Covered and Noncovered Services : Codes

Procedure Codes

HCPCS or CPT procedure 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 procedure code are denied. Providers should refer to the maximum allowable fee schedule for the most current maximum allowable fees.

The following tables list the HCPCS or CPT procedure code and modifier that providers are required to use when 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)

ForwardHealth will reimburse code 80305 for up to five tests per month, with an annual benefit limit of 42 tests per calendar year. Only one point-of-care test will be reimbursed per DOS regardless of the number of drug classes, devices, or procedures followed. A physician's order or prescription is required for point-of-care drug testing.

Psychiatric Diagnostic or Evaluative Interview Procedures

Assessment services are limited to eight hours every rolling 12 months per member before PA is required under Wis. Admin. Code § DHS 107.13(2)(c)4, for the following services:

• Adult mental health day treatment (procedure code H2012 with modifiers HE [mental health program] and U6 [functional assessment])
• Substance abuse day treatment (procedure code H2012 with modifiers HF [substance abuse program] and U6 [assessment])

^* 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

The following codes are represented by 15 minutes of service per one unit. When submitting claims, providers are required to round codes to the closest unit of time. A unit of time has been reached when a provider has completed 51 percent of the designated time.

^* 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 allowable ICD diagnosis codes for outpatient substance abuse treatment services is inclusive. However, not all Medicaid-covered outpatient substance abuse services are appropriate or allowable.

^*** Providers should use this HCPCS code for individual substance abuse intervention services.