SECTION 904 (2)(c) Part 3 TOTAL CMHSP COSTS BY SERVICE

CATEGORY AND CMHSP FY 2017

Children with Serious Emotional Disturbance (SED)

Overview The data that are presented in this section were provided by CMHSPs as required by the FY 2017 MDHHS/CMHSP contract. Cost data were collected for the reporting period October 1, 2016 to September 30, 2017 and submitted to MDHHS by March 2, 2018. The data in this section represent the total costs associated with providing mental health services to children with a serious emotional disturbance (child MI) by service category for each of the 46 CMHSPs within the State of Michigan. Definitions for terms found in this section are presented in Section 904 (3).

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Allegan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 23 202 $178,684 $7,769 $885 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 5 38 $8,016 $1,603 $211 8Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

13 63 $49,392 $3,799 $784 5Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 9 43 $15,838 $1,760 $368 5Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Allegan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 8 12 $6,981 $873 $582 2Encounter0359T U5

ABA Behavioral Follow-up Assessment 2 2 $151 $75 $75 1First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 1 6 $526 $526 $88 6Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 10 775 $25,400 $2,540 $33 78First 30 Minutes0364T U5

ABA Adaptive Treatment 10 4,339 $141,879 $14,188 $33 434Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

8 212 $13,723 $1,715 $65 27First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

8 405 $26,169 $3,271 $65 51Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 8 86 $11,935 $1,492 $139 11Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 1 16 $1,675 $1,675 $105 16First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 1 32 $1,675 $1,675 $52 32Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 141 143 $47,187 $335 $330 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 42 42 $37,267 $887 $887 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 33 67 $7,781 $236 $116 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Allegan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 42 123 $21,098 $502 $172 345 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 53 310 $76,491 $1,443 $247 660 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 1 1 $182 $182 $182 1First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 26 80 $15,596 $600 $195 3Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 48 200 $75,506 $1,573 $378 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 4 32 $5,097 $1,274 $159 8Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 1 5 $756 $756 $151 5Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 1 1 $154 $154 $154 1Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 4 5 $420 $105 $84 1Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Allegan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 1 1 $71 $71 $71 1Encounter97165

Occupational Therapy 2 2 $155 $77 $77 1Encounter97166

Occupational Therapy 2 2 $222 $111 $111 1Encounter97167

Occupational Therapy 2 2 $136 $68 $68 1Encounter97168

Occupational or Physical Therapy 7 642 $11,599 $1,657 $18 9215 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 2 11 $312 $156 $28 615 Minutes97533

Occupational or Physical Therapy 1 3 $142 $142 $47 315 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Allegan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 1 1 $101 $101 $101 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 81 238 $43,843 $541 $184 3Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 7 11 $3,277 $468 $298 2Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 7 8 $2,789 $398 $349 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 9 10 $875 $97 $87 130 Minutes99221

Additional Codes-Physician Services 3 3 $302 $101 $101 150 Minutes99222

Additional Codes-Physician Services 3 3 $302 $101 $101 170 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 10 24 $2,292 $229 $96 215 Minutes99231

Additional Codes-Physician Services 10 14 $1,254 $125 $90 125 minutes99232

Additional Codes-Physician Services 6 9 $907 $151 $101 235 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Allegan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Allegan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 1 1 $137 $137 $137 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 17 80 $50,856 $2,992 $636 5DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 26 26 $7,503 $289 $289 1EncounterH0031

Assessment for Autism 20 41 $20,457 $1,023 $499 2EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 51 86 $21,141 $415 $246 2EncounterH0032

Monitoring of Treatment - Clinician 25 31 $7,449 $298 $240 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 108 8,129 $537,346 $4,975 $66 7515 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Allegan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 1 3 $756 $756 $252 3DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 1 2 $134 $134 $67 2EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 18 33 $2,562 $142 $78 215 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 5 924 $4,411 $882 $5 18515 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 23 871 $87,742 $3,815 $101 3815 MinutesH2021

Wraparound (SED Waiver) 1 1 $341 $341 $341 1DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 11 187 $32,942 $2,995 $176 17EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Allegan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 10 66 $10,388 $1,039 $157 7EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 9 5,781 $18,770 $2,086 $3 64215 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 2 297 $965 $482 $3 14915 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 26 214 $22,284 $857 $104 815 minutesT1016

Targeted Case Management 22 352 $36,118 $1,642 $103 1615 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 62 79 $14,756 $238 $187 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Allegan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 7 58 $4,407 $630 $76 8MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 53 494 $52,570 $992 $106 9Per session. One night =

one session

T2036

Respite Care 1 2 $420 $420 $210 2Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 316 $1,772,613

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

AuSable Valley

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 7 57 $51,524 $7,361 $904 8Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 2 25 $19,893 $9,947 $796 13Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

AuSable Valley

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 7 14 $5,567 $795 $398 2Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 8 307 $13,921 $1,740 $45 38First 30 Minutes0364T U5

ABA Adaptive Treatment 4 742 $23,243 $5,811 $31 186Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

3 77 $5,342 $1,781 $69 26First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

3 773 $29,204 $9,735 $38 258Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 6 79 $11,746 $1,958 $149 13Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 61 61 $29,304 $480 $480 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 3 3 $2,180 $727 $727 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 86 153 $17,018 $198 $111 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

AuSable Valley

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 139 420 $75,296 $542 $179 345 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 280 1,453 $423,950 $1,514 $292 560 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 17 358 $96,686 $5,687 $270 21Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 165 613 $119,158 $722 $194 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 17 172 $13,513 $795 $79 10Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 7 16 $849 $121 $53 2Per Hour96101

Assessment for Autism 25 31 $13,163 $527 $425 1Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

AuSable Valley

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

AuSable Valley

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 1 $90 $0 $90 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 4 26 $3,852 $963 $148 7Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 8 57 $8,871 $1,109 $156 7Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 0 2 $366 $0 $183 0Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 192 1,190 $199,665 $1,040 $168 6Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 45 87 $16,190 $360 $186 2Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

AuSable Valley

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

AuSable Valley

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 0 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 478 501 $155,667 $326 $311 1EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 59 749 $90,229 $1,529 $120 13EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 25 2,623 $99,515 $3,981 $38 10515 MinutesH0036

Home Based Services 8 93 $5,415 $677 $58 1215 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

AuSable Valley

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 72 275 $27,197 $378 $99 415 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 139 6,673 $41,107 $296 $6 4815 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 1 1,550 $12,600 $12,600 $8 1,55015 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 1,026 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 28 2,454 $78,488 $2,803 $32 8815 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 1 6 $124 $124 $21 615 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 99 937 $202,659 $2,047 $216 9EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

AuSable Valley

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 18 22 $2,368 $132 $108 1EncounterT1001

Health Services 12 190 $5,330 $444 $28 16Up to 15 minT1002

Respite Care 1 4,853 $17,714 $17,714 $4 4,85315 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 2 54 $5,622 $2,811 $104 2715 minutesT1016

Targeted Case Management 234 6,443 $655,770 $2,802 $102 2815 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 63 138 $22,567 $358 $164 2EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

AuSable Valley

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 12 12 $1,638 $137 $137 1MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 2,262 $2,604,601

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Barry

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 10 87 $76,196 $7,620 $876 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

6 90 $89,503 $14,917 $994 15Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

1 13 $11,237 $11,237 $864 13Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Barry

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 10 15 $4,142 $414 $276 2Encounter0359T U5

ABA Behavioral Follow-up Assessment 1 1 $98 $98 $98 1First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 1 1 $98 $98 $98 1Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 13 1,036 $186,482 $14,345 $180 80First 30 Minutes0364T U5

ABA Adaptive Treatment 13 3,032 $373,572 $28,736 $123 233Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 1 189 $4,915 $4,915 $26 189First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 1 183 $4,733 $4,733 $26 183Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

13 220 $65,470 $5,036 $298 17First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

12 241 $60,813 $5,068 $252 20Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 1 6 $789 $789 $131 6Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 3 3 $2,220 $740 $740 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 39 56 $6,314 $162 $113 130 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Barry

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 131 483 $107,097 $818 $222 445 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 62 189 $61,510 $992 $325 360 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 28 43 $12,073 $431 $281 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 163 505 $121,316 $744 $240 3Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 39 316 $28,837 $739 $91 8Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 1 27 $2,508 $2,508 $93 27Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 1 1 $102 $102 $102 1Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 13 13 $2,981 $229 $229 1Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 2 4 $917 $459 $229 2Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Barry

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 1 1 $143 $143 $143 1Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 6 204 $7,309 $1,218 $36 3415 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 3 5 $537 $179 $107 2Encounter97166

Occupational Therapy 1 1 $143 $143 $143 1Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Barry

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 1 1 $53 $53 $53 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 6 7 $855 $143 $122 1Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 4 7 $1,290 $323 $184 2Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 1 1 $101 $101 $101 130 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 1 1 $101 $101 $101 170 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 1 6 $538 $538 $90 615 Minutes99231

Additional Codes-Physician Services 1 1 $101 $101 $101 125 minutes99232

Additional Codes-Physician Services 1 1 $101 $101 $101 135 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Barry

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Barry

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 18 18 $4,357 $242 $242 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 13 67 $44,036 $3,387 $657 5DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 232 243 $74,901 $323 $308 1EncounterH0031

Assessment for Autism 22 28 $7,868 $358 $281 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 194 209 $50,864 $262 $243 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 25 1,813 $203,727 $8,149 $112 7315 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Barry

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 1 4 $1,010 $1,010 $252 4DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 32 163 $13,943 $436 $86 515 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 7 2,616 $42,294 $6,042 $16 37415 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 4 374 $82,700 $20,675 $221 9415 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 0 0 $0 $0 $0 0EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Barry

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 5 34 $4,350 $870 $128 7EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 4 4 $352 $88 $88 1EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 4 6 $1,376 $344 $229 2HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 1 1 $116 $116 $116 1EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 13 12,119 $39,508 $3,039 $3 93215 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 9 47 $9,719 $1,080 $207 515 minutesT1016

Targeted Case Management 15 267 $55,213 $3,681 $207 1815 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 32 53 $26,862 $839 $507 2EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Barry

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 2 19 $4,924 $2,462 $259 10MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 331 $1,903,318

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Bay-Arenac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 17 179 $131,631 $7,743 $735 11Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

85 734 $582,835 $6,857 $794 9Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

7 45 $7,703 $1,100 $171 6Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Bay-Arenac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 10 11 $5,195 $520 $472 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 10 884 $24,402 $2,440 $28 88First 30 Minutes0364T U5

ABA Adaptive Treatment 10 4,377 $120,823 $12,082 $28 438Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

10 177 $10,660 $1,066 $60 18First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

10 319 $19,212 $1,921 $60 32Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 7 27 $3,196 $457 $118 4Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 209 209 $77,126 $369 $369 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 8 8 $3,713 $464 $464 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 140 197 $10,827 $77 $55 130 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Bay-Arenac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 673 5,925 $461,901 $686 $78 945 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 345 1,141 $246,326 $714 $216 360 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 5 7 $833 $167 $119 1First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 2 4 $140 $70 $35 2Each Additional 30

Minutes

90840

Therapy-Family Therapy 123 231 $20,939 $170 $91 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 377 1,368 $106,233 $282 $78 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 7 59 $10,166 $1,452 $172 8Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 153 473 $34,015 $222 $72 3Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 1 4 $417 $417 $104 4Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 1 1 $167 $167 $167 1Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 4 15 $3,075 $769 $205 4Per Hour96101

Assessment for Autism 7 17 $5,154 $736 $303 2Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Bay-Arenac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 5 26 $929 $186 $36 5Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 2 9 $237 $118 $26 515 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 1 1 $167 $167 $167 1Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 2 39 $1,026 $513 $26 2015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Bay-Arenac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 1 1 $101 $101 $101 1Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 1 1 $223 $223 $223 1Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 156 174 $7,200 $46 $41 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 3 3 $260 $87 $87 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 231 325 $46,922 $203 $144 1Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 505 1,410 $310,481 $615 $220 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 18 21 $6,079 $338 $289 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 3 3 $199 $66 $66 150 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Bay-Arenac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Bay-Arenac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 44 44 $3,991 $91 $91 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 1 7 $2,826 $2,826 $404 7DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 628 667 $132,330 $211 $198 1EncounterH0031

Assessment for Autism 50 51 $24,605 $492 $482 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 614 643 $117,426 $191 $183 1EncounterH0032

Monitoring of Treatment - Clinician 1 8 $998 $998 $125 8EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 162 13,704 $999,953 $6,173 $73 8515 MinutesH0036

Home Based Services 2 35 $2,533 $1,266 $72 1815 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Bay-Arenac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 29 101 $4,889 $169 $48 315 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 16 8,152 $44,597 $2,787 $5 51015 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 16 943 $143,556 $8,972 $152 5915 MinutesH2021

Wraparound (SED Waiver) 3 4 $828 $276 $207 1DaysH2022

Wraparound (SED Waiver) 2 43 $12,691 $6,346 $295 22DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 25 137 $7,804 $312 $57 5EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Bay-Arenac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 1 5 $866 $866 $173 5EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 1 1 $346 $346 $346 1EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 16 719 $78,750 $4,922 $110 4515 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 181 181 $35,971 $199 $199 1EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 5 1,272 $1,906 $381 $1 25415 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 28 467 $37,321 $1,333 $80 1715 minutesT1016

Targeted Case Management 264 8,374 $454,539 $1,722 $54 3215 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 154 207 $108,213 $703 $523 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Bay-Arenac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 3 6 $63 $21 $11 2MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 1 17 $125 $125 $7 17Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 1,119 $4,477,639

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Berrien

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 2 24 $20,749 $10,374 $865 12Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

7 72 $59,971 $8,567 $833 10Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

9 51 $39,276 $4,364 $770 6Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Berrien

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 1 3 $1,431 $1,431 $477 3Encounter0359T U5

ABA Behavioral Follow-up Assessment 3 11 $929 $310 $84 4First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 3 50 $4,223 $1,408 $84 17Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 5 398 $14,831 $2,966 $37 80First 30 Minutes0364T U5

ABA Adaptive Treatment 5 2,230 $83,099 $16,620 $37 446Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

5 119 $10,643 $2,129 $89 24First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

4 136 $12,163 $3,041 $89 34Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 8 93 $16,173 $2,022 $174 12Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 2 7 $422 $211 $60 4Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 73 75 $35,522 $487 $474 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 62 96 $16,381 $264 $171 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Berrien

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 147 475 $102,648 $698 $216 345 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 155 562 $147,955 $955 $263 460 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 17 35 $11,425 $672 $326 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 22 54 $17,396 $791 $322 2Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 26 226 $46,063 $1,772 $204 9Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 2 53 $8,690 $4,345 $164 27Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 3 4 $1,093 $364 $273 1Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Berrien

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 15 88 $9,532 $635 $108 6Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Berrien

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 4 4 $368 $92 $92 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 209 443 $91,369 $437 $206 2Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 172 304 $85,498 $497 $281 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 8 8 $3,059 $382 $382 1Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 1 3 $159 $159 $53 3Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 8 8 $682 $85 $85 130 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 2 2 $199 $99 $99 170 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 3 8 $445 $148 $56 315 Minutes99231

Additional Codes-Physician Services 11 26 $2,546 $231 $98 225 minutes99232

Additional Codes-Physician Services 9 22 $2,182 $242 $99 235 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Berrien

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Berrien

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 14 25 $5,270 $376 $211 2EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 4 16 $9,937 $2,484 $621 4DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 321 370 $125,337 $390 $339 1EncounterH0031

Assessment for Autism 9 9 $5,142 $571 $571 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 2 3 $420 $210 $140 2EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 210 11,556 $1,338,010 $6,371 $116 5515 MinutesH0036

Home Based Services 2 20 $2,344 $1,172 $117 1015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Berrien

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 1 8 $1,908 $1,908 $238 8DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 12 29 $1,635 $136 $56 215 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 18 13,030 $63,200 $3,511 $5 72415 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 12 382 $42,347 $3,529 $111 3215 MinutesH2021

Wraparound (SED Waiver) 3 37 $18,793 $6,264 $508 12DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 34 3,405 $353,666 $10,402 $104 10015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 4 63 $13,907 $3,477 $221 16EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Berrien

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 1 4 $735 $735 $184 4EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 4 3,211 $13,357 $3,339 $4 80315 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 1 809 $2,629 $2,629 $3 80915 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 25 418 $88,693 $3,548 $212 1715 minutesT1016

Targeted Case Management 47 2,337 $280,063 $5,959 $120 5015 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 83 124 $62,741 $756 $506 1EncounterT1023

Prevention Services - Direct Model 1 16 $2,385 $2,385 $149 1615 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Berrien

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 1 6 $999 $999 $166 6MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 713 $3,280,644

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Clinton Eaton Ingham

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 44 418 $359,287 $8,166 $860 10Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 2 23 $12,213 $6,107 $531 12Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

18 128 $132,193 $7,344 $1,033 7Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

4 32 $14,327 $3,582 $448 8Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

1 3 $2,466 $2,466 $822 3Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $292,776 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $23,656 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Clinton Eaton Ingham

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 0 0 $0 $0 $0 0Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0First 30 Minutes0364T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 41 85 $15,943 $389 $188 2Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 1 1 $351 $351 $351 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 201 203 $154,915 $771 $763 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 139 185 $31,517 $227 $170 130 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Clinton Eaton Ingham

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 151 301 $87,973 $583 $292 245 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 445 3,148 $870,689 $1,957 $277 760 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 111 259 $121,581 $1,095 $469 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 593 2,020 $559,842 $944 $277 3Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 38 251 $74,099 $1,950 $295 7Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Clinton Eaton Ingham

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Clinton Eaton Ingham

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 5 5 $763 $153 $153 1Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 2 2 $557 $279 $279 1Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 322 1,319 $659,190 $2,047 $500 4Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 2 2 $727 $364 $364 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 2 2 $305 $153 $153 130 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 1 2 $225 $225 $113 215 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 1 1 $201 $201 $201 135 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Clinton Eaton Ingham

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Clinton Eaton Ingham

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 149 183 $20,385 $137 $111 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 46 273 $11,943 $260 $44 615 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 1,103 1,128 $670,395 $608 $594 1EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 41 42 $9,842 $240 $234 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 1,053 69,320 $5,900,084 $5,603 $85 6615 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Clinton Eaton Ingham

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 162 1,310 $541,746 $3,344 $414 8DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 3 3 $628 $209 $209 115 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 196 19,362 $435,205 $2,220 $22 9915 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 84 1,616 $381,767 $4,545 $236 1915 MinutesH2021

Wraparound (SED Waiver) 3 4 $4,711 $1,570 $1,178 1DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 46 173 $36,857 $801 $213 4EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Clinton Eaton Ingham

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 2 2 $212 $106 $106 1Up to 15 minT1002

Respite Care 4 90 $685 $171 $8 2315 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 5 722 $3,484 $697 $5 14415 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 0 0 $0 $0 $0 015 minutesT1016

Targeted Case Management 18 712 $90,593 $5,033 $127 4015 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 353 524 $402,159 $1,139 $767 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Clinton Eaton Ingham

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 2,211 $11,926,492

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

CMH for Central Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 7 95 $46,271 $6,610 $487 14Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 1 7 $3,409 $3,409 $487 7Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

6 71 $61,770 $10,295 $870 12Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

2 20 $17,400 $8,700 $870 10Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

16 171 $108,483 $6,780 $634 11Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

4 25 $15,860 $3,965 $634 6Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

CMH for Central Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 12 12 $6,266 $522 $522 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 3 4 $996 $332 $249 1First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 2 3 $797 $398 $266 2Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 8 37,908 $7,894 $987 $0 4,739First 30 Minutes0364T U5

ABA Adaptive Treatment 8 2,122 $42,112 $5,264 $20 265Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

8 77 $12,106 $1,513 $157 10First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

8 172 $26,873 $3,359 $156 22Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 5 9 $2,693 $539 $299 2Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 135 135 $2,211 $16 $16 1Encounter90785 HF

Assessment 142 142 $103,843 $731 $731 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 118 118 $94,184 $798 $798 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 45 54 $4,685 $104 $87 130 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

CMH for Central Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 93 259 $33,780 $363 $130 345 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 177 727 $128,895 $728 $177 460 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 275 720 $137,205 $499 $191 3Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 945 6,222 $1,083,334 $1,146 $174 7Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 15 74 $5,030 $335 $68 5Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 3 86 $9,267 $3,089 $108 29Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 1 1 $176 $176 $176 1Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 1 32 $5,693 $5,693 $178 32Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 11 12 $2,454 $223 $204 1Per Hour96101

