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Program Name: BadgerCare Plus and Medicaid Handbook Area: Outpatient Mental Health and Substance Abuse Services in the Home or Community for Adults
05/20/2022  

Covered and Noncovered Services : Codes

Topic #7637

Procedure Codes

Valid procedure codes and modifiers are required on all claims for outpatient mental health and substance abuse services in the home or community for adults. Claims or adjustments received without a valid procedure code are denied. The mental health and substance abuse maximum allowable fee schedule indicates maximum allowable fees and copayment rates.

The following table lists the valid procedure codes and modifiers that providers are required to use when submitting claims for outpatient mental health and substance abuse services in the home or community for adults. Not all providers may be reimbursed for all mental health and substance abuse services in the home or community for adults.

Outpatient Mental Health and Substance Abuse Services in the Home or Community for Adults Procedure Codes

CPT Code Description Required Modifier Allowable POS Additional Information Allowable Units
+90785* Interactive complexity

(List separately in addition to the code for primary procedure)

HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
90791 Psychiatric diagnostic evaluation HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
90792 Psychiatric diagnostic evaluation with medical services UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
90832 Psychotherapy, 30 minutes with patient HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
+90833* Psychotherapy, 30 minutes with patient when performed with an evaluation and management service

(List separately in addition to the code for primary procedure)

UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99 Billed with appropriate E&M procedure code. 1
90834 Psychotherapy, 45 minutes with patient HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
+90836* Psychotherapy, 45 minutes with patient when performed with an evaluation and management service

(List separately in addition to the code for primary procedure)

UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99 Billed with appropriate E&M procedure code. 1
90837 Psychotherapy, 60 minutes with patient HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
+90838* Psychotherapy, 60 minutes with patient when performed with an evaluation and management service

(List separately in addition to the code for primary procedure)

UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99 Billed with appropriate E&M procedure code. 1
90839 Psychotherapy for crisis, first 60 minutes HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
+90840* Psychotherapy for crisis; each additional 30 minutes

(List separately in addition to the code for primary service)

HO,HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99 This is an add-on procedure code and can be used only in conjunction with procedure code 90839. N/A
90845 Psychoanalysis HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
90846 Family psychotherapy (without the patient present), 50 minutes HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
90847 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
90849 Multiple-family group psychotherapy HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
90853 Group psychotherapy (other than of a multiple-family group) HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
90875 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
90876 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 45 minutes HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
90880 Hypnotherapy HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
90887 Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
90899 Unlisted psychiatric service or procedure HO,HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   N/A
99199 Unlisted special service, procedure or report (Physician travel time) HO, HP, U3**, U6, UA, UB, UC 99   12
+99354* Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour

(List separately in addition to code for outpatient Evaluation and Management*** or psychotherapy service except with office or other outpatient services [99202–99215])

HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   1
+99355* Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes

(List separately in addition to code for prolonged service)

HO, HP, U6, UA, UB, UC 04, 12, 13, 14, 33, 34, 55, 56, 99   4

* Add-on procedure code.

** Providers are required to indicate modifier U3 in addition to the appropriate professional level modifier and informational modifier when submitting claims for travel time using procedure code 99199.

*** Only providers who are eligible to provide evaluation and management services can report this procedure code with evaluation and management services.

Inpatient hospital or residential care services: BadgerCare Plus and Wisconsin Medicaid cover "partial hospital" services under a separate benefit—day treatment/day hospital services (Wis. Admin. Code § DHS 107.13[4]).

Substance Abuse Treatment Procedure Codes

HCPCS Code Description Required Modifiers ICD Diagnoses Allowed* Allowable POS Unit Time Allocation
H0005 Alcohol and/or drug services; group counseling by a clinician HN, HO, HP, UA, UC F10–F19.99, F55.0–F55.8 04, 12, 13, 14, 33, 34, 55, 56, 99 1 unit = 15 minutes
H0022 Alcohol and/or drug intervention service
HN, HO, HP, UA, UC F10–F19.99, F55.0–F55.8 04, 12, 13, 14, 33, 34, 55, 56, 99 1 unit = 15 minutes
T1006 Alcohol and/or substance abuse services, family/couple counseling HN, HO, HP, UA, UC F10–F19.99, F55.0–F55.8 04, 12, 13, 14, 33, 34, 55, 56, 99 1 unit = 15 minutes

* The list of allowable ICD diagnosis codes for outpatient mental health and substance abuse services in the home or community is inclusive. However, not all Medicaid-covered outpatient mental health and substance abuse services in the home or community are appropriate or allowable.

 
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