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School Health Services Billing Manual

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Health First Colorado School Health Services

The Colorado School Health Services Program allows school districts and Boards of Cooperative Education Services (BOCES) to access federal Health First Colorado funds for delivering Health First Colorado allowable school health services to Health First Colorado enrolled children. Reimbursement received by a district through the School Health Services Program shall be used by the district to provide additional and expanded health services.

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School Health Services Program Manual

For an in-depth look at the policy requirements of the School Health Services Program please refer to the School Health Services Program web page for more information. The manual includes information on covered services, provider enrollment, random moment time study, reimbursement and administrative claiming.

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Prior Authorization Requirements

There are no prior authorization requirements for School Health Services.

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Procedure Codes/Billing Requirements

The School Health Services Program uses procedure codes that are approved by the Centers for Medicare & Medicaid Services (CMS). The codes are used for submitting claims for services provided to Health First Colorado members and represent services that may be provided by enrolled School Health Service Providers - provider type 51. Claims for all Medicaid - allowable school health services must be submitted within 120 days of the date of service.

The Healthcare Common Procedural Coding System (HCPCS) is divided into two principal subsystems, referred to as level I and level II of the HCPCS. Level I of the HCPCS is comprised of Current Procedural Terminology (CPT), a numeric coding system maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Level II codes are also referred to as alpha-numeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT codes are identified using 5 numeric digits. Valid codes and descriptions for the School Health Services Program are listed below.

Effective for dates of service starting January 1, 2022, for Physical Therapy, Occupational Therapy, and Speech, Language, and Hearing Services claims must contain a valid NPI of the Ordering, Referring, and Prescribing (ORP) Provider in accordance with 42 CFR 455.440.  School District/BOCES may have their NPI listed as the ordering NPI for medically necessary services documented in an Individualized Education Program (IEP), an Individualized Family Service Plan (IFSP) or other medical plan(s) of care.

Please note: Common Procedural Terminology (CPT) code descriptions are not contained in this manual. The descriptions are copyrighted by the American Medical Association (AMA). Providers should reference the 2023 CPT coding manuals for procedure code descriptions.

PROCEDURE CODE PROCEDURE CODE DESCRIPTIONS MODIFIER
1 2
Behavioral Health Services
90839 first 60 minutes    
90840 each additional 30 minutes (list separately in addition to code for primary service)
 		    
