Information For Dates of Service Before October 1, 2015

Procedure Codes

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.

Outpatient Substance Abuse Treatment Procedure Codes

(Submitted only on the 1500 Health Insurance Claim Form)

Psychiatric Diagnostic or Evaluative Interview Procedures

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:

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
(quantity of 1.0 = 1 hour)

Master's degree level

HO

All

03, 11, 21*, 22, 23, 31, 32, 51*, 54, 61*

Yes
(use "GT" modifier)

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
(quantity of 1.0 = 1 hour)

Psychiatrist

UA

All

03, 11, 21*, 22, 23, 31, 32, 51*, 54, 61*

Yes
(use "GT" modifier)

APNP with Psychiatric Specialty

UB

*

The POS codes "21," "51," and "61" are not allowable for Master's degree-level providers and substance abuse counselors. Payment is included in the hospital's DRG reimbursement.

**

Can be billed with add on procedure code 90785 (interactive complexity) when appropriate.

Substance Abuse Therapeutic Procedures

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;
312.31

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;
312.31

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;
312.31

03, 11, 21*, 22, 23, 31, 32, 51*, 54, 61* Yes (use "GT" modifier)

Master's degree level

HO

Doctoral level

HP

MD

UA
*

The POS codes, "21", "51", and "61" are not allowable for Master's degree-level providers and substance abuse counselors. Payment is included in the hospital's Medicaid DRG reimbursement.

**

The list of ICD-9-CM diagnosis codes for outpatient substance abuse treatment services is inclusive. However, not all Medicaid-covered outpatient substance abuse services are appropriate or allowable.