Exhibit 1G - RCI 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 outlines the Recovery Court Initiative (RCI) Enhancements Authorization Parameters for the Department of Mental Health and Addiction Services (DMHAS). It provides details on the various clinical, co-occurring, medication-assisted, recovery support, medical, and laboratory services that are available under the RCI program, including service rates, unit types, CPT codes, billing codes, authorization parameters, and annual client limits. The document covers the effective period of July 1, 2024 through June 30, 2025, and includes details on service encounter requirements, authorization limits, and billing codes for each service category.

The document specifies the pricing and authorization details for a range of services, including urine drug screening, oral swabs, Mantoux tests, continuing care, case management, crisis intervention, individual and group therapy, psychiatric evaluation, medication monitoring, methadone maintenance, recovery support services, Evaluation and Management (E&M) visits, and various laboratory tests. It also outlines the specific parameters and limits for Vivitrol and Buprenorphine/Naloxone services, including medication, injection, and case management components.

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Exhibit 1G - Recovery Court Initiative (RCI) Enhancements Authorization Parameters

Clinical Review

Service Rate Unit Type CPT Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Annual

Client Limit

Urine Drug Screen - Presumptive Testing $ 8.46 service Clinical H0003HF 1 12 n/a H0003HF 1 12 n/a H0003HF 1 16 n/a H0003HF 1 5 n/a n/a

Oral Swab $ 8.46 service Clinical ZSWB 1 12 n/a ZSWB 1 12 n/a ZSWB 1 16 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 2 2 n/a ZLOCI 2 2 n/a ZLOCI 2 2 n/a ZLOCI 1 2 n/a n/a

Limit Clinical Review Enhancements $164.95 $164.95 $198.79 $105.73

Co-occurring Clinical Services

Service Rate Unit Type CPT Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Annual

Client Limit

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

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 1 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 $278.55 $801.79 $171.99 $171.99

Encounter entry required before expiration of authorization (days) -

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

Recovery Court Initiative (RCI)

Fee for Service Enhancement Authorization Parameters

Encounter entry required before expiration of authorization (days) -

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

DMHAS RCI Page 1 of 6

SFY 2025

Effective 07/01/24

Revised 04/08/24

Service Rate Unit Type CPT Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Annual

Client Limit

Medication Monitoring $ 47.54 15 minutes CO Med 90862 HF 0 0 0 90862 HF 2 6 n/a 90862 HF 2 6 n/a 90862 HF 0 0 n/a n/a

Limit Co-occurring Medication Monitoring

Service Enhancement $0.00 $285.24 $285.24 $0.00

Psychiatric Evaluation

Service Rate Unit Type CPT Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Billing 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

Encounter entry required before expiration of authorization (days) -

Co-occurring Med Monitoring Services Enhancement

HWH LimitsIWM, STR & LTRT2 Limits

Encounter entry required before expiration of authorization (days) -

PC, IOP and OP Limits AWM (Detox) Limits

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

DMHAS RCI Page 2 of 6

SFY 2025

Service Rate Unit Type CPT Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Billing 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 4 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 $315.71 $0.00

Medication Assisted - Methadone Maintenance

Encounter entry required before expiration of authorization (days) -

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

DMHAS RCI Page 3 of 6

SFY 2025

Recovery Support

Service Rate Unit Type CPT Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Billing 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

Transportation - staff time $ 9.30 hour Recovery Sup ZTRAV 10 10 n/a ZTRAV 10 10 n/a ZTRAV 0 0 0 ZTRAV 0 0 0 0

Transportation - mileage $ 0.33 a mile Recovery Sup ZMIL 300 300 n/a ZMIL 300 300 n/a ZMIL 0 0 0 ZMIL 0 0 0 0

Court Liaison $ 6.87 15 minutes Recovery Sup ZCTLI 6 6 n/a ZCTLI 6 6 n/a ZCTLI 6 6 n/a ZCTLI 0 0 0 n/a

Limit Recovery Support Enhancements $655.62 $655.62 $463.62 $422.40

Medical Services

Service Rate Unit Type CPT Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Annual

Client Limit

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

AWM (Detox) LimitsHWH Limits PC, IOP and OP Limits

Encounter entry required before expiration of authorization (days) -

Encounter entry required before expiration of authorization (days) -

IWM, STR & LTRT2 Limits

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

DMHAS RCI Page 4 of 6

SFY 2025

Service Rate Unit Type CPT Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Billing 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

Service Rate Unit Type CPT Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Annual

Client Limit

Medication Monitoring - MAT $ 47.54 15 minutes V or B Z3353 2 2 n/a Z3353 2 2 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 6

Limit V or B Enhancements $1,616.29 $1,666.20 $1,666.20 $0.00

Encounter entry required before expiration of authorization (days) -

Vivitrol or Buprenorphine: Vivitrol - Pre-Induction

PC, IOP and OP Limits AWM (Detox) Limits

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

IWM, STR & LTRT2 Limits HWH Limits

Vivitrol or Buprenorphine

Encounter entry required before expiration of authorization (days) -

DMHAS RCI Page 5 of 6

SFY 2025

Service Rate Unit Type CPT Code Day Month Year Billing Code Day Month Year Billing Code Day Month Year Billing 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

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

Vivitrol or Buprenorphine: Lab Services

Encounter entry required before expiration of authorization (days) -

DMHAS RCI Page 6 of 6

SFY 2025

File details come from the government source that posted it. Updated .