Exhibit D - Covered Services Table

Draft

Coverage Responsibility Legend:

1 = HUSKY MCO - All Diagnoses

2 = KidCare - All Diagnoses

3 = KidCare for Primary Diagnoses 291-316, HUSKY MCO all other Diagnoses

4 = Not Covered

 

Code

General Hospital Inpatient

Coverage

110

Room & Board- Private

3

111

Room & Board- Private -Med/Surg/Gyn

3

112

Room & Board- Private -OB

3

113

Room & Board- Private -Pediatric

3

114

Room & Board Private  - Psychiatric

2

115

Room & Board- Private -Hospice

3

116

Room & Board Private - Detox

2

117

Room & Board- Private -Oncology

3

118

Room & Board- Private -Rehab

3

119

Room & Board- Private -Other

3

120

Room & Board-Semi-Private/2 Bed

3

121

Room & Board-Semi-Private/ 2 Bed- Med/Surg/Gyn

3

122

Room & Board-Semi-Private/ 2 Bed -OB

3

123

Room & Board-Semi-Private/ 2 Bed-Pediatric

3

124

Room & Board Semi-Private/2 Bed - Psychiatric

2

125

Room & Board-Semi-Private/ 2 Bed-Hospice

3

126

Room & Board -  Semi-Private/2 Bed -  Detox

2

127

Room & Board-Semi-Private/ 2 Bed-Oncology

3

128

Room & Board-Semi-Private/ 2 Bed-Rehab

3

129

Room & Board-Semi-Private/ 2 Bed-Other

3

130

Room & Board-Semi-Private/3-4 Bed

3

131

Room & Board-Semi-Private/3-4 Bed- Med/Surg/Gyn

3

132

Room & Board-Semi-Private/3-4 Bed-OB

3

133

Room & Board-Semi-Private/3-4 Bed-Pediatric

3

134

Room & Board -  Semi-Private/3-4 Bed - Psychiatric

2

135

Room & Board-Semi-Private/3-4 Bed-Hospice

3

136

Room & Board -  Semi-Private/3-4 Bed  - Detox

2

137

Room & Board-Semi-Private/3-4 Bed-Oncology

3

138

Room & Board-Semi-Private/3-4 Bed-Rehab

3

139

Room & Board-Semi-Private/3-4 Bed-Other

3

140

Room & Board-Private-Deluxe

3

141

Room & Board-Private-Deluxe- Med/Surg/Gyn

3

142

Room & Board-Private - Deluxe-OB

3

143

Room & Board-Private - Deluxe-Pediatric

3

144

Room & Board -  Private -  Deluxe - Psychiatric

2

145

Room & Board-Private - Deluxe-Hospice

3

146

Room & Board Private Deluxe Detox

2

147

Room & Board-Private - Deluxe-Oncology

3

148

Room & Board-Private - Deluxe-Rehab

3

149

Room & Board-Private - Deluxe-Other

3

150

Room & Board Ward

3

151

Room & Board Ward - Med/Surg/ Gyn

3

152

Room & Board Ward OB

3

153

Room & Board Ward Pediatric

3

Code

General Hospital Inpatient

Coverage

154

Room & Board - Ward - Psychiatric

2

155

Room & Board Ward Hospice

3

156

Room & Board - Ward - Detox

2

157

Room & Board Ward Oncology

3

158

Room & Board Ward Rehab

3

159

Room & Board Ward - Other

3

160

Other Room & Board 

3

164

Other Room & Board Sterile Environment

3

167

Other Room & Board Self Care

3

169

Other Room & Board - Other

3

170

Room & Board- Nursery

3

171

Room & Board- Nursery Newborn

3

172

Room & Board- Nursery Premature

3

175

Room & Board- Nursery Neonatal ICU

3

179

Room & Board- Nursery - Other

3

200

Intensive Care

3

201

Intensive Care Surgical

3

202

Intensive Care Medical

3

203

Intensive Care Pediatric

3

204

Intensive Care Psychiatric

2

205

Intensive Care Post ICU

3

207

Intensive Care Burn Treatment

3

208

Intensive Care Trauma

3

209

Intensive Care Other

3

210

Coronary Care

3

211

Coronary Care Myocardial Infarction

3

212

Coronary Care Pulmonary

3

213

Coronary Care Heart Transplant

3

214

Coronary Care Post CCU

3

219

Coronary Care Other

3

224

Late discharge/Medically necessary

3

 

