LDH List of Covered Behavioral Health Services, …...List of Covered Behavioral Health Services, Codes and Aetna Behavioral Health Authorization Requirements Codes services. Initial

LDH List of Covered Behavioral Health Services, Codes and Aetna Behavioral Health Authorization Requirements Billing Codes

Billing Mod? Service Description Auth

Required? Additional Authorization Requirement Details

100 Inpatient Admission – Mental Health, room and board plus ancillary YES

Authorization is required post emergency admissions, post-stabilization of an emergency presentation or for planned (elective) admissions (prior authorization). There are no predetermined restrictions or limitations placed on this level of care (LOC). Participating vs. non-participating is not a factor for this LOC.

114 Inpatient Admission – Mental Health YES Authorization is required post emergency admissions, post-stabilization of an emergency presentation or for planned (elective) admissions (prior authorization). There are no predetermined restrictions or limitations placed on this level of care (LOC). Participating vs. non-participating is not a factor for this LOC.

116 Inpatient Services Chemical Dependency (CD) YES Authorization is required post emergency admissions, post-stabilization of an emergency presentation or for planned (elective) admissions (prior authorization). There are no predetermined restrictions or limitations placed on this level of care (LOC). Participating vs. non-participating is not a factor for this LOC.








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LDH List of Covered Behavioral Health Services, Codes and Aetna Behavioral Health Authorization Requirements

Billing Codes





510 Post Inpatient Discharge Follow-Up Appointment- NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

519 Bridge Appointment NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

519 Post Inpatient Discharge Follow-Up Appointment- NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

760 Observation NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC




900 Psychiatric / Psychological Services: NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

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Billing Codes



901 Psychiatric / Psychological Treatment: electroshock treatment YES

Prior authorization is required. There are no predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on provider performance information.

901 Psychiatric / Psychological Treatment: electroshock treatment YES

Prior authorization is required. No predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on provider performance information.

905 Intensive Outpatient Program (IOP)- Mental Health YES Prior authorization is required. There are no predetermined restrictions or limitations placed on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

906 Intensive Outpatient Program (IOP)- Chemical Dependency YES

Prior authorization is required. There are no predetermined restrictions or limitations placed on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

907 Psychiatric / Treatment: YES Prior authorization is required. There are no predetermined restrictions or limitations placed on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.






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Billing Codes



90785 Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication

NO No authorization required. There are no predetermined restrictions or limitations placed on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

90791 Psychiatric diagnosis evaluation NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

90792 Psychiatric diagnosis evaluation with medical services NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

90832 Psychotherapy, 30 minutes with patient and/or family member NO

No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

90833

Add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 30 minutes with the patient and/or family member (time range 16-37 minutes), when performed with an evaluation and management service.

NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC



90836

Add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 45 minutes with the patient and/or family member (time range 38-52 minutes) when performed with an evaluation and management service.




90838

Add-on code for Individual psychotherapy, insight oriented, behavior modifying and/or supportive, 60 minutes with the patient and/or family member (time range 53 minutes or more), when performed with an evaluation and management service.


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Billing Codes



90839 Psychotherapy for crisis, first 60 minutes NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

90840 Psychotherapy for crisis, each additional 30 minutes NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

90845

Individual psychotherapy, insight-oriented, behavior‑modifying and/or supportive, in an office or outpatient facility, approximately 45-50 minutes face-to-face with the patient


90846 Family psychotherapy (without the patient present) NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

90847 Family psychotherapy (conjoint psychotherapy) (with patient present) NO


90849 Multiple-Family group psychotherapy NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

90853 Group psychotherapy (other than of a multiple-family group) NO


90863 Pharmacologic management, including prescription and review of medication when performed with psychotherapy services


90870 ECT- Single YES Prior authorization is required. No predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on provider performance information.

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Billing Codes



90875

Individual psycho-physiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (e.g., insight‑oriented, behavior-modifying or supportive psychotherapy), approximately 20-30 minutes


90876


NO

No authorization required. There are no predetermined restrictions or limitations placed on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

90880


YES

Prior authorization is required. There are no predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

96101 Psychological Testing YES Prior authorization is required. There are no predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

96102

Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI, and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face.

YES


96103

Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g. MMPI), administered by a computer, with qualified health care professional interpretation and report.

YES


96105

Assessment of Aphasia (includes assessment of expressive & receptive speech & language function, language comprehension , speech production ability, reading, spelling, writing, eg, by Boston DAE) with interpretation & report, per hour


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Billing Codes



96116 Neurobehavioral Status Exam (per hour) NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

96118

Neuropsychological Testing (Halstead-Reitan Neuropsychological Battery, Wechsler Memory, Wisconsin Card sort) administered by Psychologist / Physician

YES Prior authorization is required. There are no predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

96119

Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Weschler Memory Scales and Wisconsin Card Sorting Test), with qualified healthcare professional interpretation and report, administered by technician, per hour of technician time, face-to-face.


