FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6)...

24
Fund Codes FMCD FPAC FDUL (2) SDUL (2) FPRT (6) FTBI (6) UINS MCOU Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA 2013 CPT/Rev Code Modifier 1 Modifier 2 2013 Add on Code Modifier 1 Modifier 2 Service Description Claim Type Place of Service Medicaid Primary Adult Care -PAC Federally FundedMedicare/Medicaid State Funded Medicare/Medicaid PRTF TBI Uninsured Courtesy Reviews Medicaid Priamry Adult Care -PAC Medicare/Medicaid PRTF TBI Uninsured Courtesy Reviews Send Auth Request to: UB04 HCFA 1500 Inpatient Services 0113, 0114, 0118, 0123, 0124, 0133, 0134, 0143, 0153, 0154, 0169, 0203, 0204 HSCRC Yes No Yes Yes No No Yes*** Yes Yes N/C No N/C N/C N/C Yes ValueOptions X Institutes for Mental Disease (IMDs) Yes* No No No No No Yes*** Yes Yes N/C No N/C N/C N/C Yes ValueOptions X Residential Treatment Residential Treatment Center Yes No Yes Yes No No No Yes Yes N/C No N/C N/C N/C Yes ValueOptions X Regional Institute for Children and Adolescents (RICA) Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X Partial Hospitalization 0912 Partial Hospitalization - Full Day Yes No Yes Yes No No No Yes Yes N/C No N/C N/C N/C Yes ValueOptions X S0201 Partial Program - Non-Hospital Based Yes No Yes Yes No No No Yes Yes N/C No N/C N/C N/C Yes ValueOptions X S0201 52 Partial Program - Non-Hospital Based Yes No Yes Yes No No No Yes Yes N/C No N/C N/C N/C Yes ValueOptions X Intensive Outpatient S9480 Intensive Outpatient Psych Services, Per Diem (Clinic Model) 11, 22, 53, 99 Yes Yes Yes Yes No No No Yes Yes Yes Yes N/C N/C N/C Yes ValueOptions X Non HSCRC space only 0905 Intensive Outpatient Services - Psychiatric Yes No Yes Yes No No No Yes Yes N/C Yes N/C N/C N/C Yes ValueOptions X 0949 IOP - Partial Hospital Model or Partial Program - Non Regulated Space 21, 22, 52, 53, 99 Yes No Yes Yes No No No Yes Yes N/C Yes N/C N/C N/C Yes ValueOptions X Other Professional Services for IOP, PHP, CRS 90791 90792 HE HE Psychiatric Diagnostic Interview Psychiatric Diagnostic Interview--medical services 11, 12, 21, 22, 23 Yes No Yes Yes No No Yes No No N/C No N/C N/C No N/C Not Required X 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 HE HE HE HE HE HE HE HE HE HE Evaluation and Management 11, 12, 21, 22 Yes No Yes Yes No No Yes No No N/C No N/C N/C No N/C Not Required X MARYLAND SERVICE MATRIX 02/07/13 21, 51, 56, 99 21, 51, 56, 57 11, 21, 22, 52, 53, 99 0100 Public Mental Health Coverage Claim Form Pre-Authorization Required

Transcript of FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6)...

Page 1: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

Inpatient Services

0113, 0114, 0118,

0123, 0124, 0133,

0134, 0143, 0153,

0154, 0169, 0203,

0204

HSCRC Yes No Yes Yes No No Yes*** Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

Institutes for Mental Disease (IMDs) Yes* No No No No No Yes*** Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

Residential Treatment

Residential Treatment Center Yes No Yes Yes No No No Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

Regional Institute for Children and

Adolescents (RICA)

Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

Partial Hospitalization

0912 Partial Hospitalization - Full Day Yes No Yes Yes No No No Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

S0201 Partial Program - Non-Hospital Based Yes No Yes Yes No No No Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

S0201 52 Partial Program - Non-Hospital Based Yes No Yes Yes No No No Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

Intensive Outpatient

S9480 Intensive Outpatient Psych Services, Per Diem

(Clinic Model)

11, 22, 53, 99 Yes Yes Yes Yes No No No Yes Yes Yes Yes N/C N/C N/C Yes ValueOptions X Non HSCRC

space only0905 Intensive Outpatient Services - Psychiatric Yes No Yes Yes No No No Yes Yes N/C Yes N/C N/C N/C Yes ValueOptions X

0949 IOP - Partial Hospital Model or Partial Program

- Non Regulated Space

21, 22, 52, 53,

99

Yes No Yes Yes No No No Yes Yes N/C Yes N/C N/C N/C Yes ValueOptions X

Other Professional Services for IOP, PHP, CRS

90791

90792

HE

HE

Psychiatric Diagnostic Interview

Psychiatric Diagnostic Interview--medical

services

11, 12, 21, 22,

23

Yes No Yes Yes No No Yes No No N/C No N/C N/C No N/C Not Required X

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

HE

HE

HE

HE

HE

HE

HE

HE

HE

HE

Evaluation and Management 11, 12, 21, 22 Yes No Yes Yes No No Yes No No N/C No N/C N/C No N/C Not Required X