 

 

Code

General Hospital Emergency Department

Coverage

450

Emergency Room General Classification

1

451

EMTALA Emergency Medical Screening Services

1

452

Emergency Room Beyond EMTALA Screening

1

456

Urgent Care

1

459

Other Emergency Room

1

762

Observation room

1


 

Code

General Hospital Outpatient

Coverage

513 - Note

Psychiatric Clinic

2*

 

900

Psychiatric Services General

2

 

901

Electroconvulsive Therapy

2

 

905

Intensive Outpatient Services Psychiatric

2

 

906

Intensive Outpatient Services Chemical Dependency

2

 

912

Partial Hospital Less Intensive

2

 

913

Partial Hospital More Intensive

2

 

918

Psychiatric Service Testing

2

 

961

Professional Fees-Psychiatric

4

 

All others

 

1

 

 

 

 

 

 

*  Diagnosis V62.5 must be used for DCF Multidisciplinary Evaluations

 

Note -  Additional psychiatric service codes are under consideration pending completion of the rate setting process.

 

 

Code

Psychiatric Hospital Inpatient

Coverage

 

124

Room and Board-Psychiatric

2

 

224

Late discharge/Medically necessary

2

 

 

 

 

 

Code

Psychiatric Hospital Outpatient

Coverage

 

513

Clinic Visit

2

 

762

Observation room

2

 

900

Psychiatric Service General

2

 

905

Intensive Outpatient Services - Psychiatric

2

 

906

Intensive Outpatient Services - Chemical Dependency

2

 

912

Partial Hospital-Less Intensive

2

 

913

Partial Hospital-More Intensive

2

 

914

Psychiatric Service-Individual Therapy

2

 

915

Psychiatric Service-Group Therapy

2

 

916

Psychiatric Service-Family Therapy

2

 

918

Psychiatric Service-Testing

2

 

 

 

 

 

Code

Alcohol and Drug Abuse Center (Non-hospital Inpatient Detox)

Coverage

 

H0011

Acute Detoxification (residential program inpatient)

2

 

 

 

 

 

Code

Alcohol and Drug Abuse Center (Ambulatory Detoxification)

Coverage

 

H0014

Ambulatory Detoxification

2

 

 

 

 

 

Code

PRTF

Coverage

 

H2013/1001

Psychiatric health facility service, per diem

2

 

 

 

 

 

 

 

 

 

 

Code

DCF Residential

Coverage

 

N/A

DCF Funded residential facility

2

 

 

 

 

 

Code

Long Term Care Facility

Coverage

 

100

Per diem rate

1

 

183

Home reserve

1

 

185

Inpatient hospital reserve

1

 

189

Non-covered reserve

4

 

 

 

 

 

Code

MH Clinic/FQHC Mental Health Clinic

Coverage

90801

Psychiatric Diagnostic Interview (Including DCF Multidisciplinary Evaluations)

2*

90802

Interactive Psychiatric Diagnostic Interview (Including DCF Multidisciplinary Evaluations)

2

90804

Individual Psychotherapy- Office or other Outpatient (20-30 min)

2

90805

Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services

2

90806

Individual Psychotherapy-Office or other Outpatient (45-50 min)

2

90807

Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services

2

90808

Individual Psychotherapy-Office or other Outpatient (75-80 min)

2

90809

Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services

2

90810

Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min)

2

90811

Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services

2

90812

Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min)

2

90813

Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services

2

90814

Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min)

2

90815

Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services

2

90846

Family Psychotherapy (without the patient present)

2

90847

Family Psychotherapy  (conjoint psychotherapy) (with the patient present)

2

90853

Group psychotherapy

2

90857

Interactive group psychotherapy

2

90862

Pharmacologic management

2

96100

Psychological testing

2

96110

Developmental testing (Including DCF Multidisciplinary Evaluations)

