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School-Based Health Center Scope of Services (Services described in MAD policy; scope to be reviewed annually and updated as necessary) Evaluation & Management CPT Code 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99354 Service Type New patient New patient New patient New patient New patient Established patient Established patient Established patient Established patient Established patient Prolonged services Service Description Office or other outpatient visit (problem focused) Office or other outpatient visit (expanded problem focused) Office or other outpatient visit (detailed) Office or other outpatient visit (comprehensive, moderate) Office or other outpatient visit (comprehensive, high) Office or other outpatient visit (minimal) Office or other outpatient visit (problem focused) Office or other outpatient visit (expanded) Office or other outpatient visit (detailed) Office or other outpatient visit (comprehensive, high) Prolonged physician service; face-to-face pt. contact; beyond usual services Preventive Medicine Services (EPSDT) CPT Code 99381 99382 99383 99384 99385 99391 99392 99393 99394 99395 Service Type New patient New patient New patient New patient New patient Established patient Established patient Established patient Established patient Established patient Service Description Initial comprehensive preventive medicine (age under 1 year) Early childhood (age 1 through 4 years) Late childhood (age 5 through 11 years) Adolescent (age 12 through 17 years) Age 18 through 39 years Periodic comprehensive preventive medicine (age under 1 year) Early childhood (age 1 through 4 years) Late childhood (age 5 through 11 years) Adolescent (age 12 through 17 years) Age 18 through 39 years Nutritional Services Service Description Medical nutrition therapy; initial assessment and intervention; individual; face-to-face with patient, each 15 min. Medical nutrition therapy; re-assessment and intervention, individual; face-to-face, each 15 min. Medicaid FFS Rate $150.55 $150.55 $150.55 $150.55 $150.55 $89.83 $89.83 $89.83 $89.83 $89.83 Medicaid FFS Rate $36.27 $64.68 $96.41 $136.80 $174.42 $20.88 $38.03 $52.08 $81.91 $119.87 $100.46

CPT 97802 97803

Service Type New patient Established patient

Medicaid FFS Rate $16.95 $16.95

Updated 7/2009-csw

Behavioral Health Services CPT Code 90801TR 90804TR 90805TR 90806TR 90807TR 90808TR 90847TR 90853TR Service Type Psychiatric diagnostic or evaluative Office or other outpatient facility Office or other outpatient facility Office or other outpatient facility Office or other outpatient facility Office or other outpatient facility Other psychotherapy Other psychotherapy Service Description Psychiatric diagnostic interview examination Individual psychotherapy, 20-30 minutes Individual psychotherapy, 20-30 minutes, with med. eval. & management Individual psychotherapy, 45-50 minutes Individual psychotherapy, 45-50 minutes, with med. eval & management Individual psychotherapy, 75-80 minutes Family psychotherapy with the patient present Group psychotherapy Pharmacologic management Behavioral health enhanced Procedures and Laboratory CPT Code 10060 10120 11730 11740 11750 12001 12031 16000 17110 26641 28190 29130 30300 36415 54050 56501 57170 58300 Service Type Integumentary system/surgery Integumentary system/surgery Integumentary system/surgery Integumentary system/surgery Integumentary system/surgery Integumentary system/surgery Integumentary system/surgery Integumentary system/surgery Integumentary system/surgery Integumentary system/surgery Integumentary system/surgery Integumentary system/surgery Integumentary system/surgery Cardiovascular system/surgery Male genital system/surgery Female genital system/surgery Female genital system/surgery Female genital system/surgery Service Description I&D of abscess (simple) I&D of foreign body, subcutaneous (simple) Avulsion of nail plate (simple) Evacuation of subungual hematoma Excision of nail and nail matrix, partial or complete, for permanent removal Simple repair of superficial wounds Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm. or less Initial treatment of first degree burn (local); document % of body and depth of burn Destruction of flat warts Closed treatment of carpometacarpal dislocation, thumb, with manipulation Removal of foreign body, foot, subcutaneous Application of finger splint (static) Removal of foreign body, intranasal Routine venipuncture Destruction of lesion(s), penis Destruction of lesion(s), vulva Diaphragm or cervical cap fitting with instructions Insertion of intrauterine device (IUD) Medicaid FFS Rate $93.53 $129.77 $86.31 $35.56 $158.45 $143.23 $172.43 $68.62 $84.83 $331.93 $205.83 $38.62 $208.01 $3.00 $110.79 $130.47 $92.37 $40.92 MD/DO Rate $141.00 $61.00 $67.00 $100.00 $110.00 $129.65 $108.00 $30.00 Mid-Level Rate $88.00 $24.27 N/A $48.54 N/A $73.92 $80.00 $28.00

