Exhibit 3 - Annex A1 ASAM LOC Service Descriptions SFY 2024-2025 (Final).pdf

Exhibit 3 - NJ Department of Human Services (DHS) Division of Mental Health and Addiction Services (DMHAS)

ASAM Core LOC Service Descriptions – Annex A1

SUD FFS Contract Annex A1 – SFY 2024-2025 Page 1 Division of Mental Health and Addiction Services

Revised April 19, 2023 Effective: July 1, 2023

Please review carefully the Service Descriptions for the DMHAS SUD FFS Initiatives in this Contract Annex A1. Initial the boxes below to identify the ASAM Level/s of Care your agency seeks to renew. Agency must be licensed by the NJ Department of Health (DOH), Certificate of Need and Licensing (CN&L), by applicable site, for the proposed ASAM level of care. The Agency must submit one Annex A1 for all sites contracted under the same Federal ID.

Please sign and date this cover sheet below and return to DMHAS.

ASAM Levels of Care Please initial the appropriate box

Outpatient (OP) Methadone Outpatient Services (MOP) Ambulatory Withdrawal Management (Level 2 AWM) Intensive Outpatient (IOP) Partial Care (PC) Halfway House (HWH) Long Term Residential (LTR) Short Term Residential (STR) Inpatient Withdrawal Management (IWM)

I am the authorized representative of Agency. Agency understands and agrees to deliver the services indicated above in accordance with the terms of contract, including this Annex A1. Agency staff reviewed the contract requirements and Agency affirms that its policies and procedures adhere to Contract requirements.

Agency acknowledges and understands that it is subject to DMHAS monitoring for adherence to all contract requirements.

Agency Name: ________________________________

Federal ID: _________________________

Signature of Authorized Representative Date

Print Name Title

ASAM Core LOC Service Descriptions – Annex A1

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Agency must deliver all components of a bundled FFS SUD service to qualify for reimbursement. Similarly, Agency must deliver within an identified week all per diem components of a bundled FFS SUD service in order to qualify for reimbursement. In addition, Agency must maintain on file, and make available to DMHAS upon request, supportive documentation including the type of service, service date, duration or service, mode of delivery, and clinician providing service.

SUBSTANCE USE DISORDER SERVICE DESCRIPTIONS

Interim Service Pre-Admission Care Management Interim Service Pre-Admission Care Management is a behavioral health service designed to support consumers in the public system who: a) have been screened for Opioid Use Disorder and other Substance Use Disorder with complex physical or psychological needs; and b) are awaiting a full assessment but are not able to be assessed due to a lack of capacity or other barriers. Care Managers assist consumers to overcome these barriers by matching their identified needs with available resources so that they are able to engage with the provider agency and access care and services intended to meet those needs. Care managers work with consumers to implement services and address needs identified during screening and document this in the consumers’ pre-admission file while continuing to engage the consumer awaiting assessment. This service can be provided by individuals with at least a bachelor’s degree in a social services field, or a bachelor’s degree and two years of experience in the field (lived or otherwise).

(ISICRM) 15 minutes

Assessment The biopsychosocial assessment is conducted for consumers entering treatment or transferring to a different provider agency. This assessment includes completion of an ASI or other DMHAS approved screening tool, completion of American Society of Addiction Medicine (ASAM) placement criteria, a co-occurring screening, and, if appropriate, completion of the NJSAMS admission. Members of the consumer’s family and/or significant others may also be involved, if indicated and authorized by the consumer in accordance with applicable federal and State privacy laws, regulations and policy. The assessment must result in a DSM Diagnosis and Level of Care determination to be used in the consumer treatment placement and treatment planning. If the result of the assessment indicates clinical need for a level of care not provided by the assessing agency, that agency will provide a facilitated referral to the appropriate service as part of the assessment service. The assessment must produce a written document which is placed in the consumer’s clinical record. It identifies problems which must be addressed in a written treatment plan that is also placed in the consumer’s clinical record.

Counseling Services

ASAM Core LOC Service Descriptions – Annex A1

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The identified duration for each service includes documentation time.

