Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.06-083 - Child Health Management Services (CHMS) Update #71 and Section V Provider Manual Update
Current through Register Vol. 49, No. 9, September, 2024
Section V Provider Manual Update Transmittal
Section II
Child Health Management Services
Management Services (CHMS) Providers
Providers of Medicaid services must adhere to all applicable professional standards of care and conduct. Providers of Child Health Management Services (CHMS) must meet the following criteria in order to be eligible to participate in the Arkansas Medicaid Program:
For an academic medical center CHMS program, services may be provided at different sites operated by the academic medical center as long as the CHMS program falls under one administrative structure within the academic medical center.
OR
A request for certification/licensure must be directed in writing to each of the following organizations:
(licensure)
Subsequent certifications and license renewals must be submitted to the Medicaid Provider Enrollment Unit within thirty days of issue. If any of the renewal documents have not been received within this time period, the provider will have an additional, and final, 30 days to comply.
CHMS providers are required to maintain the following medical/clinical records.
Complete and accurate clinical records must be maintained for any patient who receives direct services from the CHMS clinic. Each record must contain, at a minimum, the following information:
The following additional records must be maintained for patients receiving treatment in pediatric day programs.
the Child Health Services (EPSDT) Program
The Arkansas Medical Assistance Program includes a Child Health Services (Early and Periodic Screening, Diagnosis and Treatment) Program for Medicaid beneficiaries under 21 years of age. The purpose of this program is to detect and treat health problems in their early stages.
The Arkansas Medical Assistance Program operates under a primary care case management (PCCM) system. A primary care physician (PCP) referral is required for all services not performed by the PCP, including an EPSDT Screen. A CHMS provider who is also a Child Health Services provider may perform an EPSDT Screen, with a PCP referral. The screen must be allowable within the periodicity schedule. However, if the EPSDT Screen is medically necessary but non-allowable due to the periodicity schedule it still may be performed with a PCP referral.
If a condition is diagnosed through a Child Health Services (EPSDT) Screen that requires treatment services not normally covered under the Arkansas Medicaid Program, those treatment services may be considered for coverage if they are medically necessary and permitted under federal Medicaid regulations. The PCP must prescribe and request consideration of coverage for services not otherwise covered in the Arkansas Medicaid State Plan by completing form DMS-693. This form must be submitted to the Utilization Review Section of the Division of Medical Services. View or print form DMS-693. View or print Utilization Review Section contact information.
CHMS providers interested in enrolling in the Child Health Services (EPSDT) Program should contact the Central Child Health Services Office. View or print the Central Child Health Services Office contact information.
If you are a Child Health Services (EPSDT) provider, please refer to the Child Health Services (EPSDT) manual for additional information.
Requirements for Children Ages Birth to Three
Part C of the Individuals With Disabilities Education Act (IDEA) mandates the provision of early intervention services to infants and toddlers from birth to thirty-six months of age. Part C and subsequent state legislation require that specific rules and regulations be adhered to by providers of these services to infants and toddlers regardless of funding sources or methods of service provision. The Division of Developmental Disabilities within the Department of Health and Human Services has been designated as the lead agency for the First Connections Program (Part C) in Arkansas. As mandated by Part C, it is the responsibility of the lead agency to ensure that a statewide comprehensive system of services is in place which meets all federal, state and local rules and regulations. Therefore, the Division of Developmental Disabilities has developed the following requirements:
All referrals of children, from birth to thirty-six months of age, to the CHMS program must be in turn referred to First Connections, the Arkansas Infant and Toddler Program, within two working days. Referrals may be made through the DDS Service Coordinator for the child's county of residence or directly to a licensed DDS community services provider facility.
Evaluations conducted by CHMS must meet the First Connections procedural requirements as mandated by Part C of the Individuals With Disabilities Education Act and Developmental Disabilities Services Policy. Each evaluation conducted must be multi-disciplinary in nature and must include:
Upon completion of the evaluation, a copy shall be sent to the First Connections Service Coordinator or the central fax number. View or print the Central Child Health Services number.
Services provided under the CHMS program must meet the First Connections procedural requirements, as mandated by Part C of the Individuals With Disabilities Education Act and Developmental Disabilities Services Policy.
CHMS staff must participate in transition conferences scheduled for children for whom the transition process to Part B (within 180 days of the child's third birthday) has begun. Evaluations completed by CHMS and administered within the transition period must meet the requirements of the Local Educational Cooperative's Early Childhood Program.