MARYLAND SERVICE MATRIX 02/07/13

21, 51, 56, 99

21, 51, 56, 57

11, 21, 22, 52,

53, 99

0100

Public Mental Health Coverage

Claim

FormPre-Authorization Required

Page 2: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

90832 HE Individual Therapy (30 Minutes) MD Only Yes No Yes Yes No No Yes No No N/C No N/C N/C No N/C Not Required X

90834 HE Individual Therapy (45 Minutes) MD Only Yes No Yes Yes No No Yes No No N/C No N/C N/C No N/C Not Required X

Inpatient Professional Billing Codes

99221 Initial Hospital Care - Attending Physician Only 21, 51, 52, 61 Yes No Yes Yes No No Yes*** No No N/C No N/C N/C N/C N/A Not required X

99222 Initial Hospital Care - Attending Physician Only Yes No Yes Yes No No Yes*** No No N/C No N/C N/C N/C N/A Not required X

99223 Initial Hospital Care - Attending Physician Only Yes No Yes Yes No No Yes*** No No N/C No N/C N/C N/C N/A Not required X

99231 Subsequent Hospital Care - Attending

Physician Only

Yes No Yes Yes No No Yes*** No No N/C No N/C N/C N/C N/A Not required X

99232 Subsequent Hospital Care - Attending

Physician Only

Yes No Yes Yes No No Yes*** No No N/C No N/C N/C N/C N/A Not required X

99233 Subsequent Hospital Care - Attending

Physician Only

Yes No Yes Yes No No Yes*** No No N/C No N/C N/C N/C N/A Not required X

99238 Discharge Day Management - MD Only Yes No Yes Yes No No Yes*** No No N/C No N/C N/C N/C N/A Not required X

99239 Discharge Day Management - MD Only 21, 61 Yes No Yes Yes No No Yes*** No No N/C No N/C N/C N/C N/A Not required X

99251 Initial Inpatient Consultation - Physician Only Yes No Yes Yes No No Yes*** No No N/C No N/C N/C N/C N/A Not required X

99252 Initial Inpatient Consultation - Physician Only Yes No Yes Yes No No Yes*** No No N/C No N/C N/C N/C N/A Not required X

99253 Initial Inpatient Consultation - Physician Only Yes No Yes Yes No No Yes*** No No N/C No N/C N/C N/C N/A Not required X

99254 Initial Inpatient Consultation - Physician Only Yes No Yes Yes No No Yes*** No No N/C No N/C N/C N/C N/A Not required X

99255 Initial Inpatient Consultation - Physician Only Yes No Yes Yes No No Yes*** No No N/C No N/C N/C N/C N/A Not required X

Telehealth Originating Site

Q3014 Teleheath Origination Site 11, 12, 21, 22,

23, 24, 53

Yes Yes Yes Yes No No Yes No No N/C No N/C N/C Yes N/C Not required X Non HSCRC

space onlyOutpatient Therapy Services

90791

90792

Psychiatric Diagnostic Interview

Psychiatric Diagnostic Interview--medical

services

11, 12, 13, 21,

22, 32, 33, 34,

53, 62, 71, 72

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X Non HSCRC

space only

90791

90792

GT

GT

Psychiatric Diagnostic Interview- Telehealth

Psychiatric Daignostic Interview medical

services-telehealth

Yes Yes Yes Yes No No Yes No Yes N/C No N/C N/C Yes N/C ValueOptions X

21, 31, 32, 51,

52

Page 3: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

90791

90792

22

22

Psychiatric Diagnostic Interview

Psychiatric Diagnostic Interview--medical

services

11, 12, 21, 22,

23, 53

No Yes Yes Yes No No No No N/C Yes No N/C N/C N/C N/C ValueOptions X

90832 Individual Psychotherapy (30 Minutes) 11, 12, 21, 22,

23, 24, 53

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90832 GT Individual Psychotherapy (30 Minutes) -

Telehealth

Yes Yes Yes Yes No No Yes No Yes N/C No N/C N/C Yes N/C ValueOptions X

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

90833

90836

90838

Med Eval/Mgmt with Individual Psychotherapy

(Add on codes add 30 or 45 or 60 Minutes)

(90838 allowed for OMHCs only)

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

GT

GT

GT

GT

GT

GT

GT

GT

GT

GT

90833

90836

90838

GT

GT

GT

Med Eval/Mgmt with Individual Psychotherapy

(Add on codes add 30 or 45 or 60 Minutes) -

telehealth

(90838 allowed for OMHCs only)

Yes Yes Yes Yes No No Yes No Yes N/C No N/C N/C Yes N/C ValueOptions X

90834 Individual Psychotherapy (45 Minutes) Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90834 GT Individual Psychotherapy (45 Minutes) -

Telehealth

Yes Yes Yes Yes No No Yes No Yes N/C No N/C N/C Yes N/C ValueOptions X

90846 Family Psychotherapy without Patient Present 11, 12, 13, 21,

22, 23, 53

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

Rev Codes Outpatient Services 03, 11, 12, 13,

22, 32, 33, 34,

53, 62, 71, 72,

99

Yes No Yes Yes No No No Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

Page 4: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

0914,

0915, 0916,

0917,

0919, 0510,

0513

90847 Family Psychotherapy with Patient Present 11, 12, 13, 21,

22, 23, 53

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X Non HSCRC

space only90847 52 Family Psychotherapy with Patient Present -

Abbreviated services

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90849 Multiple Family Group Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90849 52 Multiple Family Group - Abbreviated services Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90853 Group Psychotherapy Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90853 21 Group Psychotherapy - Extended Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90875 Individual psychotherapy w/ Biofeedback Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90876 Individual Psychotherapy w/ biofeedback Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