Assessment for Autism 59 61 $71,191 $1,207 $1,167 1Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

CMH for Central Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 1 19 $3,227 $3,227 $170 19Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 3 155 $6,846 $2,282 $44 5215 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 1 1 $178 $178 $178 1Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 8 8 $3,733 $467 $467 1Encounter97165

Occupational Therapy 1 1 $566 $566 $566 1Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 4 481 $12,644 $3,161 $26 12015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 7 93 $10,823 $1,546 $116 1315 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

CMH for Central Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 1 1 $451 $451 $451 1Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 1 1 $163 $163 $163 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 9 9 $1,276 $142 $142 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 327 905 $183,035 $560 $202 3Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 237 592 $164,676 $695 $278 2Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 1 1 $91 $91 $91 130 Minutes99221

Additional Codes-Physician Services 17 19 $2,329 $137 $123 150 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 9 39 $1,399 $155 $36 415 Minutes99231

Additional Codes-Physician Services 15 99 $4,871 $325 $49 725 minutes99232

Additional Codes-Physician Services 4 7 $748 $187 $107 235 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

CMH for Central Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

CMH for Central Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 0 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 993 1,053 $297,086 $299 $282 1EncounterH0031

Assessment for Autism 1 1 $1,004 $1,004 $1,004 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 839 1,256 $185,354 $221 $148 1EncounterH0032

Monitoring of Treatment - Clinician 8 9 $1,557 $195 $173 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 359 26,579 $2,140,252 $5,962 $81 7415 MinutesH0036

Home Based Services 21 930 $74,887 $3,566 $81 4415 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

CMH for Central Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 1 1 $88 $88 $88 115 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 26 216 $8,906 $343 $41 8DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 55 73 $8,649 $157 $118 1EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 55 56 $6,635 $121 $118 1EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 361 1,633 $197,552 $547 $121 515 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 51 3,433 $8,089 $159 $2 6715 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 6 7,453 $26,685 $4,447 $4 1,24215 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 47 1,990 $56,113 $1,194 $28 4215 MinutesH2019

Behavior Services 37 1,966 $55,436 $1,498 $28 5315 MinutesH2019 TT

Wraparound 48 2,146 $286,660 $5,972 $134 4515 MinutesH2021

Wraparound (SED Waiver) 15 138 $37,310 $2,487 $270 9DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 34 5,070 $519,392 $15,276 $102 14915 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 235 805 $20,233 $86 $25 3Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 2 2,525 $1,421 $711 $1 1,263Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 49 257 $29,793 $608 $116 5EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

CMH for Central Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 71 745 $178,496 $2,514 $240 10EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 2 2 $464 $232 $232 1EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 30 19,712 $58,009 $1,934 $3 65715 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 51 838 $68,403 $1,341 $82 1615 minutesT1016

Targeted Case Management 102 1,794 $149,156 $1,462 $83 1815 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 6 22 $1,079 $180 $49 4DaysT1020

Assessments 232 316 $286,096 $1,233 $905 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

CMH for Central Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 29 231 $18,619 $642 $81 8MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 24 140 $18,660 $777 $133 6Per session. One night =

one session

T2036

Respite Care 22 431 $8,039 $365 $19 20Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 1,843 $7,182,059

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Copper Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 4 39 $37,569 $9,392 $963 10Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

4 44 $35,640 $8,910 $810 11Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Copper Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 2 2 $288 $144 $144 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0First 30 Minutes0364T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 3 3 $3,410 $1,137 $1,137 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 35 140 $15,553 $444 $111 430 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Copper Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 38 90 $16,832 $443 $187 245 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 52 167 $46,718 $898 $280 360 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 18 45 $6,476 $360 $144 3Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 3 5 $829 $276 $166 2Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 0 $0 $0 $0 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 1 1 $226 $226 $226 1Per Hour96101

Assessment for Autism 1 6 $1,355 $1,355 $226 6Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Copper Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Copper Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 1 3 $530 $530 $177 3Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 27 160 $47,416 $1,756 $296 6Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 11 14 $5,401 $491 $386 1Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 1 1 $350 $350 $350 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 1 1 $139 $139 $139 150 Minutes99222

Additional Codes-Physician Services 1 2 $293 $293 $146 270 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 1 2 $423 $423 $212 235 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Copper Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Copper Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 3 3 $877 $292 $292 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 35 37 $8,876 $254 $240 1EncounterH0031

Assessment for Autism 1 1 $240 $240 $240 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 79 155 $36,228 $459 $234 2EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 11 1,216 $134,611 $12,237 $111 11115 MinutesH0036

Home Based Services 2 128 $14,170 $7,085 $111 6415 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Copper Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 2 64 $6,718 $3,359 $105 32DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 41 316 $44,493 $1,085 $141 815 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 1 293 $5,860 $5,860 $20 29315 MinutesH2015

Community Living Supports (Daily) 1 19 $2,625 $2,625 $138 19Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 1 38 $1,764 $1,764 $46 3815 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 1 1 $25 $25 $25 1Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 0 0 $0 $0 $0 0EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Copper Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 1 14 $4,366 $4,366 $312 14EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 2 151 $581 $291 $4 7615 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 8 32 $4,066 $508 $127 415 minutesT1016

Targeted Case Management 0 0 $0 $0 $0 015 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 13 21 $36,932 $2,841 $1,759 2EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Copper Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 3 20 $1,702 $567 $85 7MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 134 $523,581

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Detroit-Wayne

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 332 2,635 $1,660,050 $5,000 $630 8Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 510 4,699 $2,959,139 $5,802 $630 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 4 74 $62,500 $15,625 $845 19Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

2 6 $4,300 $2,150 $717 3Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

3 35 $31,500 $10,500 $900 12Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 651 6,932 $1,934,480 $2,972 $279 11Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Detroit-Wayne

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 68 88 $49,756 $732 $565 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 48 4,259 $142,733 $2,974 $34 89First 30 Minutes0364T U5

ABA Adaptive Treatment 48 26,354 $838,691 $17,473 $32 549Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

46 930 $67,841 $1,475 $73 20First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

45 2,023 $138,881 $3,086 $69 45Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 37 244 $32,946 $890 $135 7Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 707 1,292 $312,615 $442 $242 2Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 2,924 3,015 $870,372 $298 $289 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 4,036 12,516 $1,136,496 $282 $91 330 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Detroit-Wayne

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 4,347 19,697 $2,895,496 $666 $147 545 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 4,326 19,543 $4,226,216 $977 $216 560 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 45 50 $6,000 $133 $120 1First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 12 15 $1,300 $108 $87 1Each Additional 30

Minutes

90840

Therapy-Family Therapy 1,479 3,187 $394,490 $267 $124 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 5,614 23,257 $3,172,252 $565 $136 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 18 56 $2,667 $148 $48 3Encounter90849

Therapy-Family Therapy 55 273 $12,030 $219 $44 5Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 811 3,782 $245,789 $303 $65 5Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 1 35 $31,373 $31,373 $896 35Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 206 261 $18,707 $91 $72 1Encounter90887

Speech & Language Therapy 3 86 $5,590 $1,863 $65 29Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 3 9 $1,035 $345 $115 3Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 788 2,018 $965,473 $1,225 $478 3Per Hour96101

Assessment for Autism 39 158 $39,014 $1,000 $247 4Hour96101 U5

Psychological Testing by Technician 13 35 $2,189 $168 $63 3Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Detroit-Wayne

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 1,186 1,567 $1,000,571 $844 $639 1Encounter96110

Assessments-Other 1 1 $140 $140 $140 1Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 8 33 $911 $114 $28 4Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 2 2 $215 $108 $108 1Encounter97004

Occupational or Physical Therapy 5 391 $7,078 $1,416 $18 7815 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Detroit-Wayne

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 1 1 $142 $142 $142 1Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 1 1 $125 $125 $125 1Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 7 7 $991 $142 $142 1Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 36 37 $6,970 $194 $188 1Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 102 117 $7,163 $70 $61 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 990 2,120 $182,512 $184 $86 2Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 4,019 13,865 $2,031,454 $505 $147 3Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 1,488 3,457 $686,443 $461 $199 2Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 83 94 $28,924 $348 $308 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Detroit-Wayne

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Detroit-Wayne

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 3,862 10,867 $777,729 $201 $72 3EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 186 1,625 $638,556 $3,433 $393 9DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 10,389 24,324 $5,030,477 $484 $207 2EncounterH0031

Assessment for Autism 157 162 $98,565 $628 $608 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 9,120 23,255 $4,086,637 $448 $176 3EncounterH0032

Monitoring of Treatment - Clinician 517 880 $147,107 $285 $167 2EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 1 1 $240 $240 $240 115 MinutesH0034

Home Based Services 2,434 289,095 $19,502,486 $8,013 $67 11915 MinutesH0036

Home Based Services 47 891 $55,865 $1,189 $63 1915 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Detroit-Wayne

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 41 244 $1,625 $40 $7 615 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 2 2 $110 $55 $55 115 MinutesH0039

Community Living Supports in Independent living/own home 6 101 $9,595 $1,599 $95 17Per diemH0043

Respite 53 547 $82,951 $1,565 $152 10DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 3 3 $280 $93 $93 1EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 1,449 9,729 $234,164 $162 $24 715 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 49 980 $10,367 $212 $11 2015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 299 253,158 $1,399,978 $4,682 $6 84715 MinutesH2015

Community Living Supports (Daily) 1 1 $70 $70 $70 1Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 535 65,946 $6,147,708 $11,491 $93 12315 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 1 12 $600 $600 $50 1215 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 72 4,723 $357,257 $4,962 $76 6615 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 40 68 $11,446 $286 $168 2EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Detroit-Wayne

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 268 2,338 $403,501 $1,506 $173 9EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 3 603 $185,860 $61,953 $308 201DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 322 1,291 $100,698 $313 $78 4EncounterS9445

Health Services 5 17 $910 $182 $54 3EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 101 178 $125,846 $1,246 $707 2HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 356 361 $43,039 $121 $119 1EncounterT1001

Health Services 616 1,633 $78,221 $127 $48 3Up to 15 minT1002

Respite Care 135 73,498 $344,373 $2,551 $5 54415 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 168 2,405 $145,491 $866 $60 1415 minutesT1016

Targeted Case Management 5,088 70,472 $5,006,807 $984 $71 1415 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 1 1 $68 $68 $68 1DaysT1020

Assessments 261 317 $19,451 $75 $61 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 1 1 $125 $125 $125 1ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Detroit-Wayne

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 1 1 $116 $116 $116 1Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 8 88 $5,732 $717 $65 11MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 13,859 $71,269,611

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Genesee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 18 1,676 $1,167,013 $64,834 $696 93Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 42 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

18 905 $711,944 $39,552 $787 50Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

14 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 1,434 $441,706 $0 $308 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Genesee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 13 30 $4,747 $365 $158 2Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 21 2,358 $113,250 $5,393 $48 112First 30 Minutes0364T U5

ABA Adaptive Treatment 21 11,671 $520,887 $24,804 $45 556Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 1,916 $84,271 $0 $44 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 1,219 $65,043 $0 $53 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

20 1,144 $59,620 $2,981 $52 57First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

19 985 $51,258 $2,698 $52 52Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 16 70 $7,074 $442 $101 4Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 1,168 $112,722 $0 $97 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 31 47 $32,513 $1,049 $692 2Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 153 392 $142,399 $931 $363 3Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 95 463 $79,055 $832 $171 530 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Genesee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 254 720 $163,012 $642 $226 345 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 151 2,173 $472,673 $3,130 $218 1460 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 0 290 $95,787 $0 $330 0Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 4 340 $125,365 $31,341 $369 85Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 47 $5,088 $0 $108 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 182 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 8 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 7 4 $231 $33 $58 1Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 10 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 5 305 $36,352 $7,270 $119 61Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Genesee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 22 $616 $0 $28 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 4 1 $308 $77 $308 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 1 $36 $0 $36 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 2 1 $36 $18 $36 1Encounter97166

Occupational Therapy 1 1 $54 $54 $54 1Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 10 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Genesee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 1 $62 $0 $62 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 5 $448 $0 $90 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 3 $403 $0 $134 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 51 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 73 167 $7,535 $103 $45 2Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 225 1,593 $153,234 $681 $96 7Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 201 1,941 $303,508 $1,510 $156 10Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 1 116 $40,147 $40,147 $346 116Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 2 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 2 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 1 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 5 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 3 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 5 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Genesee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Genesee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 1 88 $307 $307 $3 88Per MileA0425

Additional Codes-Transportation 1 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 603 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 1 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 7 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 440 884 $498,154 $1,132 $564 2EncounterH0031

Assessment for Autism 38 4 $1,029 $27 $257 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 307 264 $84,867 $276 $321 1EncounterH0032

Monitoring of Treatment - Clinician 3 11 $4,181 $1,394 $380 4EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 460 37,043 $2,257,725 $4,908 $61 8115 MinutesH0036

Home Based Services 21 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Genesee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 1 77 $17,062 $17,062 $222 7715 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 220 $19,042 $0 $87 0Per diemH0043

Respite 6 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 48 557 $126,721 $2,640 $228 1215 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 6 28,941 $125,156 $20,859 $4 4,82415 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 1,199 $40,100 $0 $33 015 MinutesH2019

Behavior Services 0 1,602 $36,911 $0 $23 015 MinutesH2019 TT

Wraparound 29 3,087 $358,806 $12,373 $116 10615 MinutesH2021

Wraparound (SED Waiver) 13 300 $179,813 $13,832 $599 23DaysH2022

Wraparound (SED Waiver) 2 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 95 2,445 $484,554 $5,101 $198 2615 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 1 109 $46,548 $46,548 $427 109EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Genesee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 19 22 $1,854 $98 $84 1EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 2 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 7 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 4 $177 $0 $44 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 1 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 2 1,676 $281,628 $140,814 $168 838HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 209 0 $0 $0 $0 0EncounterT1001

Health Services 24 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 39 280,807 $1,064,512 $27,295 $4 7,20015 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 276 $1,054 $0 $4 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 6,995 $20,978 $0 $3 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 6 6,494 $401,025 $66,838 $62 1,08215 minutesT1016

Targeted Case Management 109 38,131 $2,028,262 $18,608 $53 35015 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 254 2 $1,398 $6 $699 0EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Genesee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 12 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 3 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 20 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 1,397 $13,080,265

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gogebic

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 1 20 $24,546 $24,546 $1,227 20Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 1 10 $16,364 $16,364 $1,636 10Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

4 24 $31,419 $7,855 $1,309 6Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gogebic

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 0 0 $0 $0 $0 0Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0First 30 Minutes0364T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 14 15 $10,666 $762 $711 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 7 14 $1,633 $233 $117 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gogebic

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 8 28 $4,920 $615 $176 445 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 12 84 $23,683 $1,974 $282 760 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 1 1 $163 $163 $163 1Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 0 $0 $0 $0 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gogebic

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 1 1 $231 $231 $231 1Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gogebic

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 1 16 $1,050 $1,050 $66 1615 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 1 1 $316 $316 $316 1Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 19 74 $25,144 $1,323 $340 4Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 8 17 $8,199 $1,025 $482 2Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 1 1 $80 $80 $80 130 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 1 5 $171 $171 $34 525 minutes99232

Additional Codes-Physician Services 1 5 $268 $268 $54 535 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gogebic

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gogebic

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 0 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 18 20 $7,362 $409 $368 1EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 31 41 $6,128 $198 $149 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 40 3,073 $230,813 $5,770 $75 7715 MinutesH0036

Home Based Services 5 70 $5,258 $1,052 $75 1415 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gogebic

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 27 214 $9,427 $349 $44 815 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 1 24 $71 $71 $3 2415 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 0 0 $0 $0 $0 015 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 7 125 $9,391 $1,342 $75 1815 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 23 85 $1,125 $49 $13 4Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 1 1 $300 $300 $300 1EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gogebic

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 13 137 $41,167 $3,167 $300 11EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 2 332 $1,288 $644 $4 16615 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 2 46 $3,076 $1,538 $67 2315 minutesT1016

Targeted Case Management 7 167 $11,319 $1,617 $68 2415 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 7 15 $4,330 $619 $289 2EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gogebic

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 3 18 $377 $126 $21 6MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 79 $480,286

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gratiot

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gratiot

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 18 30 $10,692 $594 $356 2Encounter0359T U5

ABA Behavioral Follow-up Assessment 2 3 $215 $108 $72 2First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 2 6 $444 $222 $74 3Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 19 1,751 $52,206 $2,748 $30 92First 30 Minutes0364T U5

ABA Adaptive Treatment 19 7,851 $238,770 $12,567 $30 413Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

20 388 $25,019 $1,251 $64 19First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

20 583 $36,531 $1,827 $63 29Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 11 43 $5,532 $503 $129 4Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 1 88 $8,936 $8,936 $102 88First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 6 887 $114,181 $19,030 $129 148Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 30 206 $11,318 $377 $55 7Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 24 24 $6,928 $289 $289 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 27 75 $10,431 $386 $139 330 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gratiot

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 85 626 $88,619 $1,043 $142 745 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 68 288 $61,853 $910 $215 460 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 3 3 $676 $225 $225 1First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 1 1 $99 $99 $99 1Each Additional 30

Minutes

90840

Therapy-Family Therapy 5 9 $1,311 $262 $146 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 30 71 $8,809 $294 $124 2Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 8 52 $3,822 $478 $74 7Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 46 255 $32,494 $706 $127 6Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gratiot

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gratiot

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 18 32 $4,093 $227 $128 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 34 88 $15,125 $445 $172 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 10 10 $2,018 $202 $202 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 2 1 $119 $60 $119 130 Minutes99221

Additional Codes-Physician Services 6 7 $1,094 $182 $156 150 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 4 20 $1,191 $298 $60 515 Minutes99231

Additional Codes-Physician Services 4 39 $3,399 $850 $87 1025 minutes99232

Additional Codes-Physician Services 12 17 $1,741 $145 $102 135 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gratiot

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gratiot

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 35 36 $7,081 $202 $197 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 255 271 $37,402 $147 $138 1EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 187 239 $8,963 $48 $38 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 99 8,796 $380,689 $3,845 $43 8915 MinutesH0036

Home Based Services 1 22 $4,333 $4,333 $197 2215 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gratiot

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 1 200 $15,305 $15,305 $77 200Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 1 10 $2,120 $2,120 $212 10EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 48 192 $12,549 $261 $65 415 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 4 2,230 $9,614 $2,404 $4 55815 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 0 0 $0 $0 $0 015 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 6 285 $8,219 $1,370 $29 4815 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 3 81 $14,326 $4,775 $177 27EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gratiot

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 13 17 $645 $50 $38 1Up to 15 minT1002

Respite Care 0 0 $0 $0 $0 015 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 30 329 $22,669 $756 $69 1115 minutesT1016

Targeted Case Management 58 1,553 $110,280 $1,901 $71 2715 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 41 54 $5,440 $133 $101 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Gratiot

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 9 147 $7,909 $879 $54 16MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 1,326 $1,395,210

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Hiawatha

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 13 106 $83,508 $6,424 $788 8Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

5 29 $22,846 $4,569 $788 6Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Hiawatha

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 1 1 $272 $272 $272 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0First 30 Minutes0364T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 2 2 $1,709 $855 $855 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 65 131 $13,893 $214 $106 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Hiawatha

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 88 497 $90,114 $1,024 $181 645 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 85 403 $94,122 $1,107 $234 560 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 2 5 $1,137 $569 $227 3Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 3 4 $586 $195 $147 1Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 6 12 $6,347 $1,058 $529 2Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Hiawatha

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Hiawatha

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 30 30 $24,995 $833 $833 1Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 2 3 $466 $233 $155 2Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 10 23 $5,133 $513 $223 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 83 296 $97,476 $1,174 $329 4Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 4 4 $2,076 $519 $519 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 1 2 $194 $194 $97 225 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Hiawatha

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Hiawatha

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 0 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 123 135 $37,326 $303 $276 1EncounterH0031

Assessment for Autism 1 1 $340 $340 $340 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 111 246 $30,046 $271 $122 2EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 15 1,206 $111,322 $7,421 $92 8015 MinutesH0036

Home Based Services 1 66 $6,051 $6,051 $92 6615 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Hiawatha

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 78 450 $51,535 $661 $115 615 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 1 5 $21 $21 $4 515 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 21 1,215 $11,853 $564 $10 5815 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 4 399 $37,227 $9,307 $93 10015 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 90 343 $0 $0 $0 4Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 7 39 $2,413 $345 $62 6EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Hiawatha