Parti cipation in the First Connections program is voluntary; however, CHMS staff may not solicit parent refusal. All family choice options for early intervention services must be presented to the family by the First Connections Service Coordinator.
Developmental Disabilities Services, as the lead agency for First Connections, the Arkansas Infant and Toddler Program, has responsibility, as mandated by Part C of IDEA, for the monitoring and supervision of all early intervention services provided to infants and toddlers who meet the eligibility criteria for the Part C program. The First Connections staff will conduct monitoring with regularly scheduled monitoring visits and technical assistance visits as needed to assist early intervention programs in meeting federal, state and local rules and regulations governing the First Connections Program. CHMS must provide access to all records pertaining to children enrolled in the program who are ages 0-36 months. CHMS staff must implement recommendations made as a result of monitoring and technical assistance visits and will receive a written report from First Connections and, as necessary, a corrective action plan.
Local education agencies (LEAs), either individually or through an Education Services Cooperative (ESC), have the responsibility for ensuring a free, appropriate public education to children with disabilities aged 3 to 5 years.
View or print the Arkansas Department of Education Special Education contact information.
Medicaid (Medical Assistance) is designed to assist Medicaid beneficiaries in obtaining medical care within the guidelines specified in Section I of this manual. Reimbursement may be made for Child Health Management Services (CHMS) provided to Medicaid beneficiaries at qualified provider facilities.
Child Health Management Services (CHMS) comprises an array of clinic services intended to provide full medical multi-discipline diagnosis, evaluation and treatment for the purpose of intervention, treatment and prevention of long term disability for Medicaid beneficiaries.
Beneficiaries of Child Health Management Services must have a problem-related diagnosis. These services are not designed to be used as a well-child check-up.
Entry into the CHMS clinic system will begin with a referral from the patient's primary care physician (PCP). The PCP's approval of the plan for treatment must be in place to initiate care.
Medical personnel and health service delivery in a CHMS clinic must be under the medical supervision, control and responsibility of a physician currently licensed in the state of Arkansas. The physician must possess documentable skills in a specific CHMS sub-specialty area as documented by annual continuing medical education (CMEs) in areas relevant to developmental pediatrics, or a practice population composed of 25% patients that have developmental concerns/delays/disabilities/risks.
The supervising physician must direct the development of individualized treatment plans.
The supervising physician shall ensure that the CHMS provider has written procedures which include an outline of the medical tasks involved in patient care and specify to whom such tasks may be delegated as well as the criteria and procedures for patient referral.
The physician must make certain the procedures conform to good medical practices of the community, and must review and update the procedures at least annually. The procedures must be on file at the clinic and made available for review at all times.
A facility used for the provision of Child Health Management Services. Each facility must be enrolled with Medicaid to obtain a unique number for billing purposes. Administrative, financial, clinical and managerial responsibility for the clinic may rest with a provider organization.
Clinic services are defined as preventive, diagnostic, therapeutic, rehabilitative or palliative items or services that are:
The Arkansas Department of Health and Human Services and its designated representatives.
The entity responsible for the operation of a CHMS clinic.
The following standards must be met or exceeded by all Child Health Management Services clinics in the state of Arkansas.
The CHMS clinic must adopt policies and procedures which safeguard patient legal, civil and human rights including, but not limited to:
Referral to a CHMS clinic may be made for any medically indicated reason as identified by the primary care physician (PCP). This referral can be made for diagnosis and/or treatment. The population typically served by CHMS providers is defined as follows:
"Children with Special Health Care Needs (CSHCN) are those who have or are at increased risk of chronic physical, developmental, behavioral, or emotional conditions and who require health and related services of a type or amount beyond that required by children generally," as defined by the Bureau of Maternal and Child Health.
CHMS are a combination of diagnostic and daily trans-disciplinary treatment programs and are a melding of developmental, medical, health and therapeutic services, some of which might be considered only educational or social. The medical aspect of these children's special needs and their needs for care by specially trained personnel makes these services health care.
Factors to be considered in determining the appropriateness of accepting a patient into the Intervention/Treatment Services Component of a CHMS program are provided below.
An individualized treatment plan must be developed by the interdisciplinary CHMS team in order to address the varied health and developmental needs of each patient.
