Procedure
Code Long Description Billing
Unit Allowed
Units Limitations Required
Modifiers Maximum Fee
80305
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (e.g., utilizing immunoassay [e.g., dipstick, cups, cards, or cartridges]), includes sample validation
when performed Per Service 6 Units 1 Per Day
81025 Urine pregnancy test, by visual color comparison methods Per Service 1 Unit
G9001 Coordinated care fee, initial rate Per Service 1 Unit
G9008
Coordinated care fee, physician coordinated care oversight
services (Includes history and physical) Per Service 5 Units 1 Per Day
H0001 Alcohol and/or drug assessment Per Diem 1 Unit
H0003 Laboratory analysis of specimens for presence of alcohol and/or
drugs Per Service 1 Unit
H0004 Behavioral health counseling and therapy, per 15 minutes
(Individual Counseling) (QCC touch) 15 Minutes 24 Units
H0006 Alcohol and/or drug services; case management Per Service 2 Units
H0014 Alcohol and/or drug services; ambulatory detoxification Per Diem 6 Units 1 Per Day H0016
Alcohol and drug services, medical/somatic (Medical intervention
in ambulatory setting) (Nurse touch) Per Service 6 Units 1 Per Day H0033 Oral medication administration, direct observation Per Service 6 Units 1 Per Day H0050 Alcohol and drug services, brief interventions, per 15 minutes 15 Minutes 10 Units
P9612 Collection of specimen, single patient (Venipuncture) Per Service 6 Units 1 Per Day T1002 RN services, up to 15 minutes (Vital signs) 15 Minutes 6 Units 1 Per Day T1003 LPN/LVN services, up to 15 minutes (Vital signs) 15 Minutes 6 Units 1 Per Day T1007
Alcohol and/or substance abuse services, treatment plan development and/or modification (Includes client discharge
planning) Per Service 1 Unit
Procedure
Code Long Description Billing
Unit Allowed
Units Limitations Required
Modifiers Maximum Fee
80305
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (e.g., utilizing immunoassay [e.g., dipstick, cups, cards, or cartridges]), includes sample validation
when performed Per Service 1 Unit
81025 Urine pregnancy test, by visual color comparison methods Per Service 1 Unit
G9001 Coordinated care fee, initial rate Per Service 1 Unit
G9008
Coordinated care fee, physician coordinated care oversight
services (Includes history and physical) Per Service 4 Units 1 Per Day H0004
Behavioral health counseling and therapy, per 15 minutes
(Individual Counseling) (QCC touch) 15 Minutes 20 Units
H0005 Alcohol and/or drug services; group counseling by a clinician Per Hour 2 Units
H0006 Alcohol and/or drug services; case management Per Service 5 Units 1 Per Day H0010
Alcohol and/or drug services; subacute detoxification (Residential
addiction program inpatient) (Recovery plan), per service Per Hour 1 Unit H0016
Alcohol and drug services, medical/somatic (Medical intervention
in ambulatory setting) (Nurse touch) Per Service 24 Units H0033 Oral medication administration, direct observation Per Service 24 Units H2027 Psychoeducational service, per 15 minutes (Individual or Group) 15 Minutes 45 Units P9612 Collection of specimen, single patient (Venipuncture) Per Service 1 Unit
S9976 Lodging, per diem, not otherwise classified (Room and board) Per Diem 5 Units 1 Per Day T1002 RN services, up to 15 minutes (Vital signs) 15 Minutes 24 Units
T1003 LPN/LVN services, up to 15 minutes (Vital signs) 15 MInutes 24 Units T1007
Alcohol and/or substance abuse services, treatment plan development and/or modification (Includes client discharge
planning) Per Service 1 Unit
T1012
Alcohol and/or substance abuse services, skills development
(Alternative activities) Per Service 3 Units
Note 3: Procedure codes H2027 and T1012 are billable as education.
Note 2: T1002 and T1003 - Initial duties performed by an RN cannot be absorbed or completed by an LPN/LVN, and vice versa.
Attachment 1 - Substance Use Disorder Fee Schedule Grouped by Treatment with Required Modifiers Table 1: Ambulatory Detoxification Treatment (H0014) - Effective Date XX/XX/XXXX
HB; HBHD;
and HA
Maximum length of stay in Ambulatory Detoxification Treatment is 6 days.