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 9 395 $36,980 $4,109 $94 4415 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 1 75 $201 $201 $3 7515 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 40 460 $78,699 $1,967 $171 1215 minutesT1016

Targeted Case Management 19 61 $44,285 $2,331 $726 315 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 32 40 $29,355 $917 $734 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Hiawatha

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 255 $922,528

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Huron

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 5 39 $21,900 $4,380 $562 8Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

8 53 $42,984 $5,373 $811 7Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

1 7 $687 $687 $98 7Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Huron

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 6 7 $3,128 $521 $447 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 6 582 $16,368 $2,728 $28 97First 30 Minutes0364T U5

ABA Adaptive Treatment 6 4,810 $135,699 $22,616 $28 802Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 1 2 $16 $16 $8 2First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

5 128 $7,656 $1,531 $60 26First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

5 249 $15,081 $3,016 $61 50Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 6 19 $1,720 $287 $91 3Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 37 37 $52,153 $1,410 $1,410 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 2 2 $934 $467 $467 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 30 54 $7,713 $257 $143 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Huron

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 71 337 $73,206 $1,031 $217 545 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 37 126 $36,159 $977 $287 360 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 2 13 $3,240 $1,620 $249 7Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 2 11 $1,907 $953 $173 6Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 0 $0 $0 $0 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 5 10 $1,625 $325 $163 2Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Huron

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Huron

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 2 8 $1,040 $520 $130 4Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 75 301 $111,248 $1,483 $370 4Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 4 9 $2,736 $684 $304 2Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 2 2 $1,087 $543 $543 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Huron

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Huron

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 0 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 115 120 $34,347 $299 $286 1EncounterH0031

Assessment for Autism 11 13 $4,082 $371 $314 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 80 170 $26,489 $331 $156 2EncounterH0032

Monitoring of Treatment - Clinician 38 42 $5,902 $155 $141 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 3 4 $1,217 $406 $304 115 MinutesH0034

Home Based Services 57 7,930 $387,601 $6,800 $49 13915 MinutesH0036

Home Based Services 2 17 $996 $498 $59 915 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Huron

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 9 67 $5,616 $624 $84 7DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 6 16 $1,164 $194 $73 3EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 3 3 $156 $52 $52 1EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 17 52 $4,440 $261 $85 315 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 12 532 $25,082 $2,090 $47 4415 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 2 3,361 $15,422 $7,711 $5 1,68115 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 16 1,036 $93,072 $5,817 $90 6515 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 1 11 $2,063 $2,063 $188 11EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Huron

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 9 142 $29,676 $3,297 $209 16EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 10 6,345 $19,191 $1,919 $3 63515 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 6 127 $8,676 $1,446 $68 2115 minutesT1016

Targeted Case Management 27 973 $46,411 $1,719 $48 3615 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 35 64 $22,776 $651 $356 2EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Huron

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 11 105 $9,282 $844 $88 10MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 165 $1,281,947

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ionia

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 2 34 $44,789 $22,395 $1,317 17Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ionia

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 0 0 $0 $0 $0 0Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0First 30 Minutes0364T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 14 14 $12,813 $915 $915 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 0 0 $42,101 $0 $0 0Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 15 17 $2,563 $171 $151 130 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ionia

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 43 79 $16,334 $380 $207 245 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 86 213 $128,553 $1,495 $604 260 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 9 20 $12,428 $1,381 $621 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 37 63 $61,076 $1,651 $969 2Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 7 20 $4,424 $632 $221 3Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 1 7 $4,440 $4,440 $634 7Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $925 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $7,556 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ionia

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $296 $0 $0 0Encounter97004

Occupational or Physical Therapy 1 3 $1,811 $1,811 $604 315 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 1 1 $194 $194 $194 1Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 1 1 $148 $148 $148 1Encounter97168

Occupational or Physical Therapy 2 9 $1,116 $558 $124 515 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $66 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $940 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ionia

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $2,631 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 20 21 $11,180 $559 $532 1Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 41 51 $117,394 $2,863 $2,302 1Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 29 34 $24,005 $828 $706 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ionia

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ionia

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $217 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 124 129 $117,431 $947 $910 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 78 102 $102,808 $1,318 $1,008 1EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 65 72 $34,009 $523 $472 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 89 2,645 $673,218 $7,564 $255 3015 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ionia

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 2 11 $206 $103 $19 615 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 9 49 $7,702 $856 $157 515 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 0 0 $8,889 $0 $0 015 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 11 258 $214,076 $19,461 $830 2315 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 18 57 $26,075 $1,449 $457 3EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ionia

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $11,185 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $510 $0 $0 0EncounterT1001

Health Services 15 39 $17,927 $1,195 $460 3Up to 15 minT1002

Respite Care 9 2,930 $45,505 $5,056 $16 32615 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 11 169 $112,844 $10,259 $668 1515 minutesT1016

Targeted Case Management 12 167 $55,905 $4,659 $335 1415 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 10 13 $22,406 $2,241 $1,724 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ionia

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $163 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 414 $1,948,859

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Kalamazoo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 4 37 $19,423 $4,856 $525 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

9 115 $94,757 $10,529 $824 13Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

29 190 $126,358 $4,357 $665 7Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Kalamazoo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 18 35 $12,732 $707 $364 2Encounter0359T U5

ABA Behavioral Follow-up Assessment 2 5 $219 $110 $44 3First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 2 7 $219 $110 $31 4Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 27 4,716 $156,229 $5,786 $33 175First 30 Minutes0364T U5

ABA Adaptive Treatment 27 26,777 $886,989 $32,851 $33 992Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 4 574 $12,165 $3,041 $21 144First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 4 622 $13,182 $3,296 $21 156Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

27 1,361 $108,212 $4,008 $80 50First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

26 2,234 $177,624 $6,832 $80 86Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 19 145 $9,750 $513 $67 8Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 1 1 $42 $42 $42 1Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 277 348 $136,326 $492 $392 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 43 49 $37,477 $872 $765 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 17 38 $4,363 $257 $115 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Kalamazoo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 117 1,104 $146,593 $1,253 $133 945 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 55 164 $26,430 $481 $161 360 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 57 432 $95,865 $1,682 $222 8Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 47 203 $29,217 $622 $144 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 2 8 $2,337 $1,168 $292 4Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 0 $0 $0 $0 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Kalamazoo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 5 5 $556 $111 $111 1Encounter97003

Occupational Therapy - Note: retired 1/1/17 5 5 $278 $56 $56 1Encounter97004

Occupational or Physical Therapy 29 1,564 $26,116 $901 $17 5415 Minutes97110

Occupational or Physical Therapy 29 1,345 $19,992 $689 $15 4615 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 1 1 $74 $74 $74 1Encounter97165

Occupational Therapy 9 11 $1,160 $129 $105 1Encounter97166

Occupational Therapy 5 5 $741 $148 $148 1Encounter97167

Occupational Therapy 25 51 $3,738 $150 $73 2Encounter97168

Occupational or Physical Therapy 18 851 $14,899 $828 $18 4715 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 5 425 $5,662 $1,132 $13 8515 Minutes97533

Occupational or Physical Therapy 1 8 $122 $122 $15 815 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Kalamazoo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 6 8 $5,193 $866 $649 1Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 17 22 $17,919 $1,054 $815 1Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 6 10 $672 $112 $67 2Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 83 221 $23,266 $280 $105 3Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 138 340 $77,102 $559 $227 2Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 187 1,185 $410,833 $2,197 $347 6Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 19 21 $1,584 $83 $75 130 Minutes99221

Additional Codes-Physician Services 5 5 $412 $82 $82 150 Minutes99222

Additional Codes-Physician Services 6 6 $494 $82 $82 170 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 21 70 $5,038 $240 $72 315 Minutes99231

Additional Codes-Physician Services 13 18 $1,416 $109 $79 125 minutes99232

Additional Codes-Physician Services 16 33 $2,642 $165 $80 235 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Kalamazoo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Kalamazoo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 35 52 $24,320 $695 $468 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 43 254 $136,102 $3,165 $536 6DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 361 917 $459,082 $1,272 $501 3Face to Face ContactH0025

Assessment 169 434 $50,314 $298 $116 3EncounterH0031

Assessment for Autism 71 104 $122,459 $1,725 $1,177 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 311 1,910 $136,782 $440 $72 6EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 318 30,231 $1,809,350 $5,690 $60 9515 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Kalamazoo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 26 2,985 $454,916 $17,497 $152 11515 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 1 63 $2,749 $2,749 $44 6315 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 1 1 $351 $351 $351 1DaysH0045

Peer Directed and Operated Support Services 145 54,759 $1,238,971 $8,545 $23 378EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 6 23 $550 $92 $24 4EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 194 2,525 $119,477 $616 $47 1315 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 4 3,616 $65,785 $16,446 $18 90415 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 157 110,579 $525,030 $3,344 $5 70415 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 16 889 $23,031 $1,439 $26 5615 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 163 11,075 $1,163,141 $7,136 $105 6815 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 0 0 $0 $0 $0 0EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Kalamazoo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 136 1,632 $316,772 $2,329 $194 12EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 1 3 $428 $428 $143 3EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 1 264 $73,057 $73,057 $277 264DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 1 1 $504 $504 $504 1EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 45 39,421 $148,083 $3,291 $4 87615 MinutesT1005

Respite Care 1 21 $142 $142 $7 2115 MinutesT1005 TD

Respite Care 1 97 $559 $559 $6 9715 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 73 30,418 $97,726 $1,339 $3 41715 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 88 3,004 $260,583 $2,961 $87 3415 minutesT1016

Targeted Case Management 189 3,228 $282,373 $1,494 $87 1715 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 14 26 $12,049 $861 $463 2EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Kalamazoo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 5 61 $6,029 $1,206 $99 12MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 1,277 $10,247,137

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lapeer

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 18 223 $156,173 $8,676 $700 12Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

14 97 $67,932 $4,852 $700 7Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $24,511 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 4 28 $10,216 $2,554 $365 7Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lapeer

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 7 7 $406 $58 $58 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 4 179 $5,629 $1,407 $31 45First 30 Minutes0364T U5

ABA Adaptive Treatment 4 671 $21,221 $5,305 $32 168Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

3 40 $1,260 $420 $32 13First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

3 49 $1,543 $514 $31 16Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 1 6 $256 $256 $43 6Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 8 8 $2,970 $371 $371 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 74 74 $28,730 $388 $388 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 39 98 $7,694 $197 $79 330 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lapeer

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 107 635 $83,059 $776 $131 645 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 76 373 $53,913 $709 $145 560 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 32 45 $5,422 $169 $120 1Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 116 645 $83,833 $723 $130 6Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 0 $0 $0 $0 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lapeer

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lapeer

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 2 2 $155 $78 $78 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 91 175 $17,810 $196 $102 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 133 381 $57,140 $430 $150 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 56 83 $18,297 $327 $220 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 1 1 $21 $21 $21 130 Minutes99221

Additional Codes-Physician Services 11 11 $315 $29 $29 150 Minutes99222

Additional Codes-Physician Services 1 1 $32 $32 $32 170 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 5 14 $116 $23 $8 315 Minutes99231

Additional Codes-Physician Services 12 55 $695 $58 $13 525 minutes99232

Additional Codes-Physician Services 2 2 $41 $21 $21 135 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lapeer

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lapeer

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 0 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 1 9 $3,593 $3,593 $399 9DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 216 225 $46,350 $215 $206 1EncounterH0031

Assessment for Autism 10 17 $1,227 $123 $72 2EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 167 244 $32,271 $193 $132 1EncounterH0032

Monitoring of Treatment - Clinician 58 76 $9,811 $169 $129 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 20 1,706 $141,520 $7,076 $83 8515 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lapeer

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 9 25 $964 $107 $39 315 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 43 3,857 $15,973 $371 $4 9015 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 1 3 $142 $142 $47 315 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 0 0 $0 $0 $0 015 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 37 305 $46,833 $1,266 $154 8EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lapeer

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 23 392 $73,716 $3,205 $188 17EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 4 228 $8,750 $2,188 $38 5715 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 1 2 $382 $382 $191 2HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 1 88 $248 $248 $3 8815 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 135 6,471 $418,484 $3,100 $65 4815 minutesT1016

Targeted Case Management 0 0 $0 $0 $0 015 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 45 64 $8,451 $188 $132 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lapeer

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 1 5 $815 $815 $163 5Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 327 $1,458,922

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lenawee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 15 113 $84,721 $5,648 $750 8Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

8 67 $53,698 $6,712 $801 8Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lenawee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 8 8 $3,523 $440 $440 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 11 600 $16,368 $1,488 $27 55First 30 Minutes0364T U5

ABA Adaptive Treatment 11 3,072 $84,219 $7,656 $27 279Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

9 84 $5,370 $597 $64 9First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

9 188 $12,044 $1,338 $64 21Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 7 16 $2,050 $293 $128 2Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 112 112 $82,685 $738 $738 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 2 2 $256 $128 $128 130 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lenawee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 5 10 $619 $124 $62 245 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 17 99 $17,832 $1,049 $180 660 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 25 174 $45,094 $1,804 $259 7Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 45 486 $131,900 $2,931 $271 11Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 4 24 $9,262 $2,315 $386 6Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lenawee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 1 1 $57 $57 $57 1Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lenawee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 1 1 $180 $180 $180 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 80 147 $23,724 $297 $161 2Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 151 364 $89,361 $592 $245 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 151 501 $182,306 $1,207 $364 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 20 25 $15,897 $795 $636 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lenawee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lenawee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 0 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 266 286 $78,618 $296 $275 1EncounterH0031

Assessment for Autism 7 7 $1,409 $201 $201 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 2 2 $194 $97 $97 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 72 7,012 $310,605 $4,314 $44 9715 MinutesH0036

Home Based Services 8 276 $16,697 $2,087 $60 3515 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lenawee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 1 4 $738 $738 $184 4DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 37 88 $8,118 $219 $92 215 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 1 1,163 $2,964 $2,964 $3 1,16315 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 5 92 $36,907 $7,381 $401 1815 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 0 0 $0 $0 $0 0EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lenawee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 4 3,622 $14,311 $3,578 $4 90615 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 35 167 $15,332 $438 $92 515 minutesT1016

Targeted Case Management 151 848 $80,405 $532 $95 615 minutesT1017

Nursing Home Mental Health Monitoring 1 2 $178 $178 $89 215 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 45 50 $11,206 $249 $224 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Lenawee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 421 $1,438,850

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

LifeWays

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 18 176 $159,669 $8,870 $907 10Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 42 402 $302,242 $7,196 $752 10Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

18 142 $112,851 $6,269 $795 8Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

14 90 $76,255 $5,447 $847 6Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

LifeWays

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 13 17 $8,656 $666 $509 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 21 1,263 $29,466 $1,403 $23 60First 30 Minutes0364T U5

ABA Adaptive Treatment 21 6,844 $159,730 $7,606 $23 326Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

20 299 $19,031 $952 $64 15First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

19 562 $35,707 $1,879 $64 30Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 16 45 $5,729 $358 $127 3Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 31 31 $26,438 $853 $853 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 157 157 $135,862 $865 $865 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 95 160 $8,264 $87 $52 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

LifeWays

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 254 1,847 $184,526 $726 $100 745 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 151 960 $101,907 $675 $106 660 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 4 15 $2,328 $582 $155 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 0 $0 $0 $0 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 182 182 $16,629 $91 $91 1Encounter90887

Speech & Language Therapy 8 265 $11,111 $1,389 $42 33Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 7 7 $819 $117 $117 1Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 10 63 $6,344 $634 $101 6Per Hour96101

Assessment for Autism 5 29 $2,819 $564 $97 6Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

LifeWays

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 4 4 $188 $47 $47 1Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 2 2 $94 $47 $47 1Encounter97166

Occupational Therapy 1 1 $47 $47 $47 1Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 10 552 $11,361 $1,136 $21 5515 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

LifeWays

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 51 78 $25,082 $492 $322 2Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 74 121 $23,852 $322 $197 2Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 227 698 $173,536 $764 $249 3Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 205 612 $223,948 $1,092 $366 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 1 1 $703 $703 $703 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 2 2 $204 $102 $102 130 Minutes99221

Additional Codes-Physician Services 2 2 $204 $102 $102 150 Minutes99222

Additional Codes-Physician Services 1 1 $102 $102 $102 170 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 5 19 $1,884 $377 $99 415 Minutes99231

Additional Codes-Physician Services 3 6 $611 $204 $102 225 minutes99232

Additional Codes-Physician Services 5 7 $709 $142 $101 135 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

LifeWays

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

LifeWays

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 1 143 $645 $645 $5 143Per MileA0425

Additional Codes-Transportation 1 1 $121 $121 $121 1Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 629 650 $105,573 $168 $162 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 1 7 $2,933 $2,933 $419 7DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 7 30 $2,387 $341 $80 4Face to Face ContactH0025

Assessment 456 465 $118,492 $260 $255 1EncounterH0031

Assessment for Autism 40 63 $14,959 $374 $237 2EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 307 660 $54,305 $177 $82 2EncounterH0032

Monitoring of Treatment - Clinician 3 9 $1,680 $560 $187 3EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 460 42,473 $3,206,817 $6,971 $76 9215 MinutesH0036

Home Based Services 21 2,529 $157,031 $7,478 $62 12015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

LifeWays

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 1 42 $1,967 $1,967 $47 4215 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 6 134 $18,021 $3,003 $134 22DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 51 268 $15,943 $313 $59 515 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 6 4,423 $34,559 $5,760 $8 73715 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 29 2,142 $116,779 $4,027 $55 7415 MinutesH2021

Wraparound (SED Waiver) 13 268 $80,908 $6,224 $302 21DaysH2022

Wraparound (SED Waiver) 2 72 $16,574 $8,287 $230 36DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 95 9,547 $675,839 $7,114 $71 10015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 1 10 $690 $690 $69 10EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

LifeWays

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 19 280 $47,081 $2,478 $168 15EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 2 274 $99,407 $49,704 $363 137DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 7 157 $20,384 $2,912 $130 22Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 1 1 $106 $106 $106 1EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 2 9 $1,966 $983 $218 5HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 216 216 $49,634 $230 $230 1EncounterT1001

Health Services 26 53 $7,274 $280 $137 2Up to 15 minT1002

Respite Care 39 22,142 $42,108 $1,080 $2 56815 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 6 118 $5,195 $866 $44 2015 minutesT1016

Targeted Case Management 109 2,463 $105,667 $969 $43 2315 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 259 347 $61,047 $236 $176 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

LifeWays

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 12 22 $8,198 $683 $373 2Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 3 16 $891 $297 $56 5Per session. One night =

one session

T2036

Respite Care 20 181 $3,265 $163 $18 9Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 1,430 $6,947,351

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Livingston

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 23 261 $159,733 $6,945 $612 11Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

22 206 $183,347 $8,334 $890 9Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 1 9 $8,648 $8,648 $961 9Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Livingston

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 6 7 $3,222 $537 $460 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 6 238 $6,552 $1,092 $28 40First 30 Minutes0364T U5

ABA Adaptive Treatment 6 1,224 $33,545 $5,591 $27 204Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

6 54 $3,372 $562 $62 9First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

6 119 $7,452 $1,242 $63 20Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 5 31 $3,970 $794 $128 6Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 81 81 $50,040 $618 $618 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 39 102 $12,123 $311 $119 330 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Livingston

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 75 282 $49,933 $666 $177 445 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 75 458 $108,813 $1,451 $238 660 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 50 140 $32,550 $651 $233 3Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 117 469 $110,690 $946 $236 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 12 74 $13,016 $1,085 $176 6Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 0 $0 $0 $0 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 7 106 $8,128 $1,161 $77 15Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 5 5 $469 $94 $94 1Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 3 3 $742 $247 $247 1Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Livingston

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 5 31 $813 $163 $26 615 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 2 2 $69 $35 $35 1Encounter97165

Occupational Therapy 2 2 $119 $60 $60 1Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 7 333 $7,663 $1,095 $23 4815 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Livingston

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 1 1 $150 $150 $150 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 2 4 $920 $460 $230 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 90 219 $64,274 $714 $293 2Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 126 467 $152,202 $1,208 $326 4Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Livingston

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Livingston

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 39 39 $7,191 $184 $184 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 146 155 $62,828 $430 $405 1EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 7 7 $2,849 $407 $407 1H0031 HW

