Sub - Section Two: Reimbursement for SUD and Addiction Services: This section: Provides information regarding the associated Medicaid fee schedule/ reimbursement for the specific services; coding; and, what modality / OASAS certified program delivers such services. Identifies SUD and addiction service limitations Coding and Medicaid Fee-for- Service Table Sub - Section Three: Listing of OASAS Certified Programs Listing of OASAS certified programs that deliver the authorized SPA / 1115 demonstration services; the applicable authorizing New York State program regulation; and, where appropriate a cross walk to ASAM levels of care. Section One - Part A: General Overview SPA /1115 service and associated OASAS Certified program / setting: New York State SUD services include an array of participant-centered crisis, inpatient, residential and outpatient services consistent with the individual’s assessed treatment needs, with a rehabilitation and recovery focus designed to promote skills for managing substance use disorder symptoms, and behaviors. SUD services are provided by programs that are OASAS certified pursuant to applicable program specific sections of Title 14 NYCRR (Part 822; Part 818, Part 820 and Part 816). Additionally, programs are subject to shared title 14 NYCRR Part 800 regulatory staffing definitions for: Clinical staff; medical director; medical staff; and, Qualified Health Professionals Appendix B. This subsection offers a brief overview on the primary SUD service settings: Outpatient(including: clinic; opioid; outpatient rehabilitation); SUD Services in a Residential Setting; and, Inpatient (including: detoxification and inpatient rehabilitation); Outpatient services Setting: OASAS Certified Title 14 NYCRR Part 822 Outpatient Clinic; Opioid and; Rehabilitation Programs. The setting will be determined by the goal which is identified to be achieved in the individual’s written treatment plan and may include OASAS outpatient settings Certified by Title 14 NYCRR Part 822 (clinic, opioid; and, outpatient rehabilitation). The 1115 give OASAS demonstration authority to provide any clinic service outside of the clinic. For
which service may be reimbursed via a negotiated rate between the plan and the provider; and any applicable coding. When services are reimbursed via a negotiated rate, it is suggested that the prevailing Medicaid FFS rate service is used as an initial starting point for rate negotiations. Inpatient Providers: The Title 14 NYCRR OASAS Certified Part 816 detoxification / crisis services; and, Title 14 NYCRR OASAS Certified Part 818 Inpatient Rehabilitation Services are already incorporated into the benefit package. Part 820 treatment services are new for the Medicaid managed care benefit package Providers of Part 816 and Part 818 services should speak with the plan regarding the plan coding, contract, and reimbursement policies. Part 820 programs are reimbursed at the government rate. However, please note that at a minimum, plans must include providers as indicated below to meet minimum network requirements. Service OASAS Regulation / Certification Authority Negotiated or Government Rate Crisis Title 14 NYCRR Part 816 Medically Managed Withdrawal Negotiated Title 14 NYCRR Part 816 Medically Supervised Inpatient Withdrawal (MSIW) W/Out Observation Days Negotiated Title 14 NYCRR Part 816 Medically Supervised Inpatient Withdrawal (MSIW) W/One Observation Days Negotiated Title 14 NYCRR Part 816 Medically Supervised Inpatient Withdrawal (MSIW) W/Two Observation Days Negotiated Title 14 NYCRR Part 816 Medically Supervised Outpatient Withdrawal (MSOW). Note: While this is not an inpatient service it is a crisis service that has been previously included in the benefit package and is not subject to government rates. Negotiated Title 14 NYCRR Part 816 Medically Supervised Inpatient Withdrawal (MSIW) Negotiated Inpatient Rehabilitation Title 14 NYCRR Part 818 Inpatient Rehabilitation Negotiated Title 14 NYCRR Part 818 Inpatient Rehabilitation - State Operated (ATC) Negotiated Residential Treatment Title 14 NYCRR Part 820 Residential Programs Government Rate 24 months See rate table below
Table Two: Outpatient CPT / HCPCS Coding For the first two years (based on the regional carve-in/implementation schedule) plans are required to utilize the CPT / HCPCS codes in Table Two below. When available both CPT and HCPCS codes are provided to support services delivery via different practitioner types / accommodate scope of practice coding requirements. In addition to the CPT / HCPCS codes, all line level service coding for SUD services must also include the “HF” modifier. Note the program should code the HF modifier to allow for data collection, however plans should not deny claims for failure to include. Table Two – Providers will enter the line level coding for SUD outpatient services including: CPT / HCPCS codes; unit (if