90862TR Other psychiatric services T1016TR Behavioral health enhanced

$75.00 N/A Managed care only

Updated 7/2009-csw

Procedures and Laboratory, Continued CPT Code 58301 69200 69210 80061 81000 81001 81002 81003 81015 81025 82270 82465 82947 82948 82962 84703 85013 85018 86308 86677 87210 87220 87430 87880 Q0091 Q0111 92567 94010 94640 Service Type Female genital system/surgery Auditory system/surgery Auditory system/surgery Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Pathology & lab Audiologic function testing Pulmonary Pulmonary Service Description Removal of intrauterine device (IUD) Removal foreign body from external auditory canal Removal impacted cerumen (one or both ears) Lipid panel Urinalysis by dipstick or tablet reagent Urinalysis, automated - with microscopy Urinalysis, non-automated - without microscopy Urinalysis, automated - without microscopy Urinalysis, microscopic only Urine pregnancy test - by visual color Blood, occult, guaiac, qualitative, feces Cholesterol, serum or whole blood, total Glucose, blood, quantitative Glucose, blood, reagent strip Glucose, blood by glucose monitoring device hCG pregnancy test (urine) - qualitative Spun microhematocrit Hemoglobin (Hgb) Heterophile antibodies; screening (Mono-spot) Immunoassay for infectious agent antibody, qualitative or semiquantitative (H. pylori) Wet mount (e.g., saline) for infectious agents Tissue examination by KOH slide Streptococcus, group A (culture) non-billable, for tracking only Streptococcus, group A (rapid strep test) PAP smear, obtaining/preparation, conveyance to laboratory Wet prep, obtaining/preparation Tympanometry (impedance testing) Spirometry, including graphic record, total and timed vital capacity Nonpressurized inhalation treatment for acute airway obstruction Medicaid FFS Rate $102.47 $117.14 $48.29 $17.93 $4.63 $4.63 $3.74 $3.28 $4.43 $9.24 $4.75 $6.36 $5.73 $4.63 $3.42 $10.97 $3.46 $3.48 $7.56 $21.19 $6.23 $6.23 $16.76 Managed care only $6.23 $20.49 $31.48 $11.30

Updated 7/2009-csw

Immunizations CPT Code Service Type 90471 Immunization administration 90472 Immunization administration 90633 Vaccines, toxoids 90645 Vaccines, toxoids 90646 Vaccines, toxoids 90647 Vaccines, toxoids 90648 Vaccines, toxoids 90649 HB Vaccines, toxoids 90649 Vaccines, toxoids 90657 Vaccines, toxoids 90658 Vaccines, toxoids 90660 Vaccines, toxoids 90669 Vaccines, toxoids 90702 Vaccines, toxoids 90700 Vaccines, toxoids 90701 Vaccines, toxoids 90707 Vaccines, toxoids 90712 Vaccines, toxoids 90713 Vaccines, toxoids 90715 Vaccines, toxoids 90716 Vaccines, toxoids 90718 Vaccines, toxoids 90732 Vaccines, toxoids 90733 Vaccines, toxoids 90734 Vaccines, toxoids 90744 Vaccines, toxoids 90748 Vaccines, toxoids Service Description Immunization administration; one vaccine Immunization administration; each additional vaccine Hepatitis A vaccine, pediatric/adolescent Hemophilius influenza b vaccine (HIB), HbOC conjugate Hemophilius influenza b vaccine (HIB), PRP-D conjugate Hemophilius influenza b vaccine (HIB), PRP-OMP conjugate Hemophilius influenza b vaccine (HIB), PRP-T conjugate Human Papilloma Virus (HPV) vaccine - females 9-10 and 19-26 years of age Human Papilloma Virus (HPV) vaccine - females 11-18 years of age Influenza virus vaccine, split virus, 6-35 months of age Influenza virus vaccine, split virus, 3 years and above Influenza virus vaccine,live, for intranasal use (Flumist) Pneumococcal conjugate vaccine, polyvalent, children under 5 years Diphtheria, tetanus toxoids Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP) Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP) Measles, mumps, rubella vaccine (MMR) Poliovirus vaccine (OPV) for oral use Poliovirus virus (IPV) for subcutaneous or intramuscular use Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP) Varicella virus vaccine Tetanus and diphtheria toxoids (Td) Pneumococcal polysaccharide vaccine 23-valent Meningococcal polysaccharide vaccine Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent) Hepatitis B vaccine, pediatric/adolescent dosage Hepatitis B and hemophilius influenza b vaccine (HepB/Hib) combination Medications, Supplies & Durable Medical Equipment HCPCS Code A4261 A4266 A4267 A4268 A4269 A4614 J0170 Service Type Supplies/DME Supplies/DME Supplies/DME Supplies/DME Supplies/DME Supplies/DME Service Description Cervical cap for contraceptive use Diaphragm for contraceptive use Condom, Male Condom, Female Spermicidal agent Peak flow meter, hand held Medicaid FFS Rate $46.65 $29.90 $0.40 $2.02 $3.00 $23.78 $0.70 Medicaid FFS Rate Managed care only Managed care only $10.94 $10.94 $10.94 $10.94 $10.94 $130.00 $10.94 $10.94 $10.94 $22.32 $95.48 $10.94 $10.94 $21.93 $10.94 $10.94 $10.94 $10.94 $10.94 $10.94 $37.61 $98.52 $10.94 $10.94 $45.62