T1015 FQHC clinic visit/encounter (all inclusive) 11 Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

T1015 GT FQHC clinic visit/encounter (all inclusive) -

Telehealth

Yes Yes Yes Yes No No Yes No Yes N/C Yes N/C N/C Yes N/C ValueOptions X

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

HH

HH

HH

HH

HH

HH

HH

HH

HH

HH

Evaluation and Management - Nursing Home 31, 32 Yes Yes Yes Yes No No Yes* No Yes Yes No N/C N/C Yes Yes ValueOptions X

Outpatient Therapy Services (for OMS Bundle)

90791

90792

Psychiatric Diagnostic Interview

Psychiatric Diagnostic Interview--medical

services

11, 12, 13, 21,

22, 32, 33, 34,

53, 62, 71, 72

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X Non HSCRC

space only

90791

90792

GT

GT

Psychiatric Diagnostic Interview- Telehealth

Pscyaitric Diagnostic Interview-medical

services-telehelath

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X Non HSCRC

space only

Page 5: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

90791

90792

22

22

Psychiatric Diagnostic Interview

Psychiatric Diagnostic Interview--medical

services

11, 12, 21, 22,

23, 53

No Yes Yes Yes No No No No N/C Yes No N/C N/C N/C N/C ValueOptions X

90832 Individual Psychotherapy (30 Minutes) 11, 12, 21, 22,

23, 24, 53

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90832 GT Individual Psychotherapy (30 Minutes) -

Telehealth

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

90833

90836

90838

Med Eval/Mgmt with Individual Psychotherapy

(Add on codes add 30 or 45 or 60 Minutes)

(90838 allowed for OMHCs only)

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

GT

GT

GT

GT

GT

GT

GT

GT

GT

GT

90833

90836

90838

GT

GT

GT

Med Eval/Mgmt with Individual Psychotherapy

(Add on codes add 30 or 45 or 60 Minutes) -

telehealth

(90838 allowed for OMHCs only)

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90834 Individual Psychotherapy (45 Minutes) Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90834 GT Individual Psychotherapy (45 Minutes) -

Telehealth

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90846 Family Psychotherapy without Patient Present 11, 12, 13, 21,

22, 23, 53

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90837 Psychotherapy, 60 Minutes with Patient and/or

family member (OMHC Only)

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X11, 12, 13, 21,

22, 23, 53

11, 12, 21, 22,

23, 24, 53

Page 6: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

90837 GT Psychotherapy, 60 Minutes with Patient and/or

family member - Telehealth (OMHC Only)

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90847 Family Psychotherapy with Patient Present Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90847 52 Family Psychotherapy with Patient Present -

abbreviated services

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90849 Multiple Family Group Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90849 52 Multiple Family Group - Abbreviated services Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90853 Group Psychotherapy Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90875 Individual psychotherapy w/ Biofeedback Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

90876 Individual Psychotherapy w/ biofeedback Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

HH

HH

HH

HH

HH

HH

HH

HH

HH

HH

Evaluation and Management - Nursing Home 31, 32 Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

Rev Codes Outpatient Services 03, 11, 12, 13,

22, 32, 33, 34,

53, 62, 71, 72,

99

Yes No Yes Yes No No No Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

0914,

0915, 0916, 0917

0918, No N/C

0919, 0510,

0513

90889 Discharge 11, 12, 13, 21,

22, 23, 53

Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

Rev Code 0929 Discharge 03, 11, 12, 13,

22, 32, 33, 34,

53, 62, 71, 72

Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

11, 12, 13, 21,

22, 23, 53

Page 7: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

90846 Family Psychotherapy w/o the identified

patient present

11, 12, 13, 21,

22, 23, 53

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X Non HSCRC

space onlyT1015 FQHC clinic visit/encounter (all inclusive) Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

T1015 GT FQHC clinic visit/encounter (all inclusive) -

Telehealth

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

BCARS

90791

90792

HA

HA

Psychiatric Diagnostic Interview

Psychiatric Diagnostic Interview--medical

services

11, 12, 13, 21,

22, 32, 33, 34,

53, 62, 71, 72

Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes No ValueOptions X

90832 HA Individual Psychotherapy (30 Minutes) 11, 12, 21, 22,

23, 24, 53

Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

HA

HA

HA

HA

HA

HA

HA

HA

HA

HA

90833

90836

90838

HA

HA

HA

Med Eval/Mgmt with Individual Psychotherapy

(Add on codes add 30, 45 or 60 Minutes)

(90838 allowed for OMHCs only)

Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

90834 HA Individual Psychotherapy (45 Minutes) Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

90837 HA Individual Psychotherapy (60 Minutes) OMHC

Only

Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions

90839 HA 90840 HA Crisis Psychotherapy 60 Minutes (Add on Code

add 30 Minutes)

Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions

90846 HA Family Psychotherapy without Patient Present 11, 12, 13, 21,

22, 23, 24, 53

Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

90847 HA Family Psychotherapy with Patient Present Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

90847 HA 52 Family Psychotherapy with Patient Present Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

90849 HA Multiple Family Group Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

90853 HA Group Psychotherapy Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

90875 HA Individual psychotherapy w/ Biofeedback Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

90876 HA Individual Psychotherapy w/ biofeedback Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

11

Page 8: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

H0002 HA Behavioral Health Screening PRP Assessment 11, 15 Yes No Yes Yes No No Yes* Yes No N/C No N/C N/C No N/A Not Required X

