Read FY 06 ben plan - services, HCPCS and units for Sally 3-22-06.xls text version

MI Benefit Plan Levels I-IV Revision for FY 1-06 as of 3-13-06

HCPCS Code

Coding Description

Local Service Code

Units of Service Reported

CRISIS SERVICES

Crisis Services do not require prior authorization Available to any citizen experiencing a mental health emergency Crisis intervention Screening for Inpatient program H2011 T1023 f:f crisis contact pre-admission screening 15 minute encounter

Services to Persons with Mental Illness Level I: A. Outpatient Therapy B. Supports Coordination

LEVEL IA: Brief Outpatient/ Limited Services

Population: MIA/MIC/SMI/SED/Co-occurring 96110 Developmental screening 96111 Developmental Testing H0002 Brief Assmt/SA screening H0031 Clinical/Behavioral/Vocational T1001 90801 90802 90887 T1002 90862 M0064 H0023 H0025 T1005 90804-90829 90846 90847 90853 90857 H0032 H2021 96110 96111 H0002 H0031 T1001 90801 90802 90887 96101 96102 96103 96116 96118 96119 96120 E1399 S5199 T1999 T2039 90849 90849HS G0177 G0177HS T2025 97803 97804 H0034 S9445 S9446 S9470 T1002 90862 M0064 T1017SE nursing assessment psychiatric evaluation psychiatric eval interactive interpretive interview nursing services - RN only medication review brief visit for med monitoring drop - in center MDCH approved program only respite care see code descriptions family tx w/ consumer fam tx w/o consumer group therapy interactive group tx tx planning - discipline, non Dr. Specialized Wraparound Facilitation Population: SMI/SED/Co-occurring Developmental screening Developmental Testing Brief Assmt/SA screening Clinical/Behavioral/Vocational nursing assessment psychiatric evaluation psychiatric eval interactive interpretive interview psychological testing (incl) psych tests by technician computerized test (event) neuropsych status exam neuropsych test battery neuropsych test technician computer neuropsych(event) durable medical equipment assistive technology misc. therapeutic items wheelchair adaptations EBP only - Joining sessions " " session w/o consumer EBP only - Family sessions " "Family w/o consumer FI for self-determination dietary counseling ind dietary counseling group medication training/support pt.education nonphysician pt.education group nutrition/dietary counseling nursing services - RN only medication review brief visit for med monitoring monitoring in nursing home

encounter encounter encounter 15 minute encounter encounter f:f contact 15 minute encounter encounter encounter encounter 15 minute

Assessment - Clinical Assessment - Health

Assessment - Psychiatric Health Service - RN services Medication Review Peer Directed - Drop In Center Prevention - Direct Model Respite (only) Therapy - individual Therapy - family Therapy - group Treatment Planning Wraparound Services (only)

LEVEL IB: Supports Coordination/ Therapeutic Stabilization and Support

encounter encounter encounter

Assessment - Clinical Assessment - Health

Assessment - Psychiatric

per hour

Assessment - Psychological Testing (# hrs. includes scoring, analysis & report)

item

Enhanced Medical / Pharmacy Family PsychoEducation / Family Joining sessions Family PsychoEducation / Multi Family Group Fiscal Intermediary

encounter encounter per month 15 minute 30 minute 15 minute encounter 15 minute encounter 15 minute

Health Services

Health Services (encounter) Health Service - RN Services Medication Review Nursing Home Mental Health Monitoring

Page 1 of 10

MI Benefit Plan Levels I-IV Draft 3 Revision for FY 1-06 as of 3-13-06

HCPCS Code Peer Directed - Drop In Center Peer Directed - Peer Specialist services Supports Coordination Therapy - individual Therapy - family Therapy - group Treatment Planning Wraparound Services H0023 H0038 T1016 90804-90829 90846 90847 90853 90857 H0032 H2021

Coding Description drop-in center delivered by peers supports coordination see code descriptions family tx w/ consumer fam tx w/o consumer group therapy interactive group tx tx planning - discipline, non Dr. Specialized Wraparound Facilitation

