Exhibit 1B - DUII Enhancements Authorization Parameters.pdf

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Attached to
T2590 - Fiscal Agent for the Division of Mental Health and Addiction Services (DMHAS)
Solicitation number
25DPP01060
Issued by
Mercer County, New Jersey

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This document is the Exhibit 1B - Driving Under the Influence Initiative (DUII) Enhancements Authorization Parameters for the state DMHAS DUII program. It outlines the fee-for-service enhancement authorization parameters for various clinical, co-occurring, medication monitoring, psychiatric evaluation, medication-assisted, recovery support, medical, and laboratory services. The document specifies the service rates, unit types, CPT codes, service limits per day/month/year, and annual client limits for these services. It also includes the encounter entry requirements before expiration of authorization for different service categories.

The document provides pricing details for the covered services, including rates for urine drug screens, oral swabs, Mantoux tests, continuing care, case management, therapy, psychiatric evaluation, medication monitoring, methadone maintenance, buprenorphine/naloxone, and recovery support services. The enhancement authorization parameters are applicable for the state fiscal year 2025, effective from July 1, 2024.

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Exhibit 1B - Driving Under the Influence Initiative (DUII) Enhancements Authorization Parameters

Clinical Review

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Urine Drug Screen - Presumptive Testing $ 8.46 service Clinical H0003HF 1 5 n/a H0003HF 1 5 n/a H0003HF 1 5 n/a H0003HF 1 5 n/a n/a

Oral Swab $ 8.46 service Clinical ZSWB 1 5 n/a ZSWB 1 5 n/a ZSWB 1 5 n/a ZSWB 1 5 n/a n/a

Mantoux Tuberculin Test $ 10.57 service Clinical 86580 1 1 n/a 86580 1 1 n/a 86580 1 1 n/a 86580 1 1 n/a n/a

Continuing Care LOCI $ 26.43 20 minutes Clinical ZLOCI 1 1 n/a ZLOCI 1 1 n/a ZLOCI 1 1 n/a ZLOCI 1 2 n/a n/a

Limit Clinical Review Enhancements $79.30 $79.30 $79.30 $105.73

Co-occurring Clinical Services

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Case Management - COOC $ 13.32 15 minutes Co-occurring T2022 HF 8 16 n/a T2022 HF 8 16 n/a T2022 HF 0 0 0 T2022 HF 0 0 n/a n/a

Comprehensive Intake Evaluation $ 171.99 service Co-occurring 90791 1 1 n/a 90791 1 1 n/a 90791 1 1 n/a 90791 1 1 n/a n/a

Crisis Intervention - Individual $ 15.12 15 minutes Co-occurring S9484 HF 0 0 0 S9484 HF 4 8 n/a S9484 HF 0 0 0 S9484 HF 0 0 n/a 0

Family Therapy $ 113.84 60 minutes Co-occurring 90847 HF 0 0 0 90847 HF 1 5 n/a 90847 HF 0 0 0 90847 HF 0 0 n/a 0

Individual Therapy $ 71.39 30 minutes Co-occurring 90832 HF 0 0 0 90832 HF 1 5 n/a 90832 HF 0 0 0 90832 HF 0 0 n/a 0

Individual Therapy $ 94.46 45 - 50 minutes Co-occurring 90834 HF 0 0 0 90834 HF 1 5 n/a 90834 HF 0 0 0 90834 HF 0 0 n/a 0

Group Therapy $ 27.48 90 min Co-occurring 90853 HF 0 0 0 90853 HF 2 5 n/a 90853 HF 0 0 0 90853 HF 0 0 n/a 0

Clinical Consultation $ 27.75 15 minutes Co-occurring 90887 0 0 0 90887 4 6 n/a 90887 0 0 0 90887 0 0 n/a 0

Limit Co-occurring Clinical Services

Enhancement $385.11 $908.35 $171.99 $171.99

Encounter entry required before expiration of authorization (days) -

Driving Under the Influence Initiative (DUII)