H0032 HA Mental Health Service Plan Development by

Non Physician BCARS

11, 12, 13, 22,

32, 33, 34, 53,

62, 71, 72

Yes No Yes Yes No No Yes* No No N/C No N/C N/C No N/A Not Required X

H0045 HA Respite Care Services - Not in home (per

diem)

11, 52 Yes* No Yes Yes No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes ValueOptions X

T1005 HA Respite Care Services - In home 15 Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

S9485 (1) HA Residential Crisis Service Yes No Yes Yes No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes ValueOptions X

S5145 (1) HA Treatment Foster Care Yes No Yes Yes No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes ValueOptions X

96152 HA TBS BCARS 12 Yes No Yes Yes No No No Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

Mental Health Service Plan

H0032 Mental Health Service Plan Development by

Non Physician

11, 12, 13, 22,

32, 33, 34, 53,

62, 71, 72

Yes Yes Yes Yes No No Yes* No No No No N/C N/C No N/A Not Required X Non HSCRC

space only

0982 Interdisciplinary team tx planning w/ patient

present

11, 12, 13, 22,

32, 33, 34, 53,

62, 71, 72

Yes Yes Yes Yes No No Yes* No No No No N/C N/C No N/A Not Required X Non HSCRC

space only

Outpatient Psychotherapy Services-Consults

90839 90840 Crisis Psychotherapy 60 Minutes (Add on Code

add 30 Minutes)

11, 12, 21, 22,

23, 24, 53

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

99241 Office Consult - MDs only 11, 22 Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

99242 Office Consult - MDs only Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

99243 Office Consult - MDs only Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

99244 Office Consult - MDs only Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

99245 Office Consult - MDs only Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

99354 Prolonged Service Requiring Face to Face

Patient Contact beyond the usual service

11, 12, 13, 22,

32, 33, 34, 53,

62, 71, 72

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

99355 Each Additional 30 minutes of a prolonged

Psych Service

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

H2027 Family Psycho-education (Evidence Based

Practice)  With Consumer Present

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

H1011 Family Psycho-education - Without Consumer

Present

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

11, 12, 15, 21,

51, 52, 56, 62,

99

Page 9: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

Therapeutic Nursery Services

H0046 Therapeutic Nursery Services 11, 12, 13, 22,

32, 33, 34, 53,

62, 71, 72

Yes No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

Case Management Services

H0031 Case Management Assessment 11, 12, 15, 23,

49, 52

Yes Yes % Yes Yes No No Yes Yes No No No N/C N/C No N/A Not Required X

T1016 Case Management - Daily 11, 12, 15, 22,

23, 49, 52, 53

Yes Yes % Yes Yes No No Yes Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

T1016 HW Transitional Case Management 11, 12, 15, 21,

22, 23, 49, 51,

52, 53, 56, 99

Yes Yes % Yes Yes No No Yes Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

TBS - Use DDA Dx and MH

96150 Initial Assessment Yes No Yes Yes No No No Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

96151 Reassessment Yes No Yes Yes No No No Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

96152 TBS Yes No Yes Yes No No No Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

Occupational Therapy Services Inpatient

97003 Occupational Therapy Evaluation Yes No Yes Yes No No Yes* No No N/C No N/C N/C No No Not Required X

97530 Therapeutic Activities, one on one patient

contact, each 15 minutes

Yes No Yes Yes No No Yes* No No N/C No N/C N/C No No Not Required X

97535 Self Care/Home Management Training, each

15 min.

Yes No Yes Yes No No Yes* No No N/C No N/C N/C No No Not Required X

97537 Community/Work Reintegration Training, each

15 min.

Yes No Yes Yes No No Yes* No No N/C No N/C N/C No No Not Required X

97532 Development of Cognitive Skills, each 15

minutes

Yes No Yes Yes No No Yes* No No N/C No N/C N/C No No Not Required X

97150 Therapeutic Procedure, group (2 or more

individuals)

Yes No Yes Yes No No Yes* No No N/C No N/C N/C No No Not Required X

97004 Reevaluation (per 15 minutes) Yes No Yes Yes No No Yes* No No N/C No N/C N/C No No Not Required X

Occupational Therapy Services Outpatient

97003 Occupational Therapy Evaluation Yes Yes Yes Yes No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

97530 Therapeutic Activities, one on one patient

contact, each 15 minutes

Yes Yes Yes Yes No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X Non HSCRC

space only97535 Self Care/Home Management Training, each

15 min.

Yes Yes Yes Yes No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

12

11, 15

21, 52

Page 10: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

97537 Community/Work Reintegration Training, each

15 min.

