![Page 1: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/1.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14Hospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 Day 2,136.14Hospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 Day 2,136.14General Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 Day 415.95Hospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
415.95
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
415.95
Psychiatric Health Facility H2013 HE 05 05 20 - 29 Day 653.20Adult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 Day 368.35Adult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 Day 368.35Adult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 Day 179.66Adult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 Day 179.66Crisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 Hour 132.03Crisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour 132.03
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)174.32
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)433.66
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)101.69
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Per Minute Per Unit
ALAMEDA (01)
Service Function
Code
Unit Basis Measurement
Code
Max Allowed Rate
Service DescriptionRevenue
CodeProcedure
CodeProcedure Modifier 1
Procedure Modifier 2
![Page 2: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/2.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Per Minute Per Unit
ALAMEDA (01)
Service Function
Code
Unit Basis Measurement
Code
Max Allowed Rate
Service DescriptionRevenue
CodeProcedure
CodeProcedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)158.73
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
55.95 3.73
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
55.95 3.73
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
55.95 3.73
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
55.95 3.73
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
55.95 3.73
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
55.95 3.73
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
55.95 3.73
![Page 3: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/3.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Per Minute Per Unit
ALAMEDA (01)
Service Function
Code
Unit Basis Measurement
Code
Max Allowed Rate
Service DescriptionRevenue
CodeProcedure
CodeProcedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
55.95 3.73
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
53.85 3.59
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
53.85 3.59
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
53.85 3.59
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
53.85 3.59
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
53.85 3.59
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
53.85 3.59
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
53.85 3.59
![Page 4: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/4.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Per Minute Per Unit
ALAMEDA (01)
Service Function
Code
Unit Basis Measurement
Code
Max Allowed Rate
Service DescriptionRevenue
CodeProcedure
CodeProcedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
53.85 3.59
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
53.85 3.59
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
53.85 3.59
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
53.85 3.59
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
53.85 3.59
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
53.85 3.59
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
53.85 3.59
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
53.85 3.59
![Page 5: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/5.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Per Minute Per Unit
ALAMEDA (01)
Service Function
Code
Unit Basis Measurement
Code
Max Allowed Rate
Service DescriptionRevenue
CodeProcedure
CodeProcedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
53.85 3.59
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
53.85 3.59
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
53.85 3.59
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
53.85 3.59
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
132.15 8.81
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
132.15 8.81
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
132.15 8.81
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
132.15 8.81
![Page 6: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/6.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Per Minute Per Unit
ALAMEDA (01)
Service Function
Code
Unit Basis Measurement
Code
Max Allowed Rate
Service DescriptionRevenue
CodeProcedure
CodeProcedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
132.15 8.81
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
132.15 8.81
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
132.15 8.81
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
132.15 8.81
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