The presence of a significant medical diagnosis may be adequate to identify a child in need of Child Health Management Services. The following, though not a complete list, are examples of diagnoses that may indicate a child in need of care. The current clinical medical records relied upon to substantiate or support the diagnosis that establishes the need for services must accompany all requests for prior authorization or extension of benefits.
AIDS
Cerebral Degeneration
Child Maltreatment Syndrome (abuse or neglect) - must provide documentation of when and what events occurred and evidence of involvement of DHHS in current social situation.
Chronic Renal Failure
CMV
Congenital Heart Disease
Congenital Hypothyroidism
Cystic Fibrosis
Down's Syndrome
Encepholomalacia
Esophageal Atresia
Failure to Thrive - must provide documentation and detailed history, medical evaluation, nutritional evaluation and up-to-date growth chart.
Gastroschisis
HIV - must provide documentation of medical treatments and necessity of daily medical care.
Hydrocephaly with Shunt
Hypopituitarism
Hypoxic Hemmorraghic Encephalopathy
Lead Poisoning - must document lead level and extent of injury
Macrocephaly - must have documented head circumference on growth chart and medical evaluation with results of MRI, CT, etc.
Metabolic Disorder
Microcephaly - must have documented head circumference on growth chart and medical evaluation with results of MRI, CT, etc.
Neuroblastoma
Newborn Intraventricular Hemorrhage - document degree of hemorrhage
Periventricular Leukomalacia
Prematurity (less than 36 weeks gestation) - must include documentation of neonatal course and any additional significant medical problems for a child less than 12 months of age.
Prenatal Drug/Alcohol Exposure - documentation of extent of exposure and medical effects of exposure.
Seizure Disorder - does not include febrile seizures. Documentation to include medications, type and frequency of seizures.
Sickle Cell Disease - documentation of actual disease, not trait. Documentation should include history of treatment for the disease.
Spina Bifida
Tracheomalacia
Tuberous Sclerosis and Other Neurodermatoses
Various Syndromes/Severity Determined by Physician
A medical diagnosis alone will not adequately document the necessity for CHMS. Documentation must include a complete medical evaluation by a pediatrician or pediatric specialist to include a history and physical. There must be documentation to support the need for ongoing intervention by a medical multi-disciplinary diagnosis and treatment team within a CHMS clinic.
Trauma/Risk/Neglect
This type of care is characterized by a less significant medical-developmental diagnosis which is coupled with one or more additional medical or developmental diagnoses and/or social-emotional trauma/risk/neglect.
These patients are at great risk for poor outcomes without appropriate intervention and management of the array of services they warrant. Despite multiple diagnoses, these patients respond rather quickly to appropriate treatment and may not require an extended period of services.
Documentation supporting the social-emotional trauma/risk/neglect must be furnished. If the child is documented to live in a high-risk environment, specific information regarding current living arrangements, custody issues and DHHS involvement is required. The current clinical medical records and documentation relied upon to substantiate or support the diagnosis that establishes the need for services must accompany all requests for prior authorization or extension of benefits.
Examples (not intended to be all inclusive) of combined diagnoses:
Children in need of this type of care require a core of services including assessment, treatment planning, developmental and medical intervention, periodic medical monitoring and may require ancillary therapy services of some sort. Parent education and service coordination are of extreme importance for those children experiencing social/emotional trauma or neglect. Without this additional service, the period of treatment services will be extended or have less likelihood of accomplishing the desired normalizing outcomes for the child.
Appropriate CHMS professionals may justify care authorization with medical evaluation, developmental testing and speech or psychological evaluation. Social history and/or completion of a standardized interview to determine risk factors may be indicated. Nutritional evaluation to support diagnosis and plan of care will be appropriate for some diagnoses.
Under the direction of a CHMS physician, a team of CHMS professionals will initiate an evaluation of each patient to establish a comprehensive range of diagnoses presented by the patient. This team will be informed by the parent/patient concerns, medical history and the current physical condition of the patient. The initial diagnosis by the medical director will determine the area of expertise of the additional team members. Multi-Disciplinary Diagnosis and Evaluation services are available to patients from birth to age 21.
Initial diagnosis and evaluation services are considered to be a complete service if this is the reason for referral from the PCP. Ongoing diagnosis and evaluation are a component of the intervention/treatment services offered at clinic sites.
