Common use of Procedures for Billing and Reimbursement for EIS Providers Clause in Contracts

Procedures for Billing and Reimbursement for EIS Providers. A procedure code table for Early Intervention Services is listed in Attachment 2 of this document. The fee schedules for IDEA/Part C services can be found at xxxxx://xxxxxx.xxx/resource/fee-schedules. Please note that only the codes listed on the table in Attachment 2 are reimbursable. Additional procedure codes on the fee schedules, but not listed in the code table, are not reimbursable. APPENDIX A: ATTACHMENTS Attachment 1: BabyNet Provider Enrollment Packet Checklist ✓ BabyNet Provider Enrollment Packet Checklist BabyNet Provider Enrollment Form BabyNet Individual User Confidentiality Agreement BabyNet Drug-Free Workplace Statement An IRS W-9 form The enrolling provider’s NPI number, or if the enrolling provider is a licensed therapy assistant, the NPI of the supervising provider Provider’s Legacy ID/Number All relevant taxonomy codes A copy of the current licensure Proof of current liability insurance A national background check that includes: Nationwide Office of Inspector General Background Check (current within 365 days of the enrollment packet) Nationwide Sex Offender Registry Background Check (current within 365 days of the enrollment packet) Nationwide Criminal Report Background Check (current within 365 days of the enrollment packet) SSN Verification Residency History Check Professional License Verification Attachment 2: Approved Procedure Codes for Early Intervention Services SERVICE LOG DROP DOWN CATEGORY with PROCEDURE CODE DESCRIPTION LIST Modifier BN Service Limit Count Pay Per BN Service Limit Frequency Audiology Evaluation and Services 92557 - Audiological Consultation U1 6 Encounter Per Year 92557 - Hearing Evaluation U2 6 Encounter Per Year 92587 - Evoked Otoacoustic Emissions; (Evaluation) 6 Encounter Per Year 92588 - Evoked Otoacoustic Emissions; (Screening) 12 Encounter Per Year 92620 - Auditory Evaluation with Report (60 Min.) 1 Encounter Per Encounter 92625 - Assessment of Tinnitus (Includes Pitch, Loudness Matching, And Masking) 1 Encounter Per Encounter 92626 - Evaluation Auditory Rehab Status 1St Hr. 10 Encounter Per Year V5020 - Conformity Evaluation 1 Encounter Per Encounter 92594 - Electroacoustic Eval Hearing Aid Monaural 6 Encounter Per Year 92595 - Electroacoustic Eval Hearing Aid Binaural 6 Encounter Per Year 92557 - Hearing Re-Evaluation 6 Encounter Per Year 92568 - Acoustic Reflex Testing; Threshold 1 Encounter Per Encounter 92550 - Tympanometry and Reflex Threshold Measurements 1 Encounter Per Encounter 92551 - Screening Test, Pure Tone, Air Only 1 Encounter Per Encounter 92552 - Pure Tone Audiometry Air Only 6 Encounter Per Year 92553 - Pure Tone Audiometry Air & Bone 1 Encounter Per Encounter 92555 - Speech Audiometry Threshold 1 Encounter Per Encounter 92556 - Speech Audiometry Threshold Speech Recognition 1 Encounter Per Encounter 92563 - Tone Decay Test 1 Encounter Per Encounter 92567 - Tympanometry 6 Encounter Per Year 92570 - Tympanogram and Acoustic Reflexes 6 Encounter Per Year 92579 - Visual Reinforcement Audiometry 1 Encounter Per Encounter 92582 - Conditioning Play Audiometry 1 Encounter Per Encounter 92583 - Select Picture Audiometry 1 Encounter Per Encounter 92584 - Electrocochleography 1 Encounter Per Encounter 92590 - Hearing Aid Examination & Selection Monaural 6 Encounter Per Year 92591 - Hearing Aid Examination & Selection Binaural 6 Encounter