132.15 8.81
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
132.15 8.81
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
132.15 8.81
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
132.15 8.81
![Page 7: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/7.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Per Minute Per Unit
ALAMEDA (01)
Service Function
Code
Unit Basis Measurement
Code
Max Allowed Rate
Service DescriptionRevenue
CodeProcedure
CodeProcedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
59.70 3.98
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
59.70 3.98
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
59.70 3.98
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
59.70 3.98
![Page 8: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/8.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Unit Per Minute
ALPINE (02)
Max Allowed Rate
![Page 9: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/9.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Unit Per Minute
ALPINE (02)
Max Allowed Rate
158.73
58.35 3.89
58.35 3.89
58.35 3.89
58.35 3.89
58.35 3.89
58.35 3.89
58.35 3.89
![Page 10: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/10.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Unit Per Minute
ALPINE (02)
Max Allowed Rate
58.35 3.89
75.15 5.01
75.15 5.01
75.15 5.01
75.15 5.01
75.15 5.01
75.15 5.01
75.15 5.01
![Page 11: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/11.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Unit Per Minute
ALPINE (02)
Max Allowed Rate
75.15 5.01
75.15 5.01
75.15 5.01
75.15 5.01
75.15 5.01
75.15 5.01
75.15 5.01
75.15 5.01
![Page 12: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/12.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Unit Per Minute
ALPINE (02)
Max Allowed Rate
75.15 5.01
75.15 5.01
75.15 5.01
75.15 5.01
138.90 9.26
138.90 9.26
138.90 9.26
138.90 9.26
![Page 13: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/13.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Unit Per Minute
ALPINE (02)
Max Allowed Rate
138.90 9.26
138.90 9.26
138.90 9.26
138.90 9.26
138.90 9.26
138.90 9.26
138.90 9.26
138.90 9.26
![Page 14: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/14.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Unit Per Minute
ALPINE (02)
Max Allowed Rate
111.75 7.45
111.75 7.45
111.75 7.45
111.75 7.45
![Page 15: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/15.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per MinutePer Unit
AMADOR (03)
![Page 16: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/16.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
AMADOR (03)
158.73
69.45 4.63
69.45 4.63
69.45 4.63
69.45 4.63
69.45 4.63
69.45 4.63
69.45 4.63
![Page 17: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/17.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
AMADOR (03)
69.45 4.63
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
![Page 18: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/18.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
AMADOR (03)
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
![Page 19: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/19.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
AMADOR (03)
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
81.00 5.40
81.00 5.40
81.00 5.40
81.00 5.40
![Page 20: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/20.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
AMADOR (03)
81.00 5.40
81.00 5.40
81.00 5.40
81.00 5.40
81.00 5.40
81.00 5.40
81.00 5.40
81.00 5.40
![Page 21: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/21.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
AMADOR (03)
46.05 3.07
46.05 3.07
46.05 3.07
46.05 3.07
![Page 22: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/22.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
715.52368.35368.35179.66179.66128.64128.64
174.32
244.84
101.69
Max Allowed Rate
Per MinutePer Unit
BUTTE (04)
![Page 23: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/23.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
BUTTE (04)
158.73
27.60 1.84
27.60 1.84
27.60 1.84
27.60 1.84
27.60 1.84
27.60 1.84
27.60 1.84
![Page 24: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/24.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
BUTTE (04)
27.60 1.84
35.70 2.38
35.70 2.38
35.70 2.38
35.70 2.38
35.70 2.38
35.70 2.38
35.70 2.38
![Page 25: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/25.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
BUTTE (04)
35.70 2.38
35.70 2.38
35.70 2.38
35.70 2.38
35.70 2.38
35.70 2.38
35.70 2.38
35.70 2.38
![Page 26: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/26.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
BUTTE (04)
35.70 2.38
35.70 2.38
35.70 2.38
35.70 2.38
66.00 4.40
66.00 4.40
66.00 4.40
66.00 4.40
![Page 27: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/27.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
BUTTE (04)
66.00 4.40
66.00 4.40
66.00 4.40
66.00 4.40
66.00 4.40
66.00 4.40
66.00 4.40
66.00 4.40
