Information For Dates of Service On and After October 1, 2015

Revenue Codes

Refer to following table or the UB-04 Uniform Billing Manual for a list of allowable revenue codes for outpatient substance abuse treatment services provided by outpatient substance abuse clinics. However, outpatient substance abuse services provided by a psychologist or psychiatrist to a hospital inpatient member must be billed on the 1500 Health Insurance Claim Form. This does not include group therapy and medication management, which are not separately billable for inpatient members. Providers should refer to the maximum allowable fee schedule for maximum allowable fees and copayment rates.

The following table lists the revenue code 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.

Substance Abuse Treatment Revenue Codes*

(Submitted Only on the UB-04 Claim Form)

For the following revenue codes, the 15-hour/$825 limit without PA is applied per billing provider, per calendar year.

Revenue Code	Description	Enrolled Providers Who May Perform Service	Modifier	ICD Diagnoses Allowed**	Telehealth Services Covered?
0944	Drug rehabilitation	Bachelor's degree level	HN	F12.10–F12.19 F12.20–F12.29 F13.10–F13.19 F13.20–F13.29 F14.10–F14.19 F14.20–F14.29 F15.10–F15.19 F15.20–F15.29 F16.10–F16.19 F16.20–F16.29 F17.20–F17.299 F18.10–F18.19 F18.20–F18.29 F19.10–F19.19 F19.20–f19.29	For individual services only.
		Master's degree level	HO
		Doctoral level	HP
0945	Alcohol rehabilitation	Bachelor's degree level	HN	F10.120–F10.19 F10.220–F10.29	For individual services only.
		Master's degree level	HO
		Doctoral level	HP
0953	Other Therapeutic Services — Chemical Dependency (Drug and Alcohol) [Note: Use to denote services related to treatment for concurrent drug and alcohol abuse.]	Bachelor's degree level	HN	F10.120–F10.19 F10.220–F10.29 F11.10–F11.19 F12.10–F12.19 F12.20–F12.29 F13.10–F13.19 F13.20–F13.29 F14.10–F14.19 F14.20–F14.29 F15.10–F15.19 F15.20–F15.29 F16.10–F16.19 F16.20–F16.29 F17.20–F17.299 F18.10–F18.19 F18.20–F18.29 F19.10–F19.19 F19.20–f19.29	For individual services only.
		Master's degree level	HO
		Doctoral level	HP

*	Outpatient substance abuse services other than group therapy and medication management that are provided by a psychologist or physician to a hospital inpatient member must be billed on the 1500 Health Insurance Claim Form.
**	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.