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Colorado Electronic Visit Verification (EVV)

Types of Service – Service Code Inclusions

Comprehensive reference for Service Codes included in EVV Types of Service for Health First Colorado (Colorado’s Medicaid Program)

February 2020

2 | EVV Types of Service – Service Codes

Contents I. Introduction ................................................................................. 3

II. Behavioral Therapies ...................................................................... 5

III. Consumer Directed Attendant Support Services (CDASS) .......................... 6

A. Consumer Directed Attendant Support Services (CDASS) ....................... 6

B. Consumer Directed Attendant Support Services SLS Health Maintenance .... 6

IV. Durable Medical Equipment .............................................................. 7

V. Home Health ............................................................................... 12

A. Home Health – Certified Nurse Aide ............................................. 12

B. Home Health – Nursing ............................................................. 12

C. Home Health - Occupational Therapy ........................................... 12

D. Home Health - Physical Therapy ................................................. 12

E. Home Health - Speech/Language Therapy ...................................... 13

VI. Homemaker ................................................................................ 14

VII. Hospice ..................................................................................... 15

A. Hospice in Home Levels of Care .................................................. 15

B. Hospice Inpatient Levels of Care ................................................. 15

VIII. Independent Living Skills Training (ILST) and Life Skills Training (LST)........ 16

IX. In-Home Support Services (IHSS)....................................................... 17

X. Occupational Therapy ................................................................... 18

XI. Pediatric Behavioral Therapies ........................................................ 22

XII. Pediatric Personal Care .................................................................. 23

XIII. Personal Care .............................................................................. 24

XIV. Physical Therapy .......................................................................... 25

XV. Private Duty Nursing ..................................................................... 29

XVI. Respite and Youth Day ................................................................... 30

XVII. Speech Therapy ........................................................................... 31


I. Introduction The 21st Century Cures Act, passed in December 2016, requires state Medicaid programs to implement an Electronic Visit Verification (EVV) system for Personal Care and Home Health services. Per section 12006, all states must implement an EVV system to avoid a reduction in federal Medicaid funding. EVV is an electronic-based system that verifies when provider visits occur and documents the precise time services begin and end, ensuring that members receive authorized services. For federal compliance, all EVV systems must collect the following six points of data.

o Type of service performed

o Individual receiving the service

o Date of the service

o Location of service delivery

o Individual providing the service

o Time the service begins and ends

In the Summer of 2020, the Department of Health Care Policy & Financing will require Medicaid providers of EVV mandated home and community based and state plan services to use EVV. Colorado is implementing EVV for federally required services and additional services that are similar in nature and service delivery.

To reduce administrative burden during service delivery, similar services are grouped into Colorado EVV Types of Service. Each Colorado EVV Type of Service has a table of corresponding billable service codes1 for easy reference.

This document serves as a resource for providers to determine which service codes will require EVV to correctly bill Health First Colorado. If a service code is listed in this document, it requires the corresponding EVV Type of Service for claims processing.

1 All service descriptions are for reference only; please continue to reference coding books and State of Colorado Billing Manuals for accurate information.

http://docs.house.gov/billsthisweek/20161128/CPRT-114-HPRT-RU00-SAHR34.pdf


The Department will cross-reference the EVV Types of Service with the service code billed during claims processing. For example, a caregiver providing HCBS Personal Care normally billed as T1019,U6 (Personal Care under the Brain Injury Waiver) will need to submit the EVV Type of Service “Personal Care” and bill as normal.

The revision date of this code list is notated on the first page. Please be advised this list is subject to change pending policy guidance or system modifications.

The latest version of this document is available at www.colorado.gov/hcpf/evv.

Please contact [email protected] with questions.

http://www.colorado.gov/hcpf/evv

mailto:[email protected]


II. Behavioral Therapies HCBS Providers (Billing Provider Type 36) in all locations*

Behavioral Therapies are all one EVV Type of Service

Procedure Modifiers Service Description

H2019 U3 Behavioral Line Staff (Developmental Disabilities Waiver)

H2019 U8 Behavioral Line Staff (Supported Living Services Waiver)

H2019 U3 22 TG Behavioral Consultation (Developmental Disabilities Waiver)

H2019 U8 22 TG Behavioral Consultation (Supported Living Services Waiver)

H2019 U3 TF TG Behavioral Counseling (Developmental Disabilities Waiver)

H2019 U8 TF TG Behavioral Counseling (Supported Living Services Waiver)

H2019 U3 TF HQ Behavioral Counseling, Group (Developmental Disabilities Waiver)

H2019 U8 TF HQ Behavioral Counseling, Group (Supported Living Services Waiver)

T2024 U3 22 Behavioral Plan Assessment (Developmental Disabilities Waiver)

T2024 U8 22 Behavioral Plan Assessment (Supported Living Services Waiver)

*Behavioral Consultations and Behavioral Plan Assessments billed with Place Of Service 11 (Office) do not require EVV.