![Page 28: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/28.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
BUTTE (04)
53.10 3.54
53.10 3.54
53.10 3.54
53.10 3.54
![Page 29: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/29.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
CALAVERAS (05)
![Page 30: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/30.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
CALAVERAS (05)
158.73
38.10 2.54
38.10 2.54
38.10 2.54
38.10 2.54
38.10 2.54
38.10 2.54
38.10 2.54
![Page 31: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/31.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
CALAVERAS (05)
38.10 2.54
45.45 3.03
45.45 3.03
45.45 3.03
45.45 3.03
45.45 3.03
45.45 3.03
45.45 3.03
![Page 32: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/32.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
CALAVERAS (05)
45.45 3.03
45.45 3.03
45.45 3.03
45.45 3.03
45.45 3.03
45.45 3.03
45.45 3.03
45.45 3.03
![Page 33: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/33.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
CALAVERAS (05)
45.45 3.03
45.45 3.03
45.45 3.03
45.45 3.03
97.50 6.50
97.50 6.50
97.50 6.50
97.50 6.50
![Page 34: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/34.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
CALAVERAS (05)
97.50 6.50
97.50 6.50
97.50 6.50
97.50 6.50
97.50 6.50
97.50 6.50
97.50 6.50
97.50 6.50
![Page 35: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/35.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
CALAVERAS (05)
35.25 2.35
35.25 2.35
35.25 2.35
35.25 2.35
![Page 36: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/36.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
COLUSA (06)
![Page 37: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/37.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
COLUSA (06)
158.73
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
![Page 38: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/38.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
COLUSA (06)
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
![Page 39: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/39.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
COLUSA (06)
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
![Page 40: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/40.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
COLUSA (06)
42.15 2.81
42.15 2.81
42.15 2.81
42.15 2.81
85.95 5.73
85.95 5.73
85.95 5.73
85.95 5.73
![Page 41: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/41.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
COLUSA (06)
85.95 5.73
85.95 5.73
85.95 5.73
85.95 5.73
85.95 5.73
85.95 5.73
85.95 5.73
85.95 5.73
![Page 42: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/42.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
COLUSA (06)
43.95 2.93
43.95 2.93
43.95 2.93
43.95 2.93
![Page 43: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/43.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
2,336.682,336.682,336.68415.95
415.95
415.95
653.20368.35368.35179.66179.66160.13160.13
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
CONTRA COSTA (07)
![Page 44: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/44.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
CONTRA COSTA (07)
158.73
30.00 2.00
30.00 2.00
30.00 2.00
30.00 2.00
30.00 2.00
30.00 2.00
30.00 2.00
![Page 45: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/45.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
CONTRA COSTA (07)
30.00 2.00
38.70 2.58
38.70 2.58
38.70 2.58
38.70 2.58
38.70 2.58
38.70 2.58
38.70 2.58
![Page 46: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/46.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
CONTRA COSTA (07)
38.70 2.58
38.70 2.58
38.70 2.58
38.70 2.58
38.70 2.58
38.70 2.58
38.70 2.58
38.70 2.58
![Page 47: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/47.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
CONTRA COSTA (07)
38.70 2.58
38.70 2.58
38.70 2.58
38.70 2.58
71.40 4.76
71.40 4.76
71.40 4.76
71.40 4.76
![Page 48: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/48.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
CONTRA COSTA (07)
71.40 4.76
71.40 4.76
71.40 4.76
71.40 4.76
71.40 4.76
71.40 4.76
71.40 4.76
71.40 4.76
![Page 49: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/49.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
CONTRA COSTA (07)
57.75 3.85
57.75 3.85
57.75 3.85
57.75 3.85
![Page 50: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/50.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
DEL NORTE (08)
![Page 51: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/51.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
DEL NORTE (08)
158.73
30.75 2.05
30.75 2.05
30.75 2.05
30.75 2.05
30.75 2.05
30.75 2.05
30.75 2.05
![Page 52: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/52.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
DEL NORTE (08)
30.75 2.05
27.90 1.86
27.90 1.86
27.90 1.86
27.90 1.86
27.90 1.86
27.90 1.86
27.90 1.86
