Procedure Codes and Rates For Dates of Service On and After October 1, 2013, and Before January 1, 2014

The following schedule lists procedure codes and rates Wisconsin Medicaid-enrolled providers will be reimbursed for covered services provided to eligible members under the SBS benefit effective for claims processed on and after October 1, 2013, and before January 1, 2014. These Wisconsin Medicaid SBS reimbursement rates are interim rates that SBS providers receive for applicable services rendered and are reconciled to costs based on cost reports.

Reimbursement Rates for School-Based Services
on and After October 1, 2013, and Before January 1, 2014

Procedure Code Description Modifier and Modifier Description Unit Rate Reimbursement Amount

92506 with modifiers "TM" and "GN"
Evaluation of speech, language, voice, communication, and/or auditory processing
TM — Individualized education program (IEP)

$28.36

$10.05

GN — Services delivered under an outpatient speech language pathology plan of care

92507 with modifiers "TM" and "GN"
Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
TM — Individualized education program (IEP)

$28.36

$10.05

GN — Services delivered under an outpatient speech language pathology plan of care

92508 with modifiers "TM" and "GN"
group, 2 or more individuals
TM — Individualized education program (IEP)

$9.37

$3.32

GN — Services delivered under an outpatient speech language pathology plan of care

97110 with modifiers "TM" and "GO"
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
TM — Individualized education program (IEP)

$24.56

$8.70

GO — Services delivered under an outpatient occupational therapy plan of care

97150 with modifiers "TM" and "GO"
Therapeutic procedure(s), group (2 or more individuals)
TM — Individualized education program (IEP)

$8.10

$2.87

GO — Services delivered under an outpatient occupational therapy plan of care

97001 with modifiers "TM" and "GP"
Physical therapy evaluation
TM — Individualized education program (IEP)

$28.43

$10.07

GP — Services delivered under an outpatient physical therapy plan of care

97003 with modifiers "TM" and "GO"
Occupational therapy evaluation
TM — Individualized education program (IEP)

$24.56

$8.70

GO — Services delivered under an outpatient occupational therapy plan of care

97110 with modifiers "TM" and "GP"
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
TM — Individualized education program (IEP)

$28.43

$10.07

GP — Services delivered under an outpatient physical therapy plan of care

97150 with modifiers "TM" and "GP"
Therapeutic procedure(s), group (2 or more individuals)
TM — Individualized education program (IEP)

$9.38

$3.32

GP — Services delivered under an outpatient physical therapy plan of care

T1024 with modifier "U1"
Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)
U1 — M-team assessment and IEP, psychological service

$25.33

$8.98

T1024 with modifier "U2"
Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)
U2 — Individual IEP, psychological service

$25.33

$8.98

T1024 with modifier "U3"
Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)
U3 — Group IEP, psychological service

$8.35

$2.96

T1024 with modifier "U4"
Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)
U4 — M-team assessment and IEP, counseling service

$24.30

$8.61

T1024 with modifier "U5"
Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)
U5 — Individual IEP, counseling service

$24.30

$8.61

T1024 with modifier "U6"
Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)
U6 — Group IEP, counseling service

$8.02

$2.84

T1024 with modifier "U7"
Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)
U7 — M-team assessment and IEP, social work service

$24.42

$8.65

T1024 with modifier "U8"
Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)
U8 — Individual IEP, social work service

$24.42

$8.65

T1024 with modifier "U9"
Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)
U9 — Group IEP, social work service

$8.06

$2.86

T1001 with modifier "TM"
Nursing assessment/evaluation
TM — Individualized education program (IEP)

$20.48

$7.26

T1002 with modifier "TM"
RN services, up to 15 minutes
TM — Individualized education program (IEP)

$20.48

$7.26

T1003 with modifier "TM"
LPN/LVN services, up to 15 minutes
TM — Individualized education program (IEP)

$20.48

$7.26

T2003 with modifier "TM"
Non-emergency transportation; encounter/trip
TM — Individualized education program (IEP)

$16.52

$5.85

A0425 with modifier "TM"
Ground mileage; per statute mile
TM — Individualized education program (IEP)

$3.77

$1.34

S5125 with modifier "TM"
Attendant care services; per 15 minutes
TM — Individualized education program (IEP)

