| Document Date: 2014-07-09 11:51:56
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Company CBC / ICU medical / / Currency USD / / Facility Hospital X Habilitation Provider / Hospital Habilitation Provider Non-Emergency Transportation / Emergency Transportation Crisis Services Provider Level I Subacute Facility / Crisis Services Provider Level I Subacute Facility / Level I Subacute Facility / I Subacute Facility / / IndustryTerm family / imaging / insurance carriers / / MedicalCondition Syphilis / HIV / Electro Shock / Infectious / MS / Max Units Current Rate Non Facility Facility Rate Rate Infectious / tuberculosis / / MedicalTreatment electroconvulsive therapy / Psychotherapy / biofeedback / / Organization IMD / Community Service Agency / / Person Psychotherapy / Max Units / Bill Magnetic / / / Position Psychologist / private COS Code DO-Physician / Licensed Independent Substance Abuse Counselor / Physician / Service Agency Air Transportation Licensed Professional Counselor Licensed Marriage/Family Therapist Licensed Clinical Social Worker / Therapist Licensed Clinical Social Worker / General / Service Type Valid Modifier Description COS Code DO-Physician / Habilitation Provider Non-Emergency Transportation Nurse Practitioner Physician Assistant / DO-Physician / Valid Modifier Description COS Code DO-Physician / Behavioral Health Therapeutic Home Rural Substance Abuse Transitional Agency Licensed Professional Counselor Licensed Marriage/Family Therapist Licensed Clinical Social Worker / Behavioral Health Therapeutic Home Rural Substance Abuse Transitional Agency Licensed Professional Counselor / Physician Assistant / / / Product Dexamethasone / Carbamazepine / Folic acid / Cyanocobalamin / / ProgrammingLanguage T / / Technology tomography / biofeedback / Telemedicine / / URL www.ahcccs.state.az.us/Rates / /
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ADHS/DBHS Allowable Procedure Code Matrix July 2014 At the time of posting all procedures identified on this matrix are allowable ADHS Covered Services, Providers should verify coverage with their respective RBHA at the