Treatment Planning 13 19 $2,747 $211 $145 1EncounterH0032

Monitoring of Treatment - Clinician 6 34 $3,050 $508 $90 6EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 146 12,344 $818,234 $5,604 $66 8515 MinutesH0036

Home Based Services 5 44 $2,920 $584 $66 915 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Livingston

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 2 27 $880 $440 $33 1415 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 7 34 $3,310 $473 $97 5DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 15 50 $3,609 $241 $72 315 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 0 0 $0 $0 $0 015 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 67 3,809 $359,413 $5,364 $94 5715 MinutesH2021

Wraparound (SED Waiver) 8 134 $51,522 $6,440 $384 17DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 27 11 $1,896 $70 $172 0EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Livingston

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 180 $18,644 $0 $104 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 4 4 $543 $136 $136 1Up to 15 minT1002

Respite Care 48 12,425 $55,313 $1,152 $4 25915 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 8 104 $13,108 $1,639 $126 1315 minutesT1016

Targeted Case Management 33 483 $30,760 $932 $64 1515 minutesT1017

Nursing Home Mental Health Monitoring 2 13 $861 $431 $66 715 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 12 15 $2,999 $250 $200 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Livingston

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 3 9 $957 $319 $106 3ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 332 $2,466,189

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Macomb

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 260 2,269 $1,310,193 $5,039 $577 9Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 8 114 $8,949 $1,119 $79 14Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

3 34 $24,538 $8,179 $722 11Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 2 2 $377 $189 $189 1# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 276 2,079 $562,838 $2,039 $271 8Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Macomb

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 43 50 $23,889 $556 $478 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 46 3,437 $103,018 $2,240 $30 75First 30 Minutes0364T U5

ABA Adaptive Treatment 46 20,334 $609,132 $13,242 $30 442Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 1 1 $9 $9 $9 1First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 1 3 $26 $26 $9 3Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

46 835 $50,224 $1,092 $60 18First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

45 2,064 $124,389 $2,764 $60 46Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 37 206 $24,566 $664 $119 6Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 3 65 $7,393 $2,464 $114 22First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 3 382 $21,625 $7,208 $57 127Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 176 182 $39,234 $223 $216 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 250 252 $57,875 $232 $230 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 231 735 $117,493 $509 $160 330 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Macomb

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 7 8 $1,544 $221 $193 130 Minutes90833

Mental Health: Outpatient Care 489 1,805 $277,786 $568 $154 445 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 12 15 $2,999 $250 $200 145 Minutes90836

Mental Health: Outpatient Care 287 1,241 $314,694 $1,096 $254 460 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 10 15 $3,146 $315 $210 260 Minutes90838

Psychotherapy for Crisis First 60 Minutes 63 79 $31,545 $501 $399 1First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 16 19 $3,664 $229 $193 1Each Additional 30

Minutes

90840

Therapy-Family Therapy 53 174 $48,673 $918 $280 3Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 713 3,243 $309,920 $435 $96 5Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 42 179 $11,440 $272 $64 4Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 4 7 $655 $164 $94 2Encounter90887

Speech & Language Therapy 9 179 $17,850 $1,983 $100 20Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 1 1 $147 $147 $147 1Encounter92522

Speech & Language Therapy 7 9 $1,197 $171 $133 1Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 6 10 $2,683 $447 $268 2Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Macomb

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 2 5 $659 $330 $132 3Encounter96372

Physical Therapy - Note: retired 1/1/17 2 2 $252 $126 $126 1Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 15 23 $8,812 $587 $383 2Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 2 105 $3,106 $1,553 $30 5315 Minutes97110

Occupational or Physical Therapy 10 75 $2,119 $212 $28 815 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 1 12 $200 $200 $17 1215 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 1 4 $71 $71 $18 415 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 9 9 $1,429 $159 $159 1Encounter97165

Occupational Therapy 10 10 $1,863 $186 $186 1Encounter97166

Occupational Therapy 3 3 $782 $261 $261 1Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 35 3,389 $107,894 $3,083 $32 9715 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 32 655 $25,018 $782 $38 2015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Macomb

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 1 1 $59 $59 $59 1Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 2 2 $189 $95 $95 1Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 6 6 $353 $59 $59 1Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 4 4 $886 $222 $222 1Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 82 108 $6,573 $80 $61 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 336 840 $55,324 $165 $66 3Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 422 1,957 $277,606 $658 $142 5Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 85 134 $33,561 $395 $250 2Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Macomb

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Macomb

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 14 15 $1,054 $75 $70 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 63 633 $228,176 $3,622 $360 10DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 1,398 2,512 $390,914 $280 $156 2EncounterH0031

Assessment for Autism 75 117 $41,815 $558 $357 2EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 812 1,224 $157,814 $194 $129 2EncounterH0032

Monitoring of Treatment - Clinician 425 677 $63,538 $150 $94 2EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 3 5 $441 $147 $88 215 MinutesH0034

Home Based Services 244 31,762 $1,535,440 $6,293 $48 13015 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Macomb

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 3 5 $245 $82 $49 215 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 1 76 $8,016 $8,016 $105 76Per diemH0043

Respite 1 29 $11,217 $11,217 $387 29DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 1 1 $145 $145 $145 1EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 146 700 $58,801 $403 $84 515 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 156 314,056 $1,792,468 $11,490 $6 2,01315 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 19 493 $40,197 $2,116 $82 2615 MinutesH2019

Behavior Services 9 534 $9,038 $1,004 $17 5915 MinutesH2019 TT

Wraparound 85 5,916 $473,558 $5,571 $80 7015 MinutesH2021

Wraparound (SED Waiver) 64 1,550 $546,540 $8,540 $353 24DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 138 1,336 $221,521 $1,605 $166 10EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Macomb

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 1 1 $145 $145 $145 1EncounterS5111 HA

Family Training 101 1,284 $243,835 $2,414 $190 13EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 27 77 $19,153 $709 $249 3EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 4 271 $11,562 $2,891 $43 6815 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 1 2 $955 $955 $478 2HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 24 24 $7,461 $311 $311 1EncounterT1001

Health Services 147 177 $16,361 $111 $92 1Up to 15 minT1002

Respite Care 145 128,376 $666,180 $4,594 $5 88515 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 10 4,112 $12,468 $1,247 $3 41115 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 26 270 $17,804 $685 $66 1015 minutesT1016

Targeted Case Management 498 9,498 $712,786 $1,431 $75 1915 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 15 18 $2,530 $169 $141 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Macomb

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 12 101 $12,470 $1,039 $123 8MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 16 57 $12,122 $758 $213 4Per session. One night =

one session

T2036

Respite Care 14 150 $5,568 $398 $37 11Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 2,015 $11,962,805

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Manistee-Benzie (Centra Wellness)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 3 31 $23,670 $7,890 $764 10Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

3 27 $22,173 $7,391 $821 9Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Manistee-Benzie (Centra Wellness)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 0 0 $0 $0 $0 0Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0First 30 Minutes0364T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 30 30 $31,718 $1,057 $1,057 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 1 1 $641 $641 $641 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 0 0 $0 $0 $0 030 Minutes90832

Substance Use Disorder: Outpatient Care 53 100 $11,740 $222 $117 230 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Manistee-Benzie (Centra Wellness)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 115 344 $60,737 $528 $177 345 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 161 805 $171,266 $1,064 $213 560 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 2 2 $1,215 $608 $608 1First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 20 33 $13,018 $651 $394 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 22 97 $23,778 $1,081 $245 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 6 15 $4,951 $825 $330 3Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 1 1 $339 $339 $339 1Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Manistee-Benzie (Centra Wellness)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Manistee-Benzie (Centra Wellness)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 1 8 $1,475 $1,475 $184 815 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 12 13 $4,904 $409 $377 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 9 17 $3,832 $426 $225 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 53 210 $76,787 $1,449 $366 4Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 4 4 $2,748 $687 $687 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Manistee-Benzie (Centra Wellness)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Manistee-Benzie (Centra Wellness)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 3 4 $2,498 $833 $625 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 209 4,597 $726,929 $3,478 $158 22Face to Face ContactH0025

Assessment 231 261 $101,756 $441 $390 1EncounterH0031

Assessment for Autism 16 16 $8,822 $551 $551 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 107 121 $27,627 $258 $228 1EncounterH0032

Monitoring of Treatment - Clinician 2 2 $1,356 $678 $678 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 42 3,246 $292,433 $6,963 $90 7715 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Manistee-Benzie (Centra Wellness)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 26 119 $44,536 $1,713 $374 515 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 1 38 $1,075 $1,075 $28 3815 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 1 71 $636 $636 $9 7115 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 1 6 $885 $885 $148 615 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 0 0 $0 $0 $0 0EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Manistee-Benzie (Centra Wellness)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 1 1 $740 $740 $740 1EncounterT1001

Health Services 1 3 $520 $520 $173 3Up to 15 minT1002

Respite Care 2 531 $2,349 $1,175 $4 26615 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 0 0 $0 $0 $0 015 minutesT1016

Targeted Case Management 37 446 $46,651 $1,261 $105 1215 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 18 25 $12,935 $719 $517 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Manistee-Benzie (Centra Wellness)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 461 $1,726,740

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Monroe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 16 142 $110,239 $6,890 $776 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

7 35 $26,602 $3,800 $760 5Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 1 9 $3,436 $3,436 $382 9Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Monroe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 2 2 $965 $483 $483 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 2 78 $1,714 $857 $22 39First 30 Minutes0364T U5

ABA Adaptive Treatment 2 344 $7,554 $3,777 $22 172Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

1 6 $362 $362 $60 6First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

1 20 $1,207 $1,207 $60 20Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 1 1 $198 $198 $198 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 85 88 $20,529 $242 $233 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 26 76 $10,689 $411 $141 330 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Monroe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 117 826 $152,100 $1,300 $184 745 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 21 81 $24,476 $1,166 $302 460 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 88 443 $149,548 $1,699 $338 5Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 137 539 $110,700 $808 $205 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 7 11 $2,766 $395 $251 2Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 16 102 $24,707 $1,544 $242 6Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 4 4 $654 $163 $163 1Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Monroe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 1 1 $464 $464 $464 1Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Monroe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 65 113 $8,118 $125 $72 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 123 322 $51,211 $416 $159 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 58 107 $23,204 $400 $217 2Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Monroe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Monroe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 0 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 313 604 $59,343 $190 $98 2EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 18 18 $1,458 $81 $81 1H0031 HW

Treatment Planning 2 2 $2,659 $1,329 $1,329 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 48 6,005 $315,443 $6,572 $53 12515 MinutesH0036

Home Based Services 1 2 $104 $104 $52 215 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Monroe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 2 3 $58 $29 $19 215 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 33 83 $10,100 $306 $122 315 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 10 244 $791 $79 $3 2415 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 37 2,889 $186,687 $5,046 $65 7815 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 66 413 $42,228 $640 $102 6EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Monroe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 1 6 $591 $591 $99 6EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 4 294 $4,369 $1,092 $15 7415 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 21 9,166 $34,922 $1,663 $4 43615 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 1 36 $2,352 $2,352 $65 3615 minutesT1016

Targeted Case Management 233 3,710 $237,477 $1,019 $64 1615 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 53 91 $19,593 $370 $215 2EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Monroe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 10 91 $9,925 $993 $109 9MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 445 $1,659,541

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Montcalm

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 17 156 $136,224 $8,013 $873 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 3 18 $3,681 $1,227 $204 6Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 3 21 $25,088 $8,363 $1,195 7Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 2 16 $511 $256 $32 8Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

9 57 $45,600 $5,067 $800 6Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

2 19 $3,470 $1,735 $183 10Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Montcalm

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 0 0 $0 $0 $0 0Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0First 30 Minutes0364T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 1 8 $247 $247 $31 8Encounter90785 HF

Assessment 29 29 $1,134 $39 $39 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 43 43 $50,411 $1,172 $1,172 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 61 72 $5,774 $95 $80 130 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Montcalm

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 116 345 $45,744 $394 $133 345 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 432 424 $69,892 $162 $165 160 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 1 3 $567 $567 $189 3Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 3 15 $2,623 $874 $175 5Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 0 $0 $0 $0 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 23 31 $6,214 $270 $200 1Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Montcalm

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Montcalm

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 20 24 $4,077 $204 $170 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 102 274 $69,218 $679 $253 3Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 70 134 $52,724 $753 $393 2Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 14 16 $10,508 $751 $657 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Montcalm

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Montcalm

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 107 109 $5,543 $52 $51 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 1 2 $1,252 $1,252 $626 2DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 348 362 $59,941 $172 $166 1EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 174 243 $30,261 $174 $125 1EncounterH0032

Monitoring of Treatment - Clinician 1 1 $125 $125 $125 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 231 16,763 $1,056,404 $4,573 $63 7315 MinutesH0036

Home Based Services 21 412 $25,964 $1,236 $63 2015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Montcalm

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 3 115 $221 $74 $2 3815 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 1 9 $2,168 $2,168 $241 9DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 10 43 $6,186 $619 $144 415 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 3 674 $7,821 $2,607 $12 22515 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 5 149 $6,757 $1,351 $45 3015 MinutesH2019

Behavior Services 4 144 $6,530 $1,633 $45 3615 MinutesH2019 TT

Wraparound 9 443 $61,769 $6,863 $139 4915 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 1 4 $528 $528 $132 415 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 15 55 $21,461 $1,431 $390 4EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Montcalm

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 13 13 $4,359 $335 $335 1EncounterT1001

Health Services 12 279 $31,348 $2,612 $112 23Up to 15 minT1002

Respite Care 27 13,088 $72,246 $2,676 $6 48515 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 0 0 $0 $0 $0 015 minutesT1016

Targeted Case Management 84 1,579 $5,308 $63 $3 1915 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 64 93 $66,776 $1,043 $718 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Montcalm

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 526 $2,006,676

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Muskegon (HealthWest)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 30 383 $384,507 $12,817 $1,004 13Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 17 149 $19,378 $1,140 $130 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

13 97 $79,068 $6,082 $815 7Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

1 5 $285 $285 $57 5Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

2 7 $5,721 $2,861 $817 4Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 4 18 $6,533 $1,633 $363 5Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Muskegon (HealthWest)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 2 5 $2,386 $1,193 $477 3Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0First 30 Minutes0364T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 227 230 $42,732 $188 $186 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 0 0 $0 $0 $0 0Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 89 198 $13,242 $149 $67 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Muskegon (HealthWest)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 125 292 $25,855 $207 $89 245 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 165 746 $116,265 $705 $156 560 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 35 86 $18,237 $521 $212 2First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 16 38 $9,548 $597 $251 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 154 659 $98,701 $641 $150 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 100 580 $34,854 $349 $60 6Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 9 14 $3,234 $359 $231 2Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Muskegon (HealthWest)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 3 9 $47 $16 $5 3Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 2 6 $1,151 $576 $192 315 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Muskegon (HealthWest)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 2 2 $315 $158 $158 1Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 1 1 $234 $234 $234 1Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 4 4 $111 $28 $28 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 44 50 $1,981 $45 $40 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 132 169 $11,957 $91 $71 1Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 267 469 $48,009 $180 $102 2Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 243 512 $74,220 $305 $145 2Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 3 3 $286 $95 $95 130 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 3 4 $350 $117 $88 115 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 1 1 $95 $95 $95 135 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Muskegon (HealthWest)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Muskegon (HealthWest)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 1 1 $105 $105 $105 1Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 1 1 $3 $3 $3 1Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 74 78 $10,589 $143 $136 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 17 82 $50,960 $2,998 $621 5DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 621 663 $194,361 $313 $293 1EncounterH0031

Assessment for Autism 9 23 $7,049 $783 $306 3EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 27 28 $6,273 $232 $224 1EncounterH0032

Monitoring of Treatment - Clinician 3 3 $866 $289 $289 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 185 14,946 $2,936,260 $15,872 $196 8115 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Muskegon (HealthWest)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 7 111 $9,849 $1,407 $89 1615 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 4 28 $6,682 $1,670 $239 7DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 73 538 $48,075 $659 $89 715 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 20 345 $3,059 $153 $9 1715 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 72 3,253 $31,433 $437 $10 4515 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 27 1,303 $79,261 $2,936 $61 4815 MinutesH2021

Wraparound (SED Waiver) 15 150 $52,544 $3,503 $350 10DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 11 363 $38,257 $3,478 $105 3315 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 169 744 $49,155 $291 $66 4EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Muskegon (HealthWest)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 1 70 $15,895 $15,895 $227 70DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 1 2 $76 $76 $38 2ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 6 22 $3,835 $639 $174 4Up to 15 minT1002

Respite Care 5 825 $22,402 $4,480 $27 16515 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 7 22 $2,164 $309 $98 315 minutesT1016

Targeted Case Management 511 9,992 $936,822 $1,833 $94 2015 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 84 112 $22,282 $265 $199 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Muskegon (HealthWest)

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 4 23 $3,769 $942 $164 6Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 3 3 $1,521 $507 $507 1ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 1,004 $5,532,851

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Network180

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 124 2,816 $2,364,436 $19,068 $840 23Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

8 60 $52,369 $6,546 $873 8Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 1 7 $1,075 $1,075 $154 7Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 69 254 $95,486 $1,384 $376 4Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Network180

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 82 158 $60,589 $739 $383 2Encounter0359T U5

ABA Behavioral Follow-up Assessment 6 9 $853 $142 $95 2First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 6 42 $3,751 $625 $89 7Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 77 6,974 $259,061 $3,364 $37 91First 30 Minutes0364T U5

ABA Adaptive Treatment 79 48,649 $1,758,129 $22,255 $36 616Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 9 161 $3,021 $336 $19 18First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 10 508 $9,573 $957 $19 51Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

77 2,315 $145,991 $1,896 $63 30First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

77 3,834 $246,010 $3,195 $64 50Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 46 222 $29,767 $647 $134 5Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 8 9 $3,950 $494 $439 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 271 278 $76,625 $283 $276 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 163 335 $34,513 $212 $103 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Network180

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 611 5,656 $543,607 $890 $96 945 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 174 530 $95,242 $547 $180 360 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 10 14 $9,867 $987 $705 1First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 2 2 $680 $340 $340 1Each Additional 30

Minutes

90840

Therapy-Family Therapy 6 6 $2,597 $433 $433 1Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 94 241 $35,288 $375 $146 3Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 5 22 $1,282 $256 $58 4Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 1 1 $522 $522 $522 1Per Hour96101

Assessment for Autism 61 288 $27,953 $458 $97 5Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Network180

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 36 219 $30,757 $854 $140 6Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 1 1 $77 $77 $77 1Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 1 92 $2,815 $2,815 $31 9215 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Network180

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 1 1 $60 $60 $60 1Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 7 7 $847 $121 $121 1Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 10 10 $10,453 $1,045 $1,045 1Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 39 39 $62,047 $1,591 $1,591 1Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 178 181 $193,938 $1,090 $1,071 1Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 3 3 $82 $27 $27 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 121 227 $15,489 $128 $68 2Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 469 1,002 $160,855 $343 $161 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 262 523 $135,087 $516 $258 2Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 31 32 $21,444 $692 $670 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Network180

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Network180

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 1 7 $24 $24 $3 7Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 1,791 2,086 $253,169 $141 $121 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 19 91 $34,547 $1,818 $380 5DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 143 153 $73,223 $512 $479 1EncounterH0031

Assessment for Autism 7 12 $4,484 $641 $374 2EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 95 321 $54,753 $576 $171 3EncounterH0032

Monitoring of Treatment - Clinician 1 1 $100 $100 $100 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 1,226 91,530 $4,111,490 $3,354 $45 7515 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Network180

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 3 15 $1,363 $454 $91 515 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 1 75 $4,185 $4,185 $56 7515 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 59 226 $81,002 $1,373 $358 4DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 216 735 $140,465 $650 $191 315 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 314 57,589 $361,420 $1,151 $6 18315 MinutesH2015

Community Living Supports (Daily) 28 698 $224,221 $8,008 $321 25Per DiemH2016

Behavior Services 29 1,136 $31,783 $1,096 $28 3915 MinutesH2019

Behavior Services 27 1,180 $12,998 $481 $11 4415 MinutesH2019 TT

Wraparound 232 9,931 $685,009 $2,953 $69 4315 MinutesH2021

Wraparound (SED Waiver) 79 1,361 $477,458 $6,044 $351 17DaysH2022

Wraparound (SED Waiver) 4 54 $14,584 $3,646 $270 14DaysH2022 TT

Supported Employment Services 1 6 $717 $717 $119 615 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 40 4,572 $313,062 $7,827 $68 11415 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 478 4,247 $317,974 $665 $75 9EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Network180

