2020-2021 Billing Codes and Rates (Effective July 1, 2020)



Oregon Problem Gambling ServicesProcedure Codes and Rates for FY2020-21 Effective: July 1, 2020CodeDescriptionPGS Payment AmountService CriteriaH0001Problem Gambling Assessment$160.17Per occurrenceService provided by qualified counselor per OAR 309-019-0100. If assessment takes longer than 90 minutes, service provider can encounter remaining time as 90785. H0001HFAssessment Complexity Add On – Co-Occurring Substance Use Disorders$58.30Per occurrence. Must be coupled with H0001 or H0004 Service provided by qualified substance use disorder professional per OAR 309-019-100. To be used in conjunction or in addition to H0001 when conducting assessment for co-occurring substance use disorders or H0004 if conducted on different date. A gambling assessment must be previously documented – either in previous session or simultaneously. Up to one hour if added to previous gambling assessment. Up to two and one half hours combined if integrated assessment on same day with H0001.90785Assessment Complexity Add On $53.20Per occurrenceService provided by qualified counselor per OAR 309-019-100. To be used only once if gambling assessment takes longer than 90 minutes. If co-occurring disorders are assessed, DO NOT use this code. Instead use 90791.90791Assessment Complexity Add On – Co-Occurring Assessment$111.50Per occurrence. Must be coupled with H0001 or H0004Service provided by LMP, LPC, LMFT, LCSW, Psychologist or QMHP or Qualified Intern. To be used in conjunction or in addition to H0001 when conducting assessment for co-occurring mental health/substance use disorders. Use in conjunction with H0004 if conducted on a different date from initial assessment. A gambling assessment must be previously documented – either in previous session or simultaneously. Up to one hour if added to previous gambling assessment. Up to two and one half hours combined if integrated assessment on same day with H0001.H0032Gambling Service Plan Development$106.40Per occurrenceService provided by qualified counselor per OAR 309-019-0100. Can be encountered on same day as H0001, 90785. Session must be dedicated to collaborative development of service plan with client. Service plan must contain gambling specific goals and objectives. H0032HFGambling/SUDs Service Plan Development$125.70Per occurrenceService provided by qualified substance abuse professional per OAR 309-019-0100. Can be encountered on same day as H0001, 90785. Session must be dedicated to collaborative development of service plan with client. Service plan must contain gambling specific goals and objectives.H0032HHGambling/Co-Occurring Service Plan Development$145.00Per occurrenceService provided by LMP, LPC, LMFT, LCSW, Psychologist, QMHP or Qualified Intern. Can be encountered on same day as 90791. Session must be dedicated to collaborative development of service plan with client. Service plan must contain gambling AND Mental Health specific goals and objectives. T1023Behavioral Health Screening per 15 min$26.60Screening to determine the appropriateness of consideration of an individual for participation in A&D 81 services. This service deferens from a gambling assessment in that the activity may be delivered over the telephone and requires not only the evaluation of a client's treatment needs, but also an evaluation of available treatment options. Service can be provided 30 days prior to enrollment and encountered for, as long as service notes per occurrence are documented and included in individual record. H0004Individual Gambling Counseling and therapy, per 15 min $26.60Service must address problem or disordered gambling or relationship issues directly affected by problem gambling behavior. Service provided by qualified counselor per OAR 309-019-0100H0004HFCo-Occurring Gambling and SUD’s counseling and therapy, per 15 minutes$33.34Service provided by qualified counselor per OAR 309-019-0100 for Gambling Counselors and SUD’s CounselorsH0004HHCo-Occurring Gambling and SUD’s and/or Mental Health Counseling and therapy, per 15 minutes$40.07Service provided by dually qualified LMP, LPC, LMFT, LCSW, Psychologist or QMHP or Qualified Intern /Certified Gambling Counselor or Candidate.H0005Gambling Treatment counseling, group per 15 min$10.90Service provided by qualified counselor per OAR 309-019-0100H0005HFSUD’s group per 15 minutes$10.90Service provided by qualified counselor per OAR 309-019-0100 for substance use treatment. Non-CGAC or CGAC candidates must complete Modules One through Three of “Problem Gambling for Social Service Professionals” training within six months of agency assignment to problem gambling client services. 90853Mental Health Group Counseling$45.07Per occurrenceService provided by LMP, LPC, LMFT, LCSW, Psychologist, QMHP or Qualified Intern. Must address MH disorder diagnosed and documented in assessment. Non-CGAC or CGAC candidates must complete Modules One through Three of “Problem Gambling for Social Service Professionals” training within six months of agency assignment to problem gambling client services. 