96156 LPC/LMFT (effective 1/1/2020)    
96156 PSY (effective 1/1/2020) AH  
96156 SW (effective 1/1/2020) AJ  
96156 Re-Assessment - LPC/LMFT (effective 1/1/2020)    
96156 Re-Assessment - PSY (effective 1/1/2020) AH  
96156 Re-Assessment - SW (effective 1/1/2020) AJ  
97153 each 15 minutes    
97153 Telehealth (each 15 minutes) GT  
97154 each 15 minutes    
97154 Telehealth (each 15 minutes) GT  
97155 each 15 minutes    
97155 Telehealth (each 15 minutes) GT  
97158 each 15 minutes    
97158 Telehealth (each 15 minutes) GT  
97151 Per Assessment Once Per Year    
97151 Telehealth (Per Assessment Once Per Year) GT  
97151 Re-assessment (limited to 2 units per six months) TJ  
97151 Re-assessment (limited to 2 units per six months), Telehealth TJ GT
H0004 Behavioral Health Counseling/Therapy Alcohol/Drug -LPC/LMFT (per 15 minutes)    
H0004 Behavioral Health Counseling/Therapy Alcohol/Drug, Telehealth -LPC/LMFT (per 15 minutes) GT  
H0004 Behavioral Health Counseling/Therapy Alcohol/Drug - PSY (per 15 minutes) AH  
H0004 Behavioral Health Counseling/Therapy Alcohol/Drug - PSY (per 15 minutes), Telehealth AH GT
H0004 Behavioral Health Counseling/Therapy Alcohol/Drug - SW (per 15 minutes) AJ  
H0004 Behavioral Health Counseling/Therapy Alcohol/Drug - SW (per 15 minutes), Telehealth AJ GT
H0004 Behavioral Health Counseling/Therapy Alcohol/Drug, Group - LPC /LMFT (per 15 minutes) HQ  
H0004 Behavioral Health Counseling/Therapy Alcohol/Drug, Group - LPC /LMFT (per 15 minutes), Telehealth HQ GT
H0004 Behavioral Health Counseling/Therapy Alcohol/Drug, Group - PSY (per 15 minutes) AH HQ
H0004 Behavioral Health Counseling/Therapy Alcohol/Drug, Group - PSY (per 15 minutes), Telehealth AH/HQ GT
H0004 Behavioral Health Counseling/Therapy Alcohol/Drug, Group - SW (per 15 minutes) AJ HQ
H0004 Behavioral Health Counseling/Therapy Alcohol/Drug, Group, - SW (per 15 minutes), Telehealth AJ/HQ GT
Motor Therapy Services
97161 1 unit per evaluation up to 20 minutes    
97161 Telehealth (1 unit per evaluation up to 20 minutes GT  
97162 1 unit per evaluation up to 30 minutes    
97162 Telehealth (1 unit per evaluation up to 30 minutes) GT  
97163 1 unit per evaluation up to 45 minutes    
97163 Telehealth (1 unit per evaluation up to 45 minutes) GT  
97164 Re-Evaluation (1 unit per evaluation typically up to 20 minutes)    
97164 Re-Evaluation, Telehealth (1 unit per evaluation typically up to 20 minutes) GT  
97110 PTA (each 15 minutes) HM  
97110 PTA (each 15 minutes), Telehealth HM GT
97150 PT (each 15 minutes) GP  
97150 PT (each 15 minutes), Telehealth GP GT
97150 PTA (each 15 minutes) HM  
97150 PTA (each 15 minutes), Telehealth HM GT
97165 1 unit per evaluation up to 30 minutes    
97165 Telehealth (1 unit per evaluation up to 30 minutes) GT  
97166 1 unit per evaluation up to 45 minutes    
97166 Telehealth (1 unit per evaluation up to 45 minutes) GT  
97167 1 unit per evaluation up to 60 minutes    
97167 Telehealth (1 unit per evaluation up to 60 minutes) GT  
97168 Re-Evaluation (1 unit per evaluation typically up to 30 minutes)    
97168 Re-Evaluation, Telehealth (1 unit per evaluation typically up to 30 minutes) GT  
97530 each 15 minutes GO  
97530 each 15 minutes, Telehealth GO GT
97530 COTA (each 15 minutes) HM  
97530 COTA (each 15 minutes), Telehealth HM GT
97139 OT (each 15 minutes) GO  
97139 COTA (each 15 minutes) HM  
97139 OT/COTA (each 15 minutes) Telehealth HM GT
97116 each 15 minutes    
97116  O & M (each 15 minutes) HQ  
97533 each 15 minutes    
97533 Telehealth (each 15 minutes) GT  
97533  O & M (each 15 minutes) HQ  
Nursing Services
T1001 Nursing Assessment/Evaluation (RN only)    
T1001 Nursing Assessment/Evaluation RN/NP only (up to 15 minutes)    
T1002 RN/NP Services, (up to 15 minutes)    
T1002 RN/NP Services, Group, (up to 15 minutes) HQ  
T1003 LPN Services, (up to 15 minutes) (delegated RN/NP service)    
T1003 LPN Services, Group, (up to 15 minutes) (delegated RN/NP service) HQ  
T1004 Qualified Nursing Aide/Health Technician, (up to 15 minutes) (delegated RN/NP service)    
T1004 Qualified Nursing Aide/Health Technician, Group, (up to 15 minutes) (delegated RN/NP service) HQ  
99201 NP (10 minutes)    
99201 Telehealth - NP (10 minutes) GT  
99202 NP (20 minutes - expanded)    
99202 Telehealth - NP (20 minutes - expanded) GT  
99203 NP (30 minutes - detailed)    
99203 Telehealth - NP (30 minutes - detailed) GT  
99204 NP (45 minutes comprehensive)    
99204 Telehealth - NP (45 minutes comprehensive) GT  
99205 NP(60 minutes high complexity)    
99205 Telehealth - NP (60 minutes high complexity) GT  
99212  NP (10 minutes straightforward)    
99212 Telehealth - NP (10 minutes straightforward) GT  
99213 NP (15 minutes low complexity)    
99213 Telehealth - NP (15 minutes low complexity) GT  
99214 NP (25 minutes moderate complexity)    
99214 Telehealth - NP (25 minutes moderate complexity) GT  
99215 NP (40 minutes high complexity)    
99215 Telehealth - NP (40 minutes high complexity) GT  
Personal Care Services
T1019 Personal Care Services, Individual (per 15 minutes)    
S5125 Personal Care Services, Group (per 15 min) - Safety/Behavior Monitoring Only    
Physician Services
90839 first 60 minutes    
90840 each additional 30 minutes (list separately in addition to code for primary service)     
99201 MD/DO (10 minutes)    
99201 MD/DO (10 minutes), Telehealth GT  
99202 MD/DO (20 minutes - expanded)    
99202 MD/DO (20 minutes - expanded), Telehealth GT  
99203 MD-DO (30 minutes - detailed)    
99203 MD-DO (30 minutes - detailed), Telehealth GT  
99204 MD/DO (45 minutes - comprehensive)    
99204 MD/DO (45 minutes - comprehensive), Telehealth GT  
99205 MD/DO (60 minutes - high complexity)    
99205 MD/DO (60 minutes - high complexity), Telehealth GT  
99212 MD/DO (10 minutes - straightforward)    
99212 MD/DO (10 minutes - straightforward), Telehealth GT  
99213 MD/DO (15 minutes - low complexity)    
99213 MD/DO (15 minutes - low complexity), Telehealth GT  
99214 MD/DO (25 minutes - moderate complexity)    
99214 MD/DO (25 minutes - moderate complexity), Telehealth GT  
99215 MD/DO (40 minutes - high complexity)    
99215 MD/DO (40 minutes - high complexity), Telehealth GT  
Speech and Audiology Services
92507 1 unit per session    
92507 Telehealth (1 unit per session) GT  
92508 1 unit per session    
92508 (GT) Telehealth, Group (1 unit per session) GT  
92521   GN  
92521 Telehealth GT  
92522   GN  
92522 Telehealth GT  
92523   GN  
92523 Telehealth GT  
92524   GN  
92524 Telehealth GT  
V5008 1 unit per evaluation - Audiologist only     
V5299 each 15 minutes)     
V5299 Group HQ  
Transportation Services
T2001 Non-Emergency Transportation - Member Attendant/Escort/Aide (per 15 minutes)    
T2001 Non-Emergency Transportation, Group - Member Attendant/Escort/Aide (per 15 minutes) HQ  
T2003 Non-Emergency Transportation - Trip Encounter (per one-way trip)    

