Rate Provisions

(1) Rates as Full Compensation. The rates under 101 CMR 306.00 constitute full compensation for mental health services provided by community health centers and mental health centers to publicly aided and industrial accident patients, including full compensation for necessary administration and professional supervision associated with patient care. (2) Rates of Payment. Except as otherwise provided in 101 CMR 306.03(5)(d), payment rates under 101 CMR 306.00 must be the lower of (a) the eligible provider's usual charge to the general public; or (b) the schedule of allowable rates for services provided by mental health centers and community health centers as set forth in 101 CMR 306.03(5)(a), and for services provided by mental health centers designated as behavioral urgent care providers, as set forth in 101 CMR 306.03(5)(b). (3) Child and Adolescent Needs and Strengths (CANS). Psychiatric diagnostic interview examination for children and adolescents younger than 21 years old. Eligible clinicians who complete the CANS for a MassHealth child or adolescent younger than 21 years old during a psychiatric diagnostic interview examination must use procedure code 90791 accompanied by a modifier -HA to bill for the service. (4) Modifiers. (a) -25: Significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health professional on the same day of the procedure or other service. Modifier -25 applies to two E/M services provided on the same day. (b) -59: Distinct Procedure Service. To identify a procedure distinct or independent from other services performed on the same day add the modifier -59 to the end of the appropriate service code. Modifier 59 is used to identify services/procedures that are not normally reported together but are appropriate under certain circumstances. However, when another already established modifier is appropriate, it should be used rather than modifier -59. (c) -AF: Specialty physician. (This modifier is to be applied to service codes billed by the mental health center that were performed by a psychiatrist.) (d) -AH: Clinical psychologist. (This modifier is to be applied to service codes billed by the mental health center that were performed by a doctoral-level clinician, including PhD, PsyD, or EdD.) (e) -EP: Group psychotherapy modifier for preventive behavioral health session (only used with 90853). (f) -HA: Child/adolescent program (only used with 90791 and H2013). (g) -HB: Adult program nongeriatric (only used with H2013). (h) -HE: Mental health program (certified peer specialist services). (i) -HL: Intern. (This modifier is to be applied to service codes billed by the mental health center that were performed by an intern-level clinician, including post-doctoral fellows and psychology interns, post-master’s mental health counselors and mental health counselor interns, post-master's marriage and family therapist, licensed alcohol and drug counselor IIs [LADC II], certified addiction counselor/certified alcohol and drug abuse counselor.) (j) -HO: Master’s Degree Level. (This modifier is to be applied to service codes billed by the mental health center that were performed by a master’s level clinician, including licensed clinical social worker [LCSWs], licensed independent clinical social workers [LICSWs], licensed alcohol and drug counselor I, licensed mental health counselor, or licensed marriage and family therapist) (k) -SA: Nurse practitioner rendering service in collaboration with a physician. (This modifier is to be applied to service codes billed by the mental health center that were performed by an advanced practice registered nurse.) (l) -UG: Child Psychiatrist. (This modifier is to be applied to service codes billed by the mental health center that were performed by a registered child psychiatrist.) (5) Fee Schedule. (a) Allowable fee for community health centers and mental health centers. Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG) Payment Rate for service codes performed by a psychiatrist (Modifier - AF) Payment Rate for service codes performed by a doctoral- level clinician (Modifier - AH) Payment Rate for service codes performed by a master’s- level clinician (Modifier - HO) Payment Rate for service codes performed by an intern (Modifier - HL) 183.87 Psychiatric diagnostic evaluation 90791-HA Psychiatric diagnostic evaluation performed with a CANS (Children and Adolescent Needs and Strengths) --- --- --- Psychiatric diagnostic evaluation with medical services Psychotherapy, 30 minutes with patient Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure.) Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG) Payment Rate for service codes performed by a psychiatrist (Modifier - AF) Payment Rate for service codes performed by a doctoral- level clinician (Modifier - AH) Payment Rate for service codes performed by a master’s- level clinician (Modifier - HO) Payment Rate for service codes performed by an intern (Modifier - HL) Psychotherapy, 45 minutes with patient Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure.) Psychotherapy, 60 minutes with patient Psychotherapy for crisis; first 60 minutes Psychotherapy for crisis; each additional 30 minutes (List separately in addition to the code for primary procedure.) Family psychotherapy (without the patient present), 50 minutes Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes Multiple family group psychotherapy (per person per session not to exceed 10 clients) Group psychotherapy (other than multiple family group) (per person per session not to exceed 12 clients) Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG) Payment Rate for service codes performed by a psychiatrist (Modifier - AF) Payment Rate for service codes performed by a doctoral- level clinician (Modifier - AH) Payment Rate for service codes performed by a master’s- level clinician (Modifier - HO) Payment Rate for service codes performed by an intern (Modifier - HL) 90853-EP Group psychotherapy (other than of a multiple family group) (per person not to exceed 12 clients) (preventive behavioral health session) Environmental intervention for medical management purposes on a psychiatric patient’s behalf with