10-144 C.M.R. ch. 101, §III-31
Procedure & Revenue Codes | Description | Unit of Service | Maximum Allowance | ||||||
T1015 | Clinic visit/encounter, all inclusive | Per visit | By report | ||||||
0521 | FQHC | ||||||||
T1015 HE | Clinic visit/encounter, all inclusive | Per visit | By report | ||||||
0521 | FQHC | ||||||||
T1015 | Home visit/encounter, all inclusive | Per visit | By report | ||||||
0522 | FQHC | ||||||||
T1015 | Visit to SNF (Part A*) | Per visit | By report | ||||||
0524 | FQHC | ||||||||
*A covered Part A stay means that Medicare A will pay the services as the primary carrier | |||||||||
T1015 | Visit to SNF (Non-covered*) | Per visit | By report | ||||||
0525 | FQHC | ||||||||
*A non-covered stay means that Medicare A is not paying for the inpatient stay/services | |||||||||
T1015 | Visit to Other Site | Per visit | By report | ||||||
0528 | FQHC | ||||||||
T1015 | Ambulatory Clinic Visit | Per visit | By report | ||||||
0529 | FQHC | ||||||||
S9441 | Asthma education, nonphysician provider, per session | Per visit | By report | ||||||
0521 | FQHC | ||||||||
G0108 | Diabetes outpatient self-management training services, individual, per 30 minutes | Per 30 minutes | By report | ||||||
0521 | FQHC | ||||||||
G0109 | Diabetes outpatient self-management training services, group session (2 or more) per 30 minutes | Per 30 minutes | By report | ||||||
0521 | FQHC | ||||||||
FQHCs are reimbursed for all Food and Drug Administration (FDA) approved pharmacotherapy for tobacco dependence treatment. | |||||||||
99406 | Smoking and Tobacco Cessation Counseling; individual, intermediate | 3-10 minutes | $8.67 | ||||||
0521 | FQHC | ||||||||
99407 | Smoking and Tobacco Cessation Counseling; individual, intensive | Greater than 10 minutes | $16.81 | ||||||
0521 | FQHC | ||||||||
99411 | [Tobacco Cessation] Preventive Medicine Counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure), approximately 30 minutes | Per session | $11.54 | ||||||
0521 | FQHC | ||||||||
99412 | [Tobacco Cessation] Preventive Medicine Counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 60 minutes | Per session | $15.04 | ||||||
0521 | FQHC | ||||||||
G0009 | Administration of Pneumococcal Vaccine | 1 unit | $5.00 | ||||||
0521 | |||||||||
G0008 | Administration of Influenza virus Vaccine | 1 unit | $5.00 | ||||||
0521 | |||||||||
FQHCs are reimbursed for all Food and Drug Adminsitration (FDA) approved Intrauterine Devices at the rate listed on the MaineCare UCR: https://mainecare.maine.gov/ | |||||||||
J1050 | Injection, medroxyprogestrone acetate, 1 mg. | 1 unit | By report | ||||||
Modifiers | Description | ||||
GT | Via interactive audio and video telecommunication systems | ||||
HE | Behavioral health | ||||
SL | State supplied vaccine | ||||
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.) | ||||
10-144 C.M.R. ch. 101, §III-31
12/1/2016 - filing 2016-194