In-Clinic 90810 U2 U6 64.95 Practitioner Level 2, Out-of-Clinic 90810 U2 U7 77.93Practitioner Level 3, In-Clinic 90810 U3 U6 50.02 Practitioner Level 3, Out-of-Clinic 90810 U3 U7 61.13Practitioner Level 4, In-Clinic 90810 U4 U6 33.83 Practitioner Level 4, Out-of-Clinic 90810 U4 U7 40.59Practitioner Level 5, In-Clinic 90810 U5 U6 25.21 Practitioner Level 5, Out-of-Clinic 90810 U5 U7 30.25Practitioner Level 2, In-Clinic 90812 U2 U6 116.90 Practitioner Level 2, Out-of-Clinic 90812 U2 U7 140.28Practitioner Level 3, In-Clinic 90812 U3 U6 90.03 Practitioner Level 3, Out-of-Clinic 90812 U3 U7 110.04Practitioner Level 4, In-Clinic 90812 U4 U6 60.89 Practitioner Level 4, Out-of-Clinic 90812 U4 U7 73.07Practitioner Level 5, In-Clinic 90812 U5 U6 45.38 Practitioner Level 5, Out-of-Clinic 90812 U5 U7 54.46Practitioner Level 2, In-Clinic 90814 U2 U6 194.84 Practitioner Level 2, Out-of-Clinic 90814 U2 U7 233.80Practitioner Level 3, In-Clinic 90814 U3 U6 150.05 Practitioner Level 3, Out-of-Clinic 90814 U3 U7 183.39Practitioner Level 4, In-Clinic 90814 U4 U6 101.48 Practitioner Level 4, Out-of-Clinic 90814 U4 U7 121.78Practitioner Level 5, In-Clinic 90814 U5 U6 75.64 Practitioner Level 5, Out-of-Clinic 90814 U5 U7 90.76Unit Value 1 encounter Maximum Daily Units 1 unitInitialAuthorization24 units Re-Authorization 24 unitsAuthorizationPeriod180 days Utilization Criteria LOCUS scores:1-6FY2013 Provider Manual for Community Behavioral Health Providers Page 78