agencies, employers, or institutions Interpretation or explanation of results of psychiatric, or other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient Preparation of report of patient’s psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other individuals, agencies, or insurance carriers Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG) Payment Rate for service codes performed by a psychiatrist (Modifier - AF) Payment Rate for service codes performed by a doctoral- level clinician (Modifier - AH) Payment Rate for service codes performed by a master’s- level clinician (Modifier - HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. --- --- --- Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. --- --- --- Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG) Payment Rate for service codes performed by a psychiatrist (Modifier - AF) Payment Rate for service codes performed by a doctoral- level clinician (Modifier - AH) Payment Rate for service codes performed by a master’s- level clinician (Modifier - HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. --- --- --- Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified healthcare professional. --- --- --- Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG) Payment Rate for service codes performed by a psychiatrist (Modifier - AF) Payment Rate for service codes performed by a doctoral- level clinician (Modifier - AH) Payment Rate for service codes performed by a master’s- level clinician (Modifier - HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. --- --- --- Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG) Payment Rate for service codes performed by a psychiatrist (Modifier - AF) Payment Rate for service codes performed by a doctoral- level clinician (Modifier - AH) Payment Rate for service codes performed by a master’s- level clinician (Modifier - HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. --- --- --- Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the outpatient Evaluation and Management service.) Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG) Payment Rate for service codes performed by a psychiatrist (Modifier - AF) Payment Rate for service codes performed by a doctoral- level clinician (Modifier - AH) Payment Rate for service codes performed by a master’s- level clinician (Modifier - HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour --- --- --- Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes (List separately in addition to code for primary procedure.) Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG) Payment Rate for service codes performed by a psychiatrist (Modifier - AF) Payment Rate for service codes performed by a doctoral- level clinician (Modifier - AH) Payment Rate for service codes performed by a master’s- level clinician (Modifier - HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Neurobehavioral status exam (clinical assessment of thinking, reasoning, and judgment, [e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified healthcare professional, both face-to- face time with the patient and time interpreting test results and preparing the report; first hour --- --- --- Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified healthcare professional, both face-to- face time with the patient and time interpreting test results and preparing the report; each additional hour (List separately in addition to code for primary procedure.) Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG) Payment Rate for service codes performed by a psychiatrist (Modifier - AF) Payment Rate for service codes performed by a doctoral- level clinician (Modifier - AH) Payment Rate for service codes performed by a master’s- level clinician (Modifier - HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Psychological testing evaluation services by physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour --- --- --- Psychological testing evaluation services by physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure.) Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG) Payment Rate for service codes performed by a psychiatrist (Modifier - AF) Payment Rate for service codes performed by a doctoral- level clinician (Modifier - AH) Payment Rate for service codes performed by a master’s- level clinician (Modifier - HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Neuropsychological testing evaluation services by physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour --- --- --- Neuropsychological testing evaluation services by physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure.) Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG) Payment Rate for service codes performed by a psychiatrist (Modifier - AF) Payment Rate for service codes performed by a doctoral- level clinician (Modifier - AH) Payment Rate for service codes performed by a master’s- level clinician (Modifier - HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Psychological or neuropsychological test administration and scoring by physician or other qualified healthcare professional, two or more tests, any method; first 30 minutes --- --- --- Psychological or neuropsychological test administration and scoring by physician or other qualified healthcare professional, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure.) --- --- --- Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes --- --- --- Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure.) Service Code Payment Rate S9480 Intensive outpatient psychiatric services, per diem. H0015 Rate as indicated in 101 CMR 444.00: Rates for Certain Substance Use Disorder Services 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 (Structured Outpatient Addiction Program, 3.5 hours, not to exceed 2 units a day). H0015-TF Rate as indicated in 101 CMR 444.00: Rates for Certain Substance Use Disorder Services 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 (Enhanced Structured Outpatient Addiction Program, 3.5 hours, not to exceed 2 units a day). H0046-HE Mental health services, not otherwise specified (certified peer specialist services) H2016-HM Rate as indicated in 101 CMR 346.00: Rates for Certain Substance- related and Addictive Disorders Programs Comprehensive community support program, per diem (Enrolled Client Day) (recovery support service by a recovery advocate trained in peer recovery coaching) Service Code Payment Rate H2015-HF Rate as indicated in 101 CMR 444.00: Rates for Certain Substance Use Disorder Services Comprehensive community support services, per 15 minutes (recovery support navigator) Community Consultation and Education (per hour) Reevaluation (per hour) (b) Allowable fee for mental health service provided by a behavioral health urgent care provider. 