Per Year 92592 - Hearing Aid Check Monaural 6 Encounter Per Year 92592 - Hearing Aid Check Monaural 6 Encounter Per Year 92593 - Hearing Aid Check Binaural 6 Encounter Per Year 92593 - Hearing Aid Check Binaural 6 Encounter Per Year 92650-Auditory evoked for potentials; screening of auditory potential with broadband stimuli, automated analysis 1 Encounter Per Encounter 92651-Hearing status determination, broadband stimuli, with interpretation and report 1 Encounter Per Encounter 92652-Threshold estimation at multiple frequencies, with interpretation and report 1 Encounter Per Encounter 92653-Neurodiagnostic, with interpretation and report 1 Encounter Per Encounter V5275 - Ear Impression, Left LT 3 Encounter Per Year V5275 - Ear Impression, Right RT 3 Encounter Per Year V5011 - Fitting/Orientation/Checking Hearing Aid 1 Encounter Per Encounter V5264 - Ear Mold/Insert, Not Disposable, Any Type 1 Encounter Per Encounter V5090 - Dispensing Fee, Unspecified Hearing Aid 1 Encounter Per Encounter Autism Evaluation 97151 - Behavior Identification Assessment 32 Units Lifetime Autism Services 97153 - Adaptive Behavior Treatment 160 Units Week 97155 - Adaptive Behavior Treatment with Protocol Modification 64 Units Month 97156 - Family Adaptive Behavior Treatment Guidance 48 Units Year Psychological Evaluation 96101 - Psychological Testing and Evaluation (Per Hour) 40 Units Lifetime 90791 - Psychiatric Diagnostic Evaluation HO 40 Encounter Lifetime 96130/96131 - Psychological testing and evaluation (1st 60 min/ Additional 60 min) HO 40 Units Lifetime 96136/96137 - Psychological testing (administration and scoring) (1st 30 min/ Additional 30 min) HO 40 Units Lifetime 96138/96139 - Psychological testing by technician (1st 30 min/ Additional 30 min) 40 Units Lifetime 96146 - Psychological testing (single standardized) 40 Units Lifetime 96112/96113 - Developmental testing (motor and language) (1st 60 min/ Additional 30 min) 40 Units Lifetime Counseling And Psychological Services 9940X - Prevent Med Counsel&/Risk Factor 1 Encounter Per Day Medical Evaluation 99381 - Initial Health Evaluation (Age 0 to 1 Year) 1 Encounter Lifetime 99382 - Initial Health Evaluation (Age 1+) 1 Encounter Lifetime 99391 - Health Evaluation (Age 0 to 1 year) 1 Encounter Per Year 99392 - Health Evaluation (Age 1+) 1 Encounter Per Year Nursing Evaluation T1001 - Nursing Assessment/Evaluation 48 Encounter Per Year Nursing Services T1002 - RN Services, Up To 15 Minutes 64 Units Per Month T1003 - LPN/LVN Services, Up To 15 Minutes 64 Units Per Month Nutrition Evaluation 97802 - Nutrition Assessment and Intervention; Initial Assessment 12 Units Per Year 97803 - Medical Nutrition Therapy; Re-Assessment And Intervention, Individual, Face-To-Face With T 12 Units Per Year Nutrition Services S9470 - Nutritional Counseling, Dietitian Visit 64 Units Per Month Occupational Therapy Evaluation 9716Y - Occupational Therapy Evaluation 2 Encounter Per Year 97168 - Occupational Therapy Re-evaluation 2 Encounter Per Year Occupational Therapy Services 97530 - Occupational Therapy Services (15 min.) GO 4 Units Per Day Physical Therapy Evaluation 9716X - Physical Therapy Evaluation 2 Encounter Per Year 97164 - Physical Therapy Re-evaluation (20 min.) 2 Encounter Per Year Physical Therapy Services 97110 - Physical Therapy Services (15 min. exercises) GP 4 Unit Per Day 97530 - Physical Therapy Services (15 min) GP Unit Social Work Services 9083X - Psychotherapy 8 Encounter Per Week Speech - Language Evaluation / Re-Evaluation 92521 - Speech Evaluation (fluency) 1 Encounter Lifetime 92522 - Speech Evaluation (sound production) 1 Encounter Lifetime 92523 - Speech Evaluation (language comprehension) 1 Encounter Lifetime 92524 - Speech Evaluation (voice and resonance) 1 Encounter Lifetime 92610 - Speech Evaluation (oral/pharyg wall) 1 Encounter Lifetime S9152 - Speech Therapy Re-evaluation 2 Encounter Per Year Speech - Language Pathology Services 92507 - Speech Therapy (voice command/auditory proc) 4 Units Per Day 92526 - Speech Therapy (swallowing/feeding) 4 Units Per Day 92609 - Speech Therapy (use of device) 1 Encounter Per Day Vision Evaluation and Services 92002 -Vision Evaluation (new patient intermediate) 1 Encounter Lifetime 92004 - Vision Evaluation (new patient comprehensive) 1 Encounter Lifetime 92012 - Vision Evaluation (established patient intermediate) 1 Encounter Per Year 92014 - Vision Evaluation (established patient comprehensive) 1 Encounter Per Year 92015 - Vision Evaluation Add-On - Refraction Test 1 Encounter Per Year SCSDB Evaluation and Services T1024 - Orientation and Mobility Evaluation U3 8 Units Lifetime T1024 - Orientation and Mobility Instruction U2 30 Units Per Week IFSP Meeting-DDSN / SCSDB T1018 - Family Training IFSP Meeting TL 8 Units Per Day IFSP Meeting-Service Providers (All) T1024 - IFSP Team Meeting/Participation (Team Members) 8 Units Per Day Service Coordination T1016 - Service Coordination TL 16 Units Per Day Family Training Counseling and Home Visits T1027 - Family Training & Counseling (15 Min.) TL 4 Units Per Day Foreign Language Services Foreign Language Translation 24 Units Per IFSP Foreign Language Interpretation 12 Units- Home/Community ($9.42), Each- Other ($5) Daily Transportation And Related Costs Transportation-Taxi No limit Miles No limit Transportation-Family Auto No limit Miles No limit Transportation-Other No limit Miles No limit Assistive Technology Device and Service Assistive Technology Device And Service As Approved Units As Approved

Procedures for Billing and Reimbursement for EIS Providers. A procedure code table for Early Intervention Services is listed in Attachment 2 of this document. The fee schedules for IDEA/Part C services can be found at xxxxx://xxxxxx.xxx/resource/fee-schedules. Please note that only the codes listed on the table in Attachment 2 Appendix A are reimbursable. Additional procedure codes on the fee schedules, but not listed in the code table, are not reimbursable. Steps for submission of claims and billing are included in Attachment 3 of this Appendix. APPENDIX A: ATTACHMENTS Attachment 1: BabyNet Provider Enrollment Packet Checklist ✓ BabyNet Provider Enrollment Packet Checklist BabyNet Provider Enrollment Form BabyNet Individual User Confidentiality Agreement BabyNet Drug-Free Workplace Statement An IRS W-9 form The enrolling provider’s NPI number, or if the enrolling provider is a licensed therapy assistant, the NPI of the supervising provider Provider’s Legacy ID/Number All relevant taxonomy codes A copy of the current licensure Proof of current liability insurance A national background check that includes: Nationwide Office of Inspector General Background Check (current within 365 days of the enrollment packet) Nationwide Sex Offender Registry Background Check (current within 365 days of the enrollment packet) Nationwide Criminal Report Background Check (current within 365 days of the enrollment packet) SSN Verification Residency History Check Professional License