96120

Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Weschler Memory Scales and Wisconsin Card Sorting Test), administered by computer, with qualified healthcare professional interpretation and report


96150

Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psycho‑physiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient, initial assessment


96151

Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psycho‑physiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient, re‑assessment


96152 Health and behavior intervention, each 15 minutes, face-to-face; individual NO


96153 Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients) NO


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Billing Codes



96154 Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present) NO


96155 Health and behavior intervention, each 15 minutes, face-to-face; family (without the patient present) NO


96372 Therapeutic, Prophylactic or Diagnostic Injection NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

99201 Psychotherapy with Med Eval/Mgmt Service NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC





99211

Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services.


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Billing Codes



99212



99213



99214



99215



99218

Initial observation care, per day, for the evaluation and management of a patient which requires these three key components: a detailed or comprehensive history, a detailed or comprehensive examination and medical decision-making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided, consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission to “observation status” are of low severity.

NO No authorization required.

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Billing Codes



99219

Initial observation care, per day, for the evaluation and management of a patient which requires these three key components: a comprehensive history, a comprehensive examination and medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided, consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission to “observation status” are of moderate severity.

NO No authorization required.

99220

Initial observation care, per day, for the evaluation and management of a patient which requires these three key components: a comprehensive history, a comprehensive examination and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided, consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission to “observation status” are of high severity.


99221 Hospital Inpatient Services – Initial Care, detailed or comprehensive, straight-forward or low complexity (30 min)

YES Authorization is required post emergency admissions, post-stabilization of an emergency presentation or for planned (elective) admissions (prior authorization). There are no predetermined restrictions or limitations placed on this level of care (LOC). Participating vs. non-participating is not a factor for this LOC.

99222 Hospital Inpatient Services – Initial Care, comprehensive, moderate complexity (50 min) YES


99223 Hospital Inpatient Services – Initial Care, comprehensive, high complexity (70 min) YES


99231 Hospital Inpatient Services – Subsequent Care, problem-focused interval, straight-forward or low complexity (15 min)


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Billing Codes



99232 Hospital Inpatient Services – Subsequent Care, expanded problem-focused interval, moderate complexity (25 min)


99233 Hospital Inpatient Services – Subsequent Care, detailed interval, high complexity (35 min) YES


99234 Observation or Inpatient Care Services (Including Admission and Discharge), detailed or comprehensive, straight-forward or low complexity (40 min)

NO

No authorization is required for observation for participating providers. Inpatient Authorization is required post emergency admissions, post-stabilization of an emergency presentation or for planned (elective) admissions (prior authorization). There are no predetermined restrictions or limitations placed on this level of care (LOC). Participating vs. non-participating is not a factor for this LOC.

99235 Observation or Inpatient Care Services (Including Admission and Discharge), comprehensive, moderate (50 min)

NO

No authorization is required for observation for participating providers. Inpatient Authorization is required post emergency admissions, post-stabilization of an emergency presentation or for planned (elective) admissions (prior authorization). There are no predetermined restrictions or limitations placed on this level of care (LOC). Participating vs. non-participating is not a factor for this LOC.

99236 Observation or Inpatient Care Services (Including Admission and Discharge), comprehensive, high (55 min)

NO

No authorization ir required for observation for participating providers. Authorization is required post emergency admissions, post-stabilization of an emergency presentation or for planned (elective) admissions (prior authorization). There are no predetermined restrictions or limitations placed on this level of care (LOC). Participating vs. non-participating is not a factor for this LOC.

99238 Hospital Discharge day management YES Authorization is required post emergency admissions, post-stabilization of an emergency presentation or for planned (elective) admissions (prior authorization). There are no predetermined restrictions or limitations placed on this level of care (LOC). Participating vs. non-participating is not a factor for this LOC.

99239 Hospital Discharge day management YES Authorization is required post emergency admissions, post-stabilization of an emergency presentation or for planned (elective) admissions (prior authorization). There are no predetermined restrictions or limitations placed on this level of care (LOC). Participating vs. non-participating is not a factor for this LOC.

99408

Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., Alcohol Use Disorders Identification Test (AUDIT), Drug Abuse Screening Test (DAST)) and brief intervention (SBI) services, 15 to 30 minutes.


H0001 HO/HN/HM Alcohol and/or Drug Assessment NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

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Billing Codes



H0004 HO/HN/HM Behavioral health counseling and therapy - per 15 minutes NO


H0005 HO/HN/HM Alcohol and/or drug services; group counseling by a clinician - per hour NO


H0011 Alcohol And/Or Drug Services; Acute Detoxification (Residential Addiction Program Inpatient) YES

Authorization is required post emergency admissions, post-stabilization of an emergency presentation or for planned (elective) admissions (prior authorization). There are no predetermined restrictions or limitations placed on this level of care (LOC).

H0012 Alcohol and/or drug services; sub-acute detoxification (residential addiction program impatient) YES

Authorization is required post emergency admissions, post-stabilization of an emergency presentation or for planned (elective) admissions (prior authorization). There are no predetermined restrictions or limitations placed on this level of care (LOC).