$4.02

$1.42

Reimbursement Rates for School-Based Services on and After October 1, 2013, and Before January 1, 2014
Procedure Code	Description	Modifier and Modifier Description	Unit Rate	Reimbursement Amount
92506 with modifiers "TM" and "GN"	Evaluation of speech, language, voice, communication, and/or auditory processing	TM — Individualized education program (IEP)	$28.36	$10.05
92506 with modifiers "TM" and "GN"		GN — Services delivered under an outpatient speech language pathology plan of care	$28.36	$10.05
92507 with modifiers "TM" and "GN"	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual	TM — Individualized education program (IEP)	$28.36	$10.05
92507 with modifiers "TM" and "GN"		GN — Services delivered under an outpatient speech language pathology plan of care	$28.36	$10.05
92508 with modifiers "TM" and "GN"	group, 2 or more individuals	TM — Individualized education program (IEP)	$9.37	$3.32
92508 with modifiers "TM" and "GN"	group, 2 or more individuals	GN — Services delivered under an outpatient speech language pathology plan of care	$9.37	$3.32
97110 with modifiers "TM" and "GO"	Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility	TM — Individualized education program (IEP)	$24.56	$8.70
97110 with modifiers "TM" and "GO"		GO — Services delivered under an outpatient occupational therapy plan of care	$24.56	$8.70
97150 with modifiers "TM" and "GO"	Therapeutic procedure(s), group (2 or more individuals)	TM — Individualized education program (IEP)	$8.10	$2.87
97150 with modifiers "TM" and "GO"	Therapeutic procedure(s), group (2 or more individuals)	GO — Services delivered under an outpatient occupational therapy plan of care	$8.10	$2.87
97001 with modifiers "TM" and "GP"	Physical therapy evaluation	TM — Individualized education program (IEP)	$28.43	$10.07
97001 with modifiers "TM" and "GP"	Physical therapy evaluation	GP — Services delivered under an outpatient physical therapy plan of care	$28.43	$10.07
97003 with modifiers "TM" and "GO"	Occupational therapy evaluation	TM — Individualized education program (IEP)	$24.56	$8.70
97003 with modifiers "TM" and "GO"	Occupational therapy evaluation	GO — Services delivered under an outpatient occupational therapy plan of care	$24.56	$8.70
97110 with modifiers "TM" and "GP"	Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility	TM — Individualized education program (IEP)	$28.43	$10.07
97110 with modifiers "TM" and "GP"		GP — Services delivered under an outpatient physical therapy plan of care	$28.43	$10.07
97150 with modifiers "TM" and "GP"	Therapeutic procedure(s), group (2 or more individuals)	TM — Individualized education program (IEP)	$9.38	$3.32
97150 with modifiers "TM" and "GP"	Therapeutic procedure(s), group (2 or more individuals)	GP — Services delivered under an outpatient physical therapy plan of care	$9.38	$3.32
T1024 with modifier "U1"	Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)	U1 — M-team assessment and IEP, psychological service	$25.33	$8.98
T1024 with modifier "U2"	Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)	U2 — Individual IEP, psychological service	$25.33	$8.98
T1024 with modifier "U3"	Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)	U3 — Group IEP, psychological service	$8.35	$2.96
T1024 with modifier "U4"	Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)	U4 — M-team assessment and IEP, counseling service	$24.30	$8.61
T1024 with modifier "U5"	Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)	U5 — Individual IEP, counseling service	$24.30	$8.61
T1024 with modifier "U6"	Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)	U6 — Group IEP, counseling service	$8.02	$2.84
T1024 with modifier "U7"	Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)	U7 — M-team assessment and IEP, social work service	$24.42	$8.65
T1024 with modifier "U8"	Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)	U8 — Individual IEP, social work service	$24.42	$8.65
T1024 with modifier "U9"	Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (Short description: team evaluation & management)	U9 — Group IEP, social work service	$8.06	$2.86
T1001 with modifier "TM"	Nursing assessment/evaluation	TM — Individualized education program (IEP)	$20.48	$7.26
T1002 with modifier "TM"	RN services, up to 15 minutes	TM — Individualized education program (IEP)	$20.48	$7.26
T1003 with modifier "TM"	LPN/LVN services, up to 15 minutes	TM — Individualized education program (IEP)	$20.48	$7.26
T2003 with modifier "TM"	Non-emergency transportation; encounter/trip	TM — Individualized education program (IEP)	$16.52	$5.85
A0425 with modifier "TM"	Ground mileage; per statute mile	TM — Individualized education program (IEP)	$3.77	$1.34
S5125 with modifier "TM"	Attendant care services; per 15 minutes	TM — Individualized education program (IEP)	$4.02	$1.42