Completion of an adequate evaluation is necessary to justify treatment.
Prior authorization does not apply to the Medical Multi-Disciplinary Diagnosis and Evaluation. PCP referral is required.
Under the direction of a CHMS physician and with input from the diagnostic evaluation team, an individualized treatment plan will be developed. This plan will include physician orders/prescription for services to be provided. A PCP referral/approval/prescription will be obtained when required. This includes occupational, physical and speech therapy services.
A separate PCP referral and prescription is required for occupational, physical and speech therapy services. The PCP must use form DMS-640 when making referrals and prescribing occupational, physical or speech therapy services. View or print form DMS-640. A copy of the prescription must be maintained in the child's record. If occupational, physical and speech therapy sessions are missed, make-up therapy services must not exceed the prescribed number of minutes per week without a PCP prescription.
The CHMS physician will determine the appropriate treatment to address the diagnosis, treatment needs and family concerns identified during evaluation.
For those children receiving intervention/treatment services on a daily/weekly basis, the individualized treatment plan will be written for a period of 12 months and will be updated as needed. The treatment plan for children birth to 3 years of age may be in the form of the state accepted Individualized Family Services Plan (IFSP). A continuing PCP referral is required every 6 months.
Prior authorization is required for admission into the CHMS program and for treatment procedures. Intervention/treatment services must be included in the individual treatment plan to be considered for coverage. Refer to Section 262.120 for a listing of the treatment procedure codes that require prior authorization.
Diagnosis/Evaluation
The deadline for receipt of the reconsideration request will be enforced pursuant to sections 190.012 and 190.013 of this manual. A request received by AFMC within 35 calendar days of a denial will be deemed timely. A request received later than 35 calendar days will be considered on an individual basis. Reconsideration requests must be mailed and will not be accepted via facsimile.
The steps in the intake process are as follows:
Need for Child l-iealth IVIanagement Services
Intervention and treatment services for IVIedicaid beneficiaries must be prior authorized in accordance with the following procedures.
The request must include a report of the findings from evaluations and a current plan for treatment. Review for medical necessity will be performed on the information sent by the provider. This information must substantiate the need for the child to receive services in a multidisciplinary CHMS clinic.
Refer to the flow chart in Section 244.000 of this manual for the process outlined above.
When an adverse decision for prior authorization of services is received from AFMC, the beneficiary may request a fair hearing of the reconsideration decision of the denial of services from the Department of Health and Human Services.
The appeal request must be in writing and received by the Appeals and Hearings Section of the Department of Health and Human Services within thirty days of the date on the letter from AFMC explaining the denial.
Submit appeal requests to the Department of Health and Human Services (DHHS), Appeals and Hearings Section. View or print Appeals and Hearings Section contact information.
A provider may request reconsideration of a Program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed. Regardless of the Program decision the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the Program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the division within 20 calendar days of receipt of the request for review or the date of the Program/Provider conference.
If the decision of the Division of Medical Services Assistant Director is unsatisfactory, the provider may appeal to the standing Rate Review Panel established by the Director of the Division of Medical Services. This panel will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Health and Human Services Management Staff, who will serve as chairman.
The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.
CHMS providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to Medicaid beneficiaries. Each claim may contain charges for only one beneficiary.
Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claims submission.
The following diagnosis/evaluation procedure codes are limited to two (2) diagnosis and evaluation encounters per state fiscal year (July 1 through June 30). If additional diagnosis and evaluation procedures are required, the CHMS provider must request an extension of benefits.
|
Procedure Codes |
||||
|
90805 |
90807 |
90809 |
92506 |
92551 |
|
92552 |
92553 |
92555 |
92557 |
92567 |
|
92582 |
92585 |
92587 |
92588 |
96105 |
|
96111 |
96118* |
99201 |
99202 |
99203 |
|
99204 |
99205 |
|||
*Effective for dates of service on and after March 1, 2006, procedure code 96117 was made non-payable and was replaced with procedure code 96118.
