HCPCS or CPT codes are required on all outpatient substance abuse treatment claims submitted on the 1500 Health Insurance Claim Form. Claims or adjustments received without a HCPCS or CPT code are denied. Providers should refer to the maximum allowable fee schedule for the most current maximum allowable fees.
For procedure codes that do not indicate a time increment, providers are required to use the rounding guidelines that are available.
The following table lists the HCPCS or CPT code and modifier that providers are required to use when requesting PA and submitting claims for outpatient substance abuse services. Not all providers may be reimbursed for all substance abuse services.
(Submitted only on the 1500 Health Insurance Claim Form)
Assessment services are limited to eight hours every rolling 12 months per member before PA is required under DHS 107.13(2)(c)4., Wis. Admin. Code, for the following services:
The 15-hour/$825 limit without PA does not accumulate when services are provided to a member in an inpatient hospital.
Procedure Code |
Description |
Enrolled Providers Who May Perform Service |
Modifier (Required) |
Allowable ICD-9-CM Diagnoses |
Allowable POS |
Telehealth Services Covered? |
90791** |
Psychiatric diagnostic interview examination |
Master's degree level |
HO |
All |
03, 11, 21*, 22, 23, 31, 32, 51*, 54, 61* |
Yes |
Doctoral level |
HP |
|||||
Psychiatrist |
UA |
|||||
APNP with Psychiatric Specialty |
UB |
|||||
90792** |
Interactive psychiatric diagnostic interview examination
using play equipment, physical devices, language interpreter, or other
mechanisms of communication |
Psychiatrist |
UA |
All |
03, 11, 21*, 22, 23, 31, 32, 51*, 54, 61* |
Yes |
APNP with Psychiatric Specialty |
UB |
|||||
For procedure codes H0005, H0022, H0047, and T1006, the 15-hour/$825 limit without PA is applied per billing provider per calendar year. The 15-hour/$825 limit without PA does not accumulate for procedure codes H0022 and H0047 when services are provided to a member in an inpatient hospital.
HCPCS Code |
Description |
Enrolled Providers Who May Perform Service |
Modifier (Required) |
ICD-9-CM Diagnoses Allowed** |
Allowable POS | Telehealth Services Covered? | |
H0005 |
Alcohol and/or drug services; group counseling by a clinician [quantity of 1.0 = 60 minutes] |
Bachelor's degree level |
HN |
303.00-305.93; 308.9; 309.24; 309.28; 309.9; 312.31 |
03, 11, 22, 23, 31, 32, 54 | No | |
Master's degree level |
HO | ||||||
Doctoral level |
HP | ||||||
MD |
UA | ||||||
H0022 |
Alcohol and/or drug intervention service (planned facilitation) [quantity of 1.0 = per person in group per 60 minutes] |
Bachelor's degree level |
HN |
303.00-305.93; 308.9; 309.24;
309.28; 309.9; |
03, 11, 21*, 22, 23, 31, 32, 51*, 54, 61* | Yes (use "GT" modifier) | |
Master's degree level |
HO | ||||||
Doctoral level |
HP | ||||||
MD |
UA | ||||||
H0047 |
Alcohol and/or other drug abuse services, not otherwise specified |
Master's degree level |
HO |
303.00-305.93; 308.9; 309.24;
309.28; 309.9; |
03, 11, 21*, 22, 23, 31, 32, 51*, 54, 61* | Yes (use "GT" modifier) | |
Doctoral level |
HP | ||||||
MD |
UA | ||||||
T1006 |
Alcohol and/or substance abuse services, family/couple counseling [quantity of 1.0 = 60 minutes] |
Bachelor's degree level |
HN |
303.00-305.93; 308.9; 309.24;
309.28; 309.9; |
03, 11, 21*, 22, 23, 31, 32, 51*, 54, 61* | Yes (use "GT" modifier) | |
Master's degree level |
HO | ||||||
Doctoral level |
HP | ||||||
MD |
UA |
|
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