Drugs administered other than oral Adrenaline, epinephrine, up to 1 ml. ampule (Epi Pen for emergency)

Updated 7/2009-csw

Medications, Supplies & Durable Medical Equipment, cont'd HCPCS Code J0560 J0570 J0580 J0696 J1055 J1056 J2550 J7300 J7302` J7303 J7304 J7307 J7602 J7603 J8499 U1 S4989 S4993 Q0144 Q3014 Service Type Drugs administered other than oral Drugs administered other than oral Drugs administered other than oral Drugs administered other than oral Drugs administered other than oral Drugs administered other than oral Drugs administered other than oral Drugs administered other than oral Drugs administered other than oral Drugs administered other than oral Drugs administered other than oral Drugs administered other than oral Drugs administered Drugs administered Drugs administered Drugs administered other than oral Drugs administered Drugs administered Telehealth Service Description Penicillin G, up to 600,000 units Penicillin G, up to1,200,000 units Penicillin G, up to 2,400,000 units Injection, Ceftriaxone 250 mg. IM per vial Injection, Depo Provera 150 mg. IM Medroxyprogesterone acetate w/estradiol cypionate 5mg/25 mg (use for Lunelle® syringe or 0.5ml vial) Promethazine HCI, injection, up to 50 mg. Intrauterine copper contraceptive Levonorgesterel-releasing intrauterine contraceptive system (Mirena®) Hormone Containing Vaginal Ring (Nuvaring®) Hormone Containing Patch (Ortho Evra®) Etonogestrel contraceptive implant system, including implants and supplies (use for Implanon®) Albuterol, concentrated form, 1 mg. Albuterol, unit dose form, 1 mg. Plan B® or similar emergency contraception IUD other than above (Progestacert®) Contraceptive pills for birth control Azithromycin oral powder 1 g. Telehealth originating site facility fee Medicaid FFS Rate $34.60 $58.20 $94.80 $1.07 $58.12 $22.88 $1.52 $377.00 $585.89 $42.36 $18.20 $653.75 $0.15 $0.44 $33.70 $627.38 $23.30 Managed care only $22.47