Note: T1002 and T1003 - Initial duties performed by an RN cannot be absorbed or completed by an LPN/LVN, and vice versa.
Table 2: Residential Detoxification Treatment (H0010) - Effective Date XX/XX/XXXX
HB; HBHD;
and HA See Note 1
See Note 1
Maximum length of stay in Residential Detoxification Treatment is 5 days.
Note 1: H0016, H0033, T1002, and T1003 - 1 unit every 4 hours for the first 72 hours/first 3 days; followed by 3 units per day on day 4 and 5.
Procedure
Code Long Description
Billing Unit
Allowed
Units Limitations
Required Modifiers
Maximum Fee
80305
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (e.g., utilizing immunoassay [e.g., dipstick, cups, cards, or cartridges]), includes sample validation
when performed Per Service 4 Units
81025 Urine pregnancy test, by visual color comparison methods Per Service 1 Unit
H0001 Alcohol and/or drug assessment Per Diem 1 Unit
16 Units HB
16 Units HBHD
24 Units HBHDTG
36 Units HA
36 Units HB
36 Units HBHD
54 Units HBHDTG
81 Units HA
12 Units HB
30 Units HBHD
45 Units HBHDTG
60 Units HA
H2015 Comprehensive community support services, per 15 minutes 15 Minutes 45 Units HA H2022 Community-based wrap-around services, per diem Per Diem
160 Units HB
160 Units HBHD
240 Units HBHDTG
360 Units HA
28 Days HB
30 Days HBHD
45 Days HBHDTG
60 Days HA
28 Days HB
30 Days HBHD
45 Days HBHDTG
60 Days HA
T1006 Alcohol and/or substance abuse services, family/couple
counseling, per service (Limited to youths) Per Service 9 Units HA
T1007
Alcohol and/or substance abuse services, treatment plan development and/or modification (Includes client discharge
planning) Per Service 2 Events
2 Per Episode of Care
HB; HBHD;
HBHDTG;
and HA
40 Hours HB
40 Hours HBHD
60 Hours HBHDTG
90 Hours HA
Maximum length of stay in Intensive Residential Treatment: Adults - 28 days; Specialized Female - 30 days; Women, Children, and Neonatal Abstinence Syndrome (NAS) - 45 days; and Youth - 60 days.
Note 1: Procedure codes H2027 and T1012 are billable as education.
S9976 Lodging, per diem, not otherwise classified (Room and board) Per Diem
T1012 Alcohol and/or substance abuse services, skills development
(Alternative activities) Per Service
H2027 Psychoeducational service, per 15 minutes (Individual or Group) 15 minutes
H2036 Alcohol and/or other drug treatment program, per diem
(Intensive Residential Treatment) Per Diem
H0005 Alcohol and/or drug services; group counseling by a clinician Per Hour
H0006 Alcohol and/or drug services; case management Per Service Table 3: Intensive Residential Treatment (H2036) - Effective Date XX/XX/XXXX
HB; HBHD;
HBHDTG;
and HA
H0004 Behavioral health counseling and therapy, per 15 minutes
(Individual Counseling) (QCC touch) 15 Minutes
Procedure
Code Long Description Billing
Unit Allowed
Units Limitations Required
Modifiers Maximum Fee
80305
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (e.g., utilizing immunoassay [e.g., dipstick, cups, cards, or cartridges]), includes sample validation
when performed Per Service 4 Units
81025 Urine pregnancy test, by visual color comparison methods Per Service 1 Unit
H0001 Alcohol and/or drug assessment Per Diem 4 Units
H0004 Behavioral health counseling and therapy, per 15 minutes
(Individual Counseling) (QCC touch) 15 Minutes 4 Units
H0005 Alcohol and/or drug services; group counseling by a clinician Per Hour 14 Hours
12 Units HB
30 Units HBHD
35 Units HBHDTG
30 Units HA
H2015 Comprehensive community support services, per 15 minutes 15 Minutes 36 Units HA H2022 Community-based wrap-around services, per diem Per Diem
56 Units HB
44 Units HBHD
56 Units HBHDTG
44 Units HA
35 Days HB
30 Days HBHD
35 Days HBHDTG
30 Days HA
35 Days HB
30 Days HBHD
35 Days HBHDTG
30 Days HA
T1006 Alcohol and/or substance abuse services, family/couple
counseling, per service (Limited to youths) Per Service 4 Units HA
T1007
Alcohol and/or substance abuse services, treatment plan development and/or modification (Includes client discharge
planning) Per Service 2 Events
HB; HBHD;
HBHDTG;
and HA
15 Hours HB
11 Hours HBHD
15 Hours HBHDTG
11 Hours HA
S9976 Lodging, per diem, not otherwise classified (Room and board)
Per Diem
T1012 Alcohol and/or substance abuse services, skills development (Alternative activities)
Per Service
Maximum length of stay in Supportive Residential Treatment: Adults - 35 days; Specialized Female - 30 days; Women, Children, and Neonatal Abstinence Syndrome (NAS) - 35 days; and Youth - 30 days.