Local Service Code

Units of Service Reported encounter 15 minute 15 minute encounter encounter encounter encounter 15 minute

Level II: SPECIALIZED OUTPATIENT BEHAVIORAL HEALTH CARE

A. SUPPORTS COORDINATION B.INTENSIVE CASE MANAGEMENT

96110 96111 H0002 H0031 T1001 90801 90802 90887 96101 96102 96103 96116 96118 96119 96120 H2030 H2015 H0043 E1399 S5199 T1999 T2039 90849 90849HS G0177 G0177HS S5111 T2025 97803 97804 H0034 S9445 S9446 S9470 T1002 T2038 90772 99506 90862 M0064 97003 97004 97001 97002

C. ACT or HOMEBASED

Developmental screening Developmental Testing Brief Assmt/SA screening Clinical/Behavioral/Vocational nursing assessment psychiatric evaluation psychiatric eval interactive interpretive interview psychological testing (incl) psych tests by technician computerized test (event) neuropsych status exam neuropsych test battery neuropsych test technician computer neuropsych(event) psychosocial rehab program CLS (see provider manual) Supported Housing durable medical equipment assistive technology misc. therapeutic items wheelchair adaptations EBP only - Joining sessions " " session w/o consumer EBP only - Family sessions " "Family w/o consumer home care training FI for self-determination dietary counseling ind dietary counseling group medication training/support pt.education nonphysician pt.education group nutrition/dietary counseling nursing services - RN only community transition medication injection med injection - home visit medication review brief visit for med monitoring OT evaluation OT re-eval PT evaluation PT re-eval

LEVEL II A: Supports Coordination/Community Supports

encounter encounter encounter

Assessment - Clinical Assessment - Health

Assessment - Psychiatric

per hour

Assessment - Psychological Testing (# hrs. includes scoring, analysis & report) Clubhouse/PSR Programs Community Living Supports Community Living Supports unlicensed/temporary

15 minute 15 minute day

item

Enhanced Medical / Pharmacy Family PsychoEducation / Family Joining sessions Family PsychoEducation / Multi Family Group Family Support & Training Fiscal Intermediary

encounter encounter encounter per month 15 minute 30 minute 15 minute encounter encounter encounter 15 minute month encounter encounter encounter encounter

Health Services

Health Services (encounter) Health Service - RN Services Housing Assistance Medication Administration Medication Review Occupational & Physical Therapy OT Evaluation OT/PT - PT Evaluation

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MI Benefit Plan Levels I-IV Draft 3 Revision for FY 1-06 as of 3-13-06

HCPCS Code 97110 97112 97113 97116 97124 97140 97530 97532 97533 97535 97537 97542 97150 S8990 H0023 H0038 T1005 H0045 H2014 92506 92610 96105 92507 92508 92526 H2023 T1016 90804-90829 90846 90847 90853 90857 H0032 H2021

Coding Description

Local Service Code

Units of Service Reported

certified OT or PT only (see code descriptions)

15 minute

OT/PT - Services OT/PT - Services (encounter) Peer Directed - Drop In Center Peer Directed - Peer Specialist services Respite Respite (day) Skill Building Assistance

certified OT or PT only (see code descriptions) drop-in center delivered by peers respite care out of home respite skill training & development speech/lang. assessment assmt of swallowing function assessment of aphasia individual speech therapy group speech therapy tx of swallowing disorder supported employment supports coordination see code descriptions family tx w/ consumer fam tx w/o consumer group therapy interactive group tx tx planning - discipline, non Dr. Specialized Wraparound Facilitation

encounter encounter 15 minute 15 minute day 15 minute encounter

Speech/Language - Evaluation

encounter 15 minute 15 minute encounter encounter encounter encounter 15 minute

Speech/Language - Therapy services Supported Employment Services Supports Coordination Therapy - individual Therapy - family Therapy - group Treatment Planning Wraparound Services