Individual Therapy Counseling provided on an individual basis to consumers with a substance use diagnosis which includes therapeutic and supportive interventions designed to:

motivate the consumer for recovery from substance use disorder, facilitate skills for the development and maintenance of that recovery, improve problems solving and coping skills, and develop relapse prevention skills. Session content and structure are designed in accordance with consumer’s treatment plan. This service can be delivered by a CADC, LCADC, an alcohol and drug counselor intern or credentialed intern under the supervision of a qualified clinical supervisor per N.J.A.C. 13:34C-6.2, or by a New Jersey licensed behavioral health professional who is also credentialed to provide therapy in accordance with the DMHAS Service Descriptions.

(90832 HF) 30 minutes (90834 HF) 45 - 50 minutes

Group Therapy Counseling provided on a group basis to consumers which uses group processes and supports to: motivate the consumer for recovery from substance use disorder, facilitate skills for the development and maintenance of that recovery, improve problem solving and coping skills, improve intra- and interpersonal development and functioning, and develop relapse prevention skills. Session content and structure are designed in accordance with consumer’s treatment plan. This service can be delivered by a CADC, LCADC, an alcohol and drug counselor intern or credentialed intern under the supervision of a qualified clinical supervisor per N.J.A.C. 13:34C-6.2, or by a New Jersey licensed behavioral health professional who is also credentialed to provide therapy in accordance with the DMHAS SUD FFS Service Descriptions.

(90853 HF) 90 minutes

Family Therapy Counseling provided to the family unit, with or without the consumer present, to impart education about the diagnosed substance use disorder, elicit family support for the consumer’s treatment, encourage family members to seek their own treatment and self-help, assess the consumers’ environment during or after treatment and to assess the consumer’s functioning outside of the treatment environment. This service can be delivered by a CADC, LCADC, an alcohol and drug counselor intern or credentialed intern under the supervision of a qualified clinical supervisor per N.J.A.C. 13:34C-6.2, or by a New Jersey licensed behavioral health professional who is also credentialed to provide counseling in accordance with the DMHAS SUD FFS Service Descriptions.

(90847 HF) 60 minutes

ASAM Core LOC Service Descriptions – Annex A1

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Psychoeducational Group Services Specific to Interim Services This is an engagement service meant to provide the consumer with education and information about SUD treatment while they are awaiting admission to their assessed level of care that supports and serves the goals of treatment. For interim services, education in a group setting should include topics such as treatment, relapse, and recovery; education on all forms of Medication Assisted Treatment (MAT); education about HIV, Tuberculosis, Hepatitis B and C and the risks of transmission of these to sexual partners; availability of HIV, TB, and Hepatitis B and C treatment services; the risks of needle sharing; information about Recovery Centers and other recovery support services within the community. For pregnant consumers, psychoeducational group services should also include information about the effects of alcohol and drug use on the fetus.

(Z3355) 90 minutes

Psychoeducational Group Services Education of a consumer in ways that support and serve the goals of treatment.

A group session that involves teaching people about substance use disorders, how to treat, and how to recognize signs of relapse so that they can get necessary treatment and support services.

(Z3355) 90 minutes

ASAM Core LOC Service Descriptions – Annex A1

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OUTPATIENT SUBSTANCE USE DISORDER TREATMENT

Level 1

In addition to the DMHAS Service Requirements stated in the Division of Mental Health and Addiction Services (DMHAS) Network Annex A, Outpatient Substance Use Disorder Treatment contractees shall comply with all applicable provisions of N.J.A.C. 10:161B and the following service parameters:

Definition: Outpatient Substance Use Disorder Treatment is provided in a DMHAS licensed outpatient facility which provides regularly scheduled individual, group and family counseling services for less than nine (9) hours per week. Services may be provided to consumers discharged from a more intensive level of care, but are not necessarily limited to this population. Twelve step meetings or other self-help meetings cannot be counted as billable Counseling Services. This care approximates ASAM Level 1 care.

Counseling Services:

Individual Therapy: in a full session, face-to-face for 45–50 minutes.

Individual Therapy: in a half-session, face-to-face for 30 minutes.

Group Therapy: minimum 90 minutes of face-to-face contact.

Family Therapy: face-to-face for 60 minutes.

Psychoeducational Group Services:

To be included in the course of treatment as needed.