H0014 Alcohol and/or Drug Services; Ambulatory Detoxification YES

Prior authorization is required. No predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

H0015 HO/HN/HM

Alcohol and/or drug services, intensive outpatient (treatment program that operates at least three hours/day and at least three days/week and is based on an individualized treatment plan), including assessment, counseling, CI and activity therapies or education (licensed and unlicensed individual under supervision of a licensed clinician) **with a modifier for degree level**

YES Prior authorization is required. No predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

H0018 Behavioral Health; Short-Term Residential (Non-Hospital Residential Treatment Program), Without Room And Board, Per Diem


H0019

Behavioral Health; Long-Term Residential (Non-Medical, Non-Acute Care In A Residential Treatment Program Where Stay Is Typically Longer Than 30 Days), Without Room And Board, Per Diem


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Billing Codes



H0036 HO/HN/HM Community psychiatric supportive treatment, face-to-face, per 15 minutes, individual office YES

Effective 1/1/2018: Prior authorization is required. No predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

H0036 HO/HN/HM Community psychiatric supportive treatment, face-to-face, per 15 minutes, home or community (12 and 99) SMO needs to specify other POS

YES Effective 1/1/2018: Prior authorization is required. No predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

H0036 HE Community psychiatric supportive treatment, face-to-face, per 15 minutes, specialized mental health programs for high-risk populations (FFT), *EBP


H0036 HO/HN

Community psychiatric supportive treatment, face-to-face, per 15 minutes, specialized mental health programs for high-risk populations (Homebuilders), *EBP


H0039 Assertive community treatment program, face-to-face, per 15 minutes, *EBP YES


H0045 HA Respite care service, not in the home; per diem, under age 21 YES


H0049 Alcohol and/or drug screening NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

H0050 Alcohol and/or drug services, brief Intervention, per 15 min – Ambulatory Detox NO


H2011 HO/HN/HM Crisis Intervention Follow Up NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

H2013 Psychiatric health facility service, per diem YES Prior authorization is required. No predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

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Billing Codes



H2017 Psychosocial Rehabilitative Services, per 15 minutes, individual office YES


H2017 HA/HQ Psychosocial Rehabilitative Services, per 15 minutes, child/adolescent program, office group YES


H2017 HA/HQ Psychosocial Rehabilitative Services, per 15 minutes, child/adolescent program, group place of service 11 or 53 for home and community


H2017 HA/HQ Psychosocial Rehabilitative Services, per 15 minutes, adult program, non-geriatric, office group YES


H2017 HA/HQ Psychosocial Rehabilitative Services, per 15 minutes, adult program, non-geriatric, group place of service 11 or 53 for home and community


H2033 HO Multisystemic therapy for juveniles, per 15 minutes, *EBP NO


H2034 Alcohol and/or drug abuse, halfway house services, per diem (Level III.1) Per diem (medical portion) NO


H2036 Alcohol and/or drug treatment program, per diem (Level III.5) HB = Adult. Per diem (medical portion) YES


S9485 HM/HN/HO Crisis intervention mental health services, per diem, less than bachelor’s level NO


T1015 Clinic visit/encounter, all-inclusive NO No authorization required for participating providers. Authorization required for non-participating based on the availability of contracted providers. There are no predetermined restrictions or limitations placed on this LOC

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Billing Codes Mod?

Billing Service Description Auth Required? Additional Authorization Requirement Details

0359T TG/TF Behavioral Identifcation Assessment YES Effective 3/1/2018: Prior authorization is required. No predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

0360T TG/TF Observational Behavior Assessment, first 30 minutes YES Effective 3/1/2018: Prior authorization is required. No predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

0361T TG/TF Observational Behavior Assessment, additional 30 minutes YES


0364T TG/TF/HN Adaptive Behavior Treatment by protocol, first 30 minutes YES


0365T TG/TF/HN Adaptive Behavior Treatment by protocol, additional 30 minutes YES


0366T TG/TF Group Adaptive Behavior Treatment, first 30 minutes YES Effective 3/1/2018: Prior authorization is required. No predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

0367T TG/TF Group Adaptive Behavior Treatment, additional 30 minutes YES


0368T TG/TF Adaptive Behavior Treatment with Modification, first 30 minutes YES


0369T TG/TF Adaptive Behavior Treatment with Modification, additional 30 minutes YES


0370T TG/TF Family Adaptive Behavior Treatment Guidance YES Effective 3/1/2018: Prior authorization is required. No predetermined restrictions or limitations place on this LOC Participating vs. non-participating may be a factor for this service based on the availability of contracted providers.

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Billing Codes Mod?

Billing Service Description Auth Required? Additional Authorization Requirement Details

0371T TG/TF Multiple Family Group Adaptive Behavior Treatment Guidance YES


0372T TG Adaptive Behavior Treatment Social Skills Training Group YES


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Documents

LDH List of Covered Behavioral Health Services, …...List of Covered Behavioral Health Services, Codes and Aetna Behavioral Health Authorization Requirements Codes services. Initial