10 (PS = 08,18) 13 Intensive Outpatient (PS = 11) 15 Evaluation (PS = 13) 16 Opioid Replacement Therapy (PS = 40) PS = Primary Service Code Units: Individual, group, family units and evaluation need to be reported in 15 minute increments. Intensive outpatient units need be reported in daily increments. Opioid Replacement Therapy, one dose equals one unit. EXAMPLE: John had weekly sessions with a counselor and attended group once a week for four weeks. John’s units would be as follows: Code Units Cost 08 0016 017.81 10 0016 006.25 Cost Per Unit: As set by Agency with certain guidelines and/or restrictions. Should be reported to TDS like the example above. DATE FORM COMPLETED: (MM/DD/YYYY) FORM COMPLETED BY: This form is to be signed by interviewer. THIS FIELD MUST BE ENTERED. FORM EDITED BY: All are to be edited for accuracy and completeness. To be signed by person editing completed forms. This may be the same person who filled out the forms originally. A copy of the TDS form should be retained in the client file. *************************************************************************** To Contact the TDS Office:
10 (PS = 08,18) 13 Intensive Outpatient (PS = 11) 15 Evaluation (PS = 13) 16 Opioid Replacement Therapy (PS = 40) PS = Primary Service Code Units: Individual, group, family units and evaluation need to be reported in 15 minute increments. Intensive outpatient units need be reported in daily increments. Opioid Replacement Therapy, one dose equals one unit. EXAMPLE: John had weekly sessions with a counselor and attended group once a week for four weeks. John’s units would be as follows: Code Units Cost 08 0016 017.81 10 0016 006.25 Cost Per Unit: As set by Agency with certain guidelines and/or restrictions. Should be reported to TDS like the example above. DATE FORM COMPLETED: (MM/DD/YYYY) FORM COMPLETED BY: This form is to be signed by interviewer. THIS FIELD MUST BE ENTERED. FORM EDITED BY: All are to be edited for accuracy and completeness. To be signed by person editing completed forms. This may be the same person who filled out the forms originally. A copy of the TDS form should be retained in the client file. *************************************************************************** To Contact the TDS Office:
TDSA-1D-1Manual2013.docx