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

Nursing Assessment and Health ServicesLPN Services,up to 15 minutesHealth andBehaviorAssessment,Face-to-Face w/Patient, InitialAssessmentHealth andBehaviorAssessment,Face-to-Face w/Patient, ReassessmentPractitioner Level 4, In-Clinic T1003 U4 U6 $20.30 Practitioner Level 4, Out-of-Clinic T1003 U4 U7 $24.36Practitioner Level 2, In-Clinic 96150 U2 U6 $38.97 Practitioner Level 2, Out-of-Clinic 96150 U2 U7 $46.76Practitioner Level 3, In-Clinic 96150 U3 U6 $30.01 Practitioner Level 3, Out-of-Clinic 96150 U3 U7 $36.68Practitioner Level 4, In-Clinic 96150 U4 U6 $20.30 Practitioner Level 4, Out-of-Clinic 96150 U4 U7 $24.36Practitioner Level 2, In-Clinic 96151 U2 U6 $38.97 Practitioner Level 2, Out-of-Clinic 96151 U2 U7 $46.76Practitioner Level 3, In-Clinic 96151 U3 U6 $30.01 Practitioner Level 3, Out-of-Clinic 96151 U3 U7 $36.68Practitioner Level 4, In-Clinic 96151 U4 U6 $20.30 Practitioner Level 4, Out-of-Clinic 96151 U4 U7 $24.36Unit Value 15 minutes Maximum Daily Units 16 units (32 for Ambulatory Detox)InitialWith the submission of MICP Registration -12 unitsRe-Authorization60 unitsAuthorization With the submission of MICP New Episode- 60 unitsAuth Period 180 days Utilization Criteria LOCUS scores:1-6This service requires face-to-face contact with the individual to monitor, evaluate, assess, and/or carry out a physician’s orders regarding the physical and/orpsychological problems of the individual. It includes:1) Providing nursing assessments and interventions to observe, monitor and care for the physical, nutritional, behavioral health and related psychosocial issues,problems or crises manifested in the course of an individual’s treatment;2) Assessing and monitoring individual’s response to medication(s) to determine the need to continue medication and/or to determine the need to refer theindividual to a physician for a medication review;3) Assessing and monitoring an individual’s medical and other health issues that are either directly related to the mental health or substance related disorder, or tothe treatment of the disorder (e.g. diabetes, cardiac and/or blood pressure issues, substance withdrawal symptoms, weight gain and fluid retention, seizures,etc);Service4) Consulting with the individual and individual-identified family and significant other(s) about medical, nutritional and other health issues related to the individual’sDefinitionmental health or substance related issues;5) Educating the individual and any identified family about potential medication side effects (especially those which may adversely affect health such as weightgain or loss, blood pressure changes, cardiac abnormalities, development of diabetes or seizures, etc);6) Consulting with the individual and the individual-identified family and significant other(s) about the various aspects of informed consent (when prescribingoccurs/APRN);7) Training for self-administration of medication; and8) Venipuncture required to monitor and assess mental health, substance disorders or directly related conditions, and to monitor side effects of psychotropicmedications, as ordered by a Licensed Physician, Physician Assistant or Advanced Practice Nurse.9) Providing assessment, testing, and referral for infectious diseases.FY2013 Provider Manual for Community Behavioral Health Providers Page 84