LEVEL II B: Intensive Case Management/Supports Coordination/ Community Supports

96110 96111 H0002 H0031 T1001 90801 90802 90887 96101 96102 96103 96116 96118 96119 96120 H2000 H2030 H0043 H2015 E1399 S5199 T1999 T2039 90849 90849HS G0177 G0177HS S5111 T2025 Developmental screening Developmental Testing Brief Assmt/SA screening Clinical/Behavioral/Vocational nursing assessment psychiatric evaluation psychiatric eval interactive interpretive interview psychological testing (incl) psych tests by technician computerized test (event) neuropsych status exam neuropsych test battery neuropsych test technician computer neuropsych(event) BMC review (meeting) MDCH approved program only Supported Housing CLS (see manual) durable medical equipment assistive technology misc. therapeutic items wheelchair adaptations EBP only - Joining sessions " " session w/o consumer EBP only - Family sessions " "Family w/o consumer home care training FI for self-determination

encounter encounter encounter

Assessment - Clinical Assessment - Health

Assessment - Psychiatric

per hour

Assessment - Psychological Testing (# hrs. includes scoring, analysis & report) Behavior Management Clubhouse/PSR Programs Community Living Supports unlicensed/ temporary Community Living Supports

encounter 15 minute day 15 minute item

Enhanced Medical / Pharmacy Family PsychoEducation / Family Joining sessions Family PsychoEducation / Multi Family Group Family Support & Training Fiscal Intermediary

encounter encounter encounter per month

Page 3 of 10

MI Benefit Plan Levels I-IV Draft 3 Revision for FY 1-06 as of 3-13-06

HCPCS Code 97803 97804 H0034 S9445 S9446 S9470 T1002 T2038 90772 99506 90862 M0064 97003 97004 97001 97002 97110 97112 97113 97116 97124 97140 97530 97532 97533 97535 97537 97542 97150 S8990 H0023 H0038 T1005 H0045 H2014 92506 92610 96105 92507 92508 92526 H2023 T1016 T1017 90804-90829 90846 90847 90853 90857 H0032 H2021

Coding Description dietary counseling ind dietary counseling group medication training/support pt.education nonphysician pt.education group nutrition/dietary counseling nursing services - RN only community transition medication injection med injection - home visit medication review brief visit for med monitoring OT evaluation OT re-eval PT evaluation PT re-eval

Local Service Code

Units of Service Reported 15 minute 30 minute 15 minute encounter encounter encounter 15 minute month encounter encounter encounter encounter

Health Services

Health Services (encounter) Health Service - RN Services Housing Assistance Medication Administration Medication Review Occupational & Physical Therapy OT Evaluation OT/PT - PT Evaluation

certified OT or PT only (see code descriptions)

15 minute

OT/PT - Services OT/PT - Services (encounter) Peer Directed - Drop In Center Peer Directed - Peer Specialist services Respite Respite (day) Skill Building Assistance

certified OT or PT only (see code descriptions) drop-in center delivered by peers respite care out of home respite skill training & development speech/lang. assessment assmt of swallowing function assessment of aphasia individual speech therapy group speech therapy tx of swallowing disorder supported employment supports coordination case maangement see code descriptions family tx w/ consumer fam tx w/o consumer group therapy interactive group tx tx planning - discipline, non Dr. Specialized Wraparound Facilitation

encounter encounter 15 minute 15 minute day 15 minute encounter

Speech/Language - Evaluation

encounter 15 minute 15 minute 15 minute encounter encounter encounter encounter 15 minute

Speech/Language - Therapy services Supported Employment Services Supports Coordination Targeted Case Management Therapy - individual Therapy - family Therapy - group Treatment Planning Wraparound Services

LEVEL II C: Assertive Community Treatment/Home-based Services

ACT Services H0039 96110 96111 H0002 H0031 T1001 90801 90802 90887 assertive community treatment Developmental screening Developmental Testing Brief Assmt/SA screening Clinical/Behavioral/Vocational nursing assessment psychiatric evaluation psychiatric eval interactive interpretive interview 15 minute encounter encounter encounter