90846Family Psychotherapy (without the patient present), per service. Service must be longer than 26 minutes.$103.34Service provided by LMP, LPC, LMFT, LCSW, Psychologist, QMHP or Qualified Intern. Non-CGAC or CGAC candidates must complete Modules One through Three, and Module Five of “Problem Gambling for Social Service Professionals” training within six months of agency assignment to problem gambling client services. 90847Family Psychotherapy (conjoint psychotherapy) with the patient present, per service. Service must be longer than 26 minutes.$128.76Service provided by LMP, LPC, LMFT, LCSW, Psychologist, QMHP or Qualified Intern.Family psychotherapy is covered when there is a need to observe the clients interaction with family members and/or where there is a need to assess the capabilities of and assist the family members in aiding in the management of the client. Individual and family therapy codes can be encountered on the same date of service if there are two separate counseling sessions- one with the client and one with the family member and patient present. Providers should not encounter an individual therapy code with the family therapy code if only one session of therapy is rendered. Non-CGAC or CGAC candidates must complete Modules One through Three, and Module Five of “Problem Gambling for Social Service Professionals” training within six months of agency assignment to problem gambling client services. 90849Multiple-family group psychotherapy, per service. Service must be longer than 26 minutes.$41.67 Service provided by LMP, LPC, LMFT, LCSW, Psychologist, QMHP or Qualified Intern Non-CGAC or CGAC candidates must complete Modules One through Three, and Module Five of “Problem Gambling for Social Service Professionals” training within six months of agency assignment to problem gambling client services. 90801 or Psychiatric Diagnostic Interview$146.54Service provided by MD, Psychiatric Mental Health Nurse Practitioner. Non-CGAC or CGAC candidates must complete Modules One through Three and Module Four of “Problem Gambling for Social Service Professionals” training within six months of agency assignment to problem gambling client services. 90792Psychiatric Diagnostic Interview, with medication services$157.13Service provided by MD or Psychiatric Mental Health Nurse Practitioner. Non-CGAC or CGAC candidates must complete Modules One through Three and Module Four of “Problem Gambling for Social Service Professionals” training within six months of agency assignment to problem gambling client services. 90832Psychotherapy, with patient and/or family member, per 30 minutes$74.17Service provided by LMP, LPC, LMFT, LCSW, Psychologist,QMHP or Qualified Intern. Individual psychotherapy, insight oriented, behavioral modifying and/or supportive. Individual must be diagnosed with a gambling disorder and mental health disorder (dual diagnosed). Code is to be used for non-gambling trained clinicians providing MH counseling – limit to three sessions or discretion of OHA Problem Gambling Services Manager. Non-CGAC or CGAC candidates must complete Modules One through Three and Module Four of “Problem Gambling for Social Service Professionals” training within six months of agency assignment to problem gambling client services. 90837Psychotherapy, with patient and/or family member, per 60 minutes$148.34Service provided by LMP, LPC, LMFT, LCSW, Psychologist, QMHP or Qualified Intern. Individual psychotherapy, insight oriented, behavioral modifying and/or supportive. Individual must be diagnosed with a gambling disorder and mental health disorder (dual diagnosed). Code is to be used for non-gambling trained clinicians providing MH counseling – limit to three sessions or discretion of OHA Problem Gambling Services Manager. Non-CGAC or CGAC candidates must complete Modules One through Three and Module Four of “Problem Gambling for Social Service Professionals” training within six months of agency assignment to problem gambling client services. 