Fee for Service Enhancement Authorization Parameters

PC, IOP & OP Limits AWM (Detox) Limits

IWM, STR & LTRT2 Limits HWH Limits PC, IOP & OP Limits AWM (Detox) Limits

IWM, STR & LTRT2 Limits HWH Limits

Encounter entry required before expiration of authorization (days) -

DMHAS DUII Page 1 of 6

SFY 2025

Effective 07/01/24

Revised 04/08/24

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Medication Monitoring $ 47.54 15 minutes CO Med 90862 HF 0 0 0 90862 HF 2 2 n/a 90862 HF 2 2 n/a 90862 HF 0 0 n/a n/a

Limit Co-occurring Medication Monitoring

Service Enhancement $0.00 $95.08 $95.08 $0.00

Psychiatric Evaluation

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Psychiatric Evaluation $ 437.76 service Psych Eval 90792 1 1 4 90792 1 1 4 90792 1 1 4 90792 1 1 4 4

Limit Co-occurring Pyschiatric Evaluation

Service Enhancement $437.76 $1,751.04 $437.76 $1,751.04 $437.76 $1,751.04 $437.76 $1,751.04 $1,751.04

PC, IOP & OP Limits AWM (Detox) Limits

Encounter entry required before expiration of authorization (days) -

IWM, STR & LTRT2 Limits HWH Limits

Encounter entry required before expiration of authorization (days) -

Co-occurring Med Monitoring Services Enhancement

AWM (Detox) LimitsIWM, STR & LTRT2 Limits PC, IOP & OP LimitsHWH Limits

DMHAS DUII Page 2 of 6

SFY 2025

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Medication Monitoring - MAT $ 47.54 15 minutes MAT IS-M Z3353 2 4 n/a Z3353 2 4 n/a Z3353 2 2 n/a Z3353 0 0 0 n/a

Methadone Maintenance $ 4.05 unit MAT IS-M H0020 HF 1 31 n/a H0020 HF 1 31 n/a H0020 HF 1 31 n/a H0020 HF 0 0 0 n/a

Limit Med Assist-Induction/Stabilization

Methadone Enhancements $315.71 $315.71 $220.63 $0.00

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Medication Monitoring - MAT $ 47.54 15 minutes MAT- MM Z3353 2 4 n/a Z3353 2 4 n/a Z3353 2 2 n/a Z3353 0 0 0 n/a

Methadone Maintenance $ 4.05 unit MAT- MM H0020 HF 1 31 n/a H0020 HF 1 31 n/a H0020 HF 1 31 n/a H0020 HF 0 0 0 n/a

Limit Medication Assisted-Methadone

Maintenance Enhancements $315.71 $315.71 $220.63 $0.00

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Medication Monitoring - MAT $ 47.54 15 minutes MAT IS-Sx Z3353 2 4 n/a Z3353 2 4 n/a Z3353 2 2 n/a Z3353 0 0 0 n/a

Buprenorphine/Naloxone Maint. (2mg/0.5mg) $ 7.66 unit MAT IS-Sx ZM05 3 93 n/a ZM05 3 93 n/a ZM05 3 93 n/a ZM05 0 0 0 n/a

Buprenorphine/Naloxone Maint. (8mg/2mg) $ 10.40 unit MAT IS-Sx ZM2G 4 124 n/a ZM2G 4 124 n/a ZM2G 4 124 n/a ZM2G 0 0 0 n/a

Buprenorphine Maintenance (8mg) $ 12.03 unit MAT IS-Sx ZM8G 4 124 n/a ZM8G 4 124 n/a ZM8G 4 124 n/a ZM8G 0 0 0 n/a

Limit Med Assist - Inductions/Stabilization

Suboxone Enhancements $1,681.88 $1,681.88 $1,586.80 $0.00

Recovery Support

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Recovery Support Care Management $ 26.40 15 minutes Recovery Sup H0023 HF 4 16 n/a H0023 HF 4 16 n/a H0023 HF 4 16 n/a H0023 HF 4 16 n/a n/a