III. Consumer Directed Attendant Support Services (CDASS) HCBS Providers (Billing Provider Type 36) in all locations

CDASS services are divided into two EVV Types of Service

A. Consumer Directed Attendant Support Services (CDASS) Procedure Modifiers Service Description

T2025 U8 Consumer Directed Attendant Support Service - Enhanced Homemaker, Homemaker, Personal Care (Supported Living Services Waiver)

T2025 U1

Consumer Directed Attendant Support Service - Health Maintenance, Homemaker, Personal Care (Elderly, Blind, and Disabled Waiver)

T2025 UA

Consumer Directed Attendant Support Services - Health Maintenance, Homemaker, Personal Care (Community Mental Health Supports Waiver)

T2025 U6

Consumer Directed Attendant Support Service - Health Maintenance, Homemaker, Personal Care (Brain Injury Waiver)

T2025 U1 SC Consumer Directed Attendant Support Service - Health Maintenance, Homemaker, Personal Care (Spinal Cord Injury Waiver)

B. Consumer Directed Attendant Support Services SLS Health Maintenance

Procedure Modifiers Service Description T2025 U8 SE Consumer Directed Attendant Support Services – Health

Maintenance (Supported Living Services Waiver)


IV. Durable Medical Equipment DME provided in Places of Service 4, 12, 15, 16, 18, or 99

Per-diem (rental) equipment portions of billing are not subject to EVV.

Procedure Service Description (Durable Medical Equipment) A4357 Bedside drainage bag, day or night, with or without anti-reflux device, with or

without tube, per set A4615 Cannula, nasal, each A7038 Filter, disposable, used with positive airway pressure device E0255 Hospital bed, variable height, Hi-Lo, with any type side rails, with mattress E0260 Hospital bed, semi-electric (head & foot adjustment), with any type side rails,

with mattress E0261 Hospital bed, semi-electric (head and foot adjustment), with any type side

rails, without mattress E0265 Hospital bed, total electric (head, foot & height adjustments) with any type

side rails, with mattress

E0266 Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress

E0294 Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress

E0295 Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress

E0297 Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress

E0301 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress

E0303 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress

E0304 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress

E0305 Bed side rails, half length, pair E0310 Bed side rails, full length, pair E0315 Bed accessory: board, table, or support device any type E0316 Safety enclosure frame/canopy for use with hospital bed, any type E0328 Hospital bed, pediatric, manual, 360-degree side enclosures, top of

headboard, footboard and side rails up to 24 inches above the spring, includes mattress

E0329 Hospital bed, pediatric, electric or semi- electric, 360-degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress

E0465 Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)


Procedure Service Description (Durable Medical Equipment) E0466 Home ventilator, any type, used with non-invasive interface, (e.g., mask,

chest shell) E0482 Cough stimulating device, alternating positive and negative airway pressure E0630 Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or

pad(s) E0910 Trapeze bars (also known as "patient helper"), attached to bed, with grab bar E0957 Wheelchair accessory, medial thigh support, any type, including fixed

mounting hardware, each E0958 Manual wheelchair accessory, one-arm drive attachment, each E0960 Wheelchair accessory, shoulder harness/straps or chest strap, including any

type mounting hardware E0961 Manual wheelchair accessory, wheel lock brake extension (handle), each E0966 Manual wheelchair accessory, headrest extension, each E0968 Commode seat, wheelchair E0971 Manual wheelchair accessory, anti- tipping device, each E0983 Manual wheelchair accessory, power add-on to convert manual wheelchair to

motorized wheelchair, joystick control E0990 Wheelchair accessory, elevating leg rest, complete assembly, each E0992 Manual wheelchair accessory, solid seat insert E0995 Wheelchair accessory, calf rest/pad, replacement only, each E1004 Wheelchair accessory, power seating system, recline only, with mechanical

shear reduction E1008 Wheelchair accessory, power seating system, combination tilt and recline,

with power shear reduction E1018 Heavy duty shock absorber for heavy duty or extra heavy-duty power

wheelchair, each E1060 Fully-reclining wheelchair, detachable arms, desk or full-length, swing-away

detachable elevating leg rests E1070 Fully-reclining wheelchair, detachable arms (desk or full-length) swing-away

