TABLE OF CONTENTS



Procedure CodeModifierDescription Unit of ServiceMaximum allowanceT2017HAHOME SUPPORT (Habilitation, residential, waiver)-Family ? hour$6.33T2017HA TJHOME SUPPORT (Habilitation, residential, waiver) –Agency? hour$6.33T2016HAHOME SUPPORT (Habilitation, residential, waiver) –FamilyPer diem$265.83T2016 HA TGHOME SUPPORT (Habilitation, residential, waiver) –Family- increased level of supportPer diem$502.79T2016HA TJHOME SUPPORT (Habilitation, residential, waiver) –AgencyPer diem$353.91S5150HARESPITE? hour$3.00S5151HARESPITEPer diem$90.00S5165HAHOME ACCESSIBILITY ADAPTATIONS (Home Modifications) Per itemized invoiceS5165CG HAHOME ACCESSIBILITY ADAPTATIONS (Home Modifications)-RepairsPer itemized invoiceV5274HACOMMUNICATION AIDS - SPEECH AMPLIFIER, AIDS, COMMUNICATORS (INCLUDING REPAIR AND MAINTENANCE), ASSISTIVE DEVICESPer itemized invoiceG9007HA HPCONSULTATION-Psychiatric? hour$63.75G9007HA AHCONSULTATION-Psychological? hour$19.80G9007HA GPCONSULTATION-Physical Therapy? hour$5.40G9007HA GNCONSULTATION-Speech Therapy? hour$5.40G9007HA GOCONSULTATION-Occupational Therapy? hour$5.40G9007HACONSULTATION-Recreational Therapy ? hour$5.40G9007HA HICONSULTATION-Behavioral? hour$21.00-762000360045Effective5/2/1400Effective5/2/14Modifiers -TJ -Agency Home SupportTG -Increased Level of SupportHA -ChildHP -Psychiatric ConsultationAH -Psychological ConsultationGP -Physical Therapy GN -Speech TherapyGO -Occupational TherapyHI -Behavioral ConsultationCG -Repairs for Home Modifications ................
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