Updated 7/2009-csw

Revised 8/09/csw

ENCOUNTER FORM SBHC

OFFICE VISIT ESTAB 99211 99212 99213 99214 99215 99354 ESTAB 99391 99392 99393 99394 99395 97802 97803 99201 99202 99203 99204 99205 99354 NEW 99381 99382 99383 99384 99385 NEW Minimal eval. Problem focused Expanded problem focused Detailed Comprehensive, mod. complexity, 45 min. Comprehensive, high complexity Add on Code to 99215 or 99205 Prolonged Service; with patient contact; beyond 30 - 74 min. EPSDT WELL CHILD EXAM / PREVENTATIVE MEDICINE Infant 1-4 years 5-11 years 12-17 years 18+ years NUTRITION Medical Nutritional Therapy, initial assessment and intervention, individual, each 15 min. Medical Nutritional Therapy, re-assessment and intervention, individual, each 15 min. PSYCHIATRIC THERAPEUTIC PROCEDURES All BH Services billed to Optum Health should be submitted with TR Modifier 90801-TR 90804-TR 90805-TR 90806-TR 90807-TR 90808-TR 90853-TR 90847-TR 90862-TR T1016-TR J0170 J0560 J0570 J0580 J0696 J1055 J1056 J2550 J7300 J7302 J7303 J7304 J7602 Adrenaline, epinephrine up to 1ml Penicillin G, up to 600,000 units Penicillin G, up to 1,200,000 units Penicillin G, up to 2,400,000 units Ceftriaxone 250 mg. IM per vial Depo Provera 150 mg. IM Medroxyprogesterone Promethazine HCI, injection up to 50 mg Intrauterine copper contraceptive Levonorgesterel-releasing intrauterine (Mirena) Hormone Containing Vaginal Ring (Nuvaring) Hormone Containing Patch (Ortho Evra) Albuterol, concentrated form, 1 mg IMMUNIZATIONS IMMUNIZATION ADMINISTRATION 90471 90633 90645 90646 90647 90648 90649 HB 90649 90657 90658 90669 90700 90701 90660 One immunization Hep A HIB(HbOC) [HibTITER] HIB(PRP-D) [ProHIBIT] HIB(PRP-OMP) [PedvaxHIB] HIB(PRP-T) [ActHIB or OmniHIB] HPV females 9-10 and 19-26 HPV females 11-18 Influenza (split virus 6-35 mo.) Influenza (split virus 3 yrs +) Pneumococcal Conjugate, IM <5 yo DTaP DT Influenza virus vaccine, live, for intranasal use (Flum 90744 90748 Managed care only 90472 VACCINATIONS 90702 90707 90712 90713 90715 90716 90718 90732 90733 90734 DT Measles, Mumps, Rubella Poliovirus IPV (polio) Tdap Varicella SQ Tetanus and Diphtheria (Td) Pneumococcal poly- valent, SQ or IM Meningococcal(polysaccharide, SQ) Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent) Hep B 3 dose IM Hep B/Hib Combination IM Each additional vaccine Managed care only Psychiatric diagnostic interview examination Individual psychotherapy, 20-30 min. Individual psychotherapy, 20-30 min., with medical eval & mgt Individual psychotherapy, 45-50 min. Individual psychotherapy, 45-50 min., with medical eval & mgt Individual psychotherapy, 65-80 min. Group therapy Family therapy with patient present Psychiatric pharmacologic management Managed Care Only MEDICATIONS, SUPPLIES & DURABLE MEDICAL EQUIPMENT J7603 A4614 A4266 A4261 A4267 A4268 A4269 J7307 S4989 S4993 Q0144 Albuterol, unit dose form, 1 mg. Peak flow meter, hand held Diaphragm device Cervical cap for contraceptive use Condom, Male Condom, Female Spermicidal agent Etenogestrel contraceptive implant system IUD other than above (Progestacert) Contraceptive pills for birth control Azithromycin oral powder 1 gm. Managed care only 12001 12031 16000 17110 26641 28190 29130 30300 36415 54050 56501 57170 58300 58301 69200 69210 87220 94640 94010 10060 10120 11730 11740 11750 92567 80061 81000 81001 81002 81003 81015 81025 82270 82465 82947 82948 82962 84703 85013 85018 86308 86677 87210 87430 87491 87880 Q0091 Q0111 Consider use of Modifier 25 (write in -25 after code) X CPT

ON-SITE LAB TESTS DESCRIPTION No labs given Lipid panel Urinalysis - dip stick Urinalysis, auto. - microscopy Urinalysis, non-auto. - no microscopy Urinalysis, auto. - no microscopy Urine - microscopic only Urine pregnancy test-by visual color Guiac, occult blood Cholesterol, total Glucose; quantitative; blood Glucose fingerstick Glucose monitoring devise hCG preg. test (urine) - qualitative Hematocrit Hemoglobin Mono-spot screen H. pylori antibody Wet mount (e.g., saline) for infectious agents Streptococcus, group A ( culture NON BILLABLE) Urine CT/GC - amplified probe NON BILLABLE Streptococcus, group A (rapid strep test) PAP smear, obtaining/preparation Managed Care Only Wet prep, obtaining/preparation subcutaneous or intramuscular Tympanometry - impedance testing PROCEDURES I & D simple I & D of foreign body, subcutaneous (simple) Nail avulsion Evacuation of subungual hematoma Excision of nail and nail maxtix, partial or complete, for permanent removal Suturing - specify body part: Layer closure of wounds of scalp, axilae, trunk and/or extremities (excluding hands & feet) 2.5 cm Initial tx - 1st o burn (local), doc. % coverage & depth Wart removal Closed tx of carpometacarpal (thumb) dislocation Removal of foreign body, foot, subcutaneous Application of finger splint (static) Removal of foreign body, intranasal Venipuncture Destruction of lesion(s), penis Destruction of lesion(s), vulva Diaphragm fitting IUD insertion IUD removal Removal foreign body from external auditory canal Removal impacted cerumen (one or both ears) KOH for skin/hair/nails Nebulizer treatment Spirometry

J8499 U1 Plan B or similar emergency contraception

TELEHEALTH SERVICE Q3014 Telehealth originating site facility fee

CONFIDENTIAL VISIT? YES

Return to SBHC (follow-up date): To Provider:

SHQ COMPLETED TODAY? YES

To:

NO

NO

DATE (Month/Day/Year) PATIENT IDENTIFICATION Name: Student ID #:

FOLLOW-UP

REFERRAL

DIAGNOSIS (ICD-9) Code # & Name DOB (Month/Day/Year): SS# Sex: Male Female PROVIDER IDENTIFICATION Provider Name: Provider Signature: Provider NPI # Insurance name Insurance # : INSURANCE INFORMATION Grade:

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