Verification Attachment 2: Approved Procedure Codes for Early Intervention Services SERVICE LOG DROP DOWN CATEGORY with PROCEDURE CODE DESCRIPTION LIST Modifier BN Service Limit Count Pay Per BN Service Limit Count BN Service Limit Frequency Audiology Evaluation AUDIOLOGY EVALUATION and Services SERVICES 92557 - Audiological Consultation U1 Encounter 6 Encounter Per Year 92557 - Hearing Evaluation U2 Encounter 6 Encounter Per Year 92587 - Evoked Otoacoustic Emissions; (Evaluation) Encounter 6 Encounter Per Year 92588 - Evoked Otoacoustic Emissions; (Screening) Encounter 12 Encounter Per Year 92620 - Auditory Evaluation with Report (60 Min.) Encounter 1 Encounter Per Encounter 92625 - Assessment of Tinnitus (Includes Pitch, Loudness Matching, And Masking) Encounter 1 Encounter Per Encounter 92626 - Evaluation Auditory Rehab Status 1St Hr. Encounter 10 Encounter Per Year V5020 - Conformity Evaluation Encounter 1 Encounter Per Encounter 92594 - Electroacoustic Eval Hearing Aid Monaural Encounter 6 Encounter Per Year 92595 - Electroacoustic Eval Hearing Aid Binaural Encounter 6 Encounter Per Year 92557 - Hearing Re-Evaluation Encounter 6 Encounter Per Year 92568 - Acoustic Reflex Testing; Threshold Encounter 1 Encounter Per Encounter 92550 - Tympanometry and Reflex Threshold Measurements Encounter 1 Encounter Per Encounter 92551 - Screening Test, Pure Tone, Air Only Encounter 1 Encounter Per Encounter 92552 - Pure Tone Audiometry Air Only Encounter 6 Encounter Per Year 92553 - Pure Tone Audiometry Air & Bone Encounter 1 Encounter Per Encounter 92555 - Speech Audiometry Threshold Encounter 1 Encounter Per Encounter 92556 - Speech Audiometry Threshold Speech Recognition Encounter 1 Encounter Per Encounter 92563 - Tone Decay Test Encounter 1 Encounter Per Encounter 92567 - Tympanometry Encounter 6 Encounter Per Year 92570 - Tympanogram and Acoustic Reflexes Encounter 6 Encounter Per Year 92579 - Visual Reinforcement Audiometry Encounter 1 Encounter Per Encounter 92582 - Conditioning Play Audiometry Encounter 1 Encounter Per Encounter 92583 - Select Picture Audiometry Encounter 1 Encounter Per Encounter 92584 - Electrocochleography Encounter 1 Per Encounter 92586 - Auditory Evoked Potentials for Evoked Response / Audiometry Nerve Encounter 1 Per Encounter 92585 - Auditory Evoked Potentials for Evoked Response (Diagnostic) Encounter 1 Per Encounter 92590 - Hearing Aid Examination & Selection Monaural Encounter 6 Encounter Per Year 92591 - Hearing Aid Examination & Selection Binaural Encounter 6 Encounter Per Year 92592 - Hearing Aid Check Monaural Encounter 6 Encounter Per Year 92592 - Hearing Aid Check Monaural 6 Encounter Per Year 92593 - Hearing Aid Check Binaural Encounter 6 Encounter Per Year 92593 - Hearing Aid Check Binaural 6 Encounter Per Year 92650-Auditory evoked for potentials; screening of auditory potential with broadband stimuli, automated analysis 1 Encounter Per Encounter 92651-Hearing status determination, broadband stimuli, with interpretation and report 1 Encounter Per Encounter 92652-Threshold estimation at multiple frequencies, with interpretation and report 1 Encounter Per Encounter 92653-Neurodiagnostic, with interpretation and report 1 Encounter Per Encounter V5275 - Ear Impression, Left LT 3 Encounter Per Year V5275 - Ear Impression, Right RT * Encounter 3 Encounter Per Year V5011 - Fitting/Orientation/Checking Hearing Aid Encounter 1 Encounter Per Encounter V5264 - Ear Mold/Insert, Not Disposable, Any Type Encounter 1 Encounter