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.
| 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]).
| 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, U6, 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, U6, 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, U6, 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.