There is a plethora of information available online about how to successfully bill Medicaid for addiction treatment services in New York. However, few sites offer all of the need-to-know information in one place. Instead, you’ll find yourself hunting and pecking through manual after manual trying to find basic information about New York’s Medicaid billing universe.
This is, in large part, due to the fact that the New York State Office of Addiction Services and Supports keeps their information about addiction treatment billing highly segmented by level of care. The site divides all of its billing information into an ambulatory site and a non-ambulatory site, but it doesn’t stop there. It further divides information into different types of services available underneath each of these umbrellas.
In this post, we’ll synthesize some of the basics of behavioral health billing for Medicaid in New York.
What is Medicaid called in New York State?
New York does not have a “fancy” name for its Medicaid program. It is simply called “Medicaid.” However, plans with different names can be selected through NY State of Health’s website. These plans may have different names and be administered under different contracts, but they are still ultimately Medicaid plans. You can search the offerings at each county here. You can apply for Medicaid - or assist patients in doing so - here.
The state also runs Essential Plan and Child Health Plus for lower income residents who earn too much to qualify for Medicaid but still need assistance covering healthcare costs.
What CPT billing codes show up most frequently in New York state Medicaid billing?
Again, the New York State Office of Addiction Services and Supports breaks this information into ambulatory care and non-ambulatory care.
Ambulatory care refers to outpatient services and MAT-based programs like OTPs (aka methadone clinics, etc). Non-ambulatory care refers to withdrawal and stabilization programs, residential treatment programs and inpatient, hospital-based programs.
For ambulatory care, the most common CPT codes used in addiction treatment services for New York Medicaid patients are:
Screening (H0049)
Brief intervention (H0050)
Assessment brief (T1023
Assessment normative H0001
Assessment extended H0002
Individual therapy - brief (G0396)
Psychiatric assessment - brief (99201 - 99205 New, 99211-99215 existing)
Individual therapy - normative (G0397)
Psychiatric assessment (99201 - 99205 new, 99211 - 99215 existing)
Brief treatment (H0004)
Family/collateral therapy
Family service with patient present
Group therapy (H0005)
Multi-family group (90849)
Medication administration and observation (H0033)
Medication administration and observation - 1st visit of the week (H0020 - use KP modifier)
Medication administration and observation additional visits (H0020)
Medication management (99201-99205 new, 99211 - 99215 existing)
Addiction medication induction/withdrawal management (H0014)
Complex care coordination
Peer advocate services (H0038)
Intensive outpatient services (S9480)
Outpatient rehabilitation, half day (H2001)
Outpatient rehabilitation, full day (H2036)
Smoking cessation (99406)
You can read more about non-ambulatory CPT codes here.
Does New York Medicaid cover peer support or peer advocate services?
Yes. Peer advocate services are covered under CPT code H0038. All services must be provided within the context of an OASAS certified program or provider. Teleconferencing, telephone sessions and asynchronous video sessions are not allowed. All peer advocate services billed under H0038 must be delivered in person in order to qualify for Medicaid reimbursement in New York.
Does New York Medicaid cover sober living homes?
No. ASAM encourages and supports sober living, as made clear in the most recent update to the ASAM criteria, but it still does not include sober living within the formal continuum of care. This informal endorsement of sober living as a concept in the recovery community does not translate into widespread state policies mandating reimbursement for sober living. Instead, the update codified standards for sober living, most likely as a way to promote regulation of the industry and foster protections for residents.
That said, Medicaid in New York will cover room and board as it relates to residential treatment services, as that expense is considered “medically necessary.”
How are New York Medicaid fee schedules organized?
In New York, Medicaid fees differ between two different areas: upstate and downstate.
For the purposes of Medicaid fees, downstate New York includes: New York County, Kings county, Queens county, Richmond county, Bronx county, Nassau, Suffolk, Westchester, Rocland Putnam, Dutchess, and Orange counties.
“Upstate” simply refers to the rest of the state.
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