detachable footrest E1086 Hemi-wheelchair, detachable arms, desk or full-length, swing-away detachable

footrests E1093 Wide heavy-duty wheelchair, detachable arms, desk or full-length, swing-away

detachable footrests E1140 Wheelchair, detachable arms, desk or full-length, swing-away detachable

footrests E1150 Wheelchair, detachable arms, desk or full-length swing-away detachable

elevating leg rests E1160 Wheelchair, fixed full-length arms, swing-away detachable elevating leg rests E1161 Manual adult size wheelchair, includes tilt- in-space E1221 Wheelchair with fixed arm, footrests E1223 Wheelchair with detachable arms, footrests E1224 Wheelchair with detachable arms, elevating leg rests E1230 Power operated vehicle, three (3) or four E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating

system


Procedure Service Description (Durable Medical Equipment) E1233 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating

system E1234 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating

system E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system E1236 Wheelchair, pediatric size, folding, adjustable, with seating system E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system E1238 Wheelchair, pediatric size, folding, adjustable, without seating system E1240 Lightweight wheelchair, detachable arms, (desk or full-length) swing-away

detachable, elevating leg rest E1260 Lightweight wheelchair, detachable arms E1285 Heavy-duty wheelchair, fixed full-length E1297 Special wheelchair seat depth, by upholstery E2205 Manual wheelchair accessory, hand rim without projections (includes

ergonomic or contoured), any type, replacement only, each E2206 Manual wheelchair accessory, wheel lock assembly, complete, replacement

only, each E2210 Wheelchair accessory, bearings, any E2228 Manual wheelchair accessory, wheel braking system and lock, complete, each E2291 Back, planar, for pediatric size wheelchair including fixed attaching hardware E2292 Seat, planar, for pediatric size wheelchair including fixed attached hardware E2293 Back, contoured, for pediatric size wheelchair including fixed attaching

hardware E2294 Seat, contoured, for pediatric size wheelchair including fixed attaching

hardware E2301 Wheelchair accessory, power standing system, any type E2313 Power wheelchair accessory, harness for upgrade to expandable controller,

including all fasteners, connectors and mounting hardware, each E2321 Power wheelchair accessory, hand control E2366 Power wheelchair accessory, battery charger, single mode, for use with only

one (1) battery type, sealed or non- sealed, each E2368 Power wheelchair component, drive wheel motor, replacement only E2370 Power wheelchair component, integrated drive wheel motor and gear box

combination, replacement only E2378 Power wheelchair component, actuator, replacement only E2392 Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated

wheel, any size, replacement only, each E2394 Power wheelchair accessory, drive wheel excludes tire, any size, replacement

only, each E2603 Skin protection wheelchair seat cushion, width less than 22 inches, any depth E2604 Skin protection wheelchair seat cushion, width 22 inches or greater, any depth E2605 Positioning wheelchair seat cushion, width less than 22 inches, any depth E2606 Positioning wheelchair seat cushion, width 22 inches or greater, any depth E2607 Skin protection and positioning


Procedure Service Description (Durable Medical Equipment) E2608 Skin protection and positioning wheelchair seat cushion, width 22 inches or

greater, any depth E2620 Positioning wheelchair back cushion, planar back with lateral supports, width

less than 22 inches, any height, including any type mounting hardware E2621 Positioning wheelchair back cushion, planar back with lateral supports, width

22 inches or greater, any height, including any type mounting hardware E2623 Skin protection wheelchair seat cushion, adjustable, width 22 inches or

greater, any depth E2625 Skin protection and positioning wheelchair seat cushion, adjustable, width 22

inches or greater, any depth E8002 Gait trainer, pediatric size, anterior support, includes all accessories and

components K0001 Standard wheelchair K0003 Lightweight wheelchair K0005 Ultra-lightweight wheelchair K0006 Heavy duty wheelchair K0007 Extra heavy-duty wheelchair K0042 Standard size footplate, replacement only, each K0053 Elevating footrests, articulating K0056 Seat height < 17” or equal to or greater than 21” for a high strength,

lightweight, or ultra-lightweight wheelchair K0669 Wheelchair accessory wheelchair seat or back cushion does not meet specific

code K0800 Power operated vehicle, group 1 standard, patient weight capacity up to and

including 300 pounds K0801 Power operated vehicle, group 1 heavy duty, patient weight capacity 301 to