Yes Yes Yes Yes No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

11, 15

Page 11: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

97532 Development of Cognitive Skills, each 15

minutes

Yes Yes Yes Yes No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

97150 Therapeutic Procedure, group (2 or more

individuals)

Yes Yes Yes Yes No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

97004 Reevaluation (per 15 minutes) Yes Yes Yes Yes No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

Rehabilitation Services - All Codes Must be Specifically Authorized Using the Appropriate Modifier (5) (6)

H0002 Behavioral Health Screening PRP Assessment 11, 15, 52 Yes Yes Yes Yes* No No Yes* Yes No No No N/C N/C No No Not Required X

H2018 U2 Any Combination of On-Site or Off-Site

services for Community PRP client, not living

independently

03, 02 49 Yes Yes Yes Yes* No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

H2018 U2 On-Site services for community PRP Client,

not living independently (minimum 2

encounters)

02 52 Yes Yes Yes Yes* No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

H2018 U2 Off-Site services for community PRP Client,

not living independently (minimum 2

encounters)

02 15 Yes Yes Yes Yes* No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

H2018 U3 Any Combination of On or Off-Site services for

Supported Living Client, living independently

(Minimum 6 encounters)

06,05,

03,02

49 Yes Yes Yes Yes* No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

H2018 U3 Any Combination of On-Site services for

Supported Living Client, living independently

(Minimum 3 encounters)

03,02 52 Yes Yes Yes Yes* No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

H2018 U3 Any Combination of Off-Site services for

Supported Living Client, living independently

(Minimum 5 encounters)

05,02 15 Yes Yes Yes Yes* No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes ValueOptions X

H2018 U5 On-Site PRP services to Intensive Residential

Clients (Minimum 4 Encounters)

04,03,

02

52 Yes Yes Yes Yes* No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes CSA X

H2018 U4 On-Site PRP services to General Residential

Clients (Minimum 4 Encounters)

04,03,

02

52 Yes Yes Yes Yes* No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes CSA X

H2018 U4 Off-Site PRP Services to RRP General Clients

(Minimum 13 Encounters)

13,05,

02

15 Yes Yes Yes Yes* No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes CSA X

H2018 U5 Off-Site PRP Services to RRP Intensive Clients

(Minimum 19 Encounters)

19,13,

05,02

15 Yes Yes Yes Yes* No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes CSA X

11, 15

Page 12: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

H2018 U6 General Residential Combined (Minimum 17

Encounters)

17,13,

06,05,

04,03,

02

49 Yes Yes Yes Yes* No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes CSA X

H2018 U7 Intensive Residential Combined (Minimum 23 23,19,

17,13,

06,05,

04,03,

02

49 Yes Yes Yes Yes* No No Yes* Yes Yes Yes Yes N/C N/C Yes Yes CSA X

T1023 Transitional PRP. Any Combination of on/off

sitePRP services to adult or TAY consumer

transitioning to an RRP or IP Facility.

49 @ Yes* No Yes* Yes* No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes CSA X

0911 Psychiatric Rehab - Johns Hopkins PRP 21, 22, 51, 56,

99

Yes No Yes Yes* No No No Yes Yes N/C Yes N/C N/C N/C Yes ValueOptions X

H2016 Encounter for PRP 15, 52 Yes Yes Yes Yes* No No Yes* No No No No N/C N/C No N/C Not Required X

H2016 U8 Transitional PRP Encounter 15, 52 Yes No Yes Yes* No No Yes* No No N/C No N/C N/C No N/C Not Required X

RRP Bed

H0019 Residential Bed Hold Yes* No Yes* Yes* No No Yes* Yes No N/C No N/C N/C No No Not Required X

T2048 Residential Room and Board Yes* No Yes* Yes* No No Yes* Yes No N/C No N/C N/C No No Not Required X

Housing Services

S5150 Enhanced Support 12, 15 Yes No Yes Yes No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes CSA X

Mobile Treatment

H0040 Mobile Treatment Monthly (Non-Evidence

Based)

11, 12, 15 Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

H0040 52 Mobile Treatment (for Medicare Recipients

Monthly)

No No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

H0040 21 Mobile Treatment - ACT (Evidence Based

Practice)

Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

H0040 U9 Mobile Treatment - ACT (for Medicare) No No Yes Yes No No Yes* Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

Respite Care

H0045 Respite Care Services - Not in home (per

diem)

11, 52 Yes* No Yes Yes No No Yes Yes Yes N/C Yes N/C N/C Yes Yes ValueOptions X

T1005 Respite Care Services - In home 15 Yes No Yes Yes No No Yes Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

Residential Crisis Services

11, 12, 15, 21,

22, 49, 51, 52,

56, 62, 99

Page 13: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

S9485 (1) Residential Crisis Service Yes No Yes Yes No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes ValueOptions

**

X

S5145 (1) Treatment Foster Care Yes No Yes Yes No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes ValueOptions

**

X

T2048 Residential Room and Board No No No No No No No No N/C N/C N/C N/C N/C N/C N/C ValueOptions

**

X

Supported Employment

H2023 Supported Employment per 15 minutes

(Intensive Job Coaching)

Yes* No Yes* Yes* No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes CSA X

H2024 Supported Employment, Pre-Placement Phase Yes* No Yes* Yes* No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes CSA X

H2024 21 Supported Employment, Job Placement Phase Yes* No Yes* Yes* No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes CSA X

H2026 Extended Support Services Yes* No Yes* Yes* No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes CSA X

H2026 21 Ongoing Support (Evidence Based Practice) Yes No Yes Yes No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes CSA X

S9445 52 Clinic Coordination (Evidence Based Practice) Yes* No Yes* Yes* No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes CSA X

S9445 On or Off-Site PRP Services for an Individual

in a Supported Employment Program

(Minimum 2 Encounters)

15, 49, 52 Yes No Yes Yes No No Yes* Yes Yes N/C Yes N/C N/C Yes Yes CSA X

H2016 U1 Encounter for Supported Employment 11, 15, 52, 99 Yes* No Yes* Yes* No No Yes* No No N/C No N/C N/C No No Not Required X