1. Services Rates. A mental health center designated as a behavioral health urgent care center must bill the encounter bundle codes in 101 CMR 306.03(5)(b)(2) for the provision of any designated service specified in 101 CMR 306.03(5)(b)(2)(c). A mental health center designated as a behavioral health urgent care center must bill the rates in 101 CMR 306.03(5)(a) for the provision of all services not specified as a designated service in 101 CMR 306.03(5)(b)(2)(c). 2. Encounter Bundle Rates. The services incorporated into the encounter bundled rate are specified in 101 CMR 306.03(5)(b)(2)(c). a. Providers must bill one H2013 flat rate encounter bundle code for the provision of any of the set designated services, regardless of the number of services provided to the individual on that date. b. The encounter bundle rates are as follows: Service Code Modifier 1 Payment H2013 HB Psychiatric health facility service, per diem (Adult Services) H2013 HA Psychiatric health facility service, per diem (Child/Adolescent Services) (c) The designated services outlined below, inclusive of all licensure levels, must be billed in conjunction with the appropriate encounter bundle code in 101 CMR 306.03(5)(b)1. The designated service codes for all services provided on the same date must be billed under one encounter bundle code, regardless of the number of services provided to the individual on that date. The bundled encounter rates incorporate the following designated services codes: Service Code Psychiatric diagnostic evaluation 90791-HA Psychiatric diagnostic evaluation performed with a CANS (Children and Adolescent Needs and Strengths) Psychiatric diagnostic evaluation with medical services Psychotherapy, 30 minutes with patient Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure.) Psychotherapy, 45 minutes with patient Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure.) Psychotherapy, 60 minutes with patient Psychotherapy for crisis; first 60 minutes Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service.) Family psychotherapy (without the patient present), 50 minutes Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes Multiple family group psychotherapy (per person per session not to exceed 10 clients) Group psychotherapy (other than of a multiple-family group) (per person per session not to exceed 12 clients) 90853-EP Group psychotherapy (other than of a multiple-family group) (per person not to exceed 12 clients) (preventive behavioral health session) Environmental intervention for medical management purposes on a psychiatric patient's behalf with agencies, employers, or institutions 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 S9480 Intensive outpatient psychiatric services, per diem Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically Service Code appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. Service Code Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the outpatient Evaluation and Management service.) Initial nursing facility 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 are of low severity. Physicians typically spend 25 minutes at the bedside and on the patient's facility floor or unit. Initial nursing facility 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 are of moderate severity. Physicians typically spend 35 minutes at the bedside and on the patient's facility floor or unit. Initial nursing facility 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 are of high severity. Physicians typically spend 45 minutes at the bedside and on the patient's facility floor or unit. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem-focused interval history; a problem-focused examination; or straightforward medical decision making. 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 patient is stable, recovering, or Service Code improving. Physicians typically spend 10 minutes at the bedside and on the patient's facility floor or unit. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: an expanded problem focused interval history; an expanded problem-focused examination; or medical decision making 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 patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 15 minutes at the bedside and on the patient's facility floor or unit. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a detailed interval history; a detailed examination; or 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 patient has developed a significant complication or a significant new problem. Physicians typically spend 25 minutes at the bedside and on the patient's facility floor or unit. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a comprehensive interval history; a comprehensive examination; or 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. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 35 minutes at the bedside and on the patient's facility floor or unit. Home visit for the evaluation and management of a new patient, which requires these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision making. 