ASAM Core LOC Service Descriptions – Annex A1

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METHADONE OUTPATIENT TREATMENT (MOP)

Level 1.OMT Opioid Maintenance Therapy

In addition to the DMHAS Service Requirements stated in the Division of Mental Health and Addiction Services (DMHAS) Network Annex A, Outpatient Substance Use Disorder Treatment contractees shall comply with all applicable provisions of N.J.A.C. 10:161B and the following service parameters.

Definition: Methadone Outpatient (MOP) is Opioid Maintenance Therapy attached to Standard Outpatient Level 1. MOP is a weekly bundled service provided by a licensed Opioid Treatment Program (OTP) that includes the following services which may not be claimed for payment separately: Case Management, Medication Monitoring, Medication and dispensing, and the counseling services specified below.

Counseling Services:

Individual Therapy: in a full session, face-to-face for 45–50 minutes.

Individual Therapy: in a half-session, face-to-face for 30 minutes.

Group Therapy: minimum 90 minutes of face-to-face contact.

Family Therapy: face-to-face for 60 minutes.

Minimum Billing Requirements:

Phase I - A minimum of four (4) encounters within an identified week, with evidence of documented outreach. A full individual counseling session will count as two (2) encounters. If consumer receives an exception for take home medication during this Phase, it shall not effect payment to agency if clearly documented in consumer’s chart.

Phase II - A minimum of two (2) encounters within an identified week, with evidence of documented outreach. A full individual counseling session will count as two (2) encounters. If consumer receives an exception for take home medication during this Phase, it shall not effect payment to agency if clearly documented in consumer’s chart.

Phase III - A minimum of one (1) encounter within an identified week, with evidence of documented outreach. If consumer receives an exception for take home medication during this Phase, it shall not effect payment to agency if clearly documented in consumer’s chart.

Phase IV, V and VI - All monthly requirements as detailed in ambulatory regulations shall be satisfied.

ASAM Core LOC Service Descriptions – Annex A1

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AMBULATORY WITHDRAWAL MANAGEMENT (AWM)

Level 2 AWM

Health and Addiction Services (DMHAS) Network Annex A, Ambulatory Withdrawal Management Substance Use Disorder Treatment contractees shall comply with all applicable provisions of N.J.A.C. 10:161B and the following service parameters:

Definition: Ambulatory Withdrawal Management (AWM) is defined as an organized service delivered by medical and nursing professionals who provide a range of services including medical and clinical interventions, laboratory testing, the dispensing and/or administration of approved medications provided to treat and monitor consumers undergoing withdrawal from drugs, including alcohol.

AWM is indicated when a consumer experiences physiological dysfunction during withdrawal, but neither life, nor significant bodily functions are threatened. The provision of AWM shall be restricted to those substance abuse treatment programs licensed by DOH CN&L to provide AWM. Programs shall be reimbursed for Level 2-AWM with extended on-site monitoring only (previously ASAM Level 2-D). AWM requires a prior authorization and shall be billed with CPT code H0014HF. The Prior authorization shall be provided by DMHAS or the DMHAS-authorized agent.

A. Per Diem AWM services shall include, but are not limited to a minimum of 2 hours of on-site monitoring through face-to-face interactions with the consumer.

1. Services include:

a. Daily medical supervision, including physician services and observation of withdrawal;

b. Monitoring of symptoms, temperature, heart rate, blood pressure and respiratory rate by the program nurse, physician, advanced practice nurse or physician assistant;

c. Dispensing and/or administration of approved medications for AWM;

d. Twenty-four (24) hour on-call access to a nurse for consumers and family; and,

e. Referral and linkages with other providers or services as indicated.

B. Initial prior authorization is limited to 5 days.

C. Continuing Care authorization can be provided for extended treatment when the consumer continues in AWM with extended on-site monitoring until the following criteria are met:

ASAM Core LOC Service Descriptions – Annex A1

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1. Withdrawal signs and symptoms are sufficiently resolved such that the consumer can participate in self-directed recovery or ongoing treatment without the need for further medical or nursing detoxification monitoring; or

2. Signs or symptoms of withdrawal have failed to respond to treatment and have intensified such that transfer to a more intensive level of care is indicated.