Outpatient ECT

90870 ECT Single Seizure with Monitoring Yes No Yes Yes No No No Yes Yes N/C No N/C N/C Yes Yes ValueOptions X

00104 Anesthesia for ECT Yes No Yes Yes No No No Yes No (2)N/C No N/C N/C No (2)Yes ValueOptions X

0901 ECT Facility Yes No Yes Yes No No No Yes No (4)N/C No N/C N/C N/C Yes ValueOptions X

Inpatient ECT Treatment

90870 ECT Single Seizure Yes No Yes Yes No No No Yes Yes N/C No N/C N/C N/C Yes ValueOptions X

00104 Anesthesia for ECT Yes No Yes Yes No No No Yes No (4)N/C No N/C N/C N/C Yes ValueOptions X

0901 ECT Facility Yes No Yes Yes No No No Yes No (4)N/C No N/C N/C N/C Yes ValueOptions X

Psych Testing

0918 Psychological Testing 11, 21, 22, 51,

52, 53, 56, 99

Yes No Yes Yes No No No Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

96101 Psychological Testing Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

96102 Psychological Testing Yes Yes Yes Yes No No Yes* Yes Yes Yes No N/C N/C Yes Yes ValueOptions X

11, 12, 15, 99

11, 22, 53

Non HSCRC

space only

21, 51, 52, 56

11, 12, 15, 21,

51, 52, 56, 62,

99

Page 14: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

Tramatic Brain Injury - Dx Code = 310.9

W0037 Residental habilitation Level 1 {per day} No No No No No Yes Yes No N/C N/C N/C N/C Yes Yes No MHA

W0038 Residental habilitation Level 2 {per day} No No No No No Yes Yes No N/C N/C N/C N/C Yes Yes No MHA

W0039 Residental habilitation Level 3 {per day} No No No No No Yes Yes No N/C N/C N/C N/C Yes Yes No MHA

W0054 Day habiliation Level 1 {per day} No No No No No Yes Yes No N/C N/C N/C N/C Yes Yes No MHA

W0055 Day habiliation Level 2 {per day} No No No No No Yes Yes No N/C N/C N/C N/C Yes Yes No MHA

W0056 Day habilitation Level 3 {per day} No No No No No Yes Yes No N/C N/C N/C N/C Yes Yes No MHA

W0057 Supported Employment Level 1 {per day} No No No No No Yes Yes No N/C N/C N/C N/C Yes Yes No MHA

W0058 Supported Employment Level 2 {per day} No No No No No Yes Yes No N/C N/C N/C N/C Yes Yes No MHA

W0059 Supported Employment Level 3 {per day} No No No No No Yes Yes No N/C N/C N/C N/C Yes Yes No MHA

W0060 Individual Support Services {ISS} No No No No No Yes Yes No N/C N/C N/C N/C Yes Yes No MHA

BMHS Capitation

G9010 Coordinated care fee, risk adjusted

maintenance, Level 4 - Chesapeake

No No No No No No No No N/C N/C N/C N/C N/C N/C N/A Not Required X

G9010 HE Coordinated care fee, risk adjusted

maintenance, Level 4 - Chesapeake

No No No No No No No No N/C N/C N/C N/C N/C N/C N/A Not Required X

G9011 Coordinated care fee, risk adjusted

maintenance, Level 5 - Creative Alternatives

No No No No No No No No N/C N/C N/C N/C N/C N/C N/A Not Required X

G9011 HE Coordinated care fee, risk adjusted

maintenance, Level 5 - Creative Alternatives

No No No No No No No No N/C N/C N/C N/C N/C N/C N/A Not Required X

Emergency Room Facility

0450, 0451, 0452 Emergency Room 21, 23 Yes Yes~ Yes Yes No No No No No No No N/C N/C N/C N/C Not Required X

Emergency Room Physician

99281 Emergency Department Visit Yes No Yes Yes No No No No No N/C No N/C N/C N/C N/A Not Required X

99282 Emergency Department Visit Yes No Yes Yes No No No No No N/C No N/C N/C N/C N/A Not Required X

99283 Emergency Department Visit Yes No Yes Yes No No No No No N/C No N/C N/C N/C N/A Not Required X

99284 Emergency Department Visit Yes No Yes Yes No No No No No N/C No N/C N/C N/C N/A Not Required X

99285 Emergency Department Visit Yes No Yes Yes No No No No No N/C No N/C N/C N/C N/A Not Required X

90791

90792

Psychiatric Diagnostic Interview 23 Yes No Yes Yes No No No No No N/C No N/C N/C No N/A Not Required X

90791

90792

HA

HA

Psychiatric Diagnostic Interview 23 Yes No Yes Yes No No No No No N/C No N/C N/C No N/A Not Required X