Note 1: Procedure codes H2027 and T1012 are billable as education.
H2027 Psychoeducational service, per 15 minutes (Individual or Group)
15 Minutes H2036 Alcohol and/or other drug treatment program, per diem
(Supportive Residential Treatment)
Per Diem Table 4: Supportive Residential Treatment (H2036) - Effective Date XX/XX/XXXX
HB; HBHD;
HBHDTG;
and HA
H0006 Alcohol and/or drug services; case management
Per Service
Procedure
Code Long Description Billing
Unit Allowed
Units Limitations Required
Modifiers Maximum Fee
H0001 Alcohol and/or drug assessment Per Diem 1 Unit
H0004 Behavioral health counseling and therapy, per 15 minutes
(Individual Counseling) (QCC touch) 15 Minutes 36 Units
H0005 Alcohol and/or drug services; group counseling by a clinician Per Hour 10 Units H0006 Alcohol and/or drug services; case management Per Service 9 Units
H0015
Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity
therapies or education Per Diem 12 Units
H2015 Comprehensive community support services, per 15 minutes 15 Minutes 36 Units HA H2027 Psychoeducational service, per 15 minutes (Individual or Group) 15 Minutes 128 Units HB; HBHD;
and HA T1006 Alcohol and/or substance abuse services, family/couple
counseling, per service (Limited to youths) Per Service 6 Units HA
T1007
Alcohol and/or substance abuse services, treatment plan development and/or modification (Includes client discharge
planning) Per Service 2 Events HB; HBHD;
and HA
Procedure
Code Long Description
Billing Unit
Allowed
Units Limitations
Required Modifiers
Maximum
H0001 Alcohol and/or drug assessment Per Diem 1 Unit Fee
H0004 Behavioral health counseling and therapy, per 15 minutes
(Individual Counseling) (QCC touch) 15 Minutes 17 Units
H0006 Alcohol and/or drug services; case management Per Service 17 Units H0046 Mental health services, not otherwise specified, per diem ((Co-
occurring Psychiatric Substance Use Disorders (COPSD)) Per Diem 17 Units
Table 6: Co-occurring Psychiatric Substance Use Disorders (COPSD) (H0046) - Effective Date XX/XX/XXXX
Note: H0001, H0004, and H0006 - A COPSD claim can only be submitted by a provider and approved by the SUD program only if a client is not currently in a level of care.
Note 2: Allowed units by population (One unit equals 15 minutes): Adults (Modifier HD) - 128 units per episode; Specialized Female (Modifier HBHD) - 128 units per episode; Women, Children, and Neonatal Abstinence Syndrome (NAS) - 128 units per episode; and Youth (HA) - 128 units per episode.
Table 5: Outpatient Treatment (H0015) - Effective Date XX/XX/XXXX
HB; HBHD;
and HA
Note 1: Procedure code H0004: One unit equals 15 minutes. 36 units for a total of 9 hours are allowed per episode.