D. Parallel care admission to AWM is allowed with the following level(s) of care:

1. OP;

2. IOP;

3. MOP (as long as the substance causing symptoms of withdrawal is not an opiate); and

4. HWH.

E. Consumers admitted to AWM and in parallel care in OP, MOP or IOP must have both admissions within the same provider agency. Minimum service provision criteria for these levels of care must be met in addition to aforementioned AWM criteria.

F. AWM does not include the initial intake assessment. The intake assessment can be billed in addition to the per diem rate for AWM. Additional enhancements to care are also available.

G. Services identified as part of the bundled AWM rate include:

1. E&M Visits [99201-5, 99212-5];

2. Case Management [T2022 HF];

3. Medication Monitoring [90862 HF, Z3353]; and

4. All prescribed medications.

H. Agencies may not submit claims for “no show” dates or for services provided by affiliated agencies.

ASAM Core LOC Service Descriptions – Annex A1

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INTENSIVE OUTPATIENT SUBSTANCE USE DISORDER TREATMENT

Level 2.1

In addition to the DMHAS Service Requirements stated in the Division of Mental Health and Addiction Services (DMHAS) Network Annex A, Intensive Outpatient Substance Use Disorder Treatment contractees shall comply with all applicable provisions of N.J.A.C. 10:161B and the following service parameters:

Definition: Intensive Outpatient (IOP) Substance Use Disorder Treatment is a rehabilitative service designed to help consumers change their substance use and related behaviors. Prior authorization for services is required. This service meets ASAM Level

2.1 care. IOP shall be provided in a licensed IOP facility and shall include a broad range of highly intensive clinical interventions including individual counseling, group substance abuse counseling, group counseling and family counseling. Services must be provided in a structured environment for no less than nine (9) hours per week. Request for more than twelve (12) hours per week of services must be pre-approved by the initiative manager or DMHAS staff. A minimum of three (3) hours of treatment services must be provided on each billable day and each billable day must include multiple services. Services must include at least one individual counseling session per week. Services must be provided a minimum of three (3) days per week. Twelve step meetings or other self-help meetings are not billable services and cannot be counted toward the minimum treatment service requirements. A consumer may not be removed from an active group session to participate in an individual session, thereby reducing the actual number of hours delivered.

Counseling Services:

Individual Therapy: A minimum of one 30-minute session or one 45 to 50-minute session per week. Additional individual therapy sessions shall be provided based upon clinical need. Individual therapy is required as part of the bundled per diem service and may not be claimed separately for payment.

Group Therapy: A minimum of six (6) hours per week.

Family Therapy: To be included monthly during course of treatment unless clinically contraindicated or the consumer and/or family members refuse to participate.

To be included in the course of treatment as needed.

PARTIAL CARE SUBSTANCE USE DISORDER TREATMENT

ASAM Core LOC Service Descriptions – Annex A1

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Level 2.5

Health and Addiction Services (DMHAS) Network Annex A, Partial Care Substance Use Disorder Treatment contractees shall comply with all applicable provisions of N.J.A.C. 10:161B and the following service parameters.

Definition: Partial Care Substance Use Disorder Treatment is provided in a licensed Partial Care facility which provides a broad range of highly clinically intensive interventions. Services are provided in a structured environment for no less than 20 hours per week. A minimum of four (4) hours of treatment services must be provided on each billable day to include one individual counseling session per week. Lunch is not a billable hour. Twelve step meetings or other self-help meetings cannot be counted as billable services. Programs have ready access to psychiatric, medical and laboratory services. A consumer may not be removed from an active group session to participate in an individual session thereby reducing the actual number of hours delivered. This care approximates ASAM Level 2.5 care.

Counseling Services:

Individual Therapy: One 45-50 minute session per week minimum.

Group Therapy: A minimum of eight (8) hours per week.

Family Therapy: To be included during course of treatment unless clinically contraindicated or the consumer and/or family members refuse to participate.

Two sessions per week minimum.