Assessment - Clinical Assessment--Health

Assessments--Psychiatric

Page 4 of 10

MI Benefit Plan Levels I-IV Draft 3 Revision for FY 1-06 as of 3-13-06

HCPCS Code 96101 96102 96103 96116 96118 96119 96120 H2000 H2030 H2015 H0043 E1399 S5199 T1999 T2039 90849 90849HS G0177 G0177HS S5111 T2025 T1002 97803 97804 H0034 S9445 S9446 S9470 H0036 T2038 90772 99506 90862 M0064 97003 97004 97001 97002 97110 97112 97113 97116 97124 97140 97530 97532 97533 97535 97537 97542 97150 S8990 H0023 H0038 T1020 T1020TF T1020TG T1005 H0045 H2014 92506 92610 96105 92507 92508 92526 H2023 T1017 90804-90829

Coding Description psychological testing (incl) psych tests by technician computerized test (event) neuropsych status exam neuropsych test battery neuropsych test technician computer neuropsych(event) BMC review (meeting) MDCH approved program only CLS (see manual) Supported Housing durable medical equipment assistive technology misc. therapeutic items wheelchair adaptations EBP only - Joining sessions " " session w/o consumer EBP only - Family sessions " "Family w/o consumer skill training & development FI for self-determination nursing services - RN only dietary counseling ind dietary counseling group medication training/support pt.education nonphysician pt.education group nutrition/dietary counseling enrolled programs only community transition medication injection med injection - home visit medication review brief visit for med monitoring OT evaluation OT re-eval PT evaluation PT re-eval

Local Service Code

Units of Service Reported

per hour

Assessment - Psychological Testing (# hrs. includes scoring, analysis & report) Behavior Management Clubhouse/PSR Programs Community Living Supports Community Living Supports unlicensed/temporary

encounter 15 minute 15 minute day item

Enhanced Medical / Pharmacy Family PsychoEducation / Family Joining sessions Family PsychoEducation / Multi Family Group Family Support & Training Fiscal Intermediary Health Services - RN Services

encounter encounter encounter per month 15 minute 15 minute 30 minute 15 minute encounter encounter encounter 15 minute month encounter encounter encounter encounter

Health Services

Health Services (encounter) Home Based Services Housing Assistance Medication Administration Medication Review Occupational & Physical Therapy OT Evaluation OT/PT - PT Evaluation

certified OT or PT only (see code descriptions)

15 minute

OT/PT - Services OT/PT - Services (encounter) Peer Directed - Drop In Center Peer Directed - Peer Specialist services

Personal Care in licensed setting Respite Respite (day) Skill Building Assistance

certified OT or PT only (see code descriptions) drop-in center delivered by peers personal care - Low personal care - Med personal care - High respite care out of home respite care skill training & development speech/lang. assessment assmt of swallowing function assessment of aphasia individual speech therapy group speech therapy tx of swallowing disorder supported employment case management see code descriptions

encounter encounter 15 minute per diem 15 minute day 15 minute encounter

Speech/Language - Evaluation

encounter 15 minute 15 minute encounter

Speech/Language - Therapy services Supported Employment Services Targeted Case management Therapy - individual

Page 5 of 10

MI Benefit Plan Levels I-IV Draft 3 Revision for FY 1-06 as of 3-13-06

HCPCS Code Therapy - family Therapy - group Treatment Planning Wraparound Services 90846 90847 90853 90857 H0032 H2021

Coding Description family tx w/ consumer fam tx w/o consumer group therapy interactive group tx tx planning - discipline, non Dr. Specialized Wraparound Facilitation

Local Service Code

Units of Service Reported encounter encounter encounter 15 minute

Level III: Residential Treatment Services Population: SMI/SED

MH IIIA: Therapeutic Foster Care (SED)

