Page 1 of 11. Effective 9/15/2018 AUTHORIZATION REQUIREMENT LEVEL OF CARE. Notes (0 = No Additional Comments)

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1 100 All inclusive room and board On All inclusive room and board On Anesthesia, ECT On Room and Board- private psychiatric On Room and Board- private room detoxification On Room and Board- private rehabilitation On Residential Treatment On Room and Board -semi private psychiatric On Room and Board- semi- private room detoxification On Room and Board - semi private rehabilitation On Room and Board bed psychiatric On Room and Board- 3-4 bed detoxification On Room and Board bed rehabilitation On Room and board private psychiatric On Room and board private- detoxification On Room and Board- ward psychiatric On Room and Board- detoxification ward On Room and Board- ward rehabilitation On leave of absence from residential On Therapeutic home time On Limit 14/year 204 Intensive Care -psychiatric On Intensive Care -psychiatric On Emergency Room Off Emergency Room Off Clinic encounter all inclusive Off Psych clinic Off Urgent Care Clinic Off Other clinic- med supervised withdrawal Off Freestanding clinic Off 0 PRO_17336E Internal Approved Page 1 of 11 SC8CADLTR17336E_0000

2 521 Rural Clinic Off Other freestanding clinic Off BH treatment services Off ECT- electroshock treatment On Intensive Outpatient - providers should be instructed to use proper code with 915 On Intensive Outpatient - providers should be instructed to use proper code with 915 On BH treatment services On Substance abuse rehabilitation Off Psychiatric/Psychological Services- Individual therapy Off Psychiatric/Psychological Services- Family therapy Off Biofeedback On Testing Off Other BH treatment services Off Drug Rehabilitation Off Alcohol Rehabilitation Off Behavioral Health Residential- psychiatric On only applies to ages 18 and under Interactive complexity add-on code Off Psychiatric diagnostic evaluation (no medical Services) Off Psychiatric diagnostic evaluation with medical services Off Psychotherapy, 30 mins On On At visit min psychotherapy add on code when performed with E/M Service- (list separately) Off Psychotherapy, 45 mins On On At visit minute psychotherapy add on code when performed with E/M Service (list separately) Off Psychotherapy, 60 mins On On At visit 21 Page 2 of 11

3 min psychotherapy when performed with E/M service (list separately Off Psychotherapy for crisis, first 60 min. On On At visit crisis code add on for each additional 30 min. Off Psychoanalysis Off Family Psychotherapy, without patient present On On At visit Family Psychotherapy, 45 min On On At visit Multiple-family group psychotherapy On On At visit Group psychotherapy On On At visit Pharmacologic management, add on code Off Narcosynthesis Off Therapeutic Repetitive Transcranial (TMS) On Therapeutic Repetitive Transcranial (TMS) On Therapeutic Repetitive Transcranial (TMS) On Electroconvulsive Therapy On Ind psycho therapy incorporating bio feedback 30 min Off Ind psycho therapy incorporating bio feedback 45 min Off Hypnotherapy On Complex care management Off Psych eval of hospital records Off Interpretation or explan of results of psych exam and procedures Outpatient Collateral, 15 min. On On At visit Prep of report of pt psych status Off Unlisted Psychiatric procedure On comp.comput.motion analysis Off Functional brain mapping Off Psychological testing On On after 5 Hours Page 3 of 11

4 96102 Psychological testing On On after 5 Hours Psychological testing On On after 5 Hours Assessment of Aphasia of speech/lang On Developmental screening with interp Off Developmental testing On On after 5 Hours Neurobehavioral status exam w clin assess On On after 5 Hours Neuropsychological Testing per hour On On after 5 Hours Neuropsych Testing Admin by Technician per hour On On after 5 Hours Neuropsych Testing Admin by Computer per occurrence On On after 5 Hours Standardized cognitive perf testing On On after 5 Hours Brief emotional needs assessment Off Nursing Assessment and Care-Initial Off Nursing Assessment and Care-Re-Assessment Off H&B individual intervention Off H&B group intervention Off Health & Behavior Intervention with patient present Off Health & Behavior Intervention without patient present Off Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument Off Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument Off Medication administration Off In connection with Vivitrol injections Services rendered after hours Off Office Emergency Services Off 0 Page 4 of 11

5 99201 New Patient Office Visit Level 1 Off New Patient Office Visit Level 2 Off New Patient Office Visit Level 3 Off New Patient Office Visit Level 4 Off New Patient Office Visit Level 5 Off Est Patient Office Visit Level 1 Off Est Patient Office Visit Level 2 Off Est Patient Office Visit Level 3 Off Est Patient Office Visit Level 4 Off Est Patient Office Visit Level 5 Off Initial Hospital Care-comprehensive; low complexity Off Initial Hospital Care-comprehensive; moderate complexity Off Initial Hospital Care-comprehensive; high complexity Off Subsequent observation Care Off Subsequent observation Care Off Subsequent observation Care Off Subsequent Hospital Care-focused; low complexity Off Subsequent Hospital Care-focused; moderate complexity Off Subsequent Hospital Care-focused; high complexity Off Observation-comprehensive; low complexity Off Observation-comprehensive; moderate complexity Off Observation-comprehensive; high complexity Off Discharge Day Management- 30 min or less Off Discharge Day Management-more than 30 min Off Problem focused; straightforward-15 min Off Expanded; straightforward-30 min Off 0 Page 5 of 11