96101Psychological Testing with interpretation and report, per hour$101.67QHHP who is licensed Psychologist or a Psychology Intern supervised by a Licensed PsychologistGMEDMedication Management $78.57Services provided by MD or Psychiatric Mental Health Nurse Practitioner. Scope of services includes prescribing medication, is the initial evaluation of the patient’s needs for medication, and ongoing medication monitoring/evaluation related to the patients use of medication. Non-CGAC or CGAC candidates must complete Modules One through Three and Module Four of “Problem Gambling for Social Service Professionals” training within six months of agency assignment to problem gambling client services. H2027Individual counseling continuing care, per 15 min$26.60This activity may be delivered to clients who have received AD81 services for up to one year following discharge. The function is of maintaining recovery and continued wellness and to prevent relapse.G2100Continuing Care Group Services, per 15 min for gambler and/or family member$10.90Services provided to clients who have completed problem gambling treatment within the past 12 months and are to be utilized to facilitate continued recovery or to avert a potential relapse. Services can be provided within an existing therapy or psycho-educational group being provided to current clients or to a group of previous clients meeting on a regular basis for aftercare.H0038Peer Delivered Services, per 15 min$16.92"Peer Delivered Services" means an array of agency or community-based services and support provided by peers, and peer support specialists, to individuals or family members with similar lived experience, that are designed to support the needs of individuals and families as applicable by current policy. "Peer Support Specialist" means a person providing peer delivered services to an individual or family member with similar life experiences, under the supervision of a qualified Clinical Supervisor. A Peer Support Specialist must complete an AMH approved training program and be: a self-identified person currently or formerly receiving mental health services; or a self-identified person in recovery from a substance use or gambling disorder, who meets the abstinence requirements for recovering staff in substance use disorders or gambling treatment programs; or a family member of an individual who is a current or former recipient of addictions or mental health services. Traditional Health Workers who do not have lived experience in gambling recovery can provide services to PG clients if completing within six months of agency assignment Modules One through Three of “Problem Gambling for Social Service Professionals” training as well as “Problem Gambling 101 for Peers” training within one yearThis could can also be encountered for as an aftercare service (effective July 1, 2016).H0038GPeer Delivered Services- Group, per 15 min$5.89Peer Delivered Services provided by Peer Support Specialist per definition provided under H0038 in a group setting. Traditional Health Workers who do not have lived experience in gambling recovery can provide services to PG clients if completing within six months of agency assignment Modules One through Three of “Problem Gambling for Social Service Professionals” as well as “Problem Gambling 101 for Peers” training within one yearThis could can also be encountered for as an aftercare service (effective July 1, 2016).H2010Comprehensive medication services, per 15 min$25.47Services delivered by a licensed registered nurse or QMHP related to the dispensing, administration and management of medications.H2013Psychiatric health facility service, per diem$407.71Services provided in a licensed mental health residential facility and intensively staffed 24-hours under a physician approved treatment plan for which treatment includes an appropriate mix and intensity of assessment, medication management, individual and group therapies and skills development to reduce or eliminate the acute symptoms of the disorder and restore the client's ability to function in a home or the community to the best possible level.H00102Problem Gambling Respite services; acute/sub-acute (residential addiction program)$150.00Services provided in a licensed residential alcohol and drug treatment facility designated with certified gambling treatment staff available. Program intensively staffed 24-hour for which treatment includes an appropriate mix and intensity of assessment, medication management, individual and group therapies and skills development to reduce or eliminate the acute symptoms of the disorder and restore the client's ability to function in a home or the community to the best possible level. 99368Team conference/consultation with Interdisciplinary team, per 30 minutes or more$24.53Medical team conference with interdisciplinary team of non-physician\health care professionals without client or family present. Can only be encountered for problem gambling treatment staff (s) that is present. Must consult on individual client for at least 30 minutes to encounter for service. G2013Residential gambling treatment service, per diem for Marion County Bridgeway Residential Program Only. For occupied beds only $250.0022.98Services provided in a licensed residential alcohol and drug treatment facility designated as a residential gambling treatment program and intensively staffed 24-hour for which treatment includes an appropriate mix and intensity of assessment, medication management, individual and group therapies and skills development to reduce or eliminate the acute symptoms of the disorder and restore the client's ability to function in a home or the community to the best possible level. This code is to be used for beds that are occupied by a client. Rate increase effective 10-1-2018.G2013RResidential gambling treatment service, per diem for Marion County Bridgeway Residential Program only. For reserved beds only.