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 44 1,037 $198,029 $4,501 $191 24EncounterS5111 HA

Family Training 156 1,482 $428,348 $2,746 $289 10EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 6 187 $55,613 $9,269 $297 31DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 365 19,819 $749,704 $2,054 $38 5415 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 24 263 $6,301 $263 $24 11DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 1 2 $140 $140 $70 2Up to 15 minT1002

Respite Care 49 9,577 $35,766 $730 $4 19515 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 250 55,304 $245,064 $980 $4 22115 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 207 6,362 $509,338 $2,461 $80 3115 minutesT1016

Targeted Case Management 519 18,310 $785,727 $1,514 $43 3515 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 411 448 $130,246 $317 $291 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Network180

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 31 751 $40,566 $1,309 $54 24T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 66 182 $17,905 $271 $98 3Per session. One night =

one session

T2036

Respite Care 15 65 $2,741 $183 $42 4Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 3,452 $16,899,709

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Newaygo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 12 124 $122,899 $10,242 $991 10Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

1 5 $4,064 $4,064 $813 5Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Newaygo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 20 26 $13,437 $672 $517 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 19 8,407 $83,710 $4,406 $10 442First 30 Minutes0364T U5

ABA Adaptive Treatment 33 3,118 $31,039 $941 $10 94Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

25 267 $21,643 $866 $81 11First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

18 248 $20,117 $1,118 $81 14Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 71 71 $61,639 $868 $868 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 0 0 $0 $0 $0 0Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 117 566 $69,774 $596 $123 530 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Newaygo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 141 510 $84,495 $599 $166 445 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 126 521 $123,829 $983 $238 460 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 3 7 $1,123 $374 $160 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 80 290 $66,239 $828 $228 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 0 $0 $0 $0 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 4 18 $5,444 $1,361 $302 5Per Hour96101

Assessment for Autism 5 21 $4,741 $948 $226 4Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Newaygo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Newaygo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 5 16 $2,939 $588 $184 3Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 122 553 $147,104 $1,206 $266 5Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Newaygo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Newaygo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 37 39 $6,778 $183 $174 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 17 20 $625 $37 $31 1Face to Face ContactH0025

Assessment 291 303 $79,205 $272 $261 1EncounterH0031

Assessment for Autism 43 45 $23,833 $554 $530 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 102 117 $22,938 $225 $196 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 131 7,300 $783,528 $5,981 $107 5615 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Newaygo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 6 17 $3,338 $556 $196 3EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 5 20 $3,997 $799 $200 4EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 12 45 $3,310 $276 $74 415 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 3 2,176 $9,494 $3,165 $4 72515 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 17 307 $20,794 $1,223 $68 1815 MinutesH2019

Behavior Services 14 528 $18,133 $1,295 $34 3815 MinutesH2019 TT

Wraparound 31 834 $100,628 $3,246 $121 2715 MinutesH2021

Wraparound (SED Waiver) 6 88 $14,662 $2,444 $167 15DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 87 335 $92,508 $1,063 $276 4EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Newaygo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 3 27 $7,509 $2,503 $278 9EncounterS5111 HA

Family Training 32 399 $78,129 $2,442 $196 12EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 3 4 $447 $149 $112 1Up to 15 minT1002

Respite Care 10 4,276 $16,818 $1,682 $4 42815 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 0 0 $0 $0 $0 015 minutesT1016

Targeted Case Management 178 2,181 $225,709 $1,268 $103 1215 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 34 50 $19,856 $584 $397 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Newaygo

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 15 84 $9,202 $613 $110 6MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 472 $2,405,676

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

North Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 44 417 $384,009 $8,727 $921 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 1 9 $1,761 $1,761 $196 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 17 159 $118,775 $6,987 $747 9Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

21 239 $211,034 $10,049 $883 11Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

5 31 $22,616 $4,523 $730 6Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

North Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 3 9 $1,835 $612 $204 3Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 3 117 $3,283 $1,094 $28 39First 30 Minutes0364T U5

ABA Adaptive Treatment 3 490 $13,795 $4,598 $28 163Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

3 51 $3,150 $1,050 $62 17First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

3 202 $10,980 $3,660 $54 67Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 3 18 $2,160 $720 $120 6Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 85 85 $49,083 $577 $577 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 62 84 $8,014 $129 $95 130 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

North Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 328 1,602 $244,032 $744 $152 545 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 96 335 $59,267 $617 $177 360 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 29 61 $8,949 $309 $147 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 89 337 $52,652 $592 $156 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 2 13 $3,210 $1,605 $247 7Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 1 1 $82 $82 $82 1Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 1 1 $189 $189 $189 1Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 5 46 $8,174 $1,635 $178 9Per Hour96101

Assessment for Autism 20 161 $27,820 $1,391 $173 8Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

North Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 2 4 $483 $242 $121 2Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

North Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 1 1 $142 $142 $142 1Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 112 207 $31,363 $280 $152 2Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 1 1 $183 $183 $183 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 7 7 $1,083 $155 $155 1Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 180 600 $174,816 $971 $291 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 48 65 $24,160 $503 $372 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 1 1 $105 $105 $105 115 Minutes99231

Additional Codes-Physician Services 3 3 $319 $106 $106 125 minutes99232

Additional Codes-Physician Services 2 3 $314 $157 $105 235 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

North Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

North Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 0 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 443 463 $186,748 $422 $403 1EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 394 580 $151,840 $385 $262 1EncounterH0032

Monitoring of Treatment - Clinician 72 97 $15,611 $217 $161 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 32 46 $4,136 $129 $90 115 MinutesH0034

Home Based Services 64 6,124 $464,954 $7,265 $76 9615 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

North Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 1 13 $1,531 $1,531 $118 13Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 37 95 $15,989 $432 $168 3EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 205 809 $40,194 $196 $50 415 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 1 82 $406 $406 $5 8215 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 1 584 $2,787 $2,787 $5 58415 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 13 1,354 $130,258 $10,020 $96 10415 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 2 9 $3,312 $1,656 $368 5EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

North Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 6 34 $13,269 $2,212 $390 6EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 2 695 $288,089 $144,045 $415 348DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 1 1 $111 $111 $111 1Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 1 1 $110 $110 $110 1EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 17 593 $60,726 $3,572 $102 3515 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 15 16 $3,773 $252 $236 1EncounterT1001

Health Services 17 19 $1,586 $93 $83 1Up to 15 minT1002

Respite Care 1 436 $1,225 $1,225 $3 43615 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 21 85 $7,634 $364 $90 415 minutesT1016

Targeted Case Management 105 2,887 $202,218 $1,926 $70 2715 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 96 126 $42,105 $439 $334 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

North Country

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 776 $3,106,450

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northeast Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 5 94 $98,434 $19,687 $1,047 19Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

13 74 $67,118 $5,163 $907 6Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northeast Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 16 20 $14,440 $903 $722 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 1 1 $109 $109 $109 1First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 1 6 $656 $656 $109 6Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 21 1,204 $58,133 $2,768 $48 57First 30 Minutes0364T U5

ABA Adaptive Treatment 21 4,284 $201,096 $9,576 $47 204Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 3 5 $134 $45 $27 2First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 3 5 $134 $45 $27 2Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

20 198 $19,523 $976 $99 10First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

18 291 $25,152 $1,397 $86 16Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 12 29 $3,184 $265 $110 2Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 67 67 $51,523 $769 $769 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 16 44 $4,128 $258 $94 330 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northeast Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 74 264 $27,420 $371 $104 445 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 48 201 $26,895 $560 $134 460 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 4 6 $911 $228 $152 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 15 42 $4,755 $317 $113 3Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 0 $0 $0 $0 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 1 5 $1,715 $1,715 $343 5Per Hour96101

Assessment for Autism 1 1 $480 $480 $480 1Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northeast Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northeast Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 21 21 $7,474 $356 $356 1Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 5 5 $2,051 $410 $410 1Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 2 2 $212 $106 $106 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 16 16 $3,288 $206 $206 1Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 199 573 $156,951 $789 $274 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 19 22 $8,661 $456 $394 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northeast Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northeast Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 11 11 $1,539 $140 $140 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 1 2 $116 $116 $58 2EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 240 246 $65,911 $275 $268 1EncounterH0031

Assessment for Autism 18 26 $17,395 $966 $669 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 180 215 $34,093 $189 $159 1EncounterH0032

Monitoring of Treatment - Clinician 31 37 $5,754 $186 $156 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 9 492 $36,717 $4,080 $75 5515 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northeast Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 89 350 $17,108 $192 $49 415 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 1 7 $41 $41 $6 715 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 33 7,007 $93,109 $2,821 $13 21215 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 14 775 $125,241 $8,946 $162 5515 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 2 21 $1,181 $591 $56 1115 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 64 101 $18,041 $282 $179 2EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northeast Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 3 100 $6,573 $2,191 $66 3315 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 1 1 $117 $117 $117 1EncounterT1001

Health Services 1 1 $30 $30 $30 1Up to 15 minT1002

Respite Care 26 24,227 $56,363 $2,168 $2 93215 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 42 915 $85,223 $2,029 $93 2215 minutesT1016

Targeted Case Management 163 6,352 $420,405 $2,579 $66 3915 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 49 67 $16,773 $342 $250 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northeast Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 3 36 $5,772 $1,924 $160 12MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 6 209 $2,035 $339 $10 35Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 414 $1,794,115

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northern Lakes

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 33 469 $409,867 $12,420 $874 14Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 3 30 $5,647 $1,882 $188 10Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

10 97 $78,859 $7,886 $813 10Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $5,160 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $5,601 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northern Lakes

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 1 1 $489 $489 $489 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 1 21 $588 $588 $28 21First 30 Minutes0364T U5

ABA Adaptive Treatment 1 60 $1,708 $1,708 $28 60Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

1 6 $366 $366 $61 6First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

1 6 $366 $366 $61 6Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 68 68 $37,205 $547 $547 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 3 3 $2,138 $713 $713 1Encounter90792 U5

Mental Health: Outpatient Care 3 22 $2,113 $704 $96 730 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northern Lakes

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 75 394 $42,927 $572 $109 545 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 13 27 $5,839 $449 $216 260 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 41 70 $9,504 $232 $136 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 370 2,507 $376,166 $1,017 $150 7Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 13 68 $4,361 $335 $64 5Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 2 3 $534 $267 $178 2Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northern Lakes

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 1 11 $1,797 $1,797 $163 11Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northern Lakes

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 1 1 $158 $158 $158 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 23 28 $3,135 $136 $112 1Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 138 454 $83,692 $606 $184 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 2 2 $478 $239 $239 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northern Lakes

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northern Lakes

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 23 23 $4,011 $174 $174 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 2 29 $13,284 $6,642 $458 15DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 532 580 $206,582 $388 $356 1EncounterH0031

Assessment for Autism 19 21 $7,792 $410 $371 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 472 788 $270,507 $573 $343 2EncounterH0032

Monitoring of Treatment - Clinician 1 1 $169 $169 $169 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 170 13,485 $1,197,296 $7,043 $89 7915 MinutesH0036

Home Based Services 1 4 $305 $305 $76 415 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northern Lakes

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 370 1,993 $190,912 $516 $96 515 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 5 1,171 $5,128 $1,026 $4 23415 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 35 3,107 $243,905 $6,969 $79 8915 MinutesH2021

Wraparound (SED Waiver) 2 46 $19,241 $9,621 $418 23DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 0 0 $0 $0 $0 0EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northern Lakes

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 11 99 $17,938 $1,631 $181 9EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 4 96 $7,329 $1,832 $76 2415 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 0 0 $0 $0 $0 015 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 2 8 $407 $204 $51 415 minutesT1016

Targeted Case Management 127 4,171 $248,881 $1,960 $60 3315 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 317 453 $201,351 $635 $444 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northern Lakes

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 2 10 $575 $288 $58 5Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 948 $3,714,311

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northpointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 3 19 $21,822 $7,274 $1,149 6Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northpointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 1 1 $158 $158 $158 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0First 30 Minutes0364T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 2 2 $885 $443 $443 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 57 57 $40,480 $710 $710 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 72 248 $22,677 $315 $91 330 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northpointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 0 0 $0 $0 $0 045 Minutes90834

Substance Use Disorder: Outpatient Care 84 243 $34,314 $409 $141 345 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 94 417 $82,756 $880 $198 460 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 34 103 $17,200 $506 $167 3Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 46 118 $23,561 $512 $200 3Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 12 76 $14,342 $1,195 $189 6Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northpointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 9 9 $3,706 $412 $412 1Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 8 8 $2,335 $292 $292 1Encounter97165

Occupational Therapy 7 7 $2,469 $353 $353 1Encounter97166

Occupational Therapy 7 7 $3,291 $470 $470 1Encounter97167

Occupational Therapy 11 11 $2,367 $215 $215 1Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northpointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 1 11 $440 $440 $40 1115 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 1 1 $555 $555 $555 1Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 1 1 $131 $131 $131 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 23 37 $4,765 $207 $129 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 111 418 $95,402 $859 $228 4Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 45 72 $30,332 $674 $421 2Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 1 1 $300 $300 $300 130 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 2 3 $901 $450 $300 215 Minutes99231

Additional Codes-Physician Services 1 2 $601 $601 $300 225 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northpointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northpointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 8 8 $2,041 $255 $255 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 109 130 $35,205 $323 $271 1EncounterH0031

Assessment for Autism 3 4 $325 $108 $81 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 177 303 $38,784 $219 $128 2EncounterH0032

Monitoring of Treatment - Clinician 34 130 $35,436 $1,042 $273 4EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 72 9,790 $383,393 $5,325 $39 13615 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northpointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 5 26 $4,256 $851 $164 5DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 1 1 $281 $281 $281 1EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 93 589 $32,272 $347 $55 615 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 34 4,330 $23,131 $680 $5 12715 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 18 3,431 $40,840 $2,269 $12 19115 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 19 1,017 $41,399 $2,179 $41 5415 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 123 510 $4,270 $35 $8 4Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 3 6 $2,757 $919 $459 2EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northpointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 1 1 $182 $182 $182 1ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 15 14,230 $48,008 $3,201 $3 94915 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 140 1,966 $109,104 $779 $55 1415 minutesT1016

Targeted Case Management 5 86 $4,773 $955 $55 1715 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 7 11 $6,345 $906 $577 2EncounterT1023

Prevention Services - Direct Model 5 141 $999 $200 $7 2815 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Northpointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 12 58 $8,804 $734 $152 5MonthT2025

Enhanced Medical Equipment-Supplies 2 2 $365 $182 $182 1ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 8 55 $476 $60 $9 7Per session. One night =

one session

T2036

Respite Care 4 36 $2,921 $730 $81 9Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 1 0 $0 $0 $0 0ALL

Total Population and Cost 350 $1,232,157

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Oakland

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 373 3,209 $1,241,349 $3,328 $387 9Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

2 19 $13,509 $6,755 $711 10Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $5,003 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Oakland

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 57 76 $14,951 $262 $197 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 58 6,284 $268,886 $4,636 $43 108First 30 Minutes0364T U5

ABA Adaptive Treatment 58 31,254 $1,361,158 $23,468 $44 539Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 16 616 $24,084 $1,505 $39 39First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 16 1,086 $45,465 $2,842 $42 68Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

57 1,334 $79,812 $1,400 $60 23First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

57 2,838 $166,049 $2,913 $59 50Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 29 77 $7,170 $247 $93 3Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 145 150 $130,269 $898 $868 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 542 550 $407,338 $752 $741 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 284 464 $52,550 $185 $113 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Oakland

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 469 1,499 $252,817 $539 $169 345 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 713 3,253 $750,703 $1,053 $231 560 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 155 274 $90,667 $585 $331 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 763 3,522 $887,787 $1,164 $252 5Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 2 6 $1,635 $818 $273 3Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 57 450 $51,276 $900 $114 8Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 11 358 $78,926 $7,175 $220 33Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 5 5 $782 $156 $156 1Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 4 6 $3,400 $850 $567 2Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Oakland

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 38 80 $9,239 $243 $115 2Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 2 2 $414 $207 $207 1Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 5 340 $37,388 $7,478 $110 6815 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 1 33 $2,212 $2,212 $67 3315 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Oakland

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 19 19 $6,349 $334 $334 1Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 83 84 $30,234 $364 $360 1Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 11 11 $2,882 $262 $262 1Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 3 3 $1,373 $458 $458 1Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 6 6 $1,844 $307 $307 1Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 9 12 $671 $75 $56 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 316 870 $221,857 $702 $255 3Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 675 2,736 $795,923 $1,179 $291 4Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 159 425 $139,428 $877 $328 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 14 15 $6,393 $457 $426 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Oakland

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Oakland

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 7 7 $1,940 $277 $277 1Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 111 122 $8,555 $77 $70 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 36 285 $92,952 $2,582 $326 8DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 1,273 1,366 $578,639 $455 $424 1EncounterH0031

Assessment for Autism 213 213 $98,494 $462 $462 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 1,519 5,525 $923,119 $608 $167 4EncounterH0032

Monitoring of Treatment - Clinician 1 1 $142 $142 $142 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 839 92,248 $5,601,106 $6,676 $61 11015 MinutesH0036

Home Based Services 6 61 $2,408 $401 $39 1015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Oakland

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 17 50 $2,537 $149 $51 315 minutesH0038

Peer Directed and Operated Support Services 56 1,680 $141,828 $2,533 $84 3015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 5 73 $3,282 $656 $45 1515 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 4 16 $2,593 $648 $162 4DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 846 2,934 $423,970 $501 $145 315 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 81 22,070 $148,813 $1,837 $7 27215 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 94 4,137 $520,357 $5,536 $126 4415 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 161 1,280 $235,212 $1,461 $184 8EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Oakland

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 1 123 $73,025 $73,025 $594 123DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 1 11 $1,242 $1,242 $113 11Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 1 1 $40 $40 $40 1EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 2 7 $157 $78 $22 4DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 233 300 $21,284 $91 $71 1Up to 15 minT1002

Respite Care 46 28,800 $148,585 $3,230 $5 62615 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 4 25 $5,209 $1,302 $208 615 minutesT1016

Targeted Case Management 180 1,581 $182,388 $1,013 $115 915 minutesT1017

Nursing Home Mental Health Monitoring 1 24 $1,357 $1,357 $57 2415 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 418 567 $402,339 $963 $710 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Oakland

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 3 14 $235 $78 $17 5MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 1 1 $3 $3 $3 1ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 2,612 $16,813,606

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ottawa

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 27 197 $183,841 $6,809 $933 7Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 10 105 $49,904 $4,990 $475 11Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

1 8 $6,524 $6,524 $816 8Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $43,629 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $1,218 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 19 90 $32,221 $1,696 $358 5Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ottawa

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 14 18 $8,855 $632 $492 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 6 13 $833 $139 $64 2First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 8 78 $4,609 $576 $59 10Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 13 1,247 $32,286 $2,484 $26 96First 30 Minutes0364T U5

ABA Adaptive Treatment 14 7,221 $175,587 $12,542 $24 516Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

13 454 $22,864 $1,759 $50 35First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

13 566 $28,850 $2,219 $51 44Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 6 74 $7,587 $1,264 $103 12Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 93 95 $51,728 $556 $545 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 78 80 $26,329 $338 $329 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 9 13 $2,633 $293 $203 130 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ottawa

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 46 184 $59,157 $1,286 $322 445 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 10 74 $31,577 $3,158 $427 760 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 1 1 $247 $247 $247 1First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 17 24 $11,164 $657 $465 1Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 192 1,999 $372,547 $1,940 $186 10Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 2 4 $157 $78 $39 2Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ottawa

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 40 203 $21,401 $535 $105 5Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ottawa

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 9 10 $409 $45 $41 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 62 100 $6,849 $110 $68 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 112 291 $33,464 $299 $115 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 24 32 $4,899 $204 $153 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ottawa

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ottawa

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 275 284 $36,458 $133 $128 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 32 169 $125,482 $3,921 $742 5DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 145 153 $72,666 $501 $475 1EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 167 173 $33,453 $200 $193 1EncounterH0032

Monitoring of Treatment - Clinician 6 10 $1,410 $235 $141 2EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 72 4,865 $493,073 $6,848 $101 6815 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ottawa