96110 96111 H0002 H0031 T1001 90801 90802 90887 96101 96102 96103 96116 96118 96119 96120 H2000 H2015 H2016 H2016TF H2016TG E1399 S5199 T1999 T2039 90849 90849HS G0177 G0177HS S5111 T2025 97803 97804 H0034 S9445 S9446 S9470 T1002 H0036 90772 99506 G0351 90862 M0064 97003 97004 97001 97002 97110 97112 97113 97116 97124 97140 97530 97532 97533 97535 97537 97542 Developmental screening Developmental Testing Brief Assmt/SA screening Clinical/Behavioral/Vocational nursing assessment psychiatric evaluation psychiatric eval interactive interpretive interview psychological testing (incl) psych tests by technician computerized test (event) neuropsych status exam neuropsych test battery neuropsych test technician computer neuropsych(event) BMC review (meeting) CLS (see provider manual) CLS in residential setting-Low CLS in residential setting-Med CLS in residential setting-High durable medical equipment assistive technology misc. therapeutic items wheelchair adaptations EBP only - Joining sessions " " session w/o consumer EBP only - Family sessions " "Family w/o consumer home care training FI for self-determination dietary counseling ind dietary counseling group medication training/support pt.education nonphysician pt.education group nutrition/dietary counseling nursing services - RN only enrolled programs only medication injection med injection - home visit medication review brief visit for med monitoring OT evaluation OT re-eval PT evaluation PT re-eval encounter encounter encounter

Assessment - Clinical Assessment - Health

Assessment - Psychiatric

per hour

Assessment - Psychological Testing (# hrs. includes scoring, analysis & report) Behavior Management Review Community Living Supports

encounter 15 minute per day

Community Living Supports in licensed setting

item

Enhanced Medical / Pharmacy Family PsychoEducation / Family Joining sessions Family PsychoEducation / Multi Family Group Family Support & Training Fiscal Intermediary

encounter encounter encounter per month 15 minute 30 minute 15 minute encounter encounter encounter 15 minute 15 minute encounter encounter encounter encounter

Health Services

Health Services (encounter) Health Services - RN Services Home Based Services

Medication Administration Medication Review Occupational & Physical Therapy OT Evaluation OT/PT - PT Evaluation

certified OT or PT only (see code descriptions)

15 minute

OT/PT - Services

Page 6 of 10

MI Benefit Plan Levels I-IV Draft 3 Revision for FY 1-06 as of 3-13-06

HCPCS Code OT/PT - Services (encounter) 97150 S8990 T1020 T1020TF T1020TG H0045 H2014 92506 92610 96105 92507 92508 92526 T1016 T1017 90804-90829 90846 90847 90853 90857 H0032 H2021

Coding Description certified OT or PT only (see code descriptions) personal care - Low personal care - Med personal care - High out of home respite care skill training & development speech/lang. assessment assmt of swallowing function assessment of aphasia individual speech therapy group speech therapy tx of swallowing disorder supports coordination case management see code descriptions family tx w/ consumer fam tx w/o consumer group therapy interactive group tx tx planning - discipline, non Dr. Specialized Wraparound Facilitation

Local Service Code

Units of Service Reported encounter per day day 15 minute encounter

Personal Care in licensed setting Respite (day) Skill Building Assistance

Speech/Language - Evaluation

encounter 15 minute 15 minute encounter encounter encounter encounter 15 minute

Speech/Language - Therapy services Supports Coordination Targeted Case Management Therapy - individual Therapy - family Therapy - group Treatment Planning Wraparound Services

LEVEL IIIB: Specialized Residential Contract (SMI & SED)

96110 96111 H0002 H0031 T1001 90801 90802 90887 96101 96102 96103 96116 96118 96119 96120 H2000 H2015 H2016 H2016TF H2016TG E1399 S5199 T1999 T2039 90849 90849HS G0177 G0177HS S5111 T2025 97803 97804 H0034 S9445 S9446 S9470 T1002 H0036 T2038 90772 99506 90862 M0064 Developmental screening Developmental Testing Brief Assmt/SA screening Clinical/Behavioral/Vocational nursing assessment psychiatric evaluation psychiatric eval interactive interpretive interview psychological testing (incl) psych tests by technician computerized test (event) neuropsych status exam neuropsych test battery neuropsych test technician computer neuropsych(event) BMC review (meeting) CLS (see provider manual) CLS in residential setting-Low CLS in residential setting-Med CLS in residential setting-High durable medical equipment assistive technology misc. therapeutic items wheelchair adaptations EBP only - Joining sessions " " session w/o consumer EBP only - Family sessions " "Family w/o consumer home care training FI for self-determination dietary counseling ind dietary counseling group medication training/support pt.education nonphysician pt.education group nutrition/dietary counseling nursing services - RN only enrolled programs only community transition medication injection med injection - home visit medication review brief visit for med monitoring

