Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-3 - Ambulatory Care Clinic Services

Current through 2024-29, July 17, 2024
TABLE 1
The following procedure codes will change to those
					 listed in Table 2 when the new claims system, MIHMS, goes live. MaineCare will
					 send a written notice to all providers at least 30 days in
					 advance.
PROC CODE
DESCRIPTION
MAXIMUM ALLOWANCE
School Health Clinic and Flu
								Clinics
Z9638
Visit
By Report
90655-90658
Seasonal Flu Vaccine, non-state supplied, only
								reimbursed when state supplied vaccine is not covered (adults).
Acquisition Cost
Z6514
Administration of State supplied non H1N1 vaccine
$5.00
Z6578
Administration of State supplied H1N1 vaccine
$5.00
School Health Clinics
Z9667
Interpreter Services (one hour during normal
								business hours)
$30.00
Z9668
Interpreter Services (one hour during non-business
								hours)
$40.00
Z9669
Interpreter Services (additional 1/4 hour)
$7.50
CPT Code
HCPCS/CPT Description of Services
Unit
Maximum Allowance
T1015*
Clinic Visit/Encounter, All Inclusive
Per visit
By Report
G0108
Diabetes outpatient self management training
								services, individual, per 30 minutes
30 minutes
By Report
G0109
Diabetes outpatient self management training
								services, group session (2 or more), per 30 minutes
30 minutes
By Report
S9441
Asthma education, non-physician provider, per
								session
Per visit
By Report
J1055
Injection, medroxyprogesterone acetate/estradiol
								cypionate, 5 mg/25 mg
Per unit
By Report
J7307
Etogestrel (contraceptive) implant system, including
								implant and supplies (Implanon)
Per unit
By Report
11976
Removal, implantable contraceptive capsules
Per unit
By Report
11981
Insertion, non-biodegradable drug delivery implant
Per unit
By Report
99381
Initial preventive medicine evaluation and
								management of an individual including an age and gender appropriate history,
								examination, counseling/anticipatory guidance/risk factor reduction
								interventions and the ordering of appropriate laboratory/diagnostic procedures,
								new patient; infant (age younger than 1 year).
Per visit
By Report
Initial preventive medicine evaluation and
								management of an individual including an age and gender appropriate history,
								examination, counseling/anticipatory guidance/risk factor reduction
								interventions and the ordering of appropriate laboratory/diagnostic procedures,
								new patient; early
99382
childhood (age 1 through 4 years).
Per visit
By Report
99383
Initial preventive medicine evaluation and
								management of an individual including an age and gender appropriate history,
								examination, counseling/anticipatory guidance/risk factor reduction
								interventions and the ordering of appropriate laboratory/diagnostic procedures,
								new patient; late childhood (age 5 through 11 years).
Per visit
By Report
99384
Initial preventive medicine evaluation and
								management of an individual including an age and gender appropriate history,
								examination, counseling/anticipatory guidance/risk factor reduction
								interventions and the ordering of appropriate laboratory/diagnostic procedures,
								new patient; adolescent (age 12 through 17 years).
Per visit
By Report
99385
Initial preventive medicine evaluation and
								management of an individual including an age and gender appropriate history,
								examination, counseling/anticipatory guidance/risk factor reduction
								interventions and the ordering of appropriate laboratory/diagnostic procedures,
								new patient; age 18 through 39 years.
Per visit
By Report
99391
Periodic comprehensive preventive medicine
								reevaluation and management of an individual including an age and gender
								appropriate history, examination, counseling/anticipatory guidance/risk factor
								reduction interventions and the ordering of appropriate laboratory/diagnostic
								procedures, established patient; infant (age younger than 1 year).
Per visit
By Report
99392
Periodic comprehensive preventive medicine
								reevaluation and management of an individual including an age and gender
								appropriate history, examination, counseling/anticipatory guidance/risk factor
								reduction interventions and the ordering of appropriate laboratory/diagnostic
								procedures, established patient; early childhood (age 1 through 4 years).
Per visit
By Report
99393
Periodic comprehensive preventive medicine
								reevaluation and management of an individual including an age and gender
								appropriate history, examination, counseling/anticipatory guidance/risk factor
								reduction interventions and the ordering of appropriate laboratory/diagnostic
								procedures, established patient; late childhood (age 5 through 11 years).
Per visit
By Report
99394
Periodic comprehensive preventive medicine
								reevaluation and management of an individual including an age and gender
								appropriate history, examination, counseling/anticipatory guidance/risk factor
								reduction interventions and the ordering of appropriate laboratory/diagnostic
								procedures, established patient; adolescent (age 12 through 17 years).
Per visit
By Report
99395
Periodic comprehensive preventive medicine
								reevaluation and management of an individual including an age and gender
								appropriate history, examination, counseling/anticipatory guidance/risk factor
								reduction interventions and the ordering of appropriate laboratory/diagnostic
								procedures, established patient; age 18 through 39 years.
Per visit
By Report
99460
Initial hospital or birthing center care, per day,
								for evaluation and management of normal newborn infant
Per diem
By Report
99461
Initial care, per day, for evaluation and management
								of normal newborn infant seen in other than hospital or birthing center
Per diem
By Report
G0008
Administration of influenza virus vaccine
Per unit
$8.09
G9141
Influenza A (H1N1) immunization administration
								(includes the physician counseling the patient/family)
Per unit
$8.09
0771
Revenue code for administration of H1N1 (also use
								HCPCS Code G9141)
Per unit
$8.09
90470
H1N1 immunization administration (intramuscular,
								intranasal), including counseling when performed
Per unit
$8.09
NOTE : When Primary Health Care Clinics, Well Child Clinics
					 and School Health Clinics provide EPSDT services, the billing and servicing
					 providers must be enrolled with the EPSDT Program. When an EPSDT service is
					 provided, ONLY the EPSDT visit code is billed. Billing for EPSDT services
					 should be done using CPT codes 99381-99385 for new patients and 99391-99395 for
					 established patients.
*For additional clinic visits/encounters, providers
					 should use one of the suggested modifiers to differentiate between the
					 visits.
Modifiers
Description
UF
Services provided in the morning (6 a.m.
								to 11:59 a.m.)
UG
Services provided in the afternoon (12
								p.m. to 5:59 p.m.)
UH
Services provided in the evening (6 p.m.
								to 11:59 p.m.)
UJ
Services provided at night (12 a.m. to
								5:59 a.m.)