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 presenting problem(s) are of low severity. Physicians Service Code typically spend 20 minutes face-to-face with the patient and/or family. Home visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem focused examination; and medical decision making 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 presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. Home visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed 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 presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. Home visit for the evaluation and management of a new 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 presenting problem(s) are of high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. Home visit for the evaluation and management of a new 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 patient is unstable or has developed a significant new problem requiring immediate physician attention. Physicians typically spend 75 minutes face-to-face with the patient and/or family. Service Code Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused interval history; a problem-focused examination; or straightforward medical decision making. 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 presenting problem(s) are self- limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family. Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused interval history; an expanded problem-focused examination; or medical decision making 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 presenting problem(s) are of low to moderate severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed interval history; a detailed examination; or 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 presenting problem(s) are moderate to high severity. Physicians typically spend 40 minutes face-to- face with the patient and/or family. Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive interval history; a comprehensive examination; or medical decision making of moderate to 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 presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 60 minutes face-to-face with the patient and/or family. (d) Allowable fee for mental health services provided by a mental health center in a nursing facility are as follows: Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG Payment Rate for service codes performed by a psychiatrist (Modifier -AF) Payment Rate for service codes performed by a doctoral-level clinician (Modifier -AH) Payment Rate for service codes performed by a master’s-level clinician (Modifier -HO) Payment Rate for service codes performed by an intern (Modifier - HL) Psychiatric diagnostic evaluation --- --- --- Psychiatric diagnostic evaluation with medical services Psychotherapy, 30 minutes with patient Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure.) Psychotherapy, 45 minutes with patient Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure.) Psychotherapy, 60 minutes with patient Psychotherapy for crisis, first 60 minutes Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG Payment Rate for service codes performed by a psychiatrist (Modifier -AF) Payment Rate for service codes performed by a doctoral-level clinician (Modifier -AH) Payment Rate for service codes performed by a master’s-level clinician (Modifier -HO) Payment Rate for service codes performed by an intern (Modifier - HL) Psychotherapy for crisis, each additional 30 minutes (List separately in addition to the code for primary procedure.) Family psychotherapy (without the patient present), 50 minutes Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes Multiple family group psychotherapy (per person per session not to exceed 10 clients) Group psychotherapy (other than multiple- family group) (per person per session not to exceed 12 clients) 90853-EP Group psychotherapy (other than of a multiple- family group) (per person not to exceed 12 clients) (preventive behavioral health session) Environmental intervention for medical management purposes on a psychiatric patient’s behalf with agencies, employers, or institutions Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG Payment Rate for service codes performed by a psychiatrist (Modifier -AF) Payment Rate for service codes performed by a doctoral-level clinician (Modifier -AH) Payment Rate for service codes performed by a master’s-level clinician (Modifier -HO) Payment Rate for service codes performed by an intern (Modifier - HL) Interpretation or explanation of results of psychiatric, or other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient Preparation of report of patient’s psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other individuals, agencies, or insurance carriers --- --- --- Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by a physician or other qualified healthcare professional, with interpretation and report; first hour Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG Payment Rate for service codes performed by a psychiatrist (Modifier -AF) Payment Rate for service codes performed by a doctoral-level clinician (Modifier -AH) Payment Rate for service codes performed by a master’s-level clinician (Modifier -HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by a physician or other qualified healthcare professional, with interpretation and report; each additional 30 minutes (List separately in addition to code for primary procedure.) --- --- --- Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by a physician or other qualified healthcare professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG Payment Rate for service codes performed by a psychiatrist (Modifier -AF) Payment Rate for service codes performed by a doctoral-level clinician (Modifier -AH) Payment Rate for service codes performed by a master’s-level clinician (Modifier -HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by a physician or other qualified healthcare professional, both face-to-face time with the patient and time interpreting test results and preparing the report; each additional hour (List separately in addition to code for primary procedure.) --- --- --- Psychological testing evaluation services by a physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG Payment Rate for service codes performed by a psychiatrist (Modifier -AF) Payment Rate for service codes performed by a doctoral-level clinician (Modifier -AH) Payment Rate for service codes performed by a master’s-level clinician (Modifier -HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Psychological testing evaluation services by a physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure.) --- --- --- Neuropsychological