450 pounds K0806 Power operated vehicle, group 2 standard, patient weight capacity up to and

including 300 pounds K0816 Power wheelchair, group 1 standard, captain’s chair, patient weight capacity

up to and including 300 pounds K0820 Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient

weight capacity up to and including 300 pounds K0821 Power wheelchair, group 2 standard, portable, captain’s chair, patient weight

capacity up to and including 300 pounds K0822 Power wheelchair, group 2 standard, sling/solid seat/back, patient weight

capacity up to and including 300 pounds K0823 Power wheelchair, group 2 standard, captain’s chair, patient weight capacity

up to and including 300 pounds K0824 Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight

capacity 301 to 450 pounds K0825 Power wheelchair, group 2 heavy duty, captain’s chair, patient weight

capacity 301 to 450 pounds K0827 Power wheelchair, group 2 very heavy duty, captain’s chair, patient weight

capacity 451 to 600 pounds K0831 Power wheelchair, group 2 standard, seat elevator, captain’s chair, patient

weight capacity up to and including 300 pounds


Procedure Service Description (Durable Medical Equipment) K0835 Power wheelchair, group 2 standard, single power option, single power option,

sling/solid seat/back, patient weight capacity up to and including 300 pounds K0836 Power wheelchair, group 2 standard, single power option, captain’s chair.

Member weight capacity up to and including 300 pounds K0841 Power wheelchair, group 2 standard, multiple power option, sling/solid

seat/back, patient weight capacity up to including 300 pounds K0848 Power wheelchair, group 3 standard, sling/solid seat/back, patient weight

capacity up to and including 300 pounds K0849 Power wheelchair, group 3 standard, captain’s chair, patient weight capacity

up K0850 Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight

capacity 301 to 450 pounds K0851 Power wheelchair, group 3 heavy duty, captain’s chair, patient weight

capacity 301 to 450 pounds K0853 Power wheelchair, group 3 very heavy duty, captain’s chair, patient weight

capacity, 451 to 600 pounds K0856 Power wheelchair, group 3 standard, single power option, sling/solid

seat/back, patient weight capacity up to and including 300 pounds K0857 Power wheelchair, group 3 standard, single power option, captain’s chair,

patient weight capacity up to and including 300 K0858 Power wheelchair, group 3 heavy duty, single power option, sling/solid

seat/back, patient weight capacity 301 to 450 pounds K0860 Power wheelchair, group 3 very heavy duty, single power option, sling/solid

seat/back. Member weight capacity 451 to 600 pounds K0861 Power wheelchair, group 3 standard, multiple power option, sling/solid

seat/back, patient weight capacity up to including 300 pounds K0862 Power wheelchair, group 3 heavy duty, multiple power option, sling/solid

seat/back, patient weight capacity 301 to 450 pounds K0868 Power wheelchair, group 4 standard, sling/solid seat/back, patient weight

capacity up to and including 300 pounds K0877 Power wheelchair, group 4 standard, single power option, sling/solid

seat/back, patient weight capacity up to including 300 pounds K0879 Power wheelchair, group 4 heavy duty, single power option, sling/solid

seat/back, patient weight capacity 301 to 450 pounds K0884 Power wheelchair, group 4 standard, multiple power option, sling/solid

seat/back, patient weight capacity up to and including 300 pounds K0886 Power wheelchair, group 4 heavy duty, multiple power option, sling/solid

seat/back, patient weight capacity 301 to 450 pounds K0890 Power wheelchair, group 5 pediatric, single power option, sling/solid

seat/back, patient weight capacity up to and including 125 pounds K0891 Power wheelchair, group 5 pediatric, multiple power option, sling/solid

seat/back, patient weight capacity up to and including 125 pounds L7368 Lithium ion battery charger, replacement only T5001 Positioning seat for persons with special orthopedic needs


V. Home Health Home Health Agencies (Billing Provider Type 10) in all locations

Home Health services are divided into five EVV Types of Service:

A. Home Health – Certified Nurse Aide Revenue

Code Service Description

570 Home Health Aide Basic (Acute) 571 Home Health Aide Basic (Long-Term) 572 Home Health Aide Extended (Acute) 579 Home Health Aide Extended (Long-Term)

B. Home Health – Nursing Revenue


550 RN/LPN Standard Visit (Acute) 551 RN/LPN Standard Visit (Long-Term) 590 Uncomplicated Nursing (Brief Visit 1st of Day) 599 Uncomplicated Nursing Visit (Visit 2+ of Day)

C. Home Health - Occupational Therapy Revenue


430 Occupational Therapy (Acute) 431 Occupational Therapy (Long-Term) 434 Occupational Therapy for HCBS Home Mod Evaluation