Per Encounter V5090 - Dispensing Fee, Unspecified Hearing Aid Encounter 1 Encounter Per Encounter Autism Evaluation *If billing V5275, enter one unit if billing for only one ear impression, no modifier. Enter 2 units if billing for 2 impressions, no modifier. Number of units is limited 6/year. AUTISM EVALUATION 97151 - Behavior Identification Assessment Units 32 Units Lifetime Autism Services AUTISM SERVICES 97153 - Adaptive Behavior Treatment Units 160 Units Week 97155 - Adaptive Behavior Treatment with Protocol Modification Units 64 Units Month 97156 - Family Adaptive Behavior Treatment Guidance Units 48 Units Year Psychological Evaluation PSYCHOLOGICAL EVALUATION 96101 - Psychological Testing and Evaluation (Per Hour) Units 40 Units Lifetime 90791 - Psychiatric Diagnostic Evaluation HO Encounter 40 Encounter Lifetime 96130/96131 - Psychological testing and evaluation (1st 60 min/ Additional 60 min) HO Units 40 Units Lifetime 96136/96137 - Psychological testing (administration and scoring) (1st 30 min/ Additional 30 min) HO Units 40 Units Lifetime 96138/96139 - Psychological testing by technician (1st 30 min/ Additional 30 min) Units 40 Units Lifetime 96146 - Psychological testing (single standardized) Units 40 Units Lifetime 96112/96113 - Developmental testing (motor and language) (1st 60 min/ Additional 30 min) Units 40 Units Lifetime Counseling And Psychological Services COUNSELING AND PSYCHOLOGICAL SERVICES 9940X - Prevent Med Counsel&/Risk Factor Encounter 1 Encounter Per Day Medical Evaluation MEDICAL EVALUATION 99381 - Initial Health Evaluation (Age 0 to 1 Year) Encounter 1 Encounter Lifetime 99382 - Initial Health Evaluation (Age 1+) Encounter 1 Encounter Lifetime 99391 - Health Evaluation (Age 0 to 1 year) Encounter 1 Encounter Per Year 99392 - Health Evaluation (Age 1+) Encounter 1 Encounter Per Year Nursing Evaluation NURSING EVALUATION T1001 - Nursing Assessment/Evaluation Encounter 48 Encounter Per Year Nursing Services NURSING SERVICES T1002 - RN Services, Up To 15 Minutes Units 64 Units Per Month T1003 - LPN/LVN Services, Up To 15 Minutes Units 64 Units Per Month Nutrition Evaluation NUTRITION EVALUATION 97802 - Nutrition Assessment and Intervention; Initial Assessment Units 12 Units Per Year SERVICE LOG DROP DOWN CATEGORY with PROCEDURE CODE DESCRIPTION LIST Modifier Pay Per BN Service Limit Count BN Service Limit Frequency 97803 - Medical Nutrition Therapy; Re-Assessment And and Intervention, Individual, Face-To-Face With T Units 12 Units Per Year Nutrition Services NUTRITION SERVICES S9470 - Nutritional Counseling, Dietitian Visit Units 64 Units Per Month Occupational Therapy Evaluation OCCUPATIONAL THERAPY EVALUATION 9716Y - Occupational Therapy Evaluation Encounter 2 Encounter Per Year 97168 - Occupational Therapy Re-evaluation Encounter 2 Encounter Per Year Occupational Therapy Services OCCUPATIONAL THERAPY SERVICES 97530 - Occupational Therapy Services (15 min.) GO Units 4 Units Per Day Physical Therapy Evaluation PHYSICAL THERAPY EVALUATION 9716X - Physical Therapy Evaluation Encounter 2 Encounter Per Year 97164 - Physical Therapy Re-evaluation (20 min.) Encounter 2 Encounter Per Year Physical Therapy Services PHYSICAL THERAPY SERVICES 97110 - Physical Therapy Services (15 min. exercises) GP Units 4 Unit Per Day 97530 - Physical Therapy Services (15 min. exercises) GP Unit Social Work Services Units 4 Per Day SOCIAL WORK SERVICES 9083X - Psychotherapy Encounter 8 Encounter Per Week Speech - Language Evaluation / ReSPEECH-Evaluation