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 4 17 $6,665 $1,666 $392 4DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 106 359 $84,606 $798 $236 315 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 0 0 $0 $0 $0 015 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 3 138 $21,323 $7,108 $155 4615 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 41 323 $54,899 $1,339 $170 8EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ottawa

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 2 5 $1,672 $836 $334 3Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 17 435 $10,253 $603 $24 2615 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 7 1,408 $19,774 $2,825 $14 20115 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 41 239 $35,798 $873 $150 615 minutesT1016

Targeted Case Management 93 208 $19,555 $210 $94 215 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 90 124 $122,200 $1,358 $985 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Ottawa

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 19 63 $3,577 $188 $57 3MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 554 $2,364,229

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pathways

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 21 261 $288,524 $13,739 $1,105 12Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

4 55 $48,781 $12,195 $887 14Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

1 5 $282 $282 $56 5Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pathways

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 0 0 $0 $0 $0 0Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0First 30 Minutes0364T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 1 1 $575 $575 $575 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 58 59 $35,470 $612 $601 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 117 234 $23,852 $204 $102 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pathways

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 149 433 $71,856 $482 $166 345 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 221 1,290 $283,658 $1,284 $220 660 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 77 219 $40,559 $527 $185 3Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 98 382 $74,321 $758 $195 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 3 28 $5,341 $1,780 $191 9Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pathways

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 1 4 $338 $338 $85 4Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 1 1 $456 $456 $456 1Encounter97166

Occupational Therapy 2 2 $901 $451 $451 1Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 2 10 $1,539 $770 $154 515 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pathways

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 2 2 $1,231 $616 $616 1Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 5 6 $693 $139 $116 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 90 161 $28,640 $318 $178 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 124 355 $82,250 $663 $232 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 17 19 $8,009 $471 $422 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 2 2 $164 $82 $82 130 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 1 1 $65 $65 $65 115 Minutes99231

Additional Codes-Physician Services 1 1 $79 $79 $79 125 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pathways

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pathways

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 2 2 $1,015 $507 $507 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 104 111 $54,389 $523 $490 1EncounterH0031

Assessment for Autism 4 4 $646 $162 $162 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 295 431 $52,914 $179 $123 1EncounterH0032

Monitoring of Treatment - Clinician 5 37 $4,884 $977 $132 7EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 147 9,540 $500,755 $3,406 $52 6515 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pathways

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 1 3 $3,906 $3,906 $1,302 3EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 147 1,094 $93,756 $638 $86 715 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 21 2,849 $7,274 $346 $3 13615 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 10 398 $10,591 $1,059 $27 4015 MinutesH2019

Behavior Services 5 271 $14,704 $2,941 $54 5415 MinutesH2019 TT

Wraparound 11 1,177 $13,412 $1,219 $11 10715 MinutesH2021

Wraparound (SED Waiver) 4 55 $62,659 $15,665 $1,139 14DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 25 91 $1,197 $48 $13 4Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 22 145 $28,606 $1,300 $197 7EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pathways

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 1 2 $453 $453 $227 2EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 8 4,081 $15,553 $1,944 $4 51015 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 74 990 $108,781 $1,470 $110 1315 minutesT1016

Targeted Case Management 14 232 $21,810 $1,558 $94 1715 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 56 88 $55,907 $998 $635 2EncounterT1023

Prevention Services - Direct Model 15 246 $6,231 $415 $25 1615 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pathways

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 491 $2,057,028

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pines

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 5 66 $54,610 $10,922 $827 13Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

4 35 $28,819 $7,205 $823 9Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

4 29 $28,951 $7,238 $998 7Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pines

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 13 18 $7,997 $615 $444 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 2 2 $191 $95 $95 1First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 2 3 $286 $143 $95 2Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 11 1,265 $53,268 $4,843 $42 115First 30 Minutes0364T U5

ABA Adaptive Treatment 11 4,603 $191,938 $17,449 $42 418Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

10 232 $20,620 $2,062 $89 23First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

10 510 $46,266 $4,627 $91 51Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 11 82 $9,927 $902 $121 7Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 46 46 $16,360 $356 $356 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 16 22 $2,615 $163 $119 130 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pines

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 99 283 $47,186 $477 $167 345 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 145 415 $82,522 $569 $199 360 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 1 1 $247 $247 $247 1Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 5 12 $2,959 $592 $247 2Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 9 54 $6,508 $723 $121 6Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 1 1 $164 $164 $164 1Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pines

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pines

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 1 1 $238 $238 $238 1Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 97 299 $26,234 $270 $88 3Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 2 2 $208 $104 $104 130 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 2 2 $212 $106 $106 170 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 1 2 $136 $136 $68 215 Minutes99231

Additional Codes-Physician Services 4 6 $631 $158 $105 225 minutes99232

Additional Codes-Physician Services 4 7 $737 $184 $105 235 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pines

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pines

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 223 228 $42,161 $189 $185 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 3 16 $10,593 $3,531 $662 5DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 173 177 $43,614 $252 $246 1EncounterH0031

Assessment for Autism 27 27 $29,237 $1,083 $1,083 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 187 271 $49,398 $264 $182 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 26 2,502 $242,225 $9,316 $97 9615 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pines

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 75 439 $34,019 $454 $77 615 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 7 11,475 $57,491 $8,213 $5 1,63915 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 12 814 $93,184 $7,765 $114 6815 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 0 0 $0 $0 $0 0EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pines

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 1 3 $27,688 $27,688 $9,229 3ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 10 10 $916 $92 $92 1EncounterT1001

Health Services 34 38 $2,677 $79 $70 1Up to 15 minT1002

Respite Care 8 9,133 $45,762 $5,720 $5 1,14215 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 38 447 $48,875 $1,286 $109 1215 minutesT1016

Targeted Case Management 9 53 $5,787 $643 $109 615 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 68 94 $78,577 $1,156 $836 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 2 8 $541 $270 $68 4ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Pines

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 1 11 $3,728 $3,728 $339 11ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 397 $1,446,302

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Saginaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 12 103 $62,929 $5,244 $611 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 2 17 $3,732 $1,866 $220 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 4 27 $15,880 $3,970 $588 7Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

92 1,063 $813,001 $8,837 $765 12Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

4 35 $2,382 $596 $68 9Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $26,773 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Saginaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 3 4 $618 $206 $155 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 4 311 $12,349 $3,087 $40 78First 30 Minutes0364T U5

ABA Adaptive Treatment 4 1,868 $74,385 $18,596 $40 467Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

4 101 $4,011 $1,003 $40 25First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

4 138 $5,494 $1,374 $40 35Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 2 4 $328 $164 $82 2Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 22 23 $8,188 $372 $356 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 157 159 $58,210 $371 $366 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 220 1,152 $194,697 $885 $169 530 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Saginaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 421 3,090 $501,692 $1,192 $162 745 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 125 592 $240,397 $1,923 $406 560 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 99 188 $55,813 $564 $297 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 210 631 $155,411 $740 $246 3Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 3 7 $4,767 $1,589 $681 2Encounter90849

Therapy-Family Therapy 16 97 $65,052 $4,066 $671 6Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 18 135 $45,862 $2,548 $340 8Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 7 149 $18,430 $2,633 $124 21Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 4 4 $565 $141 $141 1Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 1 18 $2,625 $2,625 $146 18Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 3 17 $4,142 $1,381 $244 6Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Saginaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 2 10 $1,472 $736 $147 5Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 1 1 $122 $122 $122 1Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 1 1 $115 $115 $115 1Encounter97165

Occupational Therapy 1 1 $116 $116 $116 1Encounter97166

Occupational Therapy 1 1 $210 $210 $210 1Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 4 236 $11,912 $2,978 $50 5915 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 1 27 $944 $944 $35 2715 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Saginaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 1 4 $205 $205 $51 415 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 3 3 $1,000 $333 $333 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 12 14 $1,755 $146 $125 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 174 594 $56,088 $322 $94 3Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 206 882 $288,322 $1,400 $327 4Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 3 5 $2,682 $894 $536 2Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Saginaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Saginaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 122 123 $30,088 $247 $245 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 580 827 $444,376 $766 $537 1EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 131 193 $41,471 $317 $215 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 5 574 $69,803 $13,961 $122 11515 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Saginaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 8 172 $12,888 $1,611 $75 2215 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 18 1,866 $70,726 $3,929 $38 104Per diemH0043

Respite 2 7 $1,037 $519 $148 4DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 226 1,388 $336,012 $1,487 $242 615 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 36 2,912 $18,596 $517 $6 8115 MinutesH2015

Community Living Supports (Daily) 12 1,206 $115,990 $9,666 $96 101Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 78 2,424 $642,540 $8,238 $265 3115 MinutesH2021

Wraparound (SED Waiver) 24 315 $318,247 $13,260 $1,010 13DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 58 525 $259,599 $4,476 $494 9EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Saginaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 61 1,935 $238,030 $3,902 $123 3215 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 1 1 $58 $58 $58 1Up to 15 minT1002

Respite Care 76 44,483 $184,584 $2,429 $4 58515 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 5 3,906 $15,628 $3,126 $4 78115 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 21 277 $24,539 $1,169 $89 1315 minutesT1016

Targeted Case Management 367 8,780 $522,175 $1,423 $59 2415 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 1 3 $148 $148 $49 3DaysT1020

Assessments 371 524 $263,461 $710 $503 1EncounterT1023

Prevention Services - Direct Model 17 495 $52,267 $3,075 $106 2915 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Saginaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 70 436 $55,527 $793 $127 6Per session. One night =

one session

T2036

Respite Care 84 2,045 $141,172 $1,681 $69 24Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 1,145 $6,601,638

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Sanilac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 19 163 $131,246 $6,908 $805 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

5 38 $30,783 $6,157 $810 8Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

7 114 $83,328 $11,904 $731 16Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 1 5 $1,135 $1,135 $227 5Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Sanilac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 1 1 $374 $374 $374 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 1 33 $1,502 $1,502 $46 33First 30 Minutes0364T U5

ABA Adaptive Treatment 1 111 $5,071 $5,071 $46 111Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 1 1 $28 $28 $28 1First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 1 6 $166 $166 $28 6Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

1 19 $1,278 $1,278 $67 19First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

1 1 $58 $58 $58 1Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 8 8 $2,396 $299 $299 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 33 34 $17,247 $523 $507 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 52 184 $16,758 $322 $91 430 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Sanilac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 65 248 $37,222 $573 $150 445 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 76 533 $108,490 $1,427 $204 760 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 7 12 $1,717 $245 $143 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 43 95 $16,932 $394 $178 2Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 5 9 $580 $116 $64 2Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 1 4 $568 $568 $142 4Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Sanilac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 1 12 $1,287 $1,287 $107 12Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 5 5 $1,072 $214 $214 1Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 1 1 $110 $110 $110 1Encounter97165

Occupational Therapy 1 1 $171 $171 $171 1Encounter97166

Occupational Therapy 1 1 $219 $219 $219 1Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 1 4 $216 $216 $54 415 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 3 17 $839 $280 $49 615 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Sanilac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 11 12 $2,973 $270 $248 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 73 252 $81,450 $1,116 $323 3Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 16 20 $7,944 $496 $397 1Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 1 1 $105 $105 $105 130 Minutes99221

Additional Codes-Physician Services 7 11 $2,081 $297 $189 250 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 5 37 $2,707 $541 $73 715 Minutes99231

Additional Codes-Physician Services 5 51 $5,084 $1,017 $100 1025 minutes99232

Additional Codes-Physician Services 1 6 $883 $883 $147 635 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Sanilac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Sanilac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 0 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 104 109 $51,619 $496 $474 1EncounterH0031

Assessment for Autism 4 5 $963 $241 $193 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 81 117 $33,063 $408 $283 1EncounterH0032

Monitoring of Treatment - Clinician 6 8 $1,421 $237 $178 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 45 4,480 $230,782 $5,128 $52 10015 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Sanilac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 11 79 $6,703 $609 $85 715 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 1 13 $84 $84 $6 1315 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 4 289 $1,645 $411 $6 7215 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 8 106 $563 $70 $5 1315 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 14 53 $9,772 $698 $184 4EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Sanilac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 14 15 $1,747 $125 $116 1Up to 15 minT1002

Respite Care 11 3,418 $16,019 $1,456 $5 31115 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 6 370 $868 $145 $2 6215 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 64 524 $40,173 $628 $77 815 minutesT1016

Targeted Case Management 0 0 $0 $0 $0 015 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 36 49 $20,654 $574 $422 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 2 5 $274 $137 $55 3ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Sanilac

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 3 4 $450 $150 $112 1ItemsT2028

Enhanced Medical Equipment-Supplies 1 3 $337 $337 $112 3ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 171 $981,155

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Shiawassee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 5 46 $52,413 $10,483 $1,139 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 6 103 $91,791 $15,299 $891 17Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

1 5 $4,467 $4,467 $893 5Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

10 80 $36,521 $3,652 $457 8Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Shiawassee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 1 1 $480 $480 $480 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 1 103 $6,979 $6,979 $68 103First 30 Minutes0364T U5

ABA Adaptive Treatment 1 294 $19,887 $19,887 $68 294Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

1 12 $672 $672 $56 12First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

1 20 $1,132 $1,132 $57 20Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 61 62 $21,646 $355 $349 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 52 52 $12,148 $234 $234 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 67 139 $15,611 $233 $112 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Shiawassee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 148 537 $78,274 $529 $146 445 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 190 1,126 $160,075 $843 $142 645 Minutes90836

Mental Health: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 11 29 $6,430 $585 $222 3Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 68 382 $72,795 $1,071 $191 6Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 0 $0 $0 $0 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Shiawassee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 4 4 $1,067 $267 $267 1Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 5 150 $7,595 $1,519 $51 3015 Minutes97110

Occupational or Physical Therapy 6 110 $5,499 $917 $50 1815 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 2 2 $400 $200 $200 1Encounter97166

Occupational Therapy 2 2 $533 $267 $267 1Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 8 161 $7,289 $911 $45 2015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 7 229 $10,159 $1,451 $44 3315 Minutes97533

Occupational or Physical Therapy 6 85 $3,932 $655 $46 1415 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Shiawassee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 1 1 $43 $43 $43 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 68 235 $13,186 $194 $56 3Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 35 78 $8,401 $240 $108 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 72 185 $19,663 $273 $106 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 11 12 $3,727 $339 $311 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 1 1 $110 $110 $110 130 Minutes99221

Additional Codes-Physician Services 8 9 $1,253 $157 $139 150 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 3 20 $864 $288 $43 715 Minutes99231

Additional Codes-Physician Services 8 44 $3,402 $425 $77 625 minutes99232

Additional Codes-Physician Services 2 2 $281 $141 $141 135 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Shiawassee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Shiawassee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 290 302 $55,674 $192 $184 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 258 269 $65,506 $254 $244 1EncounterH0031

Assessment for Autism 1 2 $185 $185 $93 2EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 190 205 $26,022 $137 $127 1EncounterH0032

Monitoring of Treatment - Clinician 39 42 $8,265 $212 $197 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 74 5,981 $551,375 $7,451 $92 8115 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Shiawassee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 1 19 $815 $815 $43 1915 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 3 5 $1,693 $564 $339 2EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 3 9 $1,461 $487 $162 3EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 55 196 $13,725 $250 $70 415 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 10 7,662 $65,708 $6,571 $9 76615 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 10 280 $24,337 $2,434 $87 2815 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 21 176 $42,524 $2,025 $242 8EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Shiawassee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 4 4 $858 $215 $215 1EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 42 10,725 $70,641 $1,682 $7 25515 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 13 263 $24,282 $1,868 $92 2015 minutesT1016

Targeted Case Management 24 400 $36,857 $1,536 $92 1715 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 57 70 $33,901 $595 $484 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Shiawassee

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 1 10 $1,422 $1,422 $142 10MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 490 $1,693,976

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Clair

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 65 656 $395,827 $6,090 $603 10Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 4 29 $4,764 $1,191 $164 7Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

23 178 $144,483 $6,282 $812 8Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

1 3 $740 $740 $247 3Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $7,046 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 17 106 $33,356 $1,962 $315 6Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Clair

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 3 4 $1,984 $661 $496 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 1 113 $9,482 $9,482 $84 113First 30 Minutes0364T U5

ABA Adaptive Treatment 1 295 $24,992 $24,992 $85 295Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 1 7 $587 $587 $84 7First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 1 21 $1,762 $1,762 $84 21Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

1 40 $3,130 $3,130 $78 40First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

1 45 $3,543 $3,543 $79 45Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 1 3 $474 $474 $158 3Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 2 10 $107 $54 $11 5Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 13 13 $6,323 $486 $486 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 139 141 $68,227 $491 $484 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 138 526 $40,380 $293 $77 430 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Clair

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 282 2,063 $206,934 $734 $100 745 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 201 1,932 $347,724 $1,730 $180 1060 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 69 140 $20,367 $295 $145 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 227 1,169 $168,554 $743 $144 5Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 81 860 $192,607 $2,378 $224 11Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Clair

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 2 6 $599 $299 $100 3Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 1 1 $322 $322 $322 1Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 2 136 $2,059 $1,030 $15 6815 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 1 1 $155 $155 $155 1Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 1 4 $155 $155 $39 415 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Clair

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 10 16 $1,267 $127 $79 2Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 183 590 $81,689 $446 $138 3Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 215 722 $164,660 $766 $228 3Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 31 55 $21,134 $682 $384 2Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Clair

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Clair

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 7 9 $1,765 $252 $196 1ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 0 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 22 307 $40,998 $1,864 $134 14Face to Face ContactH0025

Assessment 426 443 $213,244 $501 $481 1EncounterH0031

Assessment for Autism 16 17 $2,643 $165 $155 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 145 238 $26,805 $185 $113 2EncounterH0032

Monitoring of Treatment - Clinician 59 107 $11,290 $191 $106 2EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 182 44,922 $1,404,407 $7,717 $31 24715 MinutesH0036

Home Based Services 9 303 $10,494 $1,166 $35 3415 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Clair

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 3 12 $1,903 $634 $159 415 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 28 102 $11,297 $403 $111 415 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 83 12,112 $247,729 $2,985 $20 14615 MinutesH2015

Community Living Supports (Daily) 1 365 $305,956 $305,956 $838 365Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 13 759 $46,378 $3,568 $61 5815 MinutesH2021

Wraparound (SED Waiver) 8 124 $35,256 $4,407 $284 16DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 139 598 $115,571 $831 $193 4EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Clair

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 9 57 $8,343 $927 $146 6EncounterS5111 HA

Family Training 22 190 $39,487 $1,795 $208 9EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 13 604 $23,360 $1,797 $39 4615 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 89 253 $9,789 $110 $39 3Up to 15 minT1002

Respite Care 22 15,919 $58,767 $2,671 $4 72415 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 337 6,209 $257,525 $764 $41 1815 minutesT1016

Targeted Case Management 9 693 $16,573 $1,841 $24 7715 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 53 66 $48,810 $921 $740 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 2 5 $779 $390 $156 3ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Clair

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 3 25 $2,880 $960 $115 8MonthT2025

Enhanced Medical Equipment-Supplies 1 2 $1,779 $1,779 $889 2ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 2 14 $625 $312 $45 7Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 2 2 $1,504 $752 $752 1ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 782 $4,901,388

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Joseph

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 2 14 $11,757 $5,878 $840 7Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

8 79 $60,281 $7,535 $763 10Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Joseph

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 7 8 $3,525 $504 $441 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 6 656 $24,164 $4,027 $37 109First 30 Minutes0364T U5

ABA Adaptive Treatment 6 5,540 $202,819 $33,803 $37 923Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 3 292 $6,970 $2,323 $24 97First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 3 289 $6,899 $2,300 $24 96Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

6 258 $22,856 $3,809 $89 43First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

6 515 $45,440 $7,573 $88 86Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 6 14 $2,008 $335 $143 2Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 1 1 $24 $24 $24 1First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 1 1 $207 $207 $207 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 136 596 $52,709 $388 $88 430 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Joseph

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 159 650 $91,386 $575 $141 445 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 118 412 $63,942 $542 $155 360 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 1 1 $215 $215 $215 1First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 134 609 $59,301 $443 $97 5Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 207 924 $122,426 $591 $132 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 7 33 $8,415 $1,202 $255 5Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Joseph

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Joseph

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 1 1 $89 $89 $89 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 30 39 $4,657 $155 $119 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 77 178 $65,287 $848 $367 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 48 70 $33,062 $689 $472 1Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 3 3 $1,571 $524 $524 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 2 2 $100 $50 $50 130 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 1 1 $97 $97 $97 170 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 1 3 $19 $19 $6 315 Minutes99231

