Billing Unit PRTF Waiver W5014 W5026 W5027 W5028 W5015 W5029 W5030 W5031 W5012 W5032 W5033 W5034 W5013 W5035 W5036 W5037 Art Therapy Individual ‐ certified Art Therapy Individual ‐ certified Art Therapy Individual ‐ licensed Art Therapy Individual ‐ licensed Art Therapy Group ‐ certified Art Therapy Group ‐ certified Art Therapy Group ‐ licensed Art Therapy Group ‐ licensed Dance Therapy Individual ‐ certified Dance Therapy Individual ‐ certified Dance Therapy Individual ‐ licensed Dance Therapy Individual ‐ licensed Dance Therapy Group ‐ certified Dance Therapy Group ‐ certified Dance Therapy Group ‐ licensed Dance Therapy Group ‐ licensed 45‐50 min 75‐80 min 45‐50 min 75‐80 min 45‐60 min 75‐80 min 45‐60 min 75‐80 min 45‐50 min 75‐80 min 45‐60 min 75‐80 min 45‐60 min 75‐80 min 45‐60 min 75‐80 min W5010 Equine Assisted Therapy Individual ‐ certified W5044 Rate 2013 CPT/Rev Code Service Description Max Daily Unit/ Service Limit Place of Service $62.19 $80.85 $68.41 $89.62 $24.16 $31.41 $27.20 $35.36 $62.19 $80.85 $68.41 $89.62 $24.16 $31.41 $27.20 $35.36 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 45‐50 min $62.19 1 99 Equine Assisted Therapy Individual ‐ certified 75‐80 min $80.85 1 99 W5045 Equine Assisted Therapy Individual ‐ licensed 45‐50 min $68.41 1 99 W5046 Equine Assisted Therapy Individual ‐ licensed 75‐80 min $89.62 1 99 W5011 Equine Assisted Therapy Group ‐ certified 45‐60 min $24.16 1 99 W5047 Equine Assisted Therapy Group ‐ certified 75‐80 min $31.41 1 99 W5048 Equine Assisted Therapy Group ‐ licensed 45‐60 min $27.20 1 99 W5049 Equine Assisted Therapy Group ‐ licensed 75‐80 min $35.36 1 99 W5020 Horticultural Therapy Individual ‐ certified 45‐50 min $62.19 1 99 W5050 Horticultural Therapy Individual ‐ certified 75‐80 min $80.85 1 99 W5051 Horticultural Therapy Individual ‐ licensed 45‐50 min $68.41 1 99 W5052 Horticultural Therapy Individual ‐ licensed 75‐80 min $89.62 1 99 W5021 W5053 W5054 W5055 Horticultural Therapy Group ‐ certified Horticultural Therapy Group ‐ certified Horticultural Therapy Group ‐ licensed Horticultural Therapy Group ‐ licensed 45‐60 min 75‐80 min 45‐60 min 75‐80 min $24.16 $31.41 $27.20 $35.36 99 99 99 99 W5022 Face to face caregiver peer to peer support 15 min 15.97 15 min $7.89 15 min 1 45‐50 min 75‐80 min 45‐50 min 75‐80 min 45‐60 min 75‐80 min 45‐60 min 75‐80 min 45‐50 min 75‐80 min 45‐50 min 75‐80 min 45‐60 min 75‐80 min $25.62 $307.39 $62.19 $80.85 $68.41 $89.62 $24.16 $31.41 $27.20 $35.36 $62.19 $80.85 $68.41 $89.62 $24.16 $31.41 1 1 1 1 8/11 hrs per month 8/16 hrs per month 12 hrs 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 W5023 W5024 W5025 W5016 W5038 W5039 W5040 W5017 W5041 W5042 W5043 W5018 W5056 W5057 W5058 W5019 W5059 Collateral (telephonic) caregiver peer to peer support Mobile Crisis and Stabilization Crisis Assessment Music Therapy Individual ‐ certified Music Therapy Individual ‐ certified Music Therapy Individual ‐ licensed Music Therapy Individual ‐ licensed Music Therapy Group ‐ certified Music Therapy Group ‐ certified Music Therapy Group ‐ licensed Music Therapy Group ‐ licensed Drama Therapy Individual ‐ certified Drama Therapy Individual ‐ certified Drama Therapy Individual ‐ licensed Drama Therapy Individual ‐ licensed Drama Therapy Group ‐ certified Drama Therapy Group ‐ certified 11,12,99 11,12,99 12,99 12,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 11,99 W5060 W5061 Drama Therapy Group ‐ licensed Drama Therapy Group ‐ licensed 45‐60 min 75‐80 min $27.20 $35.36 1 1 11,99 11,99 W5000 Respite Care In Home/Commuinty Based 1 Hour $25.16 6/6hrs per day 12,99 W5001 Respite Care Residential/Out of Home 1 Hour $199.44 1/24 units per waiver year 12,99 W5062 Intensive In Home Services Weekly $248.90 (EBP rate) 1 12 W5063 Intensive In Home Services weekly 1 12 W5066 Customized Good and Services $2000.00 max 99 MDRN Grant Program (formerly ATR) MDRN1 Half Way House (clinical) MDRN2 Recovery/Supported Housing MDRN3 RSAM Intake interview MDRN4 Care Coordination Check‐ins Daily Daily Unit Unit MDRN5 Transportation MDRN6 Vital Documents MDRN7 MDRN8 MDRN9 MDRN0 Gap Services‐Transitional Services Gap Service‐ clothing Gap Services‐Support Services Gap Services‐Medical Unit (2 documents) Unit Unit Unit Unit $197.47 (non‐EBP rate) Billed Charges $50.00 $22.00 $100.00 $12.00 individualized by provider 30 day max 30 day max I Unit 24 Units $50.00 2 Units 57, 99 $1.00 $1.00 $1.00 $1.00 50 Units 50 Units 150 Units 250 Units 57, 99 57, 99 57, 99 57, 99 55, 99 14, 99 57, 99 57, 99 99 Maximum payment per consumer = $3,000.00 Grant Funded Services ‐ no claims payment, registration request only through ProviderConnect T1027 Early Intervention 0.5 * $0.00 * T1027‐TS Continuing Care * $0.00 * 57, 99 57, 99 T2022 H0038 H2034 H0043 H0013 1004 0660 H0012 1005 H0010 Coordination of Care Recovery Coaching Halfway House 3.1 Recovery/Supported Housing Detox (Level 2) Moderate Intensity Residential 3.3 Moderate Intensity Residential 3.5 Detox (Level 3.2) High Intensity Residential 3.7 Detox (Level 3.7 D) * = Data Collection Only * * * * * * * * * * $0.00 * $0.00 * $0.00 * $0.00 * $0.00 * $0.00 * $0.00 * $0.00 * $0.00 * $0.00 * 57, 99 57, 99 55, 99 14, 99 57, 99 55, 99 55, 99 55, 99 55, 99 55, 99
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