encounter encounter encounter

Assessment - Clinical Assessment - Health

Assessment - Psychiatric

per hour

Assessment - Psychological Testing (# hrs. includes scoring, analysis & report) Behavior Management Review Community Living Supports

encounter 15 minute per day

Community Living Supports in licensed setting

item

Enhanced Medical / Pharmacy Family PsychoEducation / Family Joining sessions Family PsychoEducation / Multi Family Group Family Support & Training Fiscal Intermediary

encounter encounter encounter per month 15 minute 30 minute 15 minute encounter encounter encounter 15 minute 15 minute month encounter encounter

Health Services

Health Services (encounter) Health Services - RN Services Home Based Services Housing Assistance Medication Administration Medication Review

Page 7 of 10

MI Benefit Plan Levels I-IV Draft 3 Revision for FY 1-06 as of 3-13-06

HCPCS Code Occupational & Physical Therapy OT Evaluation OT/PT - PT Evaluation 97003 97004 97001 97002 97110 97112 97113 97116 97124 97140 97530 97532 97533 97535 97537 97542 97150 S8990 H0023 H0038 T1020 T1020TF T1020TG H0045 H2014 92506 92610 96105 92507 92508 92526 H2023 T1016 T1017 90804-90829 90846 90847 90853 90857 H0032 H2021

Coding Description OT evaluation OT re-eval PT evaluation PT re-eval

Local Service Code

Units of Service Reported encounter encounter

certified OT or PT only (see code descriptions)

15 minute

OT/PT - Services OT/PT - Services (encounter) Peer Directed - Drop In Center Peer Directed - Peer Specialist services

Personal Care in licensed setting Respite (day) Skill Building Assistance

Speech/Language - Evaluation

Speech/Language - Therapy services Supported/Integrated Employment Supports Coordination Targeted Case Management Therapy - individual Therapy - family Therapy - group Treatment Planning Wraparound Services

certified OT or PT only (see code descriptions) drop-in center delivered by peers personal care - Low personal care - Med personal care - High out of home respite care skill training & development speech/lang. assessment assmt of swallowing function assessment of aphasia individual speech therapy group speech therapy tx of swallowing disorder supported employment supports coordination case management see code descriptions family tx w/ consumer fam tx w/o consumer group therapy interactive group tx tx planning - discipline, non Dr. Specialized Wraparound Facilitation

encounter encounter 15 minute per day day 15 minute encounter

encounter 15 minute 15 minute 15 minute encounter encounter encounter encounter 15 minute

LEVEL IIIC: Treatment Group Home

96110 96111 H0002 H0031 T1001 90801 90802 90887 96101 96102 96103 96116 96118 96119 96120 H2000 H2015 H2016 H2016TF H2016TG E1399 S5199 T1999 T2039 Developmental screening Developmental Testing Brief Assmt/SA screening Clinical/Behavioral/Vocational nursing assessment psychiatric evaluation psychiatric eval interactive interpretive interview psychological testing (incl) psych tests by technician computerized test (event) neuropsych status exam neuropsych test battery neuropsych test technician computer neuropsych(event) BMC meeting CLS (see provider manual CLS in residential setting-Low CLS in residential setting-Med CLS in residential setting-High durable medical equipment assistive technology misc. therapeutic items wheelchair adaptations

encounter encounter encounter

Assessment - Clinical Assessment - Health

Assessment - Psychiatric

per hour

Assessment - Psychological Testing (# hrs. includes scoring, analysis & report) Behavior Management Review Community Living Supports

