DHHS91073 Rate Table.xlsx

	A	B	C	D	E
1	DHS91073 Rate Table
2	Last Revised: 5/31/23
3	Effective Date: 7/1/2023
4	Psychotherapy Services
5	Service Name	Medicaid Billing Code	DHHS Service Code	Unit Rate	Unit
6	Psychiatric Diagnostic Interview Examination	90791	NCA	$36.14	Quarter Hour
7	Psychotherapy, 30 minutes, with patient and/or family member	90832	NT2	$59.27	Session
8	Psychotherapy, 45 minutes, with patient and/or family member	90834	NT3	$105.80	Session
9	Psychotherapy, 60 minutes, with patient and/or family member	90837	NT4	$131.66	Session
10	Psychotherapy for crisis, first 60 minutes, with patient and/or family member	90839	NTC	$118.55	Session
11	Psychotherapy for crisis, add-on	90840	NTX	$59.27	Half Hour
12	Family Psychotherapy - without patient present	90846	NFW	$29.64	Quarter Hour
13	Family Psychotherapy - with patient present	90847	NFT	$29.64	Quarter Hour
14	Multiple-Family Group Psychotherapy	90849	NFG	$6.90	Quarter Hour
15	Group Psychotherapy	90853	NGT	$6.90	Quarter Hour
16	Mental Health Assessment By Non Physician	H0031	NCN	$36.14	Quarter Hour
17	Clinical Consultation	N/A	NCC	$20.00	Quarter Hour
18	Non-Clinical Consultation	N/A	NNC	$13.30	Quarter Hour
19	Mileage & Travel Reimbursement (over 75 miles round trip)	N/A	MIR	$1.07	Mile
20
21	Psychological and Neuropsychological Evaluation Services
22	Service Name	Medicaid Billing Code	DHHS Service Code	Unit Rate	Unit
23	Assessment of Aphasia	96105	NXA	$144.36	Hour
24	Developmental Testing (Limited)	96110	NDL	$6.14	Exam
25	Developmental Test Administration - 1st Hour	96112	NDT	$144.36	Hour
26	Developmental Test Administration – Each Additional Half Hour	96113	ND2	$72.18	Half Hour
27	Neurobehavioral Status Examination - by Physician or Qualified Health Care Professional - 1st Hour	96116	NXB	$144.36	Hour
28	Neurobehavioral Status Examination – by Physician or Qualified Health Care Professional – Each Additional Hour	96121	NB2	$144.36	Hour
29	Standardized Cognitive Performance Testing by a Health Care Professional - per hour	96125	NST	$144.36	Hour
30	Psychological Testing Evaluation by Physician or Qualified Health Care Professional - 1st Hour	96130	NP1	$144.36	Hour
31	Psychological Testing Evaluation by Physician or Qualified Health Care Professional - Each Additional Hour	96131	NP2	$144.36	Hour
32	Neuropsychological Testing Evaluation by Physician or Health Care Professional - 1st Hour	96132	NP3	$144.36	Hour
33	Neuropsychological Testing Evaluation by Physician or Health Care Professional - Each Additional Hour	96133	NP4	$144.36	Hour
34	Psychological or Neuropsychological Testing by Physician or Health Care Professional - 1st Half Hour	96136	NP5	$72.18	Half Hour
35	Psychological or Neuropsychological Testing by Physician or Health Care Professional - Each Additional Half Hour	96137	NP6	$72.18	Half Hour
36	Psychological or Neuropsychological Testing by Technician - 1st Half Hour	96138	NP7	$27.30	Half Hour
37	Psychological or Neuropsychological Testing by Technician - Each Additional Half Hour	96139	NP8	$27.30	Half Hour
38	Psychological or Neuropsychological Testing by Electronic Platform - Auto Result	96146	NP9	$1.58	Exam
39	Clinical Consultation	N/A	NCC	$20.00	Quarter Hour
40	Mileage & Travel Reimbursement (over 75 miles round trip)	N/A	MIR	$1.07	Mile
41
42	Pharmacologic Evaluation and Management Services
43	Service Name	Medicaid Billing Code	DHHS Service Code	Unit Rate	Unit
44	Pharmacologic Management, Prescriber (MD/APRN) (based on complexity and time, 5 Minutes typical)	99211 with CG modifier	NM1	$18.80	Session
45	Pharmacologic Management, Prescriber (MD/APRN) (based on complexity and time, 10 Minutes typical)	99212 with CG modifier	NM2	$42.11	Session
46	Pharmacologic Management, Prescriber (MD/APRN) (based on complexity and time, 15 Minutes typical)	99213 with CG modifier	NM3	$81.01	Session