2*

 

 

*  Diagnosis V62.5 must be used for DCF Multidisciplinary Evaluations

 

 

Code

MH Clinic/FQHC Mental Health Clinic

Coverage

96117

Neuropsychological testing battery

2

H0015

Intensive Outpatient-Substance Dependence

2

H2012

Extended Day Treatment

2

H2013

Partial Hospitalization

2

J1630

Injection, Haloperidol, up to 5 mg

2

J1631

Injection, Haloperidol decanoate, per 50 mg

2

J2680

Injection, Fluphenazine decanoate, up to 25 mg

2

M0064

Brief office visit for the sole purpose of monitoring or changing drug prescriptions used in the treatment of mental psychoneurotic and personality disorders

2

S9480

Intensive Outpatient-Mental Health

2

T1015

Clinic visit/encounter all-inclusive (For use by FQHC MH Clinic)

2

 

 

 

Code

Rehabilitation Clinic

Coverage

90801

Psychiatric Diagnostic Interview

3*

90804

Individual Psychotherapy- Office or other Outpatient (20-30 min)

3

90805

Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services

3

90806

Individual Psychotherapy-Office or other Outpatient (45-50 min)

3

90807

Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services

3

90808

Individual Psychotherapy-Office or other Outpatient (75-80 min)

3

90809

Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services

3

90846

Family psychotherapy (without the patient present)

3

90847

Family psychotherapy (conjoint)

3

90853

Group psychotherapy

3

90857

Interactive Group therapy

3

96117

Neuropsychological testing battery

3

All others

 

1

 

 

*  Diagnosis V62.5 must be used for DCF Multidisciplinary Evaluations

 

 

Code

Medical Clinic/FQHC Medical Clinic/School-Based Health Centers

Coverage

90782

Therapeutic or diagnostic injection; subcutaneous or intramuscular

1

90783

Therapeutic or diagnostic injection; intra-arterial

1

90784

Therapeutic or diagnostic injection; intravenous

1

90801

Psychiatric Diagnostic Interview

3

90804

Individual psychotherapy (20-30 min)

3

90805

Individual psychotherapy (20-30 min) with medical evaluation and management

3

90806

Individual psychotherapy (45-50 min)

3

90807

Individual psychotherapy (45-50 min) with medical evaluation and management

3

Code

Medical Clinic/FQHC Medical Clinic/School-Based Health Centers

Coverage

90808

Individual psychotherapy (75-80 min)

3

90809

Individual psychotherapy (75-80 min) with medical evaluation and management

3

99211

Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. (Typically 5 minutes)

1

99212

 

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: problem focused history; problem focused examination; straightforward medical decision-making. (Typically 10 minutes face-to-face)

1

99213

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: expanded problem focused history; expanded problem focused examination; medical decision making of low complexity. (Typically 15 minutes face-to-face)

1

99214

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: detailed history; detailed examination; medical decision making of moderate complexity (Typically 25 minutes face-to-face)

1

99215

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: comprehensive history; comprehensive examination; medical decision making of high complexity (Typically 40 minutes face-to-face)

1

All others

 

1

 

 

 

 

Code

Methadone Clinic

Coverage

H0020

Methadone service; rate includes all necessary Methadone chemistries (quantitative analysis) code 83840, which are part of the all-inclusive rate for methadone services but may have been paid separately by some MCOs

2

 

 

 

 

Code

MD, DO and APRN other than Psychiatrist or Psychiatric APRN

Coverage

00104

Anesthesia for electroconvulsive therapy

1

80100

Drug screen, qualitative, chromatographic method, each procedure

1

81000

Urinalysis, by dip stick or tablet reagent, non-automated, with microscopy

1

83840

Methadone chemistry (quantitative analysis)

1

90782

Therapeutic or diagnostic injection; subcutaneous or intramuscular

1

90783

Therapeutic or diagnostic injection; intra-arterial

1

90784

Therapeutic or diagnostic injection; intravenous

1


 

Code

MD, DO and APRN other than Psychiatrist or Psychiatric APRN

Coverage

908XX

Psychotherapy codes

4

99211

Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician.  (Typically 5 minutes)

