Oregon Problem Gambling Services

Procedure Codes and Rates for FY2016-17

Effective July 1, 2016

Code / Description / PGS Payment Amount / Service Criteria
H0001 / Gambling Assessment / $139.70 / Service provided by qualified counselor per OAR 309-019-0100. If assessment takes longer than 1 hour, service provider can encounter remaining time as H0004.
T1023 / Behavioral Health Screening per 15 min / $23.86 / Screening 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.
H0004 / Gambling Treatment counseling and therapy, per 15 min / $23.86 / Service provided by qualified counselor per OAR 309-019-0100
H0005 / Gambling Treatment counseling, group per 15 min / $9.90 / Service provided by qualified counselor per OAR 309-019-0100
90846 / Family Psychotherapy (without the patient present), per service / $92.69 / Service provided by LMP, LPC, LMFT, LCSW, Psychologist or QMHP.
90847 / Family Psychotherapy (conjoint psychotherapy) with the patient present, per service / $115.49 / Service provided by LMP, LPC, LMFT, LCSW, Psychologist or QMHP.
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.
90849 / Multiple-family group psychotherapy, per service / $37.38 / Service provided by LMP, LPC, LMFT, LCSW, Psychologist or QMHP
90801 or 90791 / Psychiatric Diagnostic Interview / $131.44 / Service provided by MD, Psychiatric Mental Health Nurse Practitioner, LPC, LMFT, LCSW, Psychologist or QMHP.
90792 / Psychiatric Diagnostic Interview, with medication services / $140.94 / Service provided by MD or Psychiatric Mental Health Nurse Practitioner, LPC, LMFT, LCSW, Psychologist or QMHP.
90832 / Psychotherapy, with patient and/or family member, per 30 minutes / $66.53 / Service provided by LMP, LPC, LMFT, LCSW, Psychologist or QMHP. Individual psychotherapy, insight oriented, behavioral modifying and/or supportive. Individual must be diagnosed with a gambling disorder and mental health disorder (dual diagnosed). 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.
96101 / Psychological Testing with interpretation and report, per hour / $91.19 / QHHP who is licensed Psychologist or a Psychology Intern supervised by a Licensed Psychologist
90862 or 90863 or 90832
GMED / Medication Management Psychotherapy (Formerly known as Medication Management), per 30 minutes / $70.47
65.72 / Services 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.
Service provided by a LMP, LPC, LMFT, LCSW, Psychologist, or QMHP with patient and/or family member. Effective January 1, 2016.
H2027 / Individual counseling continuing care, per 15 min / $23.86 / This 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.
G2100 / Continuing Care Group Services, per 15 min for gambler and/or family member / $9.90 / Services 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.
H0038 / Peer Delivered Services, per 15 min / $16.00 / "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.
This could can also be encountered for as an aftercare service (effective July 1, 2016).
H0038G / Peer Delivered Services- Group, per 15 min / $5.28 / Peer Delivered Services provided by Peer Support Specialist per definition provided under H0038 in a group setting.
This could can also be encountered for as an aftercare service (effective July 1, 2016).
H2010 / Comprehensive medication services, per 15 min / $23.86 / Services delivered by a licensed registered nurse or QMHP related to the dispensing, administration and management of medications.
H2013 / Psychiatric health facility service, per diem / $350.23 / Services 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.
99368 / Team conference/consultation with Interdisciplinary team, per 30 minutes or more / 22.00 / Medical 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.
G2013 / Residential gambling treatment service, per diem Marion County Bridgeway Residential Program Only / $175.00
$200.00 / Services 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.
T1016 / Case management, per 15 min / $22.25 / Services 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,
T1016P / Case management, per 15 min / $16.00 / Peer 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.
G2030 / Financial counseling, per hour / $89.00 / Pressure 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.
T1013 / Sign language/oral interpreter service, per 15 min / $9.60 / Sign 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.
99203 / Evaluation and management physical health visit, new patient, 30 minutes maximum length / 82.56 / Evaluation 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.
99213 / Evaluation and management physical health visit, established patient, 15 minutes maximum length / $55.53 / Evaluation 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.
G5000 / Individual counseling, other technologies, per 15 min / $23.86 / Services provided by qualified counselor per current policy standards. Must meet current requirements for confidentiality with patient informed consent.
G4000 / Individual counseling, telephone, per 15 min / $23.86 / Services provided by qualified counselor per current policy standards. Must meet current requirements for confidentiality with patient informed consent.
G30 / Mileage / Current US GSA rate / Limited 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
50A* / Strategic Outreach Planning, per 15 min / $23.86 / Time spent with development of a Strategic Outreach/Referral Pathways Plan. 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 / $23.86 / Time 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 / $23.86 / 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. Includes time spent preparing for meeting and developing presentations.
50D* / Presentations to Targeted High Risk Client Groups, per 15 min / $23.86 / 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. 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 Advertising / Actual Cost / Treatment 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 / $23.86 / Exhibiting 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-authorized / As Authorized / Other as pre-authorized by OHA Problem Gambling Manager.
FLEX / Non-traditional Services or Activities / Actual Cost / Examples include wraparound (barrier removal) type services (travel vouchers for clients, childcare expenses, etc)., and workforce development needs of service provider.
50AP* / Strategic Outreach Planning, per 15 min / $16.00 / Peer Support Specialist time spent with clinician staff participating in strategic outreach plan development. 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 / $16.00 / Peer 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 / $16.00 / Peer 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 / $16.00 / Peer 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)

Note: Language in red font is updated or new language for fiscal year 2016-17.