47	Pharmacologic Management, Prescriber (MD/APRN) (based on complexity and time, 25 Minutes typical)	99214 with CG modifier	NM5	$95.49	Session
48	Pharmacologic Management, Prescriber (MD/APRN) (based on complexity and time, 40 Minutes typical)	99215 with CG modifier	NM8	$140.72	Session
49	Home Services E/M Codes – established patient - 15 Minutes	99347	NH1	$41.73	Session
50	Home Services E/M Codes – established patient - 25 Minutes	99348	NH2	$63.75	Session
51	Home Services E/M Codes – established patient - 40 Minutes	99349	NH3	$97.34	Session
52	Home Services E/M Codes – established patient - 60 Minutes	99350	NH4	$135.45	Session
53	Psychiatric Diagnostic Evaluation with Medical Services, by physician or APRN	90792	NPE	$36.14	Quarter Hour
54	Psychotherapy add-on code, witha patient and/or family member - 30 mins (added to applicable E/M service code)	90833	NMT	$59.27	Session
55	Psychotherapy add-on code, with a patient and/or family member - 45 mins (added to applicable E/M code)	90836	NMI	$88.91	Session
56	Psychotherapy add-on code, with a patient and/or family member - 60 mins (added to applicable E/M code)	90838	NMC	$118.55	Session
57	Mental Health Assessment	H0031	NCN	$36.14	Quarter Hour
58	Nurse Assessment/Evaluation	T1001	NAE	$44.38	Session
59	Therapeutic, Prophylactic, or Diagnostic Injection, Subcutaneous/Intramuscular	96372	NDI	$20.17	Session
60	Clinical Consultation	N/A	NCC	$20.00	Quarter Hour
61	Mileage & Travel Reimbursement (over 75 miles round trip)	N/A	MIR	$1.07	Mile
62
63	Psychosocial Rehabilitative Services
64	Service Name	Medicaid Billing Code	DHHS Service Code	Unit Rate	Unit
65	Individual Skills Training and Development (Psychosocial rehabilitative services with an individual)	H2014	NRI	$14.50	Quarter Hour
66	Group Psychosocial Rehabilitative Services	H2017	NRG	$3.96	Quarter Hour
67	Group Psychosocial Rehabilitative Services - Intensive	H2017 U1	NRX	$4.16	Quarter Hour
68	Non-Clinical Consultation	N/A	NNC	$13.30	Quarter Hour
69	Mileage & Travel Reimbursement (over 75 miles round trip)	N/A	MIR	$1.07	Mile
70
71	Therapeutic Behavioral Services
72	Service Name	Medicaid Billing Code	DHHS Service Code	Unit Rate	Unit
73	Individual/Family Therapeutic Behavioral Services	H2019	NBT	$18.60	Quarter Hour
74	Group Therapeutic Behavioral Services	H2019 HQ	NBG	5.71	Quarter Hour
75	Non-Clinical Consultation	N/A	NNC	$13.30	Quarter Hour
76	Mileage & Travel Reimbursement (over 75 miles round trip)	N/A	MIR	$1.07	Mile
77
78	Family and Youth Peer Support Services
79	Service Name	Medicaid Billing Code	DHHS Service Code	Unit Rate	Unit
80	Peer Support Services, individual - per 15 mins	H0038	NPS	$13.64	Quarter Hour
81	Mileage at Standard Rate of Reimbursement (over 60 miles round trip)	N/A	MSR	https://hs.utah.gov/DHHSpurchasing/mileage
82
83	Evidence-Based Program Models for Prevention of Foster Care Services
84	Service Name	Medicaid Billing Code	DHHS Service Code	Unit Rate	Unit
85	Parent-Child Interaction Therapy - Provided by a therapist who is certified or trained and working toward certification by PCIT International	N/A	PCE	$37.50	Quarter Hour
86	Trauma Focused Cognitive Behavior Therapy	N/A	TFT	$36.24	Quarter Hour
87	Functional Family Therapy	N/A	FFT	$220.00	Session
88	Motivational Interviewing	N/A	MIT	$36.24	Quarter Hour
89	Mileage & Travel Reimbursement (over 75 miles round trip)	N/A	MIR	$1.07	Mile
90
91	Mentoring Services
92	Service Name	Medicaid Billing Code	DHHS Service Code	Unit Rate	Unit
93	Mentoring (1:1)	N/A	MT1	$5.60	Quarter Hour
94	Mentoring (1:2)	N/A	MT2	$2.80	Quarter Hour
95	Mentoring (1:3)	N/A	MT3	$1.87	Quarter Hour
96	Mileage at Standard Rate of Reimbursement (over 60 miles round trip)	N/A	MSR	https://hs.utah.gov/DHHSpurchasing/mileage
97
98	Day Treatment Services
99	Service Name	Medicaid Billing Code	DHHS Service Code	Unit Rate	Unit
100	Mileage & Travel Reimbursement	N/A	MIR	$1.07	Mile