Encounter entry required before expiration of authorization (days) -

Medication Assisted - Methadone Maintenance

AWM (Detox) Limits

Encounter entry required before expiration of authorization (days) -

Medication Assisted - Induction/Stabilization Methadone

Encounter entry required before expiration of authorization (days) -

IWM, STR & LTRT2 Limits

Medication Assisted - Induction/Stabilization Buprenorphine

IWM, STR & LTRT2 Limits

Encounter entry required before expiration of authorization (days) -

PC, IOP & OP Limits

PC, IOP & OP Limits AWM (Detox) Limits

HWH Limits

HWH Limits

AWM (Detox) Limits

IWM, STR & LTRT2 Limits HWH Limits PC, IOP & OP Limits AWM (Detox) Limits

PC, IOP & OP LimitsIWM, STR & LTRT2 Limits HWH Limits

DMHAS DUII Page 3 of 6

SFY 2025

Limit Recovery Support Enhancements $422.40 $422.40 $422.40 $422.40

DMHAS DUII Page 4 of 6

SFY 2025

Medical Services

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

E & M visit - new patient (20 min) $ 82.94 20 minutes Medical Srvcs 99202 0 0 0 99202 1 1 n/a 99202 1 1 n/a 99202 0 0 0 n/a

E & M visit - new patient (30 min) $ 117.03 30 minutes Medical Srvcs 99203 0 0 0 99203 1 1 n/a 99203 1 1 n/a 99203 0 0 0 n/a

E & M visit - new patient (45 min) $ 177.73 45 minutes Medical Srvcs 99204 0 0 0 99204 1 1 n/a 99204 1 1 n/a 99204 0 0 0 n/a

E & M visit - new patient (60 min) $ 224.19 60 minutes Medical Srvcs 99205 0 0 0 99205 1 1 n/a 99205 1 1 n/a 99205 0 0 0 n/a

E & M visit - established patient (10 min) $ 49.91 10 minutes Medical Srvcs 99212 0 0 0 99212 1 1 n/a 99212 1 1 n/a 99212 0 0 0 n/a

E & M visit - established patient (15 min) $ 81.64 15 minutes Medical Srvcs 99213 0 0 0 99213 1 1 n/a 99213 1 1 n/a 99213 0 0 0 n/a

E & M visit - established patient (25 min) $ 118.08 25 minutes Medical Srvcs 99214 0 0 0 99214 1 1 n/a 99214 1 1 n/a 99214 0 0 0 n/a

E & M visit - established patient (40 min) $ 158.24 40 minutes Medical Srvcs 99215 0 0 0 99215 1 1 n/a 99215 1 1 n/a 99215 0 0 0 n/a

Limit Medical Services Enhancements $0.00 $469.11 $469.11 $0.00

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Case Management - Vivitrol $ 13.32 15 minutes V or B T2022 HF 4 4 n/a T2022 HF 4 4 n/a T2022 HF 4 4 n/a T2022 HF 0 0 n/a n/a

Urine Preg Test Visual Color Comp $ 2.85 1 test V or B 81025 1 1 6 81025 1 1 6 81025 1 1 6 81025 1 1 n/a n/a

E & M visit - new patient (20 min) $ 82.94 20 minutes V or B 99202 0 0 0 99202 1 n/a n/a 99202 1 n/a n/a 99202 0 0 0 n/a

Limit V or B: Vivitrol - Pre-Induction

Enhancements $56.13 $139.07 $139.07 $2.85

Encounter entry required before expiration of authorization (days) -

IWM, STR & LTRT2 Limits

Encounter entry required before expiration of authorization (days) -

HWH Limits PC, IOP & OP Limits AWM (Detox) Limits

IWM, STR & LTRT2 Limits HWH Limits PC, IOP & OP Limits AWM (Detox) Limits

Vivitrol or Buprenorphine: Vivitrol - Pre-Induction

DMHAS DUII Page 5 of 6

SFY 2025

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Medication Monitoring - MAT $ 47.54 15 minutes V or B Z3353 2 4 n/a Z3353 2 4 n/a Z3353 2 2 n/a Z3353 0 0 0 n/a

Buprenorphine/Naloxone Maint. (2mg/0.5mg) $ 7.66 unit V or B ZM05 3 93 n/a ZM05 3 93 n/a ZM05 3 93 n/a ZM05 0 0 0 n/a