Additional Codes-Physician Services 4 6 $487 $122 $81 225 minutes99232

Additional Codes-Physician Services 3 3 $203 $68 $68 135 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Joseph

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Joseph

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 2 2 $207 $103 $103 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 6 27 $14,734 $2,456 $546 5DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 8 198 $66,812 $8,352 $337 25Face to Face ContactH0025

Assessment 279 287 $192,774 $691 $672 1EncounterH0031

Assessment for Autism 24 26 $14,922 $622 $574 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 100 104 $15,523 $155 $149 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 39 3,259 $165,277 $4,238 $51 8415 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Joseph

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 2 7 $1,622 $811 $232 4DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 7 16 $1,474 $211 $92 215 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 66 37,471 $655,636 $9,934 $17 56815 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 1 38 $2,751 $2,751 $72 3815 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 15 173 $44,899 $2,993 $260 12EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Joseph

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 12 104 $18,632 $1,553 $179 9EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 12 13 $978 $82 $75 1EncounterT1001

Health Services 58 88 $7,022 $121 $80 2Up to 15 minT1002

Respite Care 8 3,329 $15,146 $1,893 $5 41615 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 0 0 $0 $0 $0 015 minutesT1016

Targeted Case Management 221 3,718 $356,425 $1,613 $96 1715 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 29 39 $30,659 $1,057 $786 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

St. Joseph

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 542 $2,496,404

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Summit Pointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 10 204 $200,834 $20,083 $984 20Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

1 10 $6,434 $6,434 $643 10Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

2 7 $5,210 $2,605 $744 4Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Summit Pointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 13 18 $12,524 $963 $696 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 9 256 $9,477 $1,053 $37 28First 30 Minutes0364T U5

ABA Adaptive Treatment 9 1,176 $43,611 $4,846 $37 131Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 1 16 $377 $377 $24 16First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 1 15 $354 $354 $24 15Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

9 90 $7,764 $863 $86 10First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

6 62 $5,485 $914 $88 10Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 1 1 $180 $180 $180 1Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 2 2 $212 $106 $106 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 69 69 $20,214 $293 $293 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 96 225 $22,485 $234 $100 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Summit Pointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 444 2,004 $318,574 $718 $159 545 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 373 1,380 $267,779 $718 $194 460 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 25 41 $6,532 $261 $159 2Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 316 1,451 $229,424 $726 $158 5Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 45 347 $36,189 $804 $104 8Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Summit Pointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Summit Pointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 2 2 $255 $128 $128 1Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 1 1 $180 $180 $180 1Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 3 4 $1,082 $361 $270 1Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 49 58 $19,605 $400 $338 1Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 2 6 $361 $180 $60 3Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 45 56 $4,093 $91 $73 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 311 736 $92,349 $297 $125 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 68 85 $14,750 $217 $174 1Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 2 2 $481 $240 $240 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 1 1 $95 $95 $95 170 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 1 1 $6 $6 $6 115 Minutes99231

Additional Codes-Physician Services 1 3 $286 $286 $95 325 minutes99232

Additional Codes-Physician Services 1 1 $95 $95 $95 135 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Summit Pointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Summit Pointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 1 1 $14 $14 $14 1Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 126 152 $15,842 $126 $104 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 10 45 $26,808 $2,681 $596 5DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 643 727 $170,742 $266 $235 1EncounterH0031

Assessment for Autism 20 23 $4,492 $225 $195 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 1 1 $107 $107 $107 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 207 45,483 $1,320,282 $6,378 $29 22015 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Summit Pointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 15 1,536 $32,306 $2,154 $21 10215 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 0 0 $0 $0 $0 0DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 46 226 $31,625 $687 $140 515 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 12 1,664 $10,772 $898 $6 13915 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 76 2,541 $123,755 $1,628 $49 3315 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 33 3,814 $234,926 $7,119 $62 11615 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 0 0 $0 $0 $0 0EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Summit Pointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 1 2 $116 $116 $58 2EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 1 79 $5,647 $5,647 $71 79DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 1 148 $392 $392 $3 14815 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 120 681 $125,972 $1,050 $185 615 minutesT1016

Targeted Case Management 30 2,858 $135,968 $4,532 $48 9515 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 48 79 $52,937 $1,103 $670 2EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Summit Pointe

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 2 12 $573 $286 $48 6MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 1,279 $3,620,574

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Tuscola

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 9 75 $62,607 $6,956 $835 8Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

1 30 $34,149 $34,149 $1,138 30Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

13 136 $115,834 $8,910 $852 10Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 1 $88 $0 $88 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Tuscola

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 3 7 $4,543 $1,514 $649 2Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 4 311 $11,076 $2,769 $36 78First 30 Minutes0364T U5

ABA Adaptive Treatment 4 1,572 $49,085 $12,271 $31 393Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

4 100 $8,019 $2,005 $80 25First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

4 141 $10,102 $2,525 $72 35Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 3 8 $977 $326 $122 3Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 71 74 $59,983 $845 $811 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 1 1 $518 $518 $518 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 25 38 $4,820 $193 $127 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Tuscola

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 60 256 $50,108 $835 $196 445 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 52 163 $54,678 $1,051 $335 360 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 1 1 $159 $159 $159 1Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 41 158 $38,329 $935 $243 4Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 0 $0 $0 $0 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 1 4 $415 $415 $104 4Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Tuscola

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Tuscola

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 60 121 $23,617 $394 $195 2Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 74 161 $37,583 $508 $233 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 42 78 $27,141 $646 $348 2Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 27 52 $30,886 $1,144 $594 2Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 14 16 $2,465 $176 $154 150 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 5 23 $1,024 $205 $45 515 Minutes99231

Additional Codes-Physician Services 21 98 $7,854 $374 $80 525 minutes99232

Additional Codes-Physician Services 3 6 $711 $237 $119 235 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Tuscola

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Tuscola

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 0 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 134 151 $72,029 $538 $477 1EncounterH0031

Assessment for Autism 19 19 $20,570 $1,083 $1,083 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 69 78 $23,123 $335 $296 1EncounterH0032

Monitoring of Treatment - Clinician 5 6 $754 $151 $126 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 132 16,960 $1,823,734 $13,816 $108 12815 MinutesH0036

Home Based Services 15 638 $68,641 $4,576 $108 4315 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Tuscola

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 18 141 $8,290 $461 $59 8DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 4 23 $4,316 $1,079 $188 615 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 0 0 $0 $0 $0 015 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 1 49 $2,233 $2,233 $46 4915 MinutesH2021

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 61 171 $7,764 $127 $45 3Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 0 0 $0 $0 $0 0EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Tuscola

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 1 6 $2,410 $2,410 $402 6EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 1 1 $138 $138 $138 1Up to 15 minT1002

Respite Care 14 1,639 $3,363 $240 $2 11715 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 10 77 $9,141 $914 $119 815 minutesT1016

Targeted Case Management 16 298 $30,183 $1,886 $101 1915 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 35 45 $37,672 $1,076 $837 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Tuscola

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 67 548 $4,666 $70 $9 8MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 11 92 $5,471 $497 $59 8Per session. One night =

one session

T2036

Respite Care 3 15 $368 $123 $25 5Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 271 $2,761,634

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Van Buren

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 1 8 $8,926 $8,926 $1,116 8Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

2 19 $19,859 $9,929 $1,045 10Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

2 5 $5,053 $2,526 $1,011 3Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Van Buren

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 11 15 $8,933 $812 $596 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 12 984 $52,632 $4,386 $53 82First 30 Minutes0364T U5

ABA Adaptive Treatment 12 5,760 $296,718 $24,726 $52 480Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

12 238 $27,089 $2,257 $114 20First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

12 434 $49,123 $4,094 $113 36Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 10 38 $7,958 $796 $209 4Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 1 6 $970 $970 $162 6Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 49 49 $17,950 $366 $366 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 64 238 $36,978 $578 $155 430 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Van Buren

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 124 588 $169,569 $1,367 $288 545 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 50 168 $66,632 $1,333 $397 360 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 36 43 $10,782 $299 $251 1First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 8 10 $1,567 $196 $157 1Each Additional 30

Minutes

90840

Therapy-Family Therapy 26 67 $13,835 $532 $206 3Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 70 226 $52,699 $753 $233 3Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 8 24 $2,407 $301 $100 3Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 2 2 $627 $313 $313 1Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 20 54 $16,094 $805 $298 3Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Van Buren

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 1 3 $320 $320 $107 315 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Van Buren

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 2 2 $125 $63 $63 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 130 350 $31,565 $243 $90 3Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 3 3 $588 $196 $196 1Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 1 1 $123 $123 $123 130 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 1 1 $123 $123 $123 170 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 1 1 $123 $123 $123 115 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 2 2 $246 $123 $123 135 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Van Buren

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Van Buren

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 142 158 $24,416 $172 $155 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 4 20 $16,031 $4,008 $802 5DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 1 1 $169 $169 $169 1EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 93 106 $32,164 $346 $303 1EncounterH0032

Monitoring of Treatment - Clinician 1 1 $251 $251 $251 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 27 2,326 $262,564 $9,725 $113 8615 MinutesH0036

Home Based Services 5 120 $13,540 $2,708 $113 2415 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Van Buren

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 1 5 $1,539 $1,539 $308 5DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 4 7 $2,457 $614 $351 2EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 7 29 $10,180 $1,454 $351 4EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 10 18 $1,128 $113 $63 215 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 2 6 $85 $42 $14 315 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 38 14,821 $135,636 $3,569 $9 39015 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 1 44 $5,129 $5,129 $117 4415 MinutesH2021

Wraparound (SED Waiver) 2 3 $1,580 $790 $527 2DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 0 0 $0 $0 $0 0EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Van Buren

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 8 31 $11,659 $1,457 $376 4EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 1 3 $300 $300 $100 3Up to 15 minT1002

Respite Care 10 5,112 $31,924 $3,192 $6 51115 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 5 27 $4,062 $812 $150 515 minutesT1016

Targeted Case Management 120 3,688 $649,188 $5,410 $176 3115 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 37 50 $23,507 $635 $470 1EncounterT1023

Prevention Services - Direct Model 10 237 $44,569 $4,457 $188 2415 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Van Buren

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 386 $2,171,689

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Washtenaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 27 242 $161,662 $5,987 $668 9Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

47 560 $456,102 $9,704 $814 12Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 40 379 $131,995 $3,300 $348 9Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Washtenaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 4 4 $1,792 $448 $448 1Encounter0359T U5

ABA Behavioral Follow-up Assessment 1 3 $172 $172 $57 3First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 1 5 $273 $273 $55 5Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 2 170 $4,575 $2,287 $27 85First 30 Minutes0364T U5

ABA Adaptive Treatment 2 1,094 $29,582 $14,791 $27 547Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

2 33 $1,983 $991 $60 17First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

1 70 $4,155 $4,155 $59 70Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 2 16 $1,862 $931 $116 8Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 2 2 $871 $435 $435 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 100 102 $51,173 $512 $502 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 33 41 $3,495 $106 $85 130 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Washtenaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 53 125 $16,358 $309 $131 245 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 114 537 $95,258 $836 $177 560 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 41 132 $24,601 $600 $186 3Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 250 2,143 $352,781 $1,411 $165 9Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 3 18 $4,142 $1,381 $230 6Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 18 130 $32,960 $1,831 $254 7Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Washtenaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 3 51 $7,188 $2,396 $141 17Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Washtenaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 2 2 $373 $187 $187 1Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 4 5 $720 $180 $144 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 109 205 $44,212 $406 $216 2Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 209 844 $200,568 $960 $238 4Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 6 6 $2,352 $392 $392 1Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Washtenaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Washtenaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 4 4 $1,786 $446 $446 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 0 0 $0 $0 $0 0DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 371 424 $130,372 $351 $307 1EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 10 10 $11,881 $1,188 $1,188 1H0031 HW

Treatment Planning 195 287 $117,670 $603 $410 1EncounterH0032

Monitoring of Treatment - Clinician 6 6 $2,410 $402 $402 1EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 37 3,673 $645,713 $17,452 $176 9915 MinutesH0036

Home Based Services 9 470 $86,048 $9,561 $183 5215 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Washtenaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 1 42 $1,285 $1,285 $31 4215 minutesH0038

Peer Directed and Operated Support Services 8 279 $8,722 $1,090 $31 3515 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 1 6 $447 $447 $75 6DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 45 212 $54,386 $1,209 $257 515 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 3 52 $227 $76 $4 1715 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 3 4,194 $12,163 $4,054 $3 1,39815 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 11 366 $63,754 $5,796 $174 3315 MinutesH2021

Wraparound (SED Waiver) 7 45 $30,186 $4,312 $671 6DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 20 92 $12,851 $643 $140 5EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Washtenaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 37 1,215 $51,735 $1,398 $43 3315 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 94 96 $21,905 $233 $228 1EncounterT1001

Health Services 4 4 $578 $144 $144 1Up to 15 minT1002

Respite Care 9 4,895 $18,063 $2,007 $4 54415 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 4 55 $9,149 $2,287 $166 1415 minutesT1016

Targeted Case Management 191 2,131 $342,857 $1,795 $161 1115 minutesT1017

Nursing Home Mental Health Monitoring 1 12 $24,515 $24,515 $2,043 1215 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 52 57 $32,983 $634 $579 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Washtenaw

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 605 $3,312,887

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

West Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 8 90 $80,282 $10,035 $892 11Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 2 13 $2,913 $1,457 $224 7Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

1 9 $8,053 $8,053 $895 9Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

West Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 0 0 $0 $0 $0 0Encounter0359T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0First 30 Minutes0364T U5

ABA Adaptive Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

0 0 $0 $0 $0 0Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 52 52 $31,476 $605 $605 1Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 1 1 $363 $363 $363 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 34 58 $5,391 $159 $93 230 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

West Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 61 147 $21,340 $350 $145 245 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 91 859 $166,242 $1,827 $194 960 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 14 16 $8,695 $621 $543 1First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 5 6 $1,732 $346 $289 1Each Additional 30

Minutes

90840

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 39 179 $26,514 $680 $148 5Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 9 38 $4,511 $501 $119 4Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

West Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

West Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 77 81 $16,142 $210 $199 1Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 0 0 $0 $0 $0 030 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 0 0 $0 $0 $0 070 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 6 7 $2,032 $339 $290 125 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99231

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99232

Additional Codes-Physician Services 146 436 $126,545 $867 $290 335 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

West Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

West Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 0 0 $0 $0 $0 0EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 1 5 $3,394 $3,394 $679 5DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 159 166 $53,920 $339 $325 1EncounterH0031

Assessment for Autism 0 0 $0 $0 $0 0EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 66 72 $11,378 $172 $158 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 40 4,379 $317,784 $7,945 $73 10915 MinutesH0036

Home Based Services 0 0 $0 $0 $0 015 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

West Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 1 5 $2,009 $2,009 $402 5DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 0 0 $0 $0 $0 0EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 0 0 $0 $0 $0 0EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 1 2 $272 $272 $136 215 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 1 8 $46 $46 $6 815 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 87 5,028 $42,034 $483 $8 5815 MinutesH2015

Community Living Supports (Daily) 0 0 $0 $0 $0 0Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 11 1,102 $67,365 $6,124 $61 10015 MinutesH2021

Wraparound (SED Waiver) 1 6 $1,467 $1,467 $245 6DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 95 302 $11,086 $117 $37 3Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 88 276 $63,372 $720 $230 3EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

West Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 1 1 $220 $220 $220 1EncounterS5111 HA

Family Training 0 0 $0 $0 $0 0EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 0 0 $0 $0 $0 0DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 0 0 $0 $0 $0 015 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 0 0 $0 $0 $0 0EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 3 114 $580 $193 $5 3815 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 2 24 $1,458 $729 $61 1215 minutesT1016

Targeted Case Management 140 5,312 $347,830 $2,484 $65 3815 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 29 34 $31,833 $1,098 $936 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

West Michigan

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 0 0 $0 $0 $0 0Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 0 0 $0 $0 $0 0MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 0 0 $0 $0 $0 0Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 315 $1,458,278

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Woodlands

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 bundled per diem 0 0 $0 $0 $0 0Days0100 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 4 33 $26,748 $6,687 $811 8Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital/IMD PT68 physician costs excluded 0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT68

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 bundled

per diem

0 0 $0 $0 $0 0Days0100 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

3 31 $25,093 $8,364 $809 10Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital - Acute Community PT73 physician

costs excluded

0 0 $0 $0 $0 0Days0114, 0124, 0134, 0154 PT73

Local Psychiatric Hospital/IMD 0 0 $0 $0 $0 0AmountPT68

Local Psychiatric Hospital/Acute Community 0 0 $0 $0 $0 0AmountPT73

Inpatient Hospital Ancillary Services - Room and Board 0 0 $0 $0 $0 0Days0144

Inpatient Hospital Ancillary Services - Leave of Absence 0 0 $0 $0 $0 0Days0183

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 00250-0254, 0257-0258

Inpatient Hospital Ancillary Services - Medical/Surgical Supplies

and Devices

0 0 $0 $0 $0 0# of items0270-0272

Inpatient Hospital Ancillary Services - Laboratory 0 0 $0 $0 $0 0# of tests0300-0302, 0305-0307

Inpatient Hospital Ancillary Services - Radiology 0 0 $0 $0 $0 0# of tests0320

ECT Anesthesia 0 0 $0 $0 $0 00370

Inpatient Hospital Ancillary Services - Respiratory Services 0 0 $0 $0 $0 0# of treatments0410

Inpatient Hospital Ancillary Services -Physical Therapy 0 0 $0 $0 $0 0# of treatments0420-0424

Inpatient Hospital Ancillary Services - Occupational Therapy 0 0 $0 $0 $0 0# of treatments0430-0434

Inpatient Hospital Ancillary Services - Speech-Language

Pathology

0 0 $0 $0 $0 0# of treatments0440-0444

Inpatient Hospital Ancillary Services - Emergency Room 0 0 $0 $0 $0 0# of visits0450

Inpatient Hospital Ancillary Services - Pulmonary Function 0 0 $0 $0 $0 0# of tests0460

Inpatient Hospital Ancillary Services - Audiology 0 0 $0 $0 $0 0# of tests0470-0472

Inpatient Hospital Ancillary Services - Magnetic Resonance

Technology (MRT)

0 0 $0 $0 $0 0# of tests0610-0611

Inpatient Hospital Ancillary Services - Pharmacy 0 0 $0 $0 $0 0# of units0636

ECT Recovery Room 0 0 $0 $0 $0 00710

Inpatient Hospital Ancillary Services -EKG/ECG 0 0 $0 $0 $0 0# of tests0730-0731

Inpatient Hospital Ancillary Services - EEG 0 0 $0 $0 $0 0# of tests0740

Crisis Observation Care 0 0 $0 $0 $0 0Hour0762

Additional Codes-ECT Facility Charge 0 0 $0 $0 $0 0Encounter0901

Inpatient Hospital Ancillary Services - Psychiatric/Psychological

Treatments/Services

0 0 $0 $0 $0 0# of visits0900, 0902-0904,

0911, 0914-0919

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0912

Outpatient Partial Hospitalization 0 0 $0 $0 $0 0Days0913

Inpatient Hospital Ancillary Services - Other Diagnosis Services 0 0 $0 $0 $0 0# of tests0925

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Woodlands

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Inpatient Hospital Ancillary Services - Other Therapeutic Services 0 0 $0 $0 $0 0# of visits0940-0942

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes00104

Additional Codes-ECT Anesthesia 0 0 $0 $0 $0 0Minutes0901 00104

ABA Behavior Identification Assessment 10 19 $10,268 $1,027 $540 2Encounter0359T U5

ABA Behavioral Follow-up Assessment 1 6 $559 $559 $93 6First 30 Minutes0362T U5

ABA Behavioral Follow-up Assessment 2 32 $2,699 $1,350 $84 16Each Additional 30

Minutes

0363T U5

ABA Adaptive Treatment 3 319 $15,289 $5,096 $48 106First 30 Minutes0364T U5

ABA Adaptive Treatment 3 1,107 $50,893 $16,964 $46 369Each Additional 30

Minutes

0365T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 30 Minutes0366T U5

ABA Group Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0367T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