D. Home Health - Physical Therapy Revenue


420 Physical Therapy (Acute) 421 Physical Therapy (Long-Term) 424 Physical Therapy for HCBS Home Mod Evaluation


E. Home Health - Speech/Language Therapy Revenue


440 Speech/ Language Therapy (Acute) 441 Speech/ Language Therapy (Long-Term)


VI. Homemaker HCBS Providers (Billing Provider Type 36) in all locations

Homemaker services are all one EVV Type of Service

Procedure Modifiers Service Description S5130 U1 Homemaker (Elderly, Blind, and Disabled Waiver) S5130 UA

Homemaker (Community Mental Health Supports Waiver)

S5130 U1 SC

Homemaker (Spinal Cord Injury Waiver) S5130 U8

Homemaker - Basic (Supported Living Services Waiver)

S5130 U7

Homemaker - Basic (Children's Extensive Supports Waiver)

S5130 U8 22

Homemaker - Enhanced (Supported Living Services Waiver)

S5130 U7 22

Homemaker - Enhanced (Children's Extensive Supports Waiver)


VII. Hospice Hospice (Billing Provider Type 50) in all locations, including Nursing Facilities, Type of Bill range 811-815. Hospital settings (Type of Bill range 821-825) are exempt from EVV.

Hospice services are divided into two EVV Types of Service:

A. Hospice in Home Levels of Care Revenue


650 Routine Home Care (1-60 days) 651 Routine Home Care (61+ days) 652 Continuous Home Care/Service Intensity Add-On

B. Hospice Inpatient Levels of Care Revenue


655 Inpatient Respite 656 General Inpatient Care


VIII. Independent Living Skills Training (ILST) and Life Skills Training (LST)

HCBS Providers (Billing Provider Type 36) in all locations

Independent Living Skills Training (ILST) and Life Skills Training (LST) services are all one EVV Type of Service

Procedure Modifiers Service Description T2013 U6 Independent Living Skills Training (Brain Injury

Waiver) H2014 UA Life Skills Training (Community Mental Health

Supports Waiver) H2014 U3 Life Skills Training (Developmental Disabilities

Waiver) H2014 U1

Life Skills Training (Elderly, Blind, and Disabled Waiver)

H2014 U1 SC Life Skills Training (Spinal Cord Injury Waiver) H2014 U8

Life Skills Training (Supported Living Services Waiver)


IX. In-Home Support Services (IHSS) HCBS Providers (Billing Provider Type 36) in all locations

In-Home Support Services (IHSS) services are all one EVV Type of Service

Procedure Modifiers Service Description H0038 U5 In-Home Support Services (IHSS) - Health

Maintenance (Children's Home and Community Based Services Waiver)

H0038 U1 In-Home Support Services (IHSS) - Health Maintenance (Elderly, Blind, and Disabled Waiver)

S5130 U1 KX In-Home Support Services (IHSS) - Homemaker (Elderly, Blind, and Disabled Waiver)

T1019 U1 KX In-Home Support Services (IHSS) - Personal Care (Elderly, Blind, and Disabled Waiver)

T1019 U1 HR KX In-Home Support Services (IHSS) - Relative Personal Care (Elderly, Blind, and Disabled Waiver)

H0038 U1 SC

In-Home Support Services (IHSS) - Health Maintenance (Spinal Cord Injury Waiver)

S5130 U1 SC KX In-Home Support Services (IHSS) - Homemaker (Spinal Cord Injury Waiver)

T1019 U1 SC KX In-Home Support Services (IHSS) - Personal Care (Spinal Cord Injury Waiver)

T1019 U1 SC HR KX In-Home Support Services (IHSS) - Relative Personal Care (Spinal Cord Injury Waiver)


X. Occupational Therapy Any Billing Provider billing OT in Places of Service 4, 12, 15, 16, 18, or 99

Occupational Therapy services are all one EVV Type of Service

Procedure Modifiers Service Description (Occupational Therapy)

90911 GO Biofeedback training, perineal muscles, anorectal or urethral sphincter

96112 GO

Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour

96113 GO

Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; each additional 30 minutes (List separately in addition to code for primary procedure)

97010 GO Application of hot or cold packs to 1 or more areas

97012 GO Application of mechanical traction to 1 or more areas

97014 GO Application of electrical stimulation to 1 or more areas, unattended by physical therapist

97016 GO Application of blood vessel compression or decompression device to 1 or more areas

97018 GO Application of hot wax bath to 1 or more areas 97022 GO Application of whirlpool therapy to 1 or more areas 97024 GO Application of heat wave therapy to 1 or more areas