encounter 15 minute per day

Community Living Supports in licensed setting

item

Enhanced Medical / Pharmacy

Page 8 of 10

MI Benefit Plan Levels I-IV Draft 3 Revision for FY 1-06 as of 3-13-06

HCPCS Code Family PsychoEducation / Family Joining sessions Family PsychoEducation / Multi Family Group Family Support & Training Fiscal Intermediary 90849 90849HS G0177 G0177HS S5111 T2025 97803 97804 H0034 S9445 S9446 S9470 T1002 H0036 90772 99506 90862 M0064 97003 97004 97001 97002 97110 97112 97113 97116 97124 97140 97530 97532 97533 97535 97537 97542 97150 S8990 H0023 H0038 T1020 T1020TF T1020TG H2014 92506 92610 96105 92507 92508 92526 H2023 T1016 T1017 90804-90829 90846 90847 90853 90857 H0032 H2021

Coding Description EBP only - Joining sessions " " session w/o consumer EBP only - Family sessions " "Family w/o consumer home care training FI for self-determination dietary counseling ind dietary counseling group medication training/support pt.education nonphysician pt.education group nutrition/dietary counseling nursing services - RN only enrolled programs only medication injection med injection - home visit medication review brief visit for med monitoring OT evaluation OT re-eval PT evaluation PT re-eval

Local Service Code

Units of Service Reported encounter encounter encounter per month 15 minute 30 minute 15 minute encounter encounter encounter 15 minute 15 minute encounter encounter encounter encounter

Health Services

Health Services (encounter) Health Services - RN Services Home Based Services Medication Administration Medication Review Occupational & Physical Therapy OT Evaluation OT/PT - PT Evaluation

certified OT or PT only (see code descriptions)

15 minute

OT/PT - Services OT/PT - Services (encounter) Peer Directed - Drop In Center Peer Directed - Peer Specialist services

Personal Care in licensed setting Skill Building Assistance

Speech/Language - Evaluation

Speech/Language - Therapy services Supported/Integrated Employment Supports Coordination Targeted Case Management Therapy - individual Therapy - family Therapy - group Treatment Planning Wraparound Services

certified OT or PT only (see code descriptions) drop-in center delivered by peers personal care - Low personal care - Med personal care - High skill training & development speech/lang. assessment assmt of swallowing function assessment of aphasia individual speech therapy group speech therapy tx of swallowing disorder supported employment supports coordination case maangement see code descriptions family tx w/ consumer fam tx w/o consumer group therapy interactive group tx tx planning - discipline, non Dr. Specialized Wraparound Facilitation

encounter encounter 15 minute per day 15 minute encounter

encounter 15 minute 15 minute 15 minute encounter encounter encounter encounter 15 minute

LEVEL IIID: Crisis Stabilization/Crisis Residential Services where offered (Copper and HBH)

Assessment - Clinical Assessment - Health Assessments - Psychiatric Crisis residential Services H0002 H0031 T1001 90801 H0018 Brief Assmt/ SA screening Clinical Assessment nursing assessment psychiatric evaluation certified programs only encounter encounter encounter day

Page 9 of 10

MI Benefit Plan Levels I-IV Draft 3 Revision for FY 1-06 as of 3-13-06

HCPCS Code E1399 S5199 T1999 T2039 H0034 T1002 S9484 90772 90862 M0064 Revenue Codes 0100 0124

Coding Description durable medical equipment assistive technology misc. therapeutic items wheelchair adaptations medication training/support nursing services - RN only certified programs only medication injection medication review brief visit for med monitoring

Local Service Code

Units of Service Reported

item

Enhanced Medical / Pharmacy Health Services - RN Services Intensive crisis stabilization Medication Administration Medication Review

15 minute hour encounter encounter

LEVEL IV INPATIENT PSYCHIATRIC CARE

Acute Inpatient Care (Community )

inpatient psychiatric hospital

day

Page 10 of 10

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