$250.0022.98Services provided in a licensed residential alcohol and drug treatment facility designated as a residential gambling treatment program and intensively staffed 24-hour for which treatment includes an appropriate mix and intensity of assessment, medication management, individual and group therapies and skills development to reduce or eliminate the acute symptoms of the disorder and restore the client's ability to function in a home or the community to the best possible level. This code is to be used for a beds that are spoken for/reserved and awaiting arrival of a client. Effective January 1, 2018. A bed can be held for an individual for up to 7 days. Rate increase effective 10-1-2018.T1016Case management, per 15 min$25.79Services provided for coordinating access to and provision of services from multiple agencies, establishing service linkages, advocating for treatment needs, and providing assistance in obtaining entitlements based on mental or emotional disability, . Non-CGAC or CGAC candidates must complete Modules One through Three of “Problem Gambling for Social Service Professionals” training within six months of agency assignment to problem gambling client services. T1016PCase management, per 15 min$16.92Peer Support Specialist services provided for coordinating access to and provision of services from multiple agencies, establishing service linkages, advocating for treatment and recovery needs, and providing assistance in obtaining entitlements based on mental or emotional disability. Traditional Health Workers who do not have lived experience in gambling recovery can provide services to PG clients if completing within six months of agency assignment must complete Modules One through Three of “Problem Gambling for Social Service Professionals” training as well as the “Problem Gambling 101 for Peers” training within one year.G2030Financial counseling, per hour$99.22Pressure relief counseling or other forms of counseling provided to individuals enrolled in A&D 81 services or their family members for the purpose of financial restitution of gambling debt. T1013Sign language/oral interpreter service, per 15 min$10.70Sign language/oral interpreter services necessary to ensure the provision of services for individuals with hearing impairments or in the primary language of non-English speaking individuals. Such interpreters shall be linguistically appropriate and be capable of communicating in English and the primary language of the individual and be able to translate clinical information effectively.Payment for interpreter services is only allowed when provided in conjunction with another service such as assessment, individual/family therapy, or group therapy, etc. whenever feasible, individuals should receive services from staff, who are able to provide sign and/or oral interpretive services. In this case, interpreter services cannot be billed in addition to the therapeutic service.99203Evaluation and management physical health visit, new patient, 30 minutes maximum length$92.04Evaluation and management of a new patient that requires a detailed history, detailed examination and medical decision making of low complexity. Service provided by Nurse Practitioner, Naturopathic or other qualified medical professional. Counseling and/or consultation of care with other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patients and/or family needs. Service should be provided when physical health conditions are impeding with gambling treatment. Must be face-to-face. Maximum of 2 visits per patient. Client must not have existing health insurance coverage. Goal is to get patient enrolled in Oregon Health Plan or connected to other health insurance options. 99213Evaluation and management physical health visit, established patient, 15 minutes maximum length$61.91Evaluation and management of an established patient that requires an expanded problem focused history, expanded problem focused examination and medical decision making of low complexity. Service provided by Nurse Practitioner, Naturopathic or other qualified medical professional. Counseling and/or consultation of care with other qualified health care professionals or agencies are provided consistent with the nature of the problems and the patients and/or family needs. Service should be provided when physical health conditions are impeding with gambling treatment. Must be face-to-face. Maximum of 3 visits per patient. Client must not have existing health insurance coverage. Goal is to get patient enrolled in Oregon Health Plan or connected