![Page 53: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/53.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
DEL NORTE (08)
27.90 1.86
27.90 1.86
27.90 1.86
27.90 1.86
27.90 1.86
27.90 1.86
27.90 1.86
27.90 1.86
![Page 54: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/54.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
DEL NORTE (08)
27.90 1.86
27.90 1.86
27.90 1.86
27.90 1.86
127.50 8.50
127.50 8.50
127.50 8.50
127.50 8.50
![Page 55: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/55.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
DEL NORTE (08)
127.50 8.50
127.50 8.50
127.50 8.50
127.50 8.50
127.50 8.50
127.50 8.50
127.50 8.50
127.50 8.50
![Page 56: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/56.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
DEL NORTE (08)
27.15 1.81
27.15 1.81
27.15 1.81
27.15 1.81
![Page 57: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/57.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
777.19442.68442.68179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
EL DORADO (09)
![Page 58: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/58.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
EL DORADO (09)
158.37
40.65 2.71
40.65 2.71
40.65 2.71
40.65 2.71
40.65 2.71
40.65 2.71
40.65 2.71
![Page 59: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/59.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
EL DORADO (09)
40.65 2.71
52.35 3.49
52.35 3.49
52.35 3.49
52.35 3.49
52.35 3.49
52.35 3.49
52.35 3.49
![Page 60: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/60.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
EL DORADO (09)
52.35 3.49
52.35 3.49
52.35 3.49
52.35 3.49
52.35 3.49
52.35 3.49
52.35 3.49
52.35 3.49
![Page 61: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/61.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
EL DORADO (09)
52.35 3.49
52.35 3.49
52.35 3.49
52.35 3.49
97.05 6.47
97.05 6.47
97.05 6.47
97.05 6.47
![Page 62: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/62.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
EL DORADO (09)
97.05 6.47
97.05 6.47
97.05 6.47
97.05 6.47
97.05 6.47
97.05 6.47
97.05 6.47
97.05 6.47
![Page 63: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/63.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
EL DORADO (09)
78.15 5.21
78.15 5.21
78.15 5.21
78.15 5.21
![Page 64: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/64.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
292.64
411.03
101.69
Per Minute
Max Allowed Rate
Per Unit
FRESNO (10)
![Page 65: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/65.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
FRESNO (10)
158.73
46.50 3.10
46.50 3.10
46.50 3.10
46.50 3.10
46.50 3.10
46.50 3.10
46.50 3.10
![Page 66: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/66.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
FRESNO (10)
46.50 3.10
60.15 4.01
60.15 4.01
60.15 4.01
60.15 4.01
60.15 4.01
60.15 4.01
60.15 4.01
![Page 67: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/67.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
FRESNO (10)
60.15 4.01
60.15 4.01
60.15 4.01
60.15 4.01
60.15 4.01
60.15 4.01
60.15 4.01
60.15 4.01
![Page 68: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/68.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
FRESNO (10)
60.15 4.01
60.15 4.01
60.15 4.01
60.15 4.01
111.00 7.40
111.00 7.40
111.00 7.40
111.00 7.40
![Page 69: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/69.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
FRESNO (10)
111.00 7.40
111.00 7.40
111.00 7.40
111.00 7.40
111.00 7.40
111.00 7.40
111.00 7.40
111.00 7.40
![Page 70: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/70.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
FRESNO (10)
89.40 5.96
89.40 5.96
89.40 5.96
89.40 5.96
![Page 71: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/71.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
GLENN (11)
![Page 72: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/72.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
GLENN (11)
158.73
31.80 2.12
31.80 2.12
31.80 2.12
31.80 2.12
31.80 2.12
31.80 2.12
31.80 2.12
![Page 73: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/73.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
GLENN (11)
31.80 2.12
41.10 2.74
41.10 2.74
41.10 2.74
41.10 2.74
41.10 2.74
41.10 2.74
41.10 2.74
![Page 74: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/74.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
GLENN (11)
41.10 2.74
41.10 2.74
41.10 2.74
41.10 2.74
41.10 2.74
41.10 2.74
41.10 2.74
41.10 2.74
![Page 75: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/75.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
GLENN (11)
41.10 2.74
41.10 2.74
41.10 2.74
41.10 2.74
77.10 5.14
77.10 5.14
77.10 5.14
77.10 5.14
![Page 76: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/76.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
GLENN (11)
77.10 5.14
77.10 5.14
77.10 5.14
77.10 5.14
77.10 5.14
77.10 5.14
77.10 5.14
77.10 5.14