97026 GO Application of low energy heat (infrared) to 1 or more areas

97028 GO Application of ultraviolet light to 1 or more areas

97032 GO Application of electrical stimulation to 1 or more areas, each 15 minutes

97033 GO Application of medication through skin using electrical current, each 15 minutes

97034 GO Therapeutic hot and cold baths to 1 or more areas, each 15 minutes



97035 GO Application of ultrasound to 1 or more areas, each 15 minutes

97036 GO Occupational therapy treatment to 1 or more areas, Hubbard tank, each 15 minutes

97110 GO Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes

97112 GO Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes

97113 GO Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes

97116 GO Walking training to 1 or more areas, each 15 minutes

97124 GO Therapeutic massage to 1 or more areas, each 15 minutes

97140 GO Manual (physical) therapy techniques to 1 or more regions, each 15 minutes

97150 GO Therapeutic procedures in a group setting

97161 GO Evaluation of physical therapy, low complexity typically 20 minutes

97162 GO Evaluation of physical therapy, moderate complexity typically 30 minutes

97163 GO Evaluation of physical therapy, high complexity typically 45 minutes

97164 GO Re-evaluation of physical therapy, typically 20 minutes

97530 GO Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes

G0515 GO

Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

97533 GO Sensory technique to enhance processing and adaptation to environmental demands, each 15 minutes

97535 GO Self-care or home management training, each 15 minutes

97537 GO Community or work reintegration training, each 15 minutes

97542 GO Wheelchair management training, each 15 minutes 97545 GO Work hardening or conditioning, first 2 hours 97546 GO Work hardening or conditioning add-on

97597 GO Removal of tissue from wounds per session - rmvl devital tis 20 cm/<

97598 GO Removal of tissue from wounds per session - rmvl devital tis addl 20cm/<



97602 GO Wound(s) care non-selective - removal of tissue from wounds per session

97750 GO Physical performance test or measurement with report, each 15 minutes

97755 GO Assistive technology assessment to enhance functional performance, each 15 minutes

97760 GO Training in use of orthotics (supports, braces, or splints) for arms, legs and/or trunk, per 15 minutes

97761 GO Training in use of prosthesis for arms and/or legs, per 15 minutes

97763 GO

Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes

97799 GO Unlisted physical medicine/rehabilitation service or procedure

L1902 GO Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf

L1960 GO Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated

L3730 GO Elbow orthosis, double upright with forearm/arm cuffs, extension/ flexion assist, custom fabricated

L3763 GO Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3764 GO

Elbow wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3808 GO Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment

L3900 GO

Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, wrist or finger driven, custom fabricated

L3906 GO Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3908 GO Wrist hand orthosis, wrist extension control cock-up, non-molded, prefabricated, off-the-shelf

L3912 GO Hand finger orthosis (hfo), flexion glove with elastic finger control, prefabricated, off-the-shelf



L3919 GO Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3923 GO

Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L3925 GO

Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non-torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf

L3929 GO

Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L3933 GO Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and adjustment

L3982 GO Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment

Q4040 GO Cast supplies, short leg cast, pediatric (0-10 years), fiberglass

Q4048 GO Cast supplies, short leg splint, pediatric (0-10 years), fiberglass


XI. Pediatric Behavioral Therapies Any Billing Provider billing PBT in Places of Service 4, 12, 15, 16, 18, or 99

Pediatric Behavioral Therapies are all one EVV Type of Service


97153 Adaptive behavior treatment by protocol, administered by technician under direction of qualified health care professional to one patient, each 15 minutes

97154 Adaptive behavior treatment by protocol, administered by technician under direction of qualified health care professional to multiple patients, each 15 minutes

97155 Adaptive behavior treatment with protocol modification administered by qualified health care professional to one patient, each 15 minutes

97158 Group adaptive behavior treatment with protocol modification administered by qualified health care professional to multiple patients, each 15 minutes

97151

Behavior identification assessment, face-to-face with patient and caregiver(s), includes administration of standardized and non-standardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/caregiver(s), and preparation of report.

97151 TJ Behavior identification re-assessment, limited to 2 units per six months, each 30 minutes


XII. Pediatric Personal Care Personal Care Agencies (Billing Provider Type 60) in Places of Service 4, 12, 15, 16, 18, or 99

Pediatric Personal Care service is one EVV Type of Service.