 

1

99212

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: problem focused history; problem focused examination; straightforward medical decision making. (Typically 10 minutes face-to-face)

1

99213

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: expanded problem focused history; expanded problem focused examination; medical decision making of low complexity. (Typically 15 minutes face-to-face)

1

99214

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: detailed history; detailed examination; medical decision making of moderate complexity (Typically 25 minutes face-to-face)

1

99215

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: comprehensive history; comprehensive examination; medical decision making of high complexity (Typically 40 minutes face-to-face)

1

All others

 

1

 

 

 

 

Code

Psychiatrist (MD or DO) and Psychiatric APRN

Coverage

90782

Therapeutic or diagnostic injection; subcutaneous or intramuscular

2

90783

Therapeutic or diagnostic injection; intra-arterial

2

90784

Therapeutic or diagnostic injection; intravenous

2

90801

Diagnostic Interview

2

90802

Interactive Diagnostic Interview

2

90804

Individual Psychotherapy-Office or other Outpatient (20-30 min)

2

90805

Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services

2

90806

Individual Psychotherapy-Office or other Outpatient (45-50 min)

2

90807

Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services

2

90808

Individual Psychotherapy-Office or other Outpatient (75-80 min)

2

90809

Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services

2

90810

Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min)

2

Code

Psychiatrist (MD or DO) and Psychiatric APRN

Coverage

90811

Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min) with medical evaluation and management services

2

90812

Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min)

2

90813

Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min) with medical evaluation and management services

2

90814

Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min)

2

90815

Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min) with medical evaluation and management services

2

90816

Individual Psychotherapy-Facility Based (20-30 min)

2

90817

Individual Psychotherapy-Facility Based (20-30 min) with medical evaluation and management services

2

90818

Individual Psychotherapy-Facility Based (45-50 min)

2

90819

Individual Psychotherapy-Facility Based (45-50 min) with medical evaluation and management services

2

90846

Family Psychotherapy (without the patient present)

2

90847

Family Psychotherapy (conjoint)

2

90853

Group Psychotherapy

2

90857

Interactive Group psychotherapy

2

90862

Pharmacological management, including prescription, use, and review of medication with no more than minimal medical psychotherapy

2

90865

Narcosynthesis for Psychiatric Diagnostic and Therapeutic purposes

2

90870

Electroconvulsive therapy (including necessary monitoring); single seizure

2

90875

Individual psychophysiological therapy incorporating biofeedback training (20-30 min)

2

90876

Individual psychophysiological therapy incorporating biofeedback training (45-50 min)

2

90880

Hypnotherapy

2

90887

Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons. .

2

90899

Unlisted psychiatric service or procedure

2

M0064

Brief office visit for the sole purpose of monitoring or changing prescriptions used in the treatment of mental psychoneurotic or personality disorders

2

99201-99255

Evaluation and Management Services

2

99271-99285

Evaluation and Management Services

2

All others

 

4

 

 

 


 

Code

Psychologist and Psychologist Group

Coverage

90801

Diagnostic Interview

2

90802

Interactive Diagnostic Interview

2

90804

Individual Psychotherapy-Office or other Outpatient (20-30 min)

2

90806

Individual Psychotherapy-Office or other Outpatient (45-50 min)

2

90808

Individual Psychotherapy-Office or other Outpatient (75-80 min)

2

90810

Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min)

2

90812

Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min)

2

90814

Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min)

2

90816

Individual Psychotherapy-Facility Based (20-30 min)

2

90818

Individual Psychotherapy-Facility Based (45-50 min)

2

90846

Family Psychotherapy (without the patient present)

2

90847

Family Psychotherapy (conjoint)

2

90853

Group Psychotherapy

2

90857

Interactive Group psychotherapy

2

90875

Individual psychophysiological therapy incorporating biofeedback training (20-30 min)

2

90876

Individual psychophysiological therapy incorporating biofeedback training (45-50 min)

2

90880

Hypnotherapy

2

90887

Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons. .

