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Medicaid B - Evaluation and Management (E and M) and Medication Assisted Treatment (MAT)

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About

Coverage

Medicaid B

Diagnosis Group(s)

All, Assessment Only, Developmental Disability, Mental Health, Substance Use

Age Group(s)

18, 18-20, Adult, All, Child

Authorization

Submission Requirements

  • Service Authorization Request (SAR)

Service Definition Authorization Parameters

Evaluation and Management (E and M)

  • 22 unmanaged visits per state fiscal year
  • Prior approval required beyond unmanaged benefit

Medication Assisted Treatment (MAT)

  • Prior Approval required beyond benefit maximum of 30 visits per fiscal year

Authorization Guidelines

Locus Level

1 2 3 4 5 6
Green check Green check Green check Green check Green check Green check

Calocus Level

1 2 3 4 5 6
Green check Green check Green check Green check Green check Green check

ASAM Level of Care

ALL

Service Codes & Descriptions

  • 99205 - E & M High, New Patient
  • 99212 25 E & M
  • Add on code for E&M
  • 90838GT - Psychotherapy add on to E & M
  • 90838 GT CR- Psychotherapy add on to E & M
  • 99211 25E&M established patient
  • 99213 25 E&M
  • 99214 25 E&M
  • 99215 25 E&M
  • 99282 25 ed visit
  • 99347 - home visit for the evaluation and management of an established patient, which
  • 99202 - E & M Expanded, New Patient
  • 99202 GT - E & M Expanded, New Patient
  • 99202 GT CR - E & M Expanded, New Patient
  • 99203 - E & M Detailed, New Patient
  • 99203 GT - E & M Detailed, New Patient
  • 99203 GT CR - E & M Detailed, New Patient
  • 99204 - E & M Moderate, New Patient
  • 99204 GT - E & M Moderate, New Patient
  • 99204 GT CR - E & M Moderate, New Patient
  • 99205 GT - E & M High, New Patient
  • 99205 GT CR - E & M High, New Patient
  • 99324 - domiciliary or rest home visit for the evaluation and management of a new
  • 99325 - domiciliary or rest home visit for the evaluation and management of a new
  • 99326 - domiciliary or rest home visit for the evaluation and management of a new
  • 99327 - domiciliary or rest home visit for the evaluation and management of a new
  • 99328 - domiciliary or rest home visit for the evaluation and management of a new
  • 99341 - home visit for the evaluation and management of a new patient, which requires
  • 99342 - home visit for the evaluation and management of a new patient, which requires
  • 99343 - home visit for the evaluation and management of a new patient, which requires
  • 99344 - home visit for the evaluation and management of a new patient, which requires
  • 99345 - home visit for the evaluation and management of a new patient, which requires
  • 90836 - Psychotherapy - 45 Minute Add on to E&M
  • 90836 CR - Psychotherapy - 45 Minute Add on to E&M
  • 90836 GT - Psychotherapy 45 mins
  • 90836 GT CR - Psychotherapy 45 mins
  • 90838 - Psychotherapy - 60 Minutes Addon to E&M
  • 90838 CR - Psychotherapy - 60 Minutes Addon to E&M
  • 99212 GT CR - E & M Expanded, Estab Patient
  • 99211 - E&M Minimum, Estab Patient
  • 99211 GT - E&M Minimum, Estab Patient
  • 99211 GT CR - E&M Minimum, Estab Patient
  • 99212 - E & M Expanded, Estab Patient
  • 99212 GT - E & M Expanded, Estab Patient
  • 99213 - E & M Detailed, Estab Patient
  • 99213 GT - E & M Detailed, Estab Patient
  • 99213 GT CR - E & M Detailed, Estab Patient
  • 99214 - E & M Moderate, Estab Patient
  • 99214 GT - E & M Moderate, Estab Patient
  • 99214 GT CR - E & M Moderate, Estab Patient
  • 99215 - E & M High Estab Patient
  • 99215 GT - E & M High Estab Patient
  • 99215 GT CR - E & M High Estab Patient
  • 99283 25 ER moderate
  • 99283 GT - er moderate
  • 99284 25 er visit, high severity
  • 99285 25 - emergency department visit for the evaluation and management of a patient,
  • 99305 - initial nursing facility care, per day, for the evaluation and management of
  • 99306 - initial nursing facility care, per day, for the evaluation and management of a
  • 99307 - subsequent nursing facility care, per day, for the evaluation and management of
  • 99308 - subsequent nursing facility care, per day, for the evaluation and management of
  • 99309 - subsequent nursing facility care, per day, for the evaluation and management of
  • 99310 - subsequent nursing facility care, per day, for the evaluation and management of
  • 99315 - nursing facility discharge day management; 30 minutes or less
  • 99316 - nursing facility discharge day management; 30 minutes or less more than 30
  • 99318 - evaluation and management of a patient involving an annual nursing facility
  • 99334 - domiciliary or rest home visit for the evaluation and management of an
  • 99335 - domiciliary or rest home visit for the evaluation and management of an
  • 99336 - domiciliary or rest home visit for the evaluation and management of an
  • 99337 - domiciliary or rest home visit for the evaluation and management of an
  • 99348 - home visit for the evaluation and management of an established patient, which
  • 99349 - home visit for the evaluation and management of an established patient, which
  • 99350 - home visit for the evaluation and management of an established patient, which
  • 99354 - prolonged physician service in the office or other outpatient setting requiring
  • 99355 - prolonged physician service in the office or other outpatient setting requiring
  • 99356 - prolonged physician service in the inpatient setting, requiring direct
  • 99357 - prolonged physician service in the inpatient setting, requiring direct
  • 99291 - critical care, evaluation and management of the critically ill or critically
  • 99212 22 - Medication Assisted Treatment Expanded
  • 99212 22 GT - Medication Assisted Treatment Expanded
  • 99212 22 GT CR- Medication Assisted Treatment Expanded
  • 99213 22 - Medication Assisted Treatment, Detailed
  • 99213 22 GT - Medication Assisted Treatment, Detailed
  • 99213 22 GT CR- Medication Assisted Treatment, Detailed
  • 99214 22 Medication Assisted Treatment, Moderate
  • 99214 22 GT Medication Assisted Treatment, Moderate
  • 99214 22 GT CR Medication Assisted Treatment, Moderate

Full Service Definition

<a target="_blank" href="https://medicaid.ncdhhs.gov/media/10107/open">Download PDF</a>

Alliance Statement of Work