About Medicaid, Addiction Treatment and Substance Use Disorder Billing in Washington State
The Medicaid program in Washington State is nicknamed Apple Health. Apple Health provides members with a level of coverage for behavioral healthcare that rivals many other states in the US. The Washington Health Care Authority oversees substance use treatment services for Apple Health patients in Washington.
What are Some of the Most Common Addiction Treatment CPT Codes Used for Billing Medicaid in Washington?
Washington Medicaid will reimburse for a wide variety of addiction treatment services. The following list is not complete, however, it does describe most of the covered services that can be successfully billed to Washington Medicaid. You can find all of the these CPT codes in the Substance Use Disorder Billing Guide maintained by Washington Medicaid.
H0001 HD - Substance use disorder assessment, pregnant and parenting women
H0001 HF - Alcohol and/or drug assessment, general
H0004 HF - Alcohol and/or drug services, individual therapy without family present
H0038 HF - Self-help/peer services
H0020 HF - Alcohol and/or drug services for Opiate substitution treatment, methadone
T1017 HF - Targeted case management
96164 HF - Health behavior intervention, group setting, in person, first 30 minutes
96165 HF - Health behavior intervention, group setting, in person, additional 15 minutes
96167 HF - Health behavior intervention, with family and patient present, first 30 minutes
96168 HF - Health behavior intervention, with family and patient present, additional 15 minutes
96170 HF - Health behavior intervention, just the family, no patient present, first 30 minutes
96171 HF - Health behavior intervention, just the family, no patient present, additional 15 minutes
H0010 HA - Alcohol and drug services for youth, sub-acute withdrawal management
H0010 HF - Alcohol and drug services for adults, sub-acute withdrawal management
H0011 HA - Alcohol and drug services for youth, acute withdrawal management
H0011 HF - Alcohol and drug services for adults, acute withdrawal management
H0018 HA - Alcohol and drug services for adults, recovery house
H0018 HV - Alcohol and drug services for adults, intensive inpatient residential without room and board
H0019 HA - Alcohol and drug services for youth, intensive inpatient residential without room and board
H0019 HB - Alcohol and drug services for pregnant and parenting women with children, residential treatment
H0019 HD - Alcohol and drug services for pregnant and parenting women without children, residential treatment
H0019 TG - Alcohol and drug services, residential treatment for long-term recovery
H2036 HA - Alcohol and drug treatment program for youth, specifically for room and board
H2036 HF - Alcohol and drug treatment program for adults, specifically for room and board
H2036 HD - Alcohol and drug treatment program, PPW room and board
80305 HF, 80306 HF, 80307 HF, - Drug testing
What Sorts of Billing Limitations Exist for Medicaid Patients Receiving Addiction Treatment Services in Washington?
While coverage for addiction treatment services is very robust for Medicaid patients in Washington, some limitations do apply to certain types of services. All services, of course, must be medically necessary and well-documented. All services must also be rendered by the appropriate professionals. Beyond those basics, addiction treatment billing departments need to remember the following limitations:
Case management (T1017) can’t be billed for time spent in doing outreach, reviewing notes, attending to internal staffing (staff meetings), writing court notes regarding compliance or progress, interfacing with probation officers or court reporting.
Individual therapy (H0004) is capped at 3 hours per patient, per day.
Group therapy (96164 HF, 96165 HF) is capped at 11 units per client, per day.
Family therapy (96167 HF, 96168 HF) is capped at 11 units per client, per day.
Opiate substitution treatment, substance use disorder assessments and sub-acute withdrawal management services are all capped at one service episode per day, per client.
Are Peer Support Services Covered for Medicaid Patients in Washington?
Yes, peer support services are covered in Washington state for Apple Health patients receiving Substance Use Disorder services.
Peer support services are billed under CPT code H0038 HF and they are sometimes referred to as “self-help” or “peer services.” Each instance of H0038 HF equals 15 minutes of service.
All peer support services must be medically necessary, be prescribed in detail (including goal, duration and frequency) in a service plan, and be delivered in a location that makes sense for the client logistically. Washington State does have a certification program for peer support providers. Certified peer support providers in Washington must have at least one year of recovery, be open and willing to share their recovery journey with patients, be able to pass a reading and writing test, pass HCA-approved education and testing, and maintain a counseling credential with an agency affiliated with the Department of Health.
Other Blog Posts About Addiction Treatment and Billing in Washington State
Thinking of Opening an Addiction Treatment Center in Washington? Here’s What You Need to Know.
Where Can I Find Addiction Treatment Utilization Forms for Premera Blue Cross?
Behave Health Knows Washington State Medicaid Billing for Addiction Treatment
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