016.06.05 Ark. Code R. 065
Diagnosis and evaluation procedures are limited to two (2) diagnosis and evaluation encounters per state fiscal year (July 1 through June 30). If additional diagnosis and evaluation services are required, the CHMS provider must request an extension of benefits from the Arkansas Foundation for Medical Care, Inc. (AFMC).
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. Effective for claims received on and after December 5, 2005, modifiers UA and UB must be used instead of modifiers 52 and 22.
Procedure | Codes | |||
90805 | 90807 | 90809 | 92506 | 92551 |
92552 | 92553 | 92555 | 92557 | 92567 |
92582 | 92585 | 92587 | 92588 | 96105 |
96111 | 96117 | 99201 | 99202 | 99203 |
99204 | 99205 |
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 | |
96100 | UA, UB | Psychological testing battery (1 unit = 15 minutes), maximum of 4 units; limited to 8 units per state fiscal year |
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: Assessmentyevaluation 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. Effective for claims received on and after December 5, 2005, modifiers UA and UB must be used instead of modifiers 52 and 22.
Procedure | Codes | |||
90804 | 90806 | 90808 | 90847 | 90849 |
97703 | 99211 | 99212 | 99213 | 99214 |
99215 |
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 |
Procedure Code | Required Modifier(s) | Description |
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). |
Procedure Code | Required Modifier(s) | Description |
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. Effective for claims received on and after December 5, 2005, modifiers UA and UB must be used instead of modifiers 52 and 22.
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 |
95961 | UA | Cortical Function Testing |
96100 | U1, UA | Psychological Testing, 2 or more (1 unit = 15 minutes), maximum of 8 units |
96100 | UA | Interpretation (1 unit = 15 minutes), maximum of 8 units |
99173 | Visual Screen | |
99205 99215 | U1 U1 | High Complex medical exam |
016.06.05 Ark. Code R. 065