22, 23

11, 12, 22, 53

11, 12, 15

11, 12, 15, 50,

53, 72

Page 15: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

99241 Office Consult - MDs only 23 Yes No Yes Yes No No No No No N/C No N/C N/C N/C N/A Not Required X

99242 Office Consult - MDs only Yes No Yes Yes No No No No No N/C No N/C N/C N/C N/A Not Required X

99243 Office Consult - MDs only Yes No Yes Yes No No No No No N/C No N/C N/C N/C N/A Not Required X

99244 Office Consult - MDs only Yes No Yes Yes No No No No No N/C No N/C N/C N/C N/A Not Required X

99245 Office Consult - MDs only Yes No Yes Yes No No No No No N/C No N/C N/C N/C N/A Not Required X

Page 16: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

PRTF Waiver

W5009 Caregiver Peer to Peer Support 11, 15, 21, 22,

52

No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5008 Youth Peer to Peer Support No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5002 Family and Youth Training Individual No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5003 Family and Youth Training Group No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5004 Crisis & Stabilization Service No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5014 Art Therapy Individual No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5015 Art Therapy Group No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5012 Dance Therapy Individual No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5013 Dance Therapy Group No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5010 Equine Assisted Therapy Individual No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5011 Equine Assisted Therapy Group No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5020 Horticultural Therapy Individual No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5021 Horticultural Therapy Group No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5016 Music Therapy Individual No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5017 Music Therapy Group No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5018 Drama Therapy Individual No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5019 Drama Therapy Group No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5000 Respite Care In Home No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

W5001 Respite Care Residential No No No No Yes No No No N/C N/C N/C Yes N/C N/C No ValueOptions

Transport

A0362 Ambulance service, BLS, emergency transport,

mileage, and disposable supplies separately

billed

No No No No No No No No N/C N/C N/C N/C N/C N/C No Not required X

A0380 BLS Mileage {Per Mile} No No No No No No No No N/C N/C N/C N/C N/C N/C No Not required X

A0080 Non-Emergency transportation; Per Mile

volunteer, with no vested or personal interest.

No No No No No No No No N/C N/C N/C N/C N/C N/C No Not required X

A0170 Non-Emergency transportation; ancillary,

parking fees, tolls other

No No No No No No No No N/C N/C N/C N/C N/C N/C No Not required X

Lab Services

36415 Collection blood by Venipuncture 11, 21, 22, 23,

53, 81

Yes Yes Yes Yes No No Yes* No No No No N/C N/C No No Not Required X

41, 42

Page 17: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

36415 HW Collection blood by Venipuncture Yes Yes Yes Yes No No Yes* No No No No N/C N/C No No Not Required X

80002-89999 Lab Services Yes Yes Yes Yes No No Yes* No No No No N/C N/C No No Not Required X

96372 Therapeutic Injection 11 Yes No Yes Yes No No Yes* No No N/C No N/C N/C No N/C Not Required X

0300; 0301; 0302;

0304; 0305; 0306;

0307; 0309; 0310;

0311; 0312; 0730

Lab & EKG Services 22 Yes Yes Yes Yes No No No No No No No No N/C N/C N/C Not Required X

0637 Self Administered Drugs 22 Yes Yes Yes Yes No No No No No No No No N/C N/C N/C Not Required X

0940 Therapeutic Injection 11, 21, 22, 23,

53, 81

Yes No Yes Yes No No No No No N/C No N/C N/C N/C N/C Not Required X

Page 18: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

Ancillary Services {Benefit Code ANS}

0221 Special Charges - Admission Charge Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C Not Required X

0250 Pharmacy - General Classification Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0251 Pharmacy - General Drugs Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0257 Pharmacy - Non Prescription Drugs Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0258 Pharmacy - IV Solutions Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0259 Pharmacy - Other Pharmacy Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0260 Equipment for and administration of Ivs Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0270 Medl/Surg Supplies and Devices General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0271 Medl/Surg Supplies Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0272 Med/Surg Supplies and Devices - Sterile Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0300 Laboratory - General Classification Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0301 Laboratory - Chemistry Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0302 Laboratory - Immunology Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0304 Non-Routine Dialysis Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0305 Laboratory - Hematology Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0306 Laboratory - Bacteriology & Microbiology Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0307 Laboratory - Urology Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0309 Laboratory - Other Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0310 Laboratory Pathology - General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0311 Laboratory Pathological - Cytology Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0312 Histology Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0320 Radiology-Diagnostic General Class Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0321 Angiocardiography Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0324 Radiology-Diagnostic Chest X-Ray Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0333 Radiation Therapy Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0335 Chemotherapy Administration - IV Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0340 Nuclear Medicine - Diagnostic Procedures Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0341 Nuclear Medicine - General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0349 Nuclear Medicine - Other Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0350 CT Scan - General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0351 CT Scan - Head Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0352 CT Scan - Body Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0360 Operating Room Services - General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0361 Operating Room Services - Minor Surgery Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0370 Anesthesia - General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0390 Blood - General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0391 Blood - Administration (transfusion) Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0402 Ultrasound Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

11, 12, 13, 22,

32, 33, 34, 52,

53, 62, 71, 72

21, 51, 56, 99

11, 12, 13, 32,

33, 34, 52, 53,

62, 71, 72

21, 51, 56, 99

Page 19: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

0404 Positron Emission Tomography (PET) Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0410 Respiratory Services - General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0412 Respiratory Services - Inhalation Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0420 Physical Therapy - General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0424 Physical Therapy - Eval/Re-Eval Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0430 Occupational Therapy - General Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0433 Occupational Therapy - Group Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0434 Occupational Therapy - Eval Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0440 Speech/Language Pathology - General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0444 Speech/Language Path - Eval/Re-Eval Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0460 Pulmonary Function - General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0480 Cardiology - General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0482 Cardiology - Stress Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0610 Diagnostic Services Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0611 MRI Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0612 MRI - Spinal Cord Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0615 MRA - Head & Neck Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0636 Drugs Requiring Detail Coding Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0637 Self Administable Drugs Same as LB2

above

Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0710 Recovery Room - General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0720 Labor Room - General Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0729 Other Labor Room Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0730 EKG/ECG Same as LB2

above

Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0731 Holter Monitor Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0740 EEG Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0761 23 Hour Crisis Stabilization Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0762 Treatment or Observation Room - Observation