|
Procedure Code |
Required Modifier(s) |
Description |
|
90801 |
Diagnostic evaluation/review of records (1 unit = 15 minutes), maximum of 3 units; limited to 6 units per state fiscal year |
|
|
90887 |
Interpretation of diagnosis (1 unit = 15 minutes), maximum of 3 units; limited to 6 units per state fiscal year |
|
|
96101 |
UA, UB |
Psychological testing battery (1 unit = 15 minutes), maximum of 4 units; limited to 8 units per state fiscal year Effective for dates of service on and after March 1, 2006, procedure code 96100 was replaced with procedure code 96101. |
|
97001 |
Evaluation for physical therapy (1 unit = 30 minutes), maximum of 4 units per state fiscal year |
|
|
97003 |
Evaluation for occupational therapy (1 unit = 30 minutes), maximum of 4 units per state fiscal year |
|
|
97802 |
Nutrition Screening: Review of recent nutrition history, medical record, current laboratory and anthropometric data and conference with patient, caregiver or other CHMS professional (1 unit = 15 minutes). Maximum of 2 units; limited to 4 units per state fiscal year |
|
|
97802 |
U1 |
Nutrition Assessment: Assessment/evaluation of current nutritional status through history of nutrition, activity habits and current laboratory data, weight and growth history and drug profile; determination of nutrition needs; formulation of medical nutrition therapy plan and goals of treatment; a conference will be held with parents and/or other CHMS professionals or a written plan for medical nutrition therapy management will be provided (1 unit = 15 minutes). Maximum of 2 units; limited to 4 units per state fiscal year |
|
97802 |
U2 |
Comprehensive Nutrition Assessment: Assessment/evaluation of current nutritional status through initial history of nutrition, activity and behavioral habits; review of medical records; current laboratory data, weight and growth history, nutrient analysis and current anthropometric data (when available); determination of energy, protein, fat, carbohydrate and macronutrient needs; formulation of medical nutrition therapy plan and goals of treatment. May conference with parent(s)/guardian or caregivers and/or physician for implementation of medical nutrition therapy management or provide a written plan for implementation (1 unit = 15 minutes). Maximum of 4 units; limited to 8 units per state fiscal year |
The following treatment procedures are payable for services included in the child's treatment plan. Prior authorization is required for all CHMS treatment procedures. See section 240.000 of this manual for prior authorization requirements.
|
Procedure |
Codes |
|||
|
90804 |
90806 |
90808 |
90847 |
90849 |
|
97762* |
99211 |
99212 |
99213 |
99214 |
|
99215 |
*Effective for dates of service on and after March 1, 2006, procedure code 97703 was made non-payable and was replaced with procedure code 97762.
|
Procedure Code |
Required Modifier(s) |
Description |
|
T1024 |
Brief Consultation, on site - A direct service contact by a CHMS professional on-site with a patient for the purpose of: obtaining the full range of needed services; monitoring and supervising the patient's functioning; establishing support for the patient and gathering information relevant to the patient's individual treatment plan. |
|
|
T1024 |
U1 |
Collateral Services, on site - Face-to-face contact on-site by a CHMS professional with other professionals, caregivers or other parties on behalf of an identified patient to obtain or provide relevant information necessary to the patient's assessment, evaluation or treatment. |
|
90846 |
U4 |
Family therapy, on-site, for therapy as part of the treatment plan, without the patient present (1 unit = 15 minutes) |
|
90847 |
U4 |
Family therapy, on site, for therapy as part of the treatment plan, with the patient present (1 unit = 15 minutes) |
|
97150 |
Group occupational therapy (1 unit = 15 minutes), maximum of 4 clients per group |
|
|
99361 |
UA |
Treatment Plan - Plan of treatment developed by CHMS professionals and the patient's caregiver(s). Plan must include short- and long-term goals and objectives and include appropriate activities to meet those goals and objectives (1 unit = 15 minutes). |
|
H2011 |
- |
Crisis Management Visit, on site - An unscheduled/ unplanned direct service contact on site with the identified patient for the purpose of preventing physical injury, inappropriate behavior or placement in a more restrictive service delivery system (one unit = 15 minutes) |
|
S9470 |
- |
Nutrition Counseling/Consultation - Conference with parent/guardian and/or PCP to provide results of evaluation, discuss medical nutrition therapy plan and goals of treatment and education. May provide detailed menus for home use and information on sources of special nutrition products (1 unit = 30 minutes) |
