11-179
us-hi-regs-official-91ca9dd4041e54c7544193029524d0c97db472908a6d3ab780396102499480c711-179Regulation
HAWAII ADMINISTRATIVE RULES TITLE 11 DEPARTMENT OF HEALTH CHAPTER 179 PAYMENT FEES FOR COMMUNITY MENTAL HEALTH CENTERS §11-179-1 §11-179-2 §11-179-3 §11-179-4 Purpose Definitions Liability for fees Right to appeal §11-179-1 Purpose. The purpose of this chapter is to establish a payment fee schedule for care and treat- ment of clients in community mental h~~ttQ ~~nters and to establish billing procedures. [Eff UL, U4 1991 J (Auth: HRS §334-9) (Imp: HRS §334-6) §11-179-2 Definitions. As used in this chapter: "Community mental health center"·means one or more facilities which alone or in conjunction with other facilities, public or priv~te, are part of a coordinated program providing a variety of mental health services principally for persons residing in a community or communities in or near which the center is located, and is under the jurisdiction of the state or county or derives more than fifty per cent of its revenues from the general fund of the State. "Client" means a person under the observation, care, or treatment at a community mental health center. "Der+P.rtment" means the department of health. [Eff uCT 041qg1 ] (Auth: HRS §334-9) (Imp: HRS §334-6') §11-179-3 Liability for fees. (a) Every client who receives services at a community mental health center shall be liable for payment pursuant to the rates as set forth in the Community Mental Health Charge Slip 12/1/90 and Clinic Rate Schedule 12/1/90, located at the end of this chapter, except when such payment would be in violation of federal or state law. (bl Collections shall be made pursuant to HRS §334-6. [Eff UCT 041991 ] (Auth: HRS §334.9) (Imp: HRS §334-6) 179-1 1480
CENTER--------- COMMUNITY MENTAL HEALTH CENTER CHARGE SLIP Name of Provider Name of Client CR ii DATE OF INITIAL VISIT:------ ICD-9CM DX CODE 1. DESCRIPTION ----2. 3.---- Number Date of Service Walk PATIENT COMPLAINT: ------------ CONDITION RELATED TO: y N --Y--N --Y--N --Y--N Patient's Employment Automobile Other Party Liability Accident Related Injury TYPE OF SERVICE 90000 OFV Brief, New 90010 OFV Limited, New Client 90015 OFV Inter., New Client 90020 OFV Compre. New Client -- 90030 OFV Minimal, Estb. Client 90040 OFV Brief, Estb. Client 90050 OFV Limited, Estb. Client 90060 OFV Inter. Estb. Client 90070 OFV Extended, Estb. Client 90080 OFV Compre., Estb. Client 90200 Initial Hosp. Care-Brief 90215 Initial Hosp. Care-Intermediate -- 90220 Initial Hosp. Care-Comprehensive 90600 Consultation, Initial, Limited 90605 Consultation, Initial, Interm. 90610 Consultation, Initial, Extended 90620 Consultation, Initial, Compre. 90630 Consultation, Initial, Complex 90640 F/U Consultation, Brief 90641 F/U Consultation, Limited PRESCRIPTION 90642 90643 90782 90801 90801-22 90801-52 90825 90830 90841 90843 90844 90847 90849 90853 W9205 W9205-52 W9206 F/U Consultation, Intermediate F/U Consultation, Complex Ther. Inject. Intramuscular Initial Psych. Diag/Eval. Initial Psych. Diag/Eval. Initial Psych. Diag/Eval. Psych. Eval. of Hosp. Records Psychological Testing Psychotherapy (15 minutes) Psychotherapy (25 minutes) Psychotherapy (50 minutes) Family/Conjoint Psycho-therapy Multi Family Group Therapy Group Therapy Clinic Visit Clinic Visit - Group OHS Psych. Diag./Evaluation Occupational Therapy RX NO. NATIONAL DRUG CODE QUANTITY DAYS SUPPLY REFILL CHARGES DEDUCTIBLE BALANCE 1.-------------------------------------- 2. _____________________________________ _ 3. -------------------------------------- SUMMARY/SYNOPSIS OF VISIT: Provider Signature: ------------- 12/1/90 1 4
PROC. CODE 90000 90010 90015 90020 90030 90040 90050 90060 90070 90080 90200 90215 90220 90600 90605 90610 90620 90630 90640 90641 90642 90643 90801 90801-22 90801-52 90825 90830 90841 90843 90844 90847 90853 90782 90849 W9205 W9205-52 W9206 12/1/90 DESCRIPTION CLINIC RATE SCHEDULE OFV, BRIEF, NEW OFV, LIMITED, NEW OFV, INTERMEDIATE, NEW OFV, COMPREHENSIVE, NEW OFV, MINIMAL, ESTABLISHED OFV, BRIEF, ESTABLISHED OFV, LIMITED, ESTABLISHED OFV, INTERMEDIATE, ESTABLISHED OFV, EXTENDED, ESTABLISHED OFV, COMPREHENSIVE, ESTABLISHED INITIAL HOSP. CARE - BRIEF INITIAL HOSP. CARE - INTERMEDIATE INITIAL HOSP. CARE - COMPREHENSIVE CONSULTATION, INITIAL, LIMITED CONSULTATION, INITIAL, INTERMEDIATE CONSULTATION, INITIAL, EXTENDED CONSULTATION, INITIAL, COMPREHENSIVE CONSULTATION, INITIAL, COMPLEX CONSULTATION, FOLLOW-UP, BRIEF CONSULTATION, FOLLOW-UP, LIMITED CONSULTATION, FOLLOW-UP, INTERMEDIATE CONSULTATION, FOLLOW-UP, COMPLEX PSYCHIATRIC DIAGNOSTIC EVALUATION PSYCH. EVAL DIAGNOSTIC EVALUATION PSYCHIATRIC DIAGNOSTIC EVALUATION PSYCHIATRIC EVAL. OF HOSP. RECORDS PSYCHOLOGICAL TESTING PSYCHO-THERAPY (UP TO 15 MINUTES) PSYCHO-THERAPY (UP TO 35 MINUTES) PSYCHO-THERAPY (UP TO 50 MINUTES) FAMILY/CONJOINT PSYCHO-THERAPY GROUP PSYCHO-THERAPY THER. INJECT. INTRAMUSCULAR MULTI-FAMILY GROUP THERAPY CLINIC VISIT CLINIC VISIT PSYCH. EVAL/DIAGNOSIS RATE 40.00 73.75 116.00 159.00 32.60 44.00 58.00 70.00 110.00 127.00 100.00 166.00 209.00 114.00 131.00 151. 00 169.00 190.00 42.00 59.00 85.00 109.00 141. 00 180.00 70.00 142.00 141.00 40.00 73.20 133.40 148.00 67.00 5.00 48.33 45.00 27.00 141.00 ◄
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