Waiver Provider Standards Changes – V13.4
HCPCS/
Modifiers
HCPCS/Modifier Description
BRASS Service
Tier
Level
For more information on Waiver Provider Standards Tier level requirements, see Bulletin #13-56-04
entitled “County/Tribal Review & Oversight of Non-Enrolled Tier 2 and Tier 3 Home and CommunityBased Services Waiver/Alternative Care Service Providers.”
Tier 1 – Enrollment required for these services.
Tier 2 (Market Services) – A non-enrollment option assures optimal access statewide for these services.
Tier 3 (Receipt Services) – Involve strictly the purchase of items as reimbursable goods and services.
Added End date 12/31/2013 to the following HCPCS/Modifiers.
H2032
Independent living skills, maintenance
147 - Independent living skills
647 - Independent living skills
1
S5126 TG
DD, in home family support (day)
531 - In-home family support services
1
S5135 UB
24-hour emergency assistance (15
minutes)
118- Health-related services
145 - Social and recreational 564 - Adult
supported living services
565 - Child supported living services
618 - Health-related services
622 - Companion services test new description
627 - Assisted living/customized
living/residential care
645- Social and recreational service
1
S5136
Personal support
145
564
565
622
645
1
Social Service Information System (SSIS)
Waiver Provider Standards Changes – V13.4
-
Social and recreational
Adult supported living services
Child supported living services
Companion services test new description
Social and recreational service
03/26/2014
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Waiver Provider Standards Changes – V13.4
HCPCS/
Modifiers
HCPCS/Modifier Description
S5136 UB
24-hour emergency assistance (day)
145 - Social and recreational
564- Adult supported living services
565 - Child supported living services
645 - Social and recreational service
1
S5141
Foster care, adult (month)
681 - Adult foster care
1
S5141 U9
Foster care, adult, corporate (month)
681 - Adult foster care
1
S5146
Foster care, child (month)
181 - Child family foster care
1
S5150
Respite care, in home (15 minutes)
118
189
589
689
1
T2002
DT&H, non-pilot, transportation
566 - Day Training and Habilitation (DAC)
1
T2018
Supported employment (day)
538 - Extended Supported Employment
638 - Extended employment
1
T2018 U5
Supported employment (partial day)
538 - Extended Supported Employment
1
T2020 U5
DT&H, non-pilot
566 - Day Training and Habilitation (DAC)
1
T2021 TF
DT&H pilot, Rate B
566 - Day Training and Habilitation (DAC)
1
T2021 TG
DT&H pilot, Rate A
566 - Day Training and Habilitation (DAC)
1
T2021 UB
DT&H pilot, Rate C
566 - Day Training and Habilitation (DAC)
1
T2030
Customized living services (monthly)
627 - Assisted living/customized
living/residential care
1
T2030 TG
24-hour customized living (monthly)
627 - Assisted living/customized
living/residential care
1
Social Service Information System (SSIS)
Waiver Provider Standards Changes – V13.4
BRASS Service
-
Health-related services
Respite care
Respite care
Respite care
Tier
Level
03/26/2014
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Waiver Provider Standards Changes – V13.4
HCPCS/
Modifiers
HCPCS/Modifier Description
BRASS Service
Tier
Level
T2030 TG
U9
24-hour customized living (corporate)
627 - Assisted living/customized
living/residential care
1
T2032
Supported living services, adult (semimonthly)
564- Adult supported living services
1
T2032
Supported living services, adult (month)
564 - Adult supported living services
1
T2032 HA
Supported living services, child (semimonthly)
565 - Child supported living services
1
T2032 HA
Supported living services, child (month)
565 - Child supported living services
1
T2032 U9
Supported living services, adult,
corporate AFC (semi-monthly)
564 - Adult supported living services
1
T2032 U9
Supported living services, adult,
corporate AFC (monthly)
564 - Adult supported living services
1
T2038 TF
Housing access coordination
564 - Adult supported living services
565 - Child supported living services
1
Social Service Information System (SSIS)
Waiver Provider Standards Changes – V13.4
03/26/2014
Page 3 of 9
Waiver Provider Standards Changes – V13.4
HCPCS/
Modifiers
HCPCS/Modifier Description
BRASS Service
Tier
Level
Added Service Association End date 12/31/2013 to the following HCPCS/Modifiers.