Procedure
Code Long Description Billing
Unit Allowed
Units Limitations Required
Modifiers Maximum Fee
80305HG
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (e.g., utilizing immunoassay [e.g., dipstick, cups, cards, or cartridges]), includes sample validation
when performed Per Service 2 Units
2 Per Month and No More Than 24 Per Calendar Year
81025HG Urine pregnancy test, by visual color comparison methods Per Service 1 Unit
1 Per Month and No More Than 12 Per Calendar Year G0378HG Hospital (Clinic) observation service, per hour Per Hour 12 Units 12 Hours Per Calendar Year
G9001HG Coordinated care fee, initial rate Per Service 1 Unit
G9008HG
Coordinated care fee, physician coordinated care oversight
services (Includes history and physical) Per Diem 24 Units
24 Per Calendar Year H0001HG Alcohol and/or drug assessment, per diem Per Diem 1 Unit 1 Per Calendar
Year H0003HG Alcohol and/or drug screening; laboratory analysis of specimens
for presence of alcohol and/or drugs, per diem Per Diem 24 Units 24 Per Calendar Year H0004HG
Behavioral health counseling and therapy, per 15 minutes (Individual Counseling) (QCC touch)
Per 15
Minutes See Note 1 H0005HG Alcohol and/or drug services; group counseling by a clinician Per Hour 135 Units
135 Per Calendar Year H0006HG Alcohol and/or drug services; case management Per Service 5 Units 1 Per Week H2027HG Psychoeducational service, per 15 minutes (Individual or Group) 15 Minutes See Note 2
J0571HG Buprenorphine, oral, 1 mg 1 mg Milligrams
J1230HG Injection, methadone HCI, up to 10 mg 1-10 mg Milligrams J2310HG Injection, naloxone HCI, per 1 mg (Narcan) 1 mg Milligrams J2315HG Injection, naltrexone, depot form, 1 mg 1 mg Milligrams P9612HG Collection of specimen, single patient (Venipuncture) Per Service See Note 3
S0109HG Methadone, oral, 5 mg 5 mg Milligrams
T1002HG RN services, up to 15 minutes (Vital signs) 15 Minutes T1003HG LPN/LVN services, up to 15 minutes (Vital signs) 15 Minutes T1007HG
Alcohol and/or substance abuse services, treatment plan development and/or modification (Includes client discharge
planning) Per Service See Note 5
T1012HG
Alcohol and/or substance abuse services, skills development
(Alternative activities) Per Service See Note 6
T1502HG Administration of oral, intramuscular and/or subcutaneous
medication by health care agency/professional, per visit Per Visit 365 Days
HAHB HBHDHD HBHDTG
HF HGHQ HT TJ
Per Episode Session Calendar Year Event
*Definitions
Length of stay for treatment.
A session is the period of time when a client is actively engaged in treatment.
Calendar year begins when a client enters a CDTF and concludes in 365 days (e.g., 2/20/2018 through 2/20/2019).
A single occurrence that occurs during the length of stay for treatment.
Program group, child and/or adolescent (youths), Ages 13-17 Note 8: Procedure codes H2027 and T1012 are billable as education.
*Modifiers
Child or adolescent program (youths), Ages 13-17 Adult program, non-geriatric - Ages 18-999
Pregnant or parenting women's program (adults), Ages 18-999 Specialized female
Women, children, and neonatal abstinence syndrome (NAS) Substance abuse program
Opioid addiction treatment program Group setting
Multi-disciplinary team
Note 7: T1002 and T1003 - Initial duties performed by an RN cannot be absorbed or completed by an LPN/LVN, and vice versa.
Table 7: Medication Assisted Treatment (MAT) - Methadone, Buprenorphine, and Naltrexone - Effective Date XX/XX/XXXX
HB;
HBHDTG;
and HA
See Note 4
Note 1: One unit equals 15 minutes. Week 1 through week 2 is limited to 18 units (4.5 hours per week); week 3 through week 4 is limited to 12 units (3 hours per week); and week 5 through 52 is limited to 8 units (2 hours per week). All claims submitted after one calendar year for H0004 Note 2: One unit equals 15 minutes. 4 units are allowed per month (One hour), 192 units per calendar year (48 hours).
Note 3: One unit equals one venipuncture. Year 1 is limited to 6 units; Year 2 is limited to 3 units; and Year 3 through length of treatment is limited to once per calendar year.
Note 4: The SUD-allowable fee is determined based on 15-minute increments. One unit equals 15 minutes. The recommended maximum billable time for direct nursing services if one hour per day (4 units) and 24 hours (96 units) per calendar year.
Note 5: One unit equals event. Year 1 is limited to 12 units; Year 2 is limited to 6 units; and Year 3 through length of treatment is limited to 3 per Note 6: One unit equals one hour. Year 1 is limited to 12 units and Year 2 through length of treatment is limited to once per calendar year.