Procedure Modifiers Service Description T1019 Pediatric Personal Care Service

*HCBS Personal Care services do require EVV and are listed in section XIII


XIII. Personal Care HCBS Providers (Billing Provider Type 36) in all locations

Personal Care services are all one EVV Type of Service


T1019 U1 Personal Care (Elderly, Blind, and Disabled Waiver) T1019 UA

Personal Care (Community Mental Health Supports Waiver)

T1019 U6

Personal Care (Brain Injury Waiver) T1019 U1 SC

Personal Care (Spinal Cord Injury Waiver)

T1019 U8

Personal Care (Supported Living Services Waiver) T1019 U7

life (Children's Extensive Supports Waiver)

T1019 U1 HR

Personal Care - Relative (Elderly, Blind, and Disabled Waiver)

T1019 UA

Personal Care - Relative (Community Mental Health Supports Waiver)

T1019 U6 HR

Personal Care - Relative (Brain Injury Waiver) T1019 U1 SC HR Personal Care - Relative (Spinal Cord Injury Waiver)

*Pediatric Personal Care services do require EVV and are listed in section XII


XIV. Physical Therapy Any Billing Provider billing PT in Places of Service 4, 12, 15, 16, 18, or 99

Physical Therapy services are all one EVV Type of Service

Procedure Modifiers Service Description (Physical Therapy)

90911 GP Biofeedback training, perineal muscles, anorectal or urethral sphincter

96112 GP


96113 GP


97010 GP Application of hot or cold packs to 1 or more areas

97012 GP Application of mechanical traction to 1 or more areas

97014 GP Application of electrical stimulation to 1 or more areas, unattended by physical therapist

97016 GP Application of blood vessel compression or decompression device to 1 or more areas

97018 GP Application of hot wax bath to 1 or more areas 97022 GP Application of whirlpool therapy to 1 or more areas 97024 GP Application of heat wave therapy to 1 or more areas

97026 GP Application of low energy heat (infrared) to 1 or more areas

97028 GP Application of ultraviolet light to 1 or more areas

97032 GP Application of electrical stimulation to 1 or more areas, each 15 minutes

97033 GP Application of medication through skin using electrical current, each 15 minutes

97034 GP Therapeutic hot and cold baths to 1 or more areas, each 15 minutes



97035 GP Application of ultrasound to 1 or more areas, each 15 minutes

97036 GP Occupational therapy treatment to 1 or more areas, Hubbard tank, each 15 minutes

97110 GP Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes

97112 GP Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes

97113 GP Water pool therapy with therapeutic exercises to 1 or more areas, each 15 minutes

97116 GP Walking training to 1 or more areas, each 15 minutes

97124 GP Therapeutic massage to 1 or more areas, each 15 minutes

97140 GP Manual (physical) therapy techniques to 1 or more regions, each 15 minutes

97150 GP Therapeutic procedures in a group setting

97161 GP Evaluation of physical therapy, low complexity typically 20 minutes

97162 GP Evaluation of physical therapy, moderate complexity typically 30 minutes

97163 GP Evaluation of physical therapy, high complexity typically 45 minutes

97164 GP Re-evaluation of physical therapy, typically 20 minutes

97530 GP Therapeutic activities to improve function, with one-on-one contact between patient and provider, each 15 minutes

G0515 GP


97533 GP Sensory technique to enhance processing and adaptation to environmental demands, each 15 minutes

97535 GP Self-care or home management training, each 15 minutes

97537 GP Community or work reintegration training, each 15 minutes

97542 GP Wheelchair management training, each 15 minutes 97545 GP Work hardening or conditioning, first 2 hours 97546 GP Work hardening or conditioning add-on

97597 GP Removal of tissue from wounds per session - rmvl devital tis 20 cm/<

97598 GP Removal of tissue from wounds per session - rmvl devital tis addl 20cm/<



97602 GP Wound(s) care non-selective - removal of tissue from wounds per session

97750 GP Physical performance test or measurement with report, each 15 minutes

97755 GP Assistive technology assessment to enhance functional performance, each 15 minutes

97760 GP Training in use of orthotics (supports, braces, or splints) for arms, legs and/or trunk, per 15 minutes

97761 GP Training in use of prosthesis for arms and/or legs, per 15 minutes

97763 GP

Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes

97799 GP Unlisted physical medicine/rehabilitation service or procedure

L1902 GP Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf

L1960 GP Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated

L3730 GP Elbow orthosis, double upright with forearm/arm cuffs, extension/ flexion assist, custom fabricated

L3763 GP Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3764 GP

Elbow wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3808 GP Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment

L3900 GP

Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, wrist or finger driven, custom fabricated

L3906 GP Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3908 GP Wrist hand orthosis, wrist extension control cock-up, non-molded, prefabricated, off-the-shelf