Room

Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0771 Vaccine Administration Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0900 Psychiatric/Psychological Treatment-General Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0902 Milieu Therapy Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0904 BH Treatments-Act Therapy Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0906 Intensive Outpatient Svc-Chemical Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0921 Peripheral Vascular Lab Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0925 Pregnancy Test Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

Page 20: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

0942 Other Therapeutic Services - Drug Rehab Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0981 Professional Fees - ER Yes Yes Yes No No No No No No N/C No No N/C N/C N/C X

0985 Professional Fees - EKG Yes Yes Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0490 Ambulatory Surgery Care - General Yes No Yes No No No No No No N/C No No N/C N/C N/C X

0511 Chronic Pain Center Yes No Yes No No No No No No N/C No No N/C N/C N/C X

0510 Clinic - General Yes No Yes No No No No No No N/C No No N/C N/C N/C X

0513 Psychiatric Clinic Yes No Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0914 Psychiatric/Psychological Services - Indiv Yes No Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0915 Psychiatric/Psychological Services - Group Yes No Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0916 Psychiatric/Psychological Services - Family Yes No Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0917 Biofeedback Yes No Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0918 Psychiatric/Psychological Services No No Yes Yes*** No No Yes*** No N/C N/C No No N/C N/C N/C X

0919 Psychiatric/Psychological Services - Other Yes No Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0929 Other Diagnstic Services Yes No Yes Yes*** No No Yes*** No No N/C No No N/C N/C N/C X

0949 Other Therapeutic Services 11, 12, 13, 32,

33, 34, 62, 71,

99

Yes No Yes No No No No No No N/C No No N/C N/C N/C X

0901 ECT Facility 12, 13, 32, 33,

34, 62, 71, 99

Yes No Yes No No No No No No N/C No No N/C N/C N/C X

NOTE: PRP Payment levels for case rates are affected by the HCPCS code level used, modifier, place of service code and billed

charges. There must be an exact match between the authorization and the claim. Code H2016 is an encounter data code only and

should be billed for zero dollars and must pay 0 on an EOB to be considered valid for meeting minimums for H2018, the billable code.

21, 51, 56, 99

Page 21: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

Place of Service

11

15

21

22

23

52

49

Modifiers

52

21

U1

U2

U3

U4

U5

U6

U7

Page 22: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

^ Covered for Outpatient only.

# Benefit for Uninsured Consumers Only

* State general funds as available

**First 10 days authorized by VO, all concurrents authorized by CSA.

***IP Facility/Professional can be covered for Uninsured and PAC under Purchase of Care Only

****Services covered only when provided by non-regulated hospital clinics.

~ Coverage effective 1/1/2010

(1) Auth for Residential Crisis Service and Treatment Foster Care requires a T2048 auth as well.

(2) Medicare/Medicaid Dual Eligibles - Claims will only be paid for LPC's and when Medicare is exhausted; Authorization is required for PRP, Case Management, IOP and crisis bed.

(4) One unit of anesthesia will be automatically granted per unit of ECT services (90807 or 90871).

(5) PRP Services - Medicaid or Medicaid-PAC services are authorized by ValueOptions, except when receiving RRP, then services are authorized by CSA.

(6) TBI and PRTF waiver eligibile consumers are also eligible for other services as long as they are not duplicative and are medically necessary.

State Funded Services

Non HSCRC space only

Under the Covered Services:

Yes = Covered

No = Not Covered

Under Auth Requirements:

N/C = Not Covered

Yes = Auth Required

No = No Auth Required

Page 23: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required

Page 24: FDUL SDUL FPRT FTBI Fund Codes FMCD FPAC (6) …maryland.beaconhealthoptions.com/provider/clin_ut/...Fund Codes FMCD FPAC FDUL (2) SDUL FPRT (6) FTBI UINS MCOU Benefit Package FMC1

Fund Codes FMCD FPAC

FDUL

(2)

SDUL

(2)

FPRT

(6)

FTBI

(6) UINS MCOU

Benefit Package FMC1 FPA1 FDU1 SDU1 FPR1 FTB1 UIN1 MACR

Mapset MD1 MDE MD3 MDC MD4 MD5 MD6 MDA

2013 CPT/Rev

Code Mo

dif

ier

1

Mo

dif

ier

2

2013 Add on

Code Mo

dif

ier

1

Mo

dif

ier

2

Service Description

Claim

Type

Place of

Service Me

dic

aid

Pri

ma

ry A

du

lt C

are

-P

AC

Fe

de

rall

y F

un

de

dM

ed

ica

re/M

ed

ica

id

Sta

te F

un

de

d M

ed

ica

re/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Me

dic

aid

Pri

am

ry A

du

lt C

are

-P

AC

Me

dic

are

/M

ed

ica

id

PR

TF

TB

I

Un

insu

red

Co

urt

esy R

evie

ws

Send Auth

Request to: UB

04

HC

FA

15

00

MARYLAND SERVICE MATRIX 02/07/13 Public Mental Health Coverage

Claim

FormPre-Authorization Required