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Acronyms

COTA -Certified Occupational Therapy Assistant
DO - Doctor of Osteopathic Medicine
LMFT - Licensed Marriage & Family Therapist
LPC - Licensed Practical Counselor
LPN - Licensed Practical Nurse
MD - Medical Doctor
NP - Nurse Practitioner
OT - Occupational Therapist
PSY - Psychologist
PT - Physical Therapist
PTA - Physical Therapy Assistant
RN - Registered Nurse
SLP - Speech Language Pathologist
SW - Social Worker

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Paper Claim Reference Table

The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.

School Health Services claims shall be billed as a single date of service, using the specific date a service is provided. Use number of units to identify repeated services by the same provider, on the same date.

CMS Field Number & Label Field is? Instructions
1. Insurance Type Required Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number Required Enter the member's Health First Colorado seven-digit Medicaid ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's Name Required Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex Required Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name Conditional Complete if the member is covered by a Medicare health insurance policy.
Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5. Patient's Address Not Required  
6. Patient's Relationship to Insured Conditional Complete if the member is covered by a commercial health care insurance policy.
7. Insured's Address Not Required  
8. Reserved for NUCC Use Not Required  
9. Other Insured's Name Conditional If field 11d is marked "YES", enter the insured's last name, first name and middle initial.
9a. Other Insured's Policy or Group Number Conditional If field 11d is marked "YES", enter the policy or group number.
9b. Reserved for NUCC Use    
9c. Reserved for NUCC Use    
9d. Insurance Plan or Program Name Not Required  
10a-c. Is patient's condition related to? Conditional When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d. Reserved for Local Use    
11. Insured's Policy, Group or FECA Number Conditional Complete if the member is covered by a Medicare health insurance policy.
Enter the insured's policy number as it appears on the ID card. Only complete if field 4 is completed.
11a. Insured's Date of Birth, Sex Conditional Complete if the member is covered by a Medicare health insurance policy.
Enter the insured's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070118 for July 1, 2018.
Place an "X" in the appropriate box to indicate the sex of the insured.
11b. Other Claim ID Not Required  
11c. Insurance Plan Name or Program Name Not Required  
11d. Is there another Health Benefit Plan? Conditional When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.
12. Patient's or Authorized Person's signature Required Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature Not Required  
14. Date of Current Illness Injury or Pregnancy Not Required Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Enter the applicable qualifier to identify which date is being reported.
431 - Onset of Current Symptoms or Illness
484 - Last Menstrual Period
15. Other Date Not Required  
16. Date Patient Unable to Work in Current Occupation Not Required  
17. Name of Referring Physician Conditional Complete with District/BOCES NPI number for claims with a date of service on or after January 1, 2022, for any of the following services:
  1. Physical Therapy
  2. Occupational Therapy
  3. Speech, Language, and Hearing Services
18. Hospitalization Dates Related to Current Service Conditional Complete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two digits for the month, two digits for the date, and two digits for the year. Example: 070118 for July 1, 2018. If the member is still hospitalized, the discharge date may be omitted. This information is not edited.
19. Additional Claim Information Conditional  
20. Outside Lab?
$ Charges		 Conditional Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services. Do not complete this field if any laboratory work was performed in the office.