3 87 $8,160 $2,720 $94 29First 30 Minutes0368T U5

ABA Clinical Observation and Direction of Adaptive Behavior

Treatment

3 111 $10,136 $3,379 $91 37Each Additional 30

Minutes

0369T U5

ABA Family Behavior Treatment Guidance 3 7 $1,424 $475 $203 2Encounter0370T U5

ABA Family Behavior Treatment Guidance 0 0 $0 $0 $0 0Encounter0371T U5

ABA Adaptive Behavior Treatment Social Skills Group 0 0 $0 $0 $0 0Encounter0372T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0First 60 Minutes0373T U5

ABA Exposure Adaptive Behavior Treatment 0 0 $0 $0 $0 0Each Additional 30

Minutes

0374T U5

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80300

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service80301

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80302

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0per date of service 80303

Drug Screen for Methadone Clients Only - Note: retired 12/31/16 0 0 $0 $0 $0 0each procedure80304

Drug Screen 0 0 $0 $0 $0 0Encounter80305

Drug Screen 0 0 $0 $0 $0 0Encounter80306

Drug Screen 0 0 $0 $0 $0 0Encounter80307

Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785

Assessment for Autism 0 0 $0 $0 $0 0Encounter90785 U5

Substance Abuse - Interactive Complexity - Add On Code 0 0 $0 $0 $0 0Encounter90785 HF

Assessment 0 0 $0 $0 $0 0Encounter90791

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90791 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90791 U5

Assessment 33 33 $18,336 $556 $556 1Encounter90792

Substance Use: Assessment 0 0 $0 $0 $0 0Encounter90792 HF

Assessment for Autism 0 0 $0 $0 $0 0Encounter90792 U5

Mental Health: Outpatient Care 7 23 $1,338 $191 $58 330 Minutes90832

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 030 Minutes0900, 0906, 0914,

0915, 0916, 0919

90832 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Woodlands

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment 0 0 $0 $0 $0 030 Minutes90833

Mental Health: Outpatient Care 85 225 $27,522 $324 $122 345 Minutes90834

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 045 Minutes0900, 0906, 0914,

0915, 0916, 0919

90834 HF

Assessment 0 0 $0 $0 $0 045 Minutes90836

Mental Health: Outpatient Care 6 33 $7,880 $1,313 $239 660 Minutes90837

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 060 Minutes90837 HF

Assessment 0 0 $0 $0 $0 060 Minutes90838

Psychotherapy for Crisis First 60 Minutes 0 0 $0 $0 $0 0First 30-74 Min.90839

Psychotherapy for Crisis Each Additional 30 Minutes 0 0 $0 $0 $0 0Each Additional 30

Minutes

90840

Therapy-Family Therapy 8 28 $2,739 $342 $98 4Encounter90846

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90846 HF

Therapy-Family Therapy 57 160 $26,062 $457 $163 3Encounter90847

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90847 HF

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849

Therapy-Family Therapy 0 0 $0 $0 $0 0Encounter90849 HS

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90849 HF

Therapy-Group Therapy 0 0 $0 $0 $0 0Encounter90853

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

90853 HF

Pharmacological Management (SED Waiver) 0 0 $0 $0 $0 090863

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter90870

Additional Codes-ECT Physician 0 0 $0 $0 $0 0Encounter0901 90870

Assessments-Other 0 0 $0 $0 $0 0Encounter90887

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92507

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92508

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92521

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92522

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92523

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92524

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92526

Speech & Language Therapy 0 0 $0 $0 $0 0First Hour92607

Speech & Language Therapy 0 0 $0 $0 $0 0Each Additional 30

Minutes

92608

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92609

Speech & Language Therapy 0 0 $0 $0 $0 0Encounter92610

Psychological Testing PSYCH/PHYS 0 0 $0 $0 $0 0Per Hour96101

Assessment for Autism 0 0 $0 $0 $0 0Hour96101 U5

Psychological Testing by Technician 0 0 $0 $0 $0 0Per Hour96102

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Woodlands

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Assessment for Autism 0 0 $0 $0 $0 0Hour96102 U5

Psychological Testing by Comp 0 0 $0 $0 $0 0Per Hour96103

Assessments-Other 0 0 $0 $0 $0 0Encounter96105

Assessments-Other 0 0 $0 $0 $0 0Encounter96110

Assessments-Other 0 0 $0 $0 $0 0Encounter96111

Neurobehavioral Status Exam 0 0 $0 $0 $0 0Per Hour96116

Neuropsych test by Psych/Phys 0 0 $0 $0 $0 0Per Hour96118

Assessment for Autism 0 0 $0 $0 $0 0Hour96118 U5

Neuropsych test by Tech 0 0 $0 $0 $0 0Per Hour96119

Assessment for Autism 0 0 $0 $0 $0 0Hour96119 U5

Neuropsych test Admin w/Comp 0 0 $0 $0 $0 0Per Hour96120

Assessments-Other 0 0 $0 $0 $0 096127

Medication Administration 0 0 $0 $0 $0 0Encounter96372

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97001

Physical Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97002

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97003

Occupational Therapy - Note: retired 1/1/17 0 0 $0 $0 $0 0Encounter97004

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97110

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97112

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97113

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97116

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97124

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97140

Occupational or Physical Therapy 0 0 $0 $0 $0 0Encounter97150

Physical Therapy 0 0 $0 $0 $0 0Encounter97161

Physical Therapy 0 0 $0 $0 $0 0Encounter97162

Physical Therapy 0 0 $0 $0 $0 0Encounter97163

Physical Therapy 0 0 $0 $0 $0 0Encounter97164

Occupational Therapy 0 0 $0 $0 $0 0Encounter97165

Occupational Therapy 0 0 $0 $0 $0 0Encounter97166

Occupational Therapy 0 0 $0 $0 $0 0Encounter97167

Occupational Therapy 0 0 $0 $0 $0 0Encounter97168

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97530

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97532

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97533

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97535

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97537

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97542

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97750

Occupational Therapy 0 0 $0 $0 $0 015 Minutes97755

Occupational or Physical Therapy 0 0 $0 $0 $0 015 Minutes97760

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Woodlands

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

C/O for Orthotic/Prosth Use or Physical Therapy 0 0 $0 $0 $0 015 minutes97762

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97802

Assessment or Health Services 0 0 $0 $0 $0 015 Minutes97803

Health Services 0 0 $0 $0 $0 030 Minutes97804

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97810

Substance Use Disorder: Acupuncture 0 0 $0 $0 $0 0Encounter97811

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99201

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99201 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99202

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99202 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99203

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99203 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99204

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99204 HF

New Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99205

Substance Use Disorder: New Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99205 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99211

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99211 HF

Established Patient Evaluation and Management 1 1 $70 $70 $70 1Encounter99212

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99212 HF

Established Patient Evaluation and Management 63 184 $26,319 $418 $143 3Encounter99213

Sustance Abuse: Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99213 HF

Established Patient Evaluation and Management 1 1 $70 $70 $70 1Encounter99214

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99214 HF

Established Patient Evaluation and Management 0 0 $0 $0 $0 0Encounter99215

Substance Use Disorder: Established Patient Evaluation and

Management

0 0 $0 $0 $0 0Encounter99215 HF

Additional Codes-Physician Services 3 3 $308 $103 $103 130 Minutes99221

Additional Codes-Physician Services 0 0 $0 $0 $0 050 Minutes99222

Additional Codes-Physician Services 3 5 $521 $174 $104 270 Minutes99223

Additional Codes-Physician Services 0 0 $0 $0 $0 015 Minutes99224

Additional Codes-Physician Services 0 0 $0 $0 $0 025 minutes99225

Additional Codes-Physician Services 0 0 $0 $0 $0 035 Minutes99226

Additional Codes-Physician Services 1 1 $67 $67 $67 115 Minutes99231

Additional Codes-Physician Services 4 18 $1,872 $468 $104 525 minutes99232

Additional Codes-Physician Services 5 24 $2,497 $499 $104 535 Minutes99233

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Woodlands

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 015 Minutes99241 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 030 Minutes99242 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99243 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 060 Minutes99244 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99245 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 020 Minutes99251 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 040 Minutes99252 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 055 Minutes99253 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 080 Minutes99254 HF

Substance Use Disorder: Physician Consultations 0 0 $0 $0 $0 0110 Minutes99255 HF

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99304

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99305

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 045 Minutes99306

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 010 Minutes99307

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 015 Minutes99308

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 025 minutes99309

Nursing Facility Services evaluation and management 0 0 $0 $0 $0 035 Minutes99310

Assessment 0 0 $0 $0 $0 0Encounter99324

Assessment 0 0 $0 $0 $0 0Encounter99325

Assessment 0 0 $0 $0 $0 0Encounter99326

Assessment 0 0 $0 $0 $0 0Encounter99327

Assessment 0 0 $0 $0 $0 0Encounter99328

Assessment 0 0 $0 $0 $0 0Encounter99334

Assessment 0 0 $0 $0 $0 0Encounter99335

Assessment 0 0 $0 $0 $0 0Encounter99336

Assessment 0 0 $0 $0 $0 0Encounter99337

Assessment 0 0 $0 $0 $0 0Encounter99341

Assessment 0 0 $0 $0 $0 0Encounter99342

Assessment 0 0 $0 $0 $0 0Encounter99343

Assessment 0 0 $0 $0 $0 0Encounter99344

Assessment 0 0 $0 $0 $0 0Encounter99345

Assessment 0 0 $0 $0 $0 0Encounter99347

Assessment 0 0 $0 $0 $0 0Encounter99348

Assessment 0 0 $0 $0 $0 0Encounter99349

Assessment 0 0 $0 $0 $0 0Encounter99350

Medication Administration 0 0 $0 $0 $0 0Encounter99506

Medication Management 0 0 $0 $0 $0 015 Minutes99605

Transportation 0 0 $0 $0 $0 0Per mileA0080

Transportation 0 0 $0 $0 $0 0Per mileA0090

Transportation 0 0 $0 $0 $0 0Per one-way tripA0100

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0100 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Woodlands

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per one-way tripA0110

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per one-way tripA0110 HF

Transportation 0 0 $0 $0 $0 0Per one-way tripA0120

Transportation 0 0 $0 $0 $0 0Per one-way tripA0130

Transportation 0 0 $0 $0 $0 0Per one-way tripA0140

Transportation 0 0 $0 $0 $0 0A0170

Additional Codes-Transportation 0 0 $0 $0 $0 0Per MileA0425

Additional Codes-Transportation 0 0 $0 $0 $0 0Refer to code descriptions.A0427

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsE1399

Family Training/Support EBP only 0 0 $0 $0 $0 0Encounter Session at least

45 min

G0177

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesG0409

Substance Use Disorder: Individual Assessment 0 0 $0 $0 $0 0EncounterH0001

Assessment 59 59 $17,077 $289 $289 1EncounterH0002

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0003

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0004

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 0Encounter0900, 0906, 0914,

0915, 0916, 0919

H0005

Substance Use Disorder: Case Management 0 0 $0 $0 $0 0EncounterH0006

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0010

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0012

Substance Use Disorder: Sub-Acute Detoxification 0 0 $0 $0 $0 0Days1002 H0014

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Days0906 H0015

Crisis Residential Services 5 25 $16,284 $3,257 $651 5DaysH0018

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0018 HF

Substance Use Disorder: Residential 0 0 $0 $0 $0 0Days1002 H0019 HF

Substance Use Disorder: Methadone 0 0 $0 $0 $0 0EncounterH0020

Substance Use Disorder: Early Intervention 0 0 $0 $0 $0 0EncounterH0022

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0023

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterH0023 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0Face to Face ContactH0025

Assessment 137 145 $50,368 $368 $347 1EncounterH0031

Assessment for Autism 1 1 $570 $570 $570 1EncounterH0031 U5

Support Intensity Scale (SIS) Face-to-Face Assessment 0 0 $0 $0 $0 0H0031 HW

Treatment Planning 136 146 $28,571 $210 $196 1EncounterH0032

Monitoring of Treatment - Clinician 0 0 $0 $0 $0 0EncounterH0032 TS

Substance Use Disorder: Pharmalogical Support - Suboxane 0 0 $0 $0 $0 0Direct Observation

Encounter

H0033

Health Services 0 0 $0 $0 $0 015 MinutesH0034

Home Based Services 46 3,945 $439,671 $9,558 $111 8615 MinutesH0036

Home Based Services 1 6 $681 $681 $113 615 MinutesH0036 ST

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Woodlands

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 minutesH0038

Peer Directed and Operated Support Services 0 0 $0 $0 $0 015 MinutesH0038 TJ

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 015 MinutesH0038 HF

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0NA

Assertive Community Treatment (ACT) 0 0 $0 $0 $0 015 MinutesH0039

Community Living Supports in Independent living/own home 0 0 $0 $0 $0 0Per diemH0043

Respite 5 44 $11,024 $2,205 $251 9DaysH0045

Peer Directed and Operated Support Services 0 0 $0 $0 $0 0EncounterH0046

Substance Use Disorder: Laboratory 0 0 $0 $0 $0 0EncounterH0048

Substance Use Disorder: Outpatient Treatment 0 0 $0 $0 $0 015 Minutes0900, 0906, 0914,

0915, 0916, 0919

H0050

Behavior Treatment Plan Review 1 11 $2,092 $2,092 $190 11EncounterH2000

Behavior Treatment Plan Review - Monitoring Activities 1 3 $313 $313 $104 3EncounterH2000 TS

Comprehensive Medication Services - EBP only 0 0 $0 $0 $0 015 minutesH2010

Crisis Intervention 7 40 $5,089 $727 $127 615 MinutesH2011

Substance Use Disorder: Crisis Intervention, per 15 minutes 0 0 $0 $0 $0 015 MinutesH2011 HF

Skill-Building and Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 minutesH2014

Out of Home Non Vocational Habilitation 0 0 $0 $0 $0 015 MinutesH2014 HK

Community Living Supports (15 Minutes) 13 6,583 $34,347 $2,642 $5 50615 MinutesH2015

Community Living Supports (Daily) 1 229 $45,107 $45,107 $197 229Per DiemH2016

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019

Behavior Services 0 0 $0 $0 $0 015 MinutesH2019 TT

Wraparound 8 223 $59,853 $7,482 $268 2815 MinutesH2021

Wraparound (SED Waiver) 1 1 $367 $367 $367 1DaysH2022

Wraparound (SED Waiver) 0 0 $0 $0 $0 0DaysH2022 TT

Supported Employment Services 0 0 $0 $0 $0 015 minutesH2023

Mental Health Therapy 0 0 $0 $0 $0 015 MinutesH2027

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 015 Minutes0900, 0914, 0915,

0916, 0919

H2027 HF

Clubhouse Psychosocial Rehabilitation Programs 0 0 $0 $0 $0 015 MinutesH2030

Home Based Services 0 0 $0 $0 $0 015 MinutesH2033

Substance Use Disorder: Recovery Housing 0 0 $0 $0 $0 0DaysH2034

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Hour0900, 0906, 0914,

0915, 0916, 0919

H2035 HF

Substance Use Disorder: Outpatient Care 0 0 $0 $0 $0 0Per Diem0900, 0906, 0914,

0915, 0916, 0919

H2036 HF

Telemedicine Facility Fee 0 0 $0 $0 $0 0Per ServiceQ3014 GT

Transportation 0 0 $0 $0 $0 0Per MileS0209

Transportation 0 0 $0 $0 $0 0Per MileS0215

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per MileS0215 HF

Family Training - EBP 0 0 $0 $0 $0 015 MinutesS5110

Family Training 11 44 $11,318 $1,029 $257 4EncounterS5111

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Woodlands

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Family Training 0 0 $0 $0 $0 0EncounterS5111 HA

Family Training 2 3 $772 $386 $257 2EncounterS5111 HM

Home Care Training, Non-Family (Children's Waiver) 0 0 $0 $0 $0 0EncounterS5116

Foster Care 0 0 $0 $0 $0 0DaysS5140

Foster Care 1 193 $68,791 $68,791 $356 193DaysS5145

Respite 0 0 $0 $0 $0 015 MinutesS5150

Respite 0 0 $0 $0 $0 0Per DiemS5151

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0EncounterS5160

Personal Emergency Response System (PERS) 0 0 $0 $0 $0 0MonthS5161

Environmental Modification 0 0 $0 $0 $0 0ServiceS5165

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsS5199

Occupational or Physical Therapy 0 0 $0 $0 $0 0EncounterS8990

Health Services 0 0 $0 $0 $0 0EncounterS9445

Health Services 0 0 $0 $0 $0 0EncounterS9446

Health Services 0 0 $0 $0 $0 0EncounterS9470

Prevention Services - Direct Model 1 16 $319 $319 $20 1615 minutesS9482

Intensive Crisis Stabilization-Enrolled Program 0 0 $0 $0 $0 0HourS9484

Residential Room and Board 0 0 $0 $0 $0 0DaysS9976

Substance Use Disorder: Residential Room and Board 0 0 $0 $0 $0 0DaysS9976 HF

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TD

Private Duty Nursing 0 0 $0 $0 $0 0Up to 15 minT1000 TE

Assessment 1 1 $209 $209 $209 1EncounterT1001

Health Services 0 0 $0 $0 $0 0Up to 15 minT1002

Respite Care 10 6,557 $29,043 $2,904 $4 65615 MinutesT1005

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TD

Respite Care 0 0 $0 $0 $0 015 MinutesT1005 TE

Respite Care (Children's Waiver & SED Waiver) 0 0 $0 $0 $0 015 minutesT1005 TT

Substance Use Disorder: Treatment Planning 0 0 $0 $0 $0 0EncounterT1007 HF

Substance Use Disorder: Child Sitting Services 0 0 $0 $0 $0 0EncounterT1009

Substance Use Disorder: Recovery Support Services 0 0 $0 $0 $0 0EncounterT1012

Family Psycho-Education - EBP 0 0 $0 $0 $0 0EncounterT1015

Supports Coordination/Wrap Facilitation 24 528 $58,257 $2,427 $110 2215 minutesT1016

Targeted Case Management 22 341 $35,855 $1,630 $105 1615 minutesT1017

Nursing Home Mental Health Monitoring 0 0 $0 $0 $0 015 minutesT1017 SE

Personal Care in Licensed Specialized Residential Setting 0 0 $0 $0 $0 0DaysT1020

Assessments 21 24 $12,845 $612 $535 1EncounterT1023

Prevention Services - Direct Model 0 0 $0 $0 $0 015 MinutesT1027

Enhanced Medical Supplies or Pharmacy 0 0 $0 $0 $0 0ItemsT1999

Transportation 0 0 $0 $0 $0 0EncounterT2001

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2001 HF

Michigan Department of Health and Human Services

Division of Quality Management and Planning

CMHSP Cost Data by Service Category

Children with Serious Emotional Disturbance

State of Michigan

Fiscal Year 2017SUB-ELEMENT COST REPORT: QMPmeasures@michigan.gov

Woodlands

Cases UnitsUnit

Measure Cost Cost/Case Cost/Unit Unit/CaseService Category Revenue Code HCPCS Code Modifier

Transportation 0 0 $0 $0 $0 0Per DiemT2002

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Per DiemT2002 HF

Transportation 1 101 $40 $40 $0 101Encounter / TripT2003

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0Encounter / TripT2003 HF

Transportation 0 0 $0 $0 $0 0EncounterT2004

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2004 HF

Transportation 0 0 $0 $0 $0 0EncounterT2005

Substance Use Disorder: Transportation 0 0 $0 $0 $0 0EncounterT2005 HF

Prevention Services - Direct Model 0 0 $0 $0 $0 0T2024

Fiscal Intermediary Services 1 17 $2,253 $2,253 $133 17MonthT2025

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2028

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2029

Respite Care 2 4 $613 $307 $153 2Per session. One night =

one session

T2036

Respite Care 0 0 $0 $0 $0 0Per session. One

day/partial day = one

session

T2037

Housing Assistance 0 0 $0 $0 $0 0ServiceT2038

Enhanced Medical Equipment-Supplies 0 0 $0 $0 $0 0ItemsT2039

Goods and Services 0 0 $0 $0 $0 0Per ItemT5999 HK

Wraparound Services 0 0 $0 $0 $0 0Per ItemT5999

Pharmacy (Drugs and Other Biologicals) 0 0 $0 $0 $0 0

Other 0 0 $0 $0 $0 0

Aggregate for 'J' Codes 0 0 $0 $0 $0 0ALL

Total Population and Cost 308 $1,198,598

Michigan Department of Health and Human Services

Division of Quality Management and Planning