applicable); and, the HF modifier on each service line APG OASAS Service Category Description CPT Codes CPT Code Description HCPCS Codes HCPCS description 315 Psychiatric Assessment with Counseling – Brief (30 minute min) E&M Code Plus 90833 Psychiatric Assessment with Counseling-30 minutes Select E&M Code from Range: 99201-99205, 99211-99215 PLUS Add-on Code 90833 N/A 316 Psychiatric Assessment with Counseling (45-50 minute min) E&M Code Plus 90836 Psychiatric Assessment with Counseling-45-50 minutes Select E&M Code from Range: 99201-99205, 99211-99215 PLUS Add-On Code 90836 N/A 315 Individual Therapy – Brief 25 minute minimum 90832 Alcohol/Substance Interview (Individual Brief 25 minutes minimum) G0396 Alcohol/Substance assessment and brief intervention 316 Individual Therapy – Normative 45 minute minimum 90834 Alcohol/Substance Interview (Individual Normative 45 minutes minimum) G0397 Alcohol/Substance assessment and brief intervention 317 Family/Collateral Therapy w/o patient 30 minute minimum 90846 Family/Couple Counseling (30 minute minimum) w/o patient T1006 Alcohol/Substance services family / couple counseling 318 Group Therapy 90853 Alcohol &/or Drug H0005 Alcohol/Substance;
60 minute minimum Services (group counseling by a clinician) group counseling by a clinician 318 Group Therapy 60 minute minimum 90849 Multiple Family Group (adolescent patients) (60-90 minutes) N/A 322 Medication Administration & Observation No minimum time N/A H0033 Oral Medication, direct observation 322 Medication Administration & Observation No minimum time N/A H0020 Alcohol / drug services methadone admin 323 Assessment – Normative 30 minute minimum N/A H0001 Alcohol / drug assessment 323 Assessment – Extended 75 minute minimum 90791 Behavioral Health Screening – Admission Eligibility (75 minute minimum) H0002 Behavioral health screening to determine admission eligibility 324 Assessment – Brief 15 minute minimum N/A T1023 Determine appropriateness of individual for participation in a program 324 Screening 15 minute minimum N/A H0049 Alcohol &/or Drug Screening 324 Brief Intervention 15 minute minimum N/A H0050 Alcohol &/or Drug Services, Brief Intervention – 15 min service 324 Brief Treatment 15 minute minimum N/A H0004 Alcohol &/or Drug Services, Brief Treatment – 15 min service 426 Addiction Medication Induction/ Withdrawal Management 30 minute minimum N/A H0014 Alcohol &/or Drug Services, Ambulatory Detox 426 Medication Management & Monitoring – Routine 10 minute minimum New Patient Existing Patient N/A 426 Medication Management & Monitoring – Complex E&M Medication N/A 99205
30 minute minimum Code (15 minute minimum) Select E&M Code from Range: 99201-99205, 99211-99215 451 Smoking Cessation Treatment 3 to 10 minutes N/A 99406 Behavior change Smoking prevention intervention counseling 451 Smoking Cessation Treatment >10 minutes N/A 99407 Behavior change Smoking prevention 490 Complex Care Coordination 45 minute minimum 90882 Environmental Manipulation – Complex Care Coordination N/A 490 Peer Counseling 30 minute minimum N/A H0038 Self-Help/Peer Services-per 15 minutes 327 Intensive Outpatient Program 9hrs/week at 3hrs/day N/A S9480 Intensive Outpatient Program 328 Outpatient Rehabilitation 2-4 Hour Duration N/A H2001 Rehab program per ½ day 328 Outpatient Rehabilitation 4 Hours and Above Duration N/A H2036 Alcohol / drug program per diem 840-843 Physical Health – New/Existing Patient – Select CPT Code from Range: New: Existing: Select Diagnosis: □ 99201 □ 99204 □ 99211 □ 99214 □ 99202 □ □ 99212 □ 99215 □ 99203 □ 99213 840 Physical Health – Opioid Dependence □ Evaluation & Management – No Counseling 841 Physical Health – Cocaine Dependence □ Evaluation & Management – No Counseling 842 Physical Health – Alcohol Dependence □ Evaluation & Management – No Counseling
843 Physical Health – Other CD □ Evaluation & Management – No Counseling 840-843 Physical Exam – New/Existing Patient – Select CPT Code from Range: New: Existing: Select Diagnosis: □ 99382 □ 99385 □ 99392 □ 99395 □ 99383 □ 99386 □ 99393 □ 99396 □ 99384 □ 99387 □ 99394 □ 99397 840 Physical Exam – Opioid Dependence □ Physical Exam – New/Established Patient 841 Physical Exam – Cocaine Dependence □ Physical Exam – New/Established Patient 842 Physical Exam – Alcohol Dependence □ Physical Exam – New/Established Patient 843 Physical Exam – Other CD □ Physical Exam – New/Established Patient Section Three Below is a list of OASAS certified programs that deliver the authorized SPA services; the applicable authorizing New York State program regulation; and where appropriate, a crosswalk to ASAM levels of care. OASAS Program Type New York State Regulation ASAM Outpatient Outpatient Clinic Title 14 NYCRR Part 822 Level I Outpatient Day Rehabilitation Title 14 NYCRR Part 822 Level II.5 Intensive Outpatient Title 14 NYCRR Part 822 Level II.I Opioid Treatment Programs Title 14 NYCRR Part 822 Level I