2

96100

Psychological testing, per hour

2

96110

Developmental testing with report

2

96115

Neurobehavioral status exam, per hour

2

96117

Neuropsychological testing battery, per hour

2

 

 

 

Code

Independent Practice Behavioral Health Professional (LCSW, LMFT, LPC, LADC)

Coverage

90801

Diagnostic Interview

2

90802

Interactive Diagnostic Interview

2

90804

Individual Psychotherapy-Office or other Outpatient (20-30 min)

2

90806

Individual Psychotherapy-Office or other Outpatient (45-50 min)

2

90808

Individual Psychotherapy-Office or other Outpatient (75-80 min)

2

90810

Interactive Individual Psychotherapy-Office or other Outpatient (20-30 min)

2

90812

Interactive Individual Psychotherapy-Office or other Outpatient (45-50 min)

2

90814

Interactive Individual Psychotherapy-Office or other Outpatient (75-80 min)

2

Code

Independent Practice Behavioral Health Professional (LCSW, LMFT, LPC, LADC)

Coverage

90816

Individual Psychotherapy-Facility Based (20-30 min)

2

90818

Individual Psychotherapy-Facility Based (45-50 min)

2

90821

Individual Psychotherapy-Facility Based (75-80 min)

2

90823

Interactive Individual Psychotherapy-Facility Based (20-30 min)

2

90826

Interactive Individual Psychotherapy-Facility Based (45-50 min)

2

90828

Interactive Individual Psychotherapy-Facility Based (75-80 min)

2

90846

Family Psychotherapy (without the patient present)

2

90847

Family Psychotherapy (conjoint)

2

90853

Group Psychotherapy

2

90857

Interactive Group psychotherapy

2

90875

Individual psychophysiological therapy incorporating biofeedback training (20-30 min)

2

90876

Individual psychophysiological therapy incorporating biofeedback training (45-50 min)

2

90880

Hypnotherapy

2

90887

Interpretation or explanation of results of psychiatric or other medical examinations and procedures or other accumulated data to family or other responsible persons. .

2

 

 

 

Code

RCC/HCPC

Home Health

Coverage

421

Physical Therapy

1

424

Physical Therapy Evaluation

1

431

Occupational Therapy

1

434

Occupational Therapy Evaluation

1

441

Speech Therapy

1

444

Speech Therapy Evaluation

1

562

Social Work visit

3

570/T1004

Services of a qualified nursing aide, up to 15 minutes

3

580/S9123

Nursing care, in the home by an RN, per hour

3

580/S9124

Nursing Care, in the home by an LPN, per hour

3

580/T1001

Nursing Assessment/Evaluation

3

580/T1002

RN Services, up to 15 minutes

3

580/T1003

LPN/LVN services, up to 15 minutes

3

580/T1016

Case management, each 15 minutes

3

580/T1052

Administration of oral, intramuscular and/or subcutaneous medication by health care agency/professional, per visit

3

 

 

 

Code

Independent Occupational Therapist

Coverage

All codes

 

1

 

 

 

Code

Independent Physical Therapist

Coverage

All codes

 

1

Code

Medical Transportation

Coverage

All codes

 

1

 

 

 

Code

Emergency Medical Transportation

Coverage

All codes

 

1

 

 

 

Code

Independent Laboratory Services

Coverage

80100

Drug screen, qualitative, chromatographic method, each procedure

1

81000

Urinalysis, by dip stick or tablet reagent, non-automated, with microscopy

1

83840

Methadone chemistry (quantitative analysis); covered by KidCare only as part of all-inclusive Methadone Clinic rate for methadone services

3

All other codes

 

1

 

 

 

Code

Pharmacy

Coverage

All codes

 

1

 

 

 

Code

Special Services

Coverage

90887

Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient (Behavioral Consultation)

2

H1011

Family Assessment by Licensed Behavioral Health Professional for State Defined Purposes  (Behavioral Consultation)

2

H2019

Therapeutic Behavioral Services, per 15 minutes (DCF Home-based Services/Clinical)

2

H2032

Activity Therapy, per 15 minutes (Therapeutic Mentoring/Behavioral Management Service)

2

T1016

Case Management, each 15 minutes  (DCF Home-based Services/CM)

2