ASAM Core LOC Service Descriptions – Annex A1

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CLINICALLY MANAGED LOW-INTENSITY RESIDENTIAL TREATMENT

HALFWAY HOUSE SUBSTANCE USE DISORDER TREATMENT

Level 3.1

Health and Addiction Services (DMHAS) Network Annex A, Halfway House Substance Use Disorder Treatment contractees shall comply with all applicable provisions of N.J.A.C. 10:161A and the following service parameters:

Definition: Halfway House Substance Use Disorder Treatment is provided in a licensed residential facility which provides room, board, and services designed to apply recovery skills, prevent relapse, improve emotional functioning, promote personal responsibility and reintegrate the consumer into work, education and family life. Halfway House services must be physically separated from a short term and/or long term residential program. In addition, clinical services must be separate from short term and long term residential services. This modality includes no less than 3 hours per week of counseling services. A minimum of 7 hours per day of structured activities must be provided on each billable day. This care approximates ASAM Level 3.1 care.

Medical Services must be provided in compliance with applicable provisions of N.J.A.C.

10:161A

Counseling Services:

Individual Therapy: One 45–50 minute session per week minimum.

Group Therapy: Two (2) hours per week minimum.

Family Therapy: To be included during course of treatment unless clinically contraindicated or the consumer and/or family member refuse to participate.

Psychoeducational Group Services:

Two (2) hours per week minimum.

Family education and information sessions as clinically indicated.

Structured Activities: Seven (7) hours of structured activity each day is required.

Example of activities:

a. Counseling Services.

b. Psychoeducation.

c. Employment.

d. Vocational Training.

e. Self Help, NA and/or AA meetings.

f. Recovery Support Services.

g. Recreation.

ASAM Core LOC Service Descriptions – Annex A1

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CLINICALLY MANAGED HIGH-INTENSITY RESIDENTIAL TREATMENT

LONG TERM RESIDENTIAL SUBSTANCE USE DISORDER TREATMENT

Level 3.5

In addition to the DMHAS Service Requirements stated in the Division of Mental Health and Addiction Services (DMHAS) Network Annex A, Long Term Residential Substance Use Disorder Treatment contractees shall comply with all applicable provisions of N.J.A.C. 10:161A and the following service parameters:

Definition: Long Term Residential Substance Use Disorder Treatment or Therapeutic Community is provided in a licensed long term residential facility which provides a structured recovery environment, combined with professional clinical services, designed to address addiction and living skills problems for persons with substance use diagnosis who require longer treatment stays to support and promote recovery. (Note: Self-help meetings may be included as part of structured activities). Long Term Residential includes no less than 8 hours per week of counseling services on at least five (5) separate occasions. A minimum of 7 hours per day of structured activities must be provided on each billable day. Intervention focuses on reintegration into the greater community with particular emphasis on education and vocational development. This care approximates ASAM Level 3.5 care.

Medical Services must be provided in compliance with applicable provisions of N.J.A.C.

10:161A

Counseling Services:

Individual Therapy: One 45–50 minute session per week minimum.

Group Therapy: Seven (7) hours per week minimum.

Family Therapy: To be included during course of treatment unless clinically contraindicated or the consumer and/or family member refuse to participate.

Psychoeducational Group Services:

Didactic sessions: Three (3) hours per week minimum.

Family Education and Information sessions as clinically indicated.

a. Counseling Services.

b. Psychoeducation.

c. Vocational Training.

d. Recovery Support Services.

e. Self Help, NA and/or AA meetings.

f. Recreation.

Same day treatment conflicts:

ASAM Core LOC Service Descriptions – Annex A1

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FFS claims may not be submitted for the following services if provided in a Long Term Residential setting:

99202 E & M visit - new patient (20 min) 99203 E & M visit - new patient (30 min) 99204 E & M visit - new patient (45 min) 99205 E & M visit - new patient (60 min) 99212 E & M visit - established patient (10 min) 99213 E & M visit - established patient (15 min) 99214 E & M visit - established patient (25 min) 99215 E & M visit - established patient (40 min) S9484 HF Crisis Intervention - Individual 90847 HF Family Therapy 90832 HF Individual Therapy in a full session, face-to-face for 45–50 minutes.