6 99243 Detailed; low complexity-40 min Off Comprehensive; moderate complexity-60 min Off Comprehensive; high complexity-80 min Off Initial Consultation-focused, straightforward Off Initial Consultation-expanded, straightforward Off Initial Consultation-detailed, low complexity Off Initial Consultation-comprehensive, moderate complexity Off Initial Consultation-comprehensive, high complexity Off ER Consultation-focused, straightforward Off ER Consultation-expanded; low complexity Off ER Consultation-expanded; moderate complexity Off ER Consultation-detailed; moderate complexity Off ER Consultation-comprehensive; high complexity Off Nursing facility consultation 25 min Off Nursing facility consultation 35 min Off Nursing facility consultation 45 min Off Evaluation Management nursing facility 10 min Off Evaluation Management nursing facility 15 min Off Evaluation Management nursing facility 25 min Off Evaluation Management nursing facility 35 min Off Home visit, new patient Off Home visit, new patient Off Home visit, new patient Off Home visit, new patient Off Home visit, new patient Off Home visit, est patient Off Home visit, est patient Off Home visit, est patient Off 0 Page 6 of 11

7 99350 Home visit, est patient Off Prolonged evaluation and mgmt psycho therapy svs Off Prolonged evaluation and mgmt psycho therapy svs Off Medical team conference Off Medical team conference with family Off Medical team conference without family Off Preventive counseling, individual Off Preventive counseling, individual 30 min Off Preventive counseling, individual 45 min Off Preventive counseling, individual Off Smoking cessation Off Smoking cessation Off Alcohol substance abuse BH change intervention Off Alcohol and substance abuse screening and brief intervention Off Preventive counseling, individual 60 min Off Preventive medicine group counseling- 60 min Off Home visit, single, family counseling Off T Behavior Identification Assessment (ABA) On T, 0365T Adaptive Behavior Treatment By Protocol On T & 0369T Adaptive Behavior Treatment With Protocol Modification On T Family Adaptive Behavior Treatment Guidance On and G0410, G0411, or H0035 Partial Hospitalization On DAODAS only 915, H0015 BH intensive outpatient substance abuse On 0 915, S9480 BH intensive outpatient psychiatric On 0 Page 7 of 11

8 G0176 Recreation, related to the care and treatment of patients disabling mental health problems; per session (45 minutes or more) Off 0 G0177 patients disabling mental health problems per session (45 minutes or more) Off 0 G0396 Alcohol/subs interv 15-30mn On 0 G0397 Alcohol/subs interv >30 min On 0 G0409 Social work and psychological services, directly relating to and/or furthering the patient s rehabilitation goals Off 0 G0410 Partial Hospitalization On 0 G0411 BH intensive outpatient substance abuse On 0 G0436 Tobacco-use counsel 3-10 min Off 0 G0437 Tobacco-use counsel>10min Off 0 G0442 Annual alcohol misuse screening 15 min Off 0 G0443 Alcohol mis use and screening -various markets; Iowa=face to face BH counseling-15 min Off 0 G0444 Depression Screening Off 0 G0445 High intensity BH counseling 30 min Off 0 G0446 Intensive BH therapy Off 0 G0447 Face to face behavioral counseling-15 min Off 0 G0451 Developmental testing with I & R Off 0 G0463 Hospital outpatient clinic visit Off 0 H0001 Alcohol and/or drug assessment Off 0 H0002 Behavioral Health Screen to determine eligibility for admission to treatment program Off 0 H0004 Behavioral health counseling and therapy; per 15 minutes Off 0 Page 8 of 11

9 H0005 Alcohol and/or drug services; group counseling by a clinician Off 0 H0010 H0011 H0012 H0015 H0018 H0019 Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient) On Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) On 0 Alcohol and/or drug services; sub-acute detoxification (residential addiction program outpatient) On DAODAS only; ASAM Level III.7D Alcohol and/or drug services; intensive outpatient treatment (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan) including assessment, counseling, crisis intervention, and activity therapies or education On 0 Behavioral health; short-term residential (non hospital residential treatment program), without room and board; per diem On 0 Behavioral health; long term residential (non-medical, non-acute care in a residential treatment program where stay is typically longer than 30 days), without room and board; per diem On 0 H0020 Alcohol and/or drug services; methadone administration and/or service (provisions of the drug by a licensed program) On H0031 Mental health assessment, by non-physician Off 0 H0032 Mental health service plan development by non-physician Off 0 H0033 Oral medication administration, direct observation Off 0 Page 9 of 11

10 H0034 Medication training and support; per 15 minutes Off 0 H0038 Self-help/peer services; per 15 minutes Off 0 H2000 Comprehensive multidisciplinary evaluation On Total of identified HCPC Series Codes H2010 Comprehensive medication services; per 15 minutes Off 0 H2011 Crisis Intervention Services; per 15 Minutes On visit 81 H2014 Skills training and development; per 15 minutes On Use MN Criteria for Behavior Modification H2017 Psychosocial rehabilitation services; per 15 minutes On 0 H2019 Therapeutic behavioral services; per 15 minutes On H2030 Clubhouse services ; per 15 min On Total of identified HCPC Series Codes Page 10 of 11

11 H2035 Alcohol and/or drug treatment program; per hour On Use MN Criteria for BHP auth type H2036 Alcohol and/or other drug treatment program; per diem On Developmental delay prevention activities, dependent child of client, per H minutes On 0 M0064 Brief Office Visit for the Sole Purpose of Monitoring or Changing Drug Prescriptions Used in the Treatment of Mental Psychoneurotic and Personality Disorders Off 0 Q3014 Telehealth original site facility Off 0 S9482 Family stabilization services; per 15 minutes On 0 S9484 Crisis intervention mental health services; per hour On S9485 Crisis intervention mental health services; per diem On Total of identified HCPC Series Codes Total of identified HCPC Series Codes T1014 Telehealth telemedicine Off 0 T1015 Clinic encounter all inclusive Off 0 T1016 Case management, each 15 minutes Off 0 Page 11 of 11