to other health insurance options. G5000Individual counseling, other technologies, per 15 min$26.60Services provided by qualified counselor per current policy standards. Must meet current requirements for confidentiality with patient informed consent.G4000Individual counseling, telephone, per 15 min$26.60Services provided by qualified counselor per current policy standards. Must meet current requirements for confidentiality with patient informed consent.G30MileageCurrent US GSA rateLimited to: 1. Service provider's travel to and from primary site providing AD81 services and ancillary AD81 service site; 2. Mileage charges by program or case consultants; 3. Service provider’s travel bringing clients to the treatment site. 4. Service providers transportation costs to bring clients to and from the residential treatment site. 5. Client transportation costs G40Engagement, per 15 minutes$26.60Time spent in agency setting providing communication with potential or current client with intention of engaging/reengaging and enrolling/continuing them in services. Could be in-person or by other technology provided by a gambling informed/trained staff person. This code could be attached to a client ID or used as non-client code (similar to outreach codes). (Gambling informed means person has received a minimum of 3 hours of gambling specific training)G60Recommendation for Referral- Client Refused$0Number count of problem gambling positive screenings by agency staff for further assessment or referral to treatment where client refused additional service. This code is a non-client code (similar to outreach codes). G70Recommendation for Referral – Client Enrollment$0Number count of problem gambling positive screenings by agency staff for further assessment or referral to treatment, which leads to client enrollment in problem gambling treatment program. This code is a non-client code (similar to outreach codes). G000No Shows$0Number count of enrolled or non-enrolled client no shows. This code could be attached to a client ID or used as non-client code (similar to outreach codes). 50A*Strategic Outreach Planning/Strategic Program Development, per 15 min$26.60Time spent with development of a Strategic Outreach/Referral Pathways Plan or Program Development. This could include 1 hour from Technical Assistance visit with OHA and quarterly TA development plan calls if call includes strategic planning. Limited to maximum of 10% of A&D 81 allocations unless preauthorized by OHA Problem Gambling Services Manager.50B*Referral Agreement Development, per 15 min$26.60Time spent with allied agencies to develop and follow up on formal referral agreements. Limited to 8 hours per allied agency, unless preauthorized by OHA Problem Gambling Services Manager. Includes time spent preparing for meetings and development of presentation, process and paperwork. 50C*Presentations to Allied Professionals, per 15 min$26.60Time spent delivering presentations to professionals in health/medicine/social services/legal/financial with the express intent to follow up with individual contacts in order to establish relationship, develop screening and referral agreements and protocols, etc. Limited to 8 hours per allied agency, unless preauthorized by OHA Problem Gambling Services Manager. Includes time spent preparing for meeting and developing presentations. 50D*Presentations to Targeted High Risk Client Groups, per 15 min$26.60Time spent delivering presentations to targeted high risk clients groups, including but not limited to: Incarcerated individuals A/D clients (OP/Residential) MH clients (OP/Residential) CAF clients. These presentations shall be focused on signs and symptoms of disordered gambling, treatment options and how to access treatment. Code can be used to provide individual or group consultation/education with potential family member client(s) for the purpose of explaining importance of treatment and what can be expected, in hopes that family member will enroll. Includes time spent preparing and developing presentations. 50E*Treatment AdvertisingActual CostTreatment Ads (yellow pages, web-based ads, radio, TV, newspaper). Limited to maximum of 20% of AD81 allocations unless preauthorized by OHA Problem Gambling Services Manager. 