Maximum Maximum Maximum Allowance Allowance Allowance Procedure Code Modifier Modifier Unit Service Description per unit PA/UR per unit per unit effective through 8/1/18-6/30/19* 7/1/19* 7/31/18 Psychological testing -Psychologist or Physician, includes both face-to-face time administering to the member and time TM 1 hour interpreting these results and preparing the $79.20 $80.92 $80.78 N report. Individualized education program (IEP). Psychological testing- Psychological Examiner interpretation and report, 96102 1 hour $50.22 $51.31 $51.22 N administered by a technician, face-to-face Psychological testing- Psychological Examiner interpretation and report, administered by a technician, TL 1 hour $50.22 $51.31 $51.22 N Early intervention/individualized family service plan (IFSP). Psychological testing-Psychological Examiner interpretation and report, 96102 TM 1 hour administered by a technician, face-to-face. $50.22 $51.31 $51.22 N Individualized education plan (IEP). Children’s Assertive Community Treatment (ACT) H0040 HA Per diem By Report By Report By Report Y Maximum Maximum Maximum Allowance Allowance Allowance Procedure Code Modifier Modifier Unit Service Description per unit PA/UR per unit per unit effective through 8/1/18-6/30/19* 7/1/19* 7/31/18 Children's Home and Community Based Treatment
Procedure Code Modifier Modifier Unit Service Description Maximum Allowance per unit through 7/31/18 Maximum Allowance per unit 8/1/18-6/30/19* Maximum Allowance per unit effective 7/1/19* PA/UR TM 1 hour Psychological testing -Psychologist or Physician, includes both face-to-face time administering to the member and time interpreting these results and preparing the report. Individualized education program (IEP). $79.20 $80.92 $80.78 N 96102 1 hour Psychological testing- Psychological Examiner interpretation and report, administered by a technician, face-to-face $50.22 $51.31 $51.22 N TL 1 hour Psychological testing- Psychological Examiner interpretation and report, administered by a technician, Early intervention/individualized family service plan (IFSP). $50.22 $51.31 $51.22 N 96102 TM 1 hour Psychological testing-Psychological Examiner interpretation and report, administered by a technician, face-to-face. Individualized education plan (IEP). $50.22 $51.31 $51.22 N H0040 HA Per diem Children’s Assertive Community Treatment (ACT) By Report By Report By Report Y Procedure Code Modifier Modifier Unit Service Description Maximum Allowance per unit through 7/31/18 Maximum Allowance per unit 8/1/18-6/30/19* Maximum Allowance per unit effective 7/1/19* PA/UR Children's Home and Community Based Treatment