LANGUAGE EVALUATION/RE-EVALUATION 92521 - Speech Evaluation (fluency) Encounter 1 Encounter Lifetime 92522 - Speech Evaluation (sound production) Encounter 1 Encounter Lifetime 92523 - Speech Evaluation (language comprehension) Encounter 1 Encounter Lifetime 92524 - Speech Evaluation (voice and resonance) Encounter 1 Encounter Lifetime 92610 - Speech Evaluation (oral/pharyg pharyngeal wall) Encounter 1 Encounter Lifetime S9152 - Speech Therapy Re-evaluation Encounter 2 Encounter Per Year Speech - Language Pathology Services SPEECH-LANGUAGE PATHOLOGY SERVICES 92507 - Speech Therapy (voice command/auditory proc) Units 4 Units Per Day 92526 - Speech Therapy (swallowing/feeding) Units 4 Units Per Day 92609 - Speech Therapy (use of device) Encounter 1 Encounter Per Day Vision Evaluation and Services VISION EVALUATION AND SERVICES 92002 -Vision Evaluation (new patient intermediate) Encounter 1 Encounter Lifetime 92004 - Vision Evaluation (new patient comprehensive) Encounter 1 Encounter Lifetime 92012 - Vision Evaluation (established patient intermediate) Encounter 1 Encounter Per Year 92014 - Vision Evaluation (established patient comprehensive) Encounter 1 Encounter Per Year 92015 - Vision Evaluation Add-On - Refraction Test Encounter 1 Encounter Per Year SCSDB Evaluation EVALUATION AND SERVICES Interpretation: Deaf and Services Hard of Hearing Units 8 Per Day Cued Language Units 4 Per Day T1024 - Orientation and Mobility Evaluation U3 Units 8 Units Lifetime T1024 - Orientation and Mobility Instruction U2 Units 30 Units Per Week IFSP MeetingMEETING-DDSN / SCSDB SERVICE COORDINATION T1018 - Family Training IFSP Meeting TL Units 8 Units Per Day IFSP MeetingMEETING-Service Providers SERVICE PROVIDERS (AllALL) T1024 - IFSP Team Meeting/Participation (Team Members) Units 8 Units Per Day Service Coordination SERVICE COORDINATION T1016 - Service Coordination TL Units 16 Units Per Day Family Training Counseling and Home Visits FAMILY TRAINING, COUNSELING, AND HOME VISITS (SPECIAL INSTRUCTION SERVICES) T1027 - Family Training & Counseling (15 Min.) TL Units 4 Units Per Day Foreign Language Services FOREIGN LANGUAGE SERVICES FLT00- Foreign Language Translation 24 Units 6 Per IFSP FLI00- Foreign Language Interpretation Units 12 Units- Home/Community ($9.42), Each- Other ($5) Daily Transportation And Related Costs TRANSPORTATION AND RELATED COSTS TT000- Transportation-Taxi No limit Miles No limit No limit TFA00- Transportation-Family Auto No limit Miles No limit No limit TO000- Transportation-Other No limit Miles No limit No limit ASSISTIVE TECHOLOGY SERVICES AND DEVICES ATDAS- Assistive Technology Device Services and Service Assistive Technology Device And Service Devices Units As Approved Units As ApprovedApproved Step Submitting Claims for IDEA/Part C Early Intervention Services 1 Provider confirms with Service Coordinator that service payor is correct in BRIDGES. NOTE: IDEA/Part C must always be Payor 1 for all assistive technology services and devices, foreign language interpretation, foreign language translation, transportation, and compensatory services. NOTE: Private Insurance will never be Payor 1 for service coordinator or special instruction services. 2 Provider secures Prior Authorization from payor source before initiation of services (see table below). 3 Provider delivers services as documented in IFSP. 4 Provider enters service log in BRIDGES and clicks ‘Save.’ 5 The saved service log is captured as BRIDGES Accounts Payable journal entry.