|
90853 |
- |
Group Psychotherapy/counseling (1 unit = 5 minutes) |
|
92507 |
- |
Individual Speech Session (1 unit = 15 minutes) |
|
92507 |
UB |
Individual Speech Therapy by Speech-Language Pathology Assistant (1 unit = 15 minutes) |
|
92508 |
- |
Group Speech Session (1 unit = 15 minutes), maximum of 4 clients per group |
|
92508 |
UB |
Group Speech Therapy by Speech-Language Pathology Assistant (1 unit = 15 minutes), maximum of 4 clients per group |
|
97110 |
- |
Individual Physical Therapy (1 unit = 15 minutes) |
|
97110 |
UB |
Individual Physical Therapy by Physical Therapy Assistant (1 unit = 15 minutes) |
|
97150 |
- |
Group Physical Therapy (1 unit = 15 minutes), maximum of 4 clients per group |
|
97150 |
U2 |
Group Occupational Therapy (1 unit = 15 minutes), maximum of 4 clients per group |
|
97150 |
U1, UB |
Group Occupational Therapy by Occupational Therapy Assistant (1 unit = 15 minutes), maximum of 4 clients per group |
|
97150 |
UB |
Group Physical Therapy by Physical Therapy Assistant (1 unit = 15 minutes), maximum of 4 clients per group |
|
97530 |
- |
Individual Occupational Therapy (1 unit = 15 minutes) |
|
97530 |
UB |
Individual Occupational Therapy by Occupational Therapy Assistant (1 unit = 15 minutes) |
|
97530 |
U1 |
Developmental Motor Activity Services - Individualized activities provided by, or under the direction of, an Early Childhood Developmental Specialist to improve general motor skills by increasing coordination, strength and/or range of motion. Activities will be directed toward accomplishment of a motor goal identified in the patient's individualized treatment plan as authorized by the responsible CHMS physician (1 unit = 15 minutes) |
|
97532 |
- |
Cognitive Development Services - Individualized activities to increase the patient's intellectual development and competency. Activities will be those appropriate to carry out the treatment plan for the patient as authorized by the responsible CHMS physician. Cognitive Development Services will be provided by or under the direction of an Early Childhood Developmental Specialist. Activities will address goals of cognitive and communication skills development: (1 unit = 15 minutes). |
|
97535 |
UB |
Self Care and Social/Emotional Developmental Services - Individualized activities provided by or under the direction of an Early Childhood Developmental Specialist to increase the patient's self-care skills and/or ability to interact with peers or adults in a daily life setting/situation. Activities will be those appropriate to carry out the treatment plan for the patient as authorized by the responsible CHMS physician. (1 unit = 15 minutes). |
|
97803 |
- |
Nutrition follow-up: Reassess recent nutrition history, new anthropometer and laboratory data to evaluate progress toward meeting medical nutritional goals. May include a conference with parent or other CHMS professional (1 unit = 15 minutes). |
Refer to section 202.000 of this manual for Arkansas Medicaid Participation Requirements for Providers of Comprehensive Health Assessments for Foster Children.
The following procedure codes are to be used for the mandatory comprehensive health assessments of children entering the Foster Care Program. Claims for these codes must be billed with a type of service (TOS) code "M " when filled on paper. These procedures do not require prior authorization.
|
Procedure Code |
Required Modifier(s) |
Description |
|
T1016 |
Informing (1 unit = 15 minutes), maximum of 4 units |
|
|
T1023 |
Staffing (1 unit = 15 minutes), maximum of 4 units |
|
|
T1025 |
Developmental Testing |
|
|
90801 |
U1 |
Diagnostic Interview, includes evaluation and reports (1 unit = 15 minutes), maximum of 8 units |
|
92506 |
U1 |
Speech Testing (1 unit = 15 minutes), maximum of 8 units |
|
92551 |
U1 |
Audio Screen |
|
92567 |
U1 |
Tympanometry |
|
92587** |
U1 |
Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products) |
|
95961 |
UA |
Cortical Function Testing |
|
96101* |
U1, UA |
Psychological Testing, 2 or more (1 unit = 15 minutes), maximum of 8 units |
|
96101* |
UA |
Interpretation (1 unit = 15 minutes), maximum of 8 units |
|
99173 |
Visual Screen |
|
|
99205 99215 |
U1 U1 |
High Complex medical exam |
* Effective for dates of service on and after March 1, 2006, procedure code 96100 was made non-payable and was replaced with procedure code 96101.
** Effective for dates of service on and after January 1, 2007, procedure code 92587 is payable as a comprehensive health assessment procedure for foster children.