Buprenorphine/Naloxone Maint. (8mg/2mg) $ 10.40 unit V or B ZM2G 4 124 n/a ZM2G 4 124 n/a ZM2G 4 124 n/a ZM2G 0 0 0 n/a

Buprenorphine Maintenance (8mg) $ 12.03 unit V or B ZM8G 4 124 n/a ZM8G 4 124 n/a ZM8G 4 124 n/a ZM8G 0 0 0 n/a

Case Management - Vivitrol $ 13.32 15 minutes V or B T2022 HF 2 2 n/a T2022 HF 2 2 n/a T2022 HF 2 2 n/a T2022 HF 0 0 0 n/a

Urine Preg Test Visual Color Comp $ 2.85 1 test V or B 81025 1 1 6 81025 1 1 6 81025 1 1 6 81025 0 0 0 n/a

E & M visit - established patient (10 min) $ 49.91 10 minutes V or B 99212 0 0 0 99212 1 n/a n/a 99212 1 n/a n/a 99212 0 0 0 n/a

Vivitrol Medication and Injection $ 1,232.34 injection V or B ZVIV 1 1 6 ZVIV 1 1 6 ZVIV 1 1 6 ZVIV 0 0 0 n/a

Limit V or B: Vivitrol - On-going Induction

Enhancements $1,711.37 $1,761.28 $1,761.28 $0.00

Service Rate Unit Type CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year CPT Code Day Month Year Annual client limit

Comprehensive Metabolic Panel $ 9.99 service V or B - Lab 80053 1 1 n/a 80053 1 1 n/a 80053 1 1 n/a 80053 0 0 n/a n/a

Transferase, Alanine Amino Panel (ALT) $ 2.85 service V or B - Lab 84460 1 1 n/a 84460 1 1 n/a 84460 1 1 n/a 84460 0 0 n/a n/a

Transferase, Aspartate Amino Panel (AST) $ 2.85 service V or B - Lab 84450 1 1 n/a 84450 1 1 n/a 84450 1 1 n/a 84450 0 0 n/a n/a

Bilirubin Panel $ 2.85 service V or B - Lab 82247 1 1 n/a 82247 1 1 n/a 82247 1 1 n/a 82247 0 0 n/a n/a

Mantoux Tuberculin Test $ 10.57 service V or B - Lab 86580 1 1 n/a 86580 1 1 n/a 86580 1 1 n/a 86580 0 0 n/a n/a

Hepatic Function Panel $ 6.66 service V or B - Lab 80076 1 1 n/a 80076 1 1 n/a 80076 1 1 n/a 80076 0 0 n/a n/a

Complete Blood Count $ 4.76 service V or B - Lab 85025 1 1 n/a 85025 1 1 n/a 85025 1 1 n/a 85025 0 0 n/a n/a

Quantitative Syphilis Test $ 2.85 service V or B - Lab 86593 1 1 n/a 86593 1 1 n/a 86593 1 1 n/a 86593 0 0 n/a n/a

Urine Drug Screen - Presumptive Testing $ 8.46 service V or B - Lab H0003 HF 1 1 n/a H0003 HF 1 1 n/a H0003 HF 1 1 n/a H0003 HF 0 0 n/a n/a

Urine Preg Test Visual Color Comp $ 2.85 service V or B - Lab 81025 1 1 6 81025 1 1 6 81025 1 1 6 81025 0 0 n/a 6

Limit Laboratory Services Enhancements $46.14 $46.14 $46.14 $0.00

Encounter entry required before expiration of authorization (days) -

Vivitrol or Buprenorphine

Encounter entry required before expiration of authorization (days) -

Vivitrol or Buprenorphine: Lab Services

IWM, STR & LTRT2 Limits HWH Limits PC, IOP & OP Limits AWM (Detox) Limits

IWM, STR & LTRT2 Limits HWH Limits PC, IOP & OP Limits AWM (Detox) Limits

DMHAS DUII Page 6 of 6

SFY 2025

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