90834 HF Individual Therapy in a half-session, face-to-face for 30 minutes 90853 HF Group Therapy 90887 Clinical Consultation 90862 Medication Monitoring Z3353 Medication Monitoring MAT

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MEDICALLY MONITORED INTENSIVE INPATIENT TREATMENT

SHORT TERM RESIDENTIAL SUBSTANCE USE DISORDER TREATMENT

Level 3.7

Health and Addiction Services (DMHAS) Network Annex A, Short Term Residential Substance Use Disorder Treatment contractees shall comply with all applicable provisions of N.J.A.C. 10:161A and the following service parameters:

Definition: Short Term Residential Substance Use Disorder Treatment is provided in a licensed short term residential facility which provides a highly structured recovery environment, combined with a commensurate level of professional clinical services, designed to address specific addiction and living skills problems for persons who are deemed amenable to intervention through short term residential treatment.

Short Term Residential treatment must include no less than 12 hours per week of counseling services on at least 6 separate occasions. A minimum of 7 hours of structured programming must be provided on a billable day. Self-help meetings may be included as part of structured activities. This care approximates ASAM Level 3.7 care.

Medical Services must be provided in compliance with applicable provisions of N.J.A.C.

10:161A.

Counseling Services:

Individual Therapy: One 45–50 minute sessions per week minimum.

Group Therapy: Ten (10) hours per week minimum.

Family Therapy: To be included during course of treatment unless clinically contraindicated or the consumer and/or family member refuse to participate.

Eight (8) hours per week minimum.

Family Education and Information sessions as clinically indicated.

a. Counseling Services.

b. Psychoeducation.

c. Vocational Training.

d. Recovery Support Services.

e. Self Help, NA and/or AA meetings.

f. Recreation.

ASAM Core LOC Service Descriptions – Annex A1

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Same day treatment conflicts

FFS claims may not be submitted for the following services if provided in a Short Term Residential setting:

99202 E & M visit - new patient (20 min) 99203 E & M visit - new patient (30 min) 99204 E & M visit - new patient (45 min) 99205 E & M visit - new patient (60 min) 99212 E & M visit - established patient (10 min) 99213 E & M visit - established patient (15 min) 99214 E & M visit - established patient (25 min) 99215 E & M visit - established patient (40 min) S9484 HF Crisis Intervention - Individual 90847 HF Family Therapy 90832 HF Individual Therapy 90834 HF Individual Therapy 90853 HF Group Therapy 90887 Clinical Consultation

ASAM Core LOC Service Descriptions – Annex A1

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INPATIENT WITHDRAWAL MANAGEMENT

Level 3.7WM

In addition to the DMHAS Service Requirements stated in the Division of Mental Health and Addiction Services (DMHAS) Network Annex A, Medically Monitored Inpatient Withdrawal Management Substance Use Disorder Treatment contractees shall comply with all applicable provisions of N.J.A.C. 10:161A and the following service parameters:

Definition: Inpatient Withdrawal Management is an organized service delivered by medical and nursing professionals, which provides 24-hour medically supervised evaluation and withdrawal management in a permanent facility with inpatient beds.

Services are delivered under a defined set of physician-approved policies and physician monitored procedures for clinical protocols. This level provides care to consumers whose withdrawal signs and symptoms are sufficiently severe to require 24-hour medical monitoring care.

This level of care includes 2 hours per week of counseling services. Self-help meetings may be included as part of daily activities. This care approximates ASAM Level

3.7WM.

Medical Services must be provided in compliance with applicable provisions of N.J.A.C.

10:161A, in the facility under the supervision of a Medical Director.

Counseling Services:

Individual Therapy: One 45–50 minute session per week minimum.

Group Therapy: One session per week minimum.

Minimum of two hours per week minimum.

Same day treatment conflicts:

FFS claims may not be submitted for the following services if provided in an Inpatient Withdrawal Management (IWM) setting:

99202 E & M visit - new patient (20 min) 99203 E & M visit - new patient (30 min) 99204 E & M visit - new patient (45 min) 99205 E & M visit - new patient (60 min) 99212 E & M visit - established patient (10 min) 99213 E & M visit - established patient (15 min) 99214 E & M visit - established patient (25 min)

99215 E & M visit - established patient (40 min)

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S9484 HF Crisis Intervention - Individual 90847 HF Family Therapy 90832 HF Individual Therapy 90834 HF Individual Therapy 90853 HF Group Therapy 90887 Clinical Consultation

To be included in the course of treatment as needed.