testing evaluation services by a physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG Payment Rate for service codes performed by a psychiatrist (Modifier -AF) Payment Rate for service codes performed by a doctoral-level clinician (Modifier -AH) Payment Rate for service codes performed by a master’s-level clinician (Modifier -HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Neuropsychological testing evaluation services by a physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure.) --- --- --- Psychological or neuropsychological test administration and scoring by a physician or other qualified healthcare professional, two or more tests, any method; first 30 minutes --- --- --- Psychological or neuropsychological test administration and scoring by a physician or other qualified healthcare professional, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure.) Service Code Payment Rate for service codes performed by a child psychiatrist (Modifier - UG Payment Rate for service codes performed by a psychiatrist (Modifier -AF) Payment Rate for service codes performed by a doctoral-level clinician (Modifier -AH) Payment Rate for service codes performed by a master’s-level clinician (Modifier -HO) Payment Rate for service codes performed by an intern (Modifier - HL) --- --- --- Psychological or neuropsychological test administration and scoring by a technician, two or more tests, any method; first 30 minutes --- --- --- Psychological or neuropsychological test administration and scoring by a technician, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure.) Service Code Payment Rate H0046-HE Mental health services, not otherwise specified (certified peer specialist services) H2016-HM Rate as indicated in 101 CMR 346.00: Rates for Certain Substance- Related and Addictive Disorders Programs Comprehensive community support program, per diem (Enrolled Client Day) (recovery support service by a recovery advocate trained in peer recovery coaching) Service Code Payment Rate H2015-HF Rate as indicated in 101 CMR 444.00: Rates for Certain Substance Use Disorder Services Comprehensive community support services, per 15 minutes (recovery support navigator) (e) Rates for Medication Visit. Services for a medication visit must be billed using the appropriate E/M code: 99202-99205, 99211-99215, 99304-99310, 99341-99345, 99347- 99350, and 99417. Definitions, payment rules, and rates as listed in 101 CMR 306.03(5)(a) for: 99202-99205, 99211-99215, and 99417 are in 101 CMR 306.03(5)(a)-(b). Definitions, payment rules, and rates for services provided outside the encounter bundled services for 99304-99310, 99341-99345, and 99347-99350 are in 101 CMR 317.00: Rates for Medicine Services. (f) The allowable fee for payment for covered E/M services provided by a practitioner other than a psychiatrist is 85% of the fees described in 101 CMR 306.03(5)(e). (g) The allowable fee for payment for covered services provided by an advanced practice registered nurse and billed with the -SA modifier is 85% of the allowable fees for psychiatrists described in 101 CMR 306.03(5)(a). (h) Rates for State-operated Community Mental Health Centers. A state-operated community mental health center is paid at rates based on that center’s reasonable cost of providing covered services to eligible MassHealth members. 1. The methodology set forth below governs rates for non-Emergency Service Program services provided by a state-operated community mental health center between June 1, 2008, and June 30, 2009. a. Initial Payments. Initial payments were made at the rates in effect on the date of service. b. Preliminary Reconciliation. There was a preliminary reconciliation for each state- operated community mental health center based on the difference between the initial payments and payments based on rates calculated using the center’s preliminary projected FY2009 reasonable costs. In order to determine the preliminary projected FY2009 reasonable costs, EOHHS reviewed costs reported in the FY2008 UFR by each state-operated community mental health center and applied a cost adjustment factor based on the Massachusetts Consumer Price Index. c. Final Reconciliation. There was a final reconciliation for each state-operated community mental health center based on the difference between total payments pursuant to the preliminary reconciliation and payments based rates calculated using the center’s reported reasonable costs for the rate period. To determine the reported reasonable costs, EOHHS reviewed costs reported in the FY2009 UFR by each state- operated community mental health center. 2. Rates effective July 1, 2009. Payments for services provided effective July 1, 2009, are determined as follows: a. Initial Payments. Initial payments are based on rates calculated by applying a cost adjustment factor to the reasonable costs reported by each center in its most recently submitted UFR. b. Final Reconciliation. For each fiscal year beginning July 1, 2009, there is a final reconciliation for each state-operated community mental health center based on the difference between the initial payments and payments based on rates calculated using the center’s final reasonable costs for that fiscal year. In order to determine the final reasonable costs, EOHHS reviews the costs reported in each center’s UFR submitted for that fiscal year. (6) Coding Updates and Corrections. EOHHS may publish procedure code updates and corrections in the form of an administrative bulletin. The publication of such updates and corrections will list (a) codes for which the code numbers only changed, with the corresponding cross-walk; (b) codes for which the code remains the same but the description has changed; and (c) deleted codes for which there is no cross-walk. In addition, for entirely new codes which require new pricing, EOHHS will list these codes and apply Individual Consideration in reimbursing these new codes until rates are established. (7) Billing. Each clinic must bill the governmental unit according to the appropriate fee schedule on a prescribed form. Each specific service must be separately enumerated on the bill.