![Page 77: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/77.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
GLENN (11)
62.10 4.14
62.10 4.14
62.10 4.14
62.10 4.14
![Page 78: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/78.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,608.531,608.531,608.53415.95
415.95
415.95
653.20368.35368.35179.66179.6677.9877.98
174.32
244.84
88.17
Max Allowed Rate
Per Unit Per Minute
HUMBOLDT (12)
![Page 79: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/79.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
HUMBOLDT (12)
158.73
31.65 2.11
31.65 2.11
31.65 2.11
31.65 2.11
31.65 2.11
31.65 2.11
31.65 2.11
![Page 80: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/80.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
HUMBOLDT (12)
31.65 2.11
40.80 2.72
40.80 2.72
40.80 2.72
40.80 2.72
40.80 2.72
40.80 2.72
40.80 2.72
![Page 81: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/81.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
HUMBOLDT (12)
40.80 2.72
40.80 2.72
40.80 2.72
40.80 2.72
40.80 2.72
40.80 2.72
40.80 2.72
40.80 2.72
![Page 82: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/82.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
HUMBOLDT (12)
40.80 2.72
40.80 2.72
40.80 2.72
40.80 2.72
63.00 4.20
63.00 4.20
63.00 4.20
63.00 4.20
![Page 83: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/83.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
HUMBOLDT (12)
63.00 4.20
63.00 4.20
63.00 4.20
63.00 4.20
63.00 4.20
63.00 4.20
63.00 4.20
63.00 4.20
![Page 84: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/84.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
HUMBOLDT (12)
60.75 4.05
60.75 4.05
60.75 4.05
60.75 4.05
![Page 85: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/85.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.12
101.69
Max Allowed Rate
Per Unit Per Minute
IMPERIAL (13)
![Page 86: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/86.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
IMPERIAL (13)
158.73
49.35 3.29
49.35 3.29
49.35 3.29
49.35 3.29
49.35 3.29
49.35 3.29
49.35 3.29
![Page 87: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/87.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
IMPERIAL (13)
49.35 3.29
63.75 4.25
63.75 4.25
63.75 4.25
63.75 4.25
63.75 4.25
63.75 4.25
63.75 4.25
![Page 88: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/88.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
IMPERIAL (13)
63.75 4.25
63.75 4.25
63.75 4.25
63.75 4.25
63.75 4.25
63.75 4.25
63.75 4.25
63.75 4.25
![Page 89: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/89.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
IMPERIAL (13)
63.75 4.25
63.75 4.25
63.75 4.25
63.75 4.25
117.75 7.85
117.75 7.85
117.75 7.85
117.75 7.85
![Page 90: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/90.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
IMPERIAL (13)
117.75 7.85
117.75 7.85
117.75 7.85
117.75 7.85
117.75 7.85
117.75 7.85
117.75 7.85
117.75 7.85
![Page 91: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/91.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
IMPERIAL (13)
94.20 6.28
94.20 6.28
94.20 6.28
94.20 6.28
![Page 92: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/92.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
INYO (14)
![Page 93: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/93.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
INYO (14)
158.73
72.60 4.84
72.60 4.84
72.60 4.84
72.60 4.84
72.60 4.84
72.60 4.84
72.60 4.84
![Page 94: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/94.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
INYO (14)
72.60 4.84
52.65 3.51
52.65 3.51
52.65 3.51
52.65 3.51
52.65 3.51
52.65 3.51
52.65 3.51
![Page 95: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/95.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
INYO (14)
52.65 3.51
52.65 3.51
52.65 3.51
52.65 3.51
52.65 3.51
52.65 3.51
52.65 3.51
52.65 3.51
![Page 96: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/96.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
INYO (14)
52.65 3.51
52.65 3.51
52.65 3.51
52.65 3.51
88.50 5.90
88.50 5.90
88.50 5.90
88.50 5.90
![Page 97: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/97.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
INYO (14)
88.50 5.90
88.50 5.90
88.50 5.90
88.50 5.90
88.50 5.90
88.50 5.90
88.50 5.90
88.50 5.90
![Page 98: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/98.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
INYO (14)
57.75 3.85
57.75 3.85
57.75 3.85
57.75 3.85
![Page 99: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/99.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,984.011,984.011,984.01415.95
415.95
415.95
653.20368.35368.35179.66179.66130.36130.36
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
KERN (15)
![Page 100: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/100.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
KERN (15)
158.73
46.95 3.13
46.95 3.13
46.95 3.13
46.95 3.13
46.95 3.13
46.95 3.13
46.95 3.13
