10-144-101 Me. Code R. § III-3
Current through 2024-46, November 13, 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.) |
10-144 C.M.R. ch. 101, § III-3