L3912 GP Hand finger orthosis (hfo), flexion glove with elastic finger control, prefabricated, off-the-shelf



L3919 GP Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3923 GP

Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L3925 GP

Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non-torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf

L3929 GP

Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L3933 GP Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and adjustment

L3982 GP Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment

Q4040 GP Cast supplies, short leg cast, pediatric (0-10 years), fiberglass

Q4048 GP Cast supplies, short leg splint, pediatric (0-10 years), fiberglass


XV. Private Duty Nursing Home Health Agencies (Billing Provider Type 10) in all locations

Private Duty Nursing services are all one EVV Type of Service

Revenue Code Service Description

552 Private Duty Nursing -RN 559 Private Duty Nursing -LPN 580 Private Duty Nursing -RN (group-per client) 581 Private Duty Nursing - LPN (group-per client) 582 Blended Group rate (RN/LPN)


XVI. Respite and Youth Day HCBS Providers (Billing Provider Type 36) in all locations for below procedure codes

Respite and Youth Day services are all one EVV Type of Service

Procedure Modifiers Service Description S5150 U6 Respite - In-Home (Brain Injury Waiver) S5150 U7 Respite - Individual (Children's Extensive Supports

Waiver) S5151 U7

Respite - Individual, Per Diem (Children's Extensive Supports Waiver)

S5151 U7 HQ Respite - Group (Children's Extensive Supports Waiver)

S5150 U9 HA Individual – In Family Home (15 minutes) (Children’s Habilitation Residential Program Waiver)

S5151 U9 HA Individual – In Family Home (Day) (Children’s Habilitation Residential Program Waiver)

T1005 UD

Respite - CNA (4 hours or less) (Children with Life Limiting Illness Waiver)

S9125 UD

Respite - CNA (4 hours or more) (Children with Life Limiting Illness Waiver)

T1005 UD TD Respite - Skilled RN/LPN (4 hours or less) (Children with Life Limiting Illness Waiver)

S9125 UD TD Respite - Skilled RN/LPN (4 hours or more) (Children with Life Limiting Illness Waiver)

S5150 UD Respite - Unskilled (4 hours or less) (Children with Life Limiting Illness Waiver)

S5151 UD Respite - Unskilled (4 hours or more) (Children with Life Limiting Illness Waiver)

S5150 U1 Respite - In-Home (Elderly, Blind, and Disabled Waiver)

S5151 U8 HQ Respite - Group (Supported Living Services Waiver) S5150 U1 SC Respite - In-Home (Spinal Cord Injury Waiver) S5150 U8

Respite - Individual (Supported Living Services Waiver)

S5151 U8

Respite - Individual - Day (Supported Living Services Waiver)

T2026 U7 HQ Youth Day Services - Group (Children's Extensive Supports Waiver)

T2027 U7 Youth Day Services - Individual (Children's Extensive Supports Waiver)


XVII. Speech Therapy Any Billing Provider billing S/LT in Places of Service 4, 12, 15, 16, 18, or 99

Speech Therapy services are all one EVV Type of Service

Procedure Modifiers Service Description (Speech Therapy) 92521 GN Evaluation of speech fluency (e.g. stuttering, cluttering)

92522 GN Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria)

92523 GN

Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language)

92524 GN Behavioral and qualitative analysis of voice and resonance

92507 GN Treatment of speech, language, voice, communication and/or auditory disorder; individual.

92508 GN Speech/hearing treatment, group, 2 or more individuals 92520 GN Laryngeal function studies 92526 GN treatment of swallowing and/or oral feeding function 92597 GN #N/A 92605 GN Evaluate for device 92606 GN Non-speech device service 92607 GN Evaluation for speech generating device, first hour 92608 GN Additional 30 minutes of evaluation for 92607 92609 GN Use of speech device service 92610 GN Evaluation of oral and pharyngeal swallowing function 92611 GN Motion fluoroscopic evaluation of swallowing function

92612 GN Flexible fiber optic endoscopic evaluation by cine or video recording

92614 GN Flexible fiber optic endoscopic laryngeal sensory testing by cine or video recording

92626 GN Evaluation of auditory rehab status; first hour 92627 GN Each additional 15 minutes of 92626 96105 GN Assessment of aphasia, per hour

96111 GN Developmental testing; extended with interpretation and report, per hour

96112 GN



Procedure Modifiers Service Description (Speech Therapy)

96113 GN


G0515 GN


97755 GN Assistive technology assessment to enhance functional performance, each 15 minutes

Q3014 GN Telehealth originating site facility fee

electronic visit verification service code inclusions ... evv types of... · e0304 hospital bed,...

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