![Page 101: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/101.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
KERN (15)
46.95 3.13
60.60 4.04
60.60 4.04
60.60 4.04
60.60 4.04
60.60 4.04
60.60 4.04
60.60 4.04
![Page 102: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/102.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
KERN (15)
60.60 4.04
60.60 4.04
60.60 4.04
60.60 4.04
60.60 4.04
60.60 4.04
60.60 4.04
60.60 4.04
![Page 103: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/103.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
KERN (15)
60.60 4.04
60.60 4.04
60.60 4.04
60.60 4.04
112.05 7.47
112.05 7.47
112.05 7.47
112.05 7.47
![Page 104: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/104.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
KERN (15)
112.05 7.47
112.05 7.47
112.05 7.47
112.05 7.47
112.05 7.47
112.05 7.47
112.05 7.47
112.05 7.47
![Page 105: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/105.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
KERN (15)
90.30 6.02
90.30 6.02
90.30 6.02
90.30 6.02
![Page 106: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/106.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per MinutePer Unit
Max Allowed Rate
KINGS (16)
![Page 107: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/107.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per MinutePer Unit
Max Allowed Rate
KINGS (16)
158.73
27.30 1.82
27.30 1.82
27.30 1.82
27.30 1.82
27.30 1.82
27.30 1.82
27.30 1.82
![Page 108: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/108.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per MinutePer Unit
Max Allowed Rate
KINGS (16)
27.30 1.82
35.25 2.35
35.25 2.35
35.25 2.35
35.25 2.35
35.25 2.35
35.25 2.35
35.25 2.35
![Page 109: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/109.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per MinutePer Unit
Max Allowed Rate
KINGS (16)
35.25 2.35
35.25 2.35
35.25 2.35
35.25 2.35
35.25 2.35
35.25 2.35
35.25 2.35
35.25 2.35
![Page 110: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/110.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per MinutePer Unit
Max Allowed Rate
KINGS (16)
35.25 2.35
35.25 2.35
35.25 2.35
35.25 2.35
65.25 4.35
65.25 4.35
65.25 4.35
65.25 4.35
![Page 111: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/111.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per MinutePer Unit
Max Allowed Rate
KINGS (16)
65.25 4.35
65.25 4.35
65.25 4.35
65.25 4.35
65.25 4.35
65.25 4.35
65.25 4.35
65.25 4.35
![Page 112: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/112.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per MinutePer Unit
Max Allowed Rate
KINGS (16)
52.50 3.50
52.50 3.50
52.50 3.50
52.50 3.50
![Page 113: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/113.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Unit
Max Allowed Rate
Per Minute
LAKE (17)
![Page 114: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/114.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Unit
Max Allowed Rate
Per Minute
LAKE (17)
158.73
29.25 1.95
29.25 1.95
29.25 1.95
29.25 1.95
29.25 1.95
29.25 1.95
29.25 1.95
![Page 115: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/115.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Unit
Max Allowed Rate
Per Minute
LAKE (17)
29.25 1.95
37.80 2.52
37.80 2.52
37.80 2.52
37.80 2.52
37.80 2.52
37.80 2.52
37.80 2.52
![Page 116: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/116.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Unit
Max Allowed Rate
Per Minute
LAKE (17)
37.80 2.52
37.80 2.52
37.80 2.52
37.80 2.52
37.80 2.52
37.80 2.52
37.80 2.52
37.80 2.52
![Page 117: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/117.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Unit
Max Allowed Rate
Per Minute
LAKE (17)
37.80 2.52
37.80 2.52
37.80 2.52
37.80 2.52
69.90 4.66
69.90 4.66
69.90 4.66
69.90 4.66
![Page 118: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/118.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Unit
Max Allowed Rate
Per Minute
LAKE (17)
69.90 4.66
69.90 4.66
69.90 4.66
69.90 4.66
69.90 4.66
69.90 4.66
69.90 4.66
69.90 4.66
![Page 119: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/119.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Unit
Max Allowed Rate
Per Minute
LAKE (17)
56.25 3.75
56.25 3.75
56.25 3.75
56.25 3.75
![Page 120: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/120.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
LASSEN (18)
![Page 121: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/121.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
LASSEN (18)
189.94
43.65 2.91
43.65 2.91
43.65 2.91
43.65 2.91
43.65 2.91
43.65 2.91
43.65 2.91
![Page 122: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/122.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
LASSEN (18)
43.65 2.91
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
![Page 123: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/123.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
LASSEN (18)
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
![