H0025
Behavioral Support, by analyst
118 - Health-related services
618- Health-related services
1
H0025 TF
Behavioral Support, by specialist
118 - Health-related services
618- Health-related services
1
H0025 TG
Behavioral Support, by professional
118 - Health-related services
618- Health-related services
1
H2032 HQ
Independent living skills, group therapy
147 - Independent living skills
647 - Independent living skills
1
H2032 TF
Independent living skills, counseling
147 - Independent living skills
647 - Independent living skills
1
H2032 TG
Independent living skills, individual
therapy
147 - Independent living skills
647 - Independent living skills
1
S5100
Day care services, adult (15 minutes)
649 – Adult day care
1
S5100 TF
Adult day care bath
649 – Adult day care
1
S5100 U7
Family adult day services (FADS) (15
minutes)
649 – Adult day care
1
S5102
Day care services, adult (day)
649 – Adult day care
1
S5102 U7
Family adult day services (FADS) (day)
649 – Adult day care
1
S5125
DD, in home family support (15
minutes)
531 - In-home family support services
1
S5131
Homemaker Services (day)
625 - Homemaking services
1
Social Service Information System (SSIS)
Waiver Provider Standards Changes – V13.4
03/26/2014
Page 4 of 9
Waiver Provider Standards Changes – V13.4
HCPCS/
Modifiers
HCPCS/Modifier Description
BRASS Service
Tier
Level
S5135
Companion care, adult/Personal support
145 - Social and recreational
645 - Social and recreational service
622 - Companion services test new description
564 - Adult supported living services
565 - Child supported living services
618 - Health-related services
627 - Assisted living/customized
living/residential care
1
S5135 UA
BI night supervision
118 - Health-related services
145 - Social and recreational
564 - Adult supported living services
565 - Child supported living services
618 - Health-related services
622 - Companion services test new description
627 - Assisted living/customized
living/residential care
645 - Social and recreational service
1
S5140
Foster care, adult (day)
681 - Adult foster care
1
S5140 U9
Foster care, adult, corporate (day)
681 - Adult foster care
1
S5141 HQ
Foster care, adult (month)
681 - Adult foster care
1
S5145
Foster care, child (day)
181 - Child family foster care
1
S5170
Home delivered meals
628 - Home delivered meals
1
S9125
Crisis respite (day)
589 - Respite care
1
Social Service Information System (SSIS)
Waiver Provider Standards Changes – V13.4
03/26/2014
Page 5 of 9
Waiver Provider Standards Changes – V13.4
HCPCS/
Modifiers
HCPCS/Modifier Description
BRASS Service
Tier
Level
S9470
Nutritional counseling, diet
118 - Health-related services
618 - Health-related services
1
T1005
Crisis respite (15 minutes)
589 - Respite care
1
T1005 TG
Crisis respite, specialized
589 - Respite care
1
T2013
Specialist service
564 - Adult supported living services
565- Child supported living services
1
T2014
Prevocational services (day)
649 - Adult day care
1
T2015
Prevocational services (hour)
649 - Adult day care
1
T2016
Supported living services, adult (day)
564 - Adult supported living services
1
T2016 HA
Supported living services, child (day)
565 - Child supported living services
1
T2016 U9
Supported living services, adult,
corporate AFC (day)
564 - Adult supported living services
1
T2017
Supported living services, adult (15
minutes)
564 - Adult supported living services
1
T2017 HA
Supported living services, child (15
minutes)
565 - Child supported living services
1
T2017 U9
Supported living services, adult,
corporate AFC (15 minutes)
564 - Adult supported living services
1
T2019
Supported employment (15 minutes)
538 - Extended Supported Employment
638 - Extended employment
1
T2020
DT&H, non-pilot/Structured day program
566 - Day Training and Habilitation (DAC)
618 - Health-related services
1
Social Service Information System (SSIS)
Waiver Provider Standards Changes – V13.4
03/26/2014
Page 6 of 9
Waiver Provider Standards Changes – V13.4
HCPCS/
Modifiers
HCPCS/Modifier Description
BRASS Service
Tier
Level
T2021
DT&H pilot, Rate D/Structured day
program
566 - Day Training and Habilitation (DAC)
618 - Health-related services
1
T2028 U1
CDCS - Personal assistance
158 - Approved pilot projects
558 - Approved pilot projects
658 - Approved pilot projects
1
T2028 U2
CDCS - Treatment and training
158 - Approved pilot projects
558 - Approved pilot projects
658 - Approved pilot projects
1
T2028 U3
CDCS - Environmental modifications and
provisions
158 - Approved pilot projects
558 - Approved pilot projects
658 - Approved pilot projects
1
T2028 U4
CDCS - Self direction support activities
158 - Approved pilot projects
558 - Approved pilot projects
658 - Approved pilot projects
1
T2028 U8
CDCS - Flexible case management
158 - Approved pilot projects
558 - Approved pilot projects
658 - Approved pilot projects
1
T2031
Customized living services (daily)
627 - Assisted living/customized
living/residential care
1
T2033
Residential care services (Day)
627 - Assisted living/customized
living/residential care
1
T2040
CDCS - Background check
158 - Approved pilot projects
558 - Approved pilot projects
658 - Approved pilot projects
1
Social Service Information System (SSIS)
Waiver Provider Standards Changes – V13.4
03/26/2014
Page 7 of 9
Waiver Provider Standards Changes – V13.4
HCPCS/
Modifiers
HCPCS/Modifier Description
BRASS Service
Tier
Level
Added Service Association End date 06/30/2014 to the following HCPCS/Modifiers.
H0045
Respite care services, not in home
189489589689-
Respite care
Child Respite care
Respite care
Respite care
1
S5150 UB
Respite care, out of home
189 - Respite care
589 - Respite care
689 - Respite care
1
S5151
Respite care, in home (day)
189 - Respite care
589 - Respite care
689 - Respite care
1
Changed the HCPCS/Modifier Description for the following HCPCS (13.4 release)
HCPCS
Old Description
S5110
Tier
Level
Family counseling/training
New Description
Family Training
3
S5130
Homemaker services (15 minutes)
Homemaker service – cleaning only (15 minutes)
2
S5165
Environmental accessibility adaptations
Environmental accessibility adaptations, Home
Modifications/Install and Expenses
2
Social Service Information System (SSIS)
Waiver Provider Standards Changes – V13.4
03/26/2014
Page 8 of 9
Waiver Provider Standards Changes – V13.4
HCPCS/
Modifiers
HCPCS/
HCPCS
Modifier
unit
Description type
Start
Date/ End
Date
Claim
Diag
Category nosis
Req
Include Include
Time
Payments
BRASS
ActiviServices ties
Waiver
and AC
Yes
689 Respite
care
Tier
Level
Added the following HCPCS/Modifiers
S5150
Respite care, 15
in home (15 minutes
minutes)
01/01/2014
Social Service Information System (SSIS)
Waiver Provider Standards Changes – V13.4
Yes
No
107 –
1
Service
delivery
, in
home
03/26/2014
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