50F*Exhibiting at Professional Conferences, per 15 min$26.60Exhibiting at a conference or meeting of professionals that we know from experience are likely to have problem gamblers in their practices and are in a position to potentially refer (i.e., physicians, nurses, social services, corrections, legal, financial). This is in contrast to a conference for service organizations (i.e. Kiwanis, Elks), schools, PTAs and health fairs. Limited to (4 hours) per exhibit, unless preauthorized by OHA Problem Gambling Manager.50G*Other as Pre-authorizedAs AuthorizedOther as pre-authorized by OHA Problem Gambling Manager.FLEXNon-traditional Services or ActivitiesActual CostExamples include wraparound (barrier removal) type services (travel vouchers for clients, childcare expenses, etc.), and workforce development needs of service provider. Code to be used when additional FLEX codes do not apply. FLEX01Staff Professional Development Actual CostRate for online trainings: $26.60/15 minutesIncludes registration cost, travel, lodging and per diem, contracts for certification supervision or consulting. This code is permitted for use for time spent participating in online trainings at $26.60/15 minutes.FLEX02TransportationActual CostClient travel to services, bus/taxi passes, etc.? All other clinician travel for client services should be coded to mileage G30. Approval should be based on internal organization clinical judgement, barrier to success of gambling treatment, and availability of unused gambling treatment funds. FLEX03Community/Social EngagementActual CostLong standing alternative activities- limited partial gym membership/membership fee, local art-type community classes, etc.? Approval should be based on internal organization clinical judgement, barrier to success of gambling treatment, and availability of unused gambling treatment funds. FLEX04Overall WellbeingActual CostItems to improve employment prospects, eye glasses, etc. Approval should be based on internal organization clinical judgement, barrier to success of gambling treatment, and availability of unused gambling treatment funds. FLEX05Nutrition for EventsActual CostFood and beverages for client activities. Approval should be based on internal organization clinical judgement, barrier to success of gambling treatment, and availability of unused gambling treatment funds. FLEX06Temporary HousingActual CostShort term housing, oxford house, hotels, cleaning fees, pet fees, deposits to assist client with permanent housing plan, other than rent.?Approval should be based on internal organization clinical judgement, barrier to success of gambling treatment, and availability of unused gambling treatment funds. 50AP*Strategic Outreach Planning/program development planning, per 15 min$16.60Peer Support Specialist time spent with clinician staff participating in strategic outreach plan development or program development planning. Limited to maximum of 10% of A&D 81 allocations unless preauthorized by OHA Problem Gambling Manager.50CP*Presentations to allied professionals, per 15 min$16.60Peer Support Specialist time spent delivering presentations to professionals in health/medicine/social services/legal/financial with the express intent to follow up with individual contacts in order to establish relationship, develop screening and referral agreements and protocols, etc. Limited to 8 hours per allied agency, unless preauthorized by OHA Problem Gambling Services Manager. 50DP*Presentations to targeted high risk client groups, per 15 min$16.60Peer Support Specialist time spent delivering presentations to targeted high risk clients groups, including but not limited to: Incarcerated individuals A/D clients (OP/Residential) MH clients (OP/Residential) CAF clients. These presentations shall be focused on signs and symptoms of disordered gambling, treatment options and how to access treatment. Limited to 8 hours per allied agency, unless preauthorized by OHA Problem Gambling Services Manager.50FP*Exhibiting at Professional Conferences, per 15 min$16.60Peer Support Specialist time spend exhibiting at a conference or meeting of professionals with the intention of educating potential gambling treatment referral sources about problem gambling, recovery, treatment, screening tools, and available problem gambling help in Oregon. This is in contrast to a conference for service organizations (i.e. Kiwanis, Elks), schools, PTAs and health fairs. Limited to (4 hours) per exhibit, unless preauthorized by OHA Problem Gambling Manager.*50A-50G codes, known as Referral Pathways Codes, have the primary purpose of getting problem gamblers and/or family members enrolled in services, geared specifically towards increasing the number of clients receiving treatment. It is targeted, generally involves repeated contacts and the development of a relationship with the provider. The provider is generally another professional and the goal is to increase the number of clients they assess and refer to your program. For Referral Pathways documentation requirement, please keep on file a copy of strategic outreach plan, referral agreements, documentation of meetings, outline of presentations, copy of ads, flight schedules of media, exhibitor confirmation letter, etc. *** Providers must bill at rates, based upon the cost of services determined through a cost allocation, not in excess of their usual and customary charge to the general public ** (OAR 309-016-0105 and OAR 309-016-0420) ................
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