Practitioners may not request payment for services performed by an independent or hospital laboratory.
21. Diagnosis or Nature of Illness or Injury Required Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.
22. Medicaid Resubmission Code Conditional List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left-hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization Conditional CLIA
When applicable, enter the word "CLIA" followed by the number.

Prior Authorization
Enter the six-character prior authorization number from the approved Prior Authorization Request (PAR). Do not combine services from more than one approved PAR on a single claim form. Do not attach a copy of the approved PAR unless advised to do so by the authorizing agent or the fiscal agent.
24. Claim Line Detail Information The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of Service Required The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010116 for January 1, 2016.
From To
01 01 19            
or
From To
01 01 19 01 01 19
Span dates of service
From To
01 01 19 01 31 19
Practitioner claims must be consecutive days.
Single Date of Service: Enter the six-digit date of service in the "From" field. Completion of the "To field is not required. Do not spread the date entry across the two fields.

Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.

Supplemental Qualifier
To enter supplemental information, begin at 24A by entering the qualifier and then the information.
ZZ - Narrative description of unspecified code
VP - Vendor Product Number
OZ - Product Number
CTR - Contract Rate
JP - Universal/National Tooth Designation
JO - Dentistry Designation System for Tooth & Areas of Oral Cavity
24B. Place of Service Required Enter the Place of Service (POS) code that describes the location where services were rendered. The Health First Colorado accepts the CMS place of service codes.
24C. EMG Conditional Enter a "Y" for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life-threatening condition or one that requires immediate medical intervention.

If a "Y" for YES is entered, the service on this detail line is exempt from co-payment requirements.
24D. Procedures, Services, or Supplies Required Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.

HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).

Only approved codes from the current CPT or HCPCS publications will be accepted.
24D. Modifier Required Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.
24E. Diagnosis Pointer Required Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges Required Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado-covered individuals for the same service.

Do not deduct Health First Colorado co-pay or commercial insurance payments from the usual and customary charges.
24G. Days or Units Required Enter the number of services provided for each procedure code.
Enter whole numbers only- do not enter fractions or decimals.
Codes that define units as inclusive numbers
Some services such as allergy testing define units by the number of services as an inclusive number, not as additional services.
24H. EPSDT/Family Plan Conditional EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:
AV Available- Not Used
S2 Under Treatment
ST New Service Requested NU Not Used
Family Planning (unshaded area)
If the service is Family Planning, enter "Y" for YES or "N" for NO in the bottom, unshaded area of the field.
24I. ID Qualifier Not Required  
24J. Rendering Provider ID # Required In the shaded portion of the field, enter the NPI of the Health First Colorado provider number assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID Number Not Required  
26. Patient's Account Number Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment? Required The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total Charge Required Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid Conditional Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30. Rsvd for NUCC Use    
31. Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.
32. 32- Service Facility Location Information
32a- NPI Number
32b- Other ID #		 Required Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #		 Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number Required  
33b- Other ID #   If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

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School Health Services Revisions Log

Revision Date Addition/Changes Made by
8/2/2018 Creation of separate School Health Services Manual HCPF
2/19/2020 Replaced procedure codes 96150 and 96151 with one code 96156 effective 1/1/2020 HCPF
2/26/2020 Updated claim reference table layout HCPF
2/27/2020 Converted to web page HCPF
9/14/2020 Added Line to Box 32 under the CMS 1500 Paper Claim Reference Table HCPF
9/28/2020 Added procedure codes for new qualified provider types and removed Target Case Management category HCPF
12/21/2020 Added telemedicine modifier code GT to procedure code 97139 HCPF
11/15/2021 Added Ordering, Referring, and Prescribing (ORP) Provider Requirements HCPF
08/23/2022 Added procedure codes 90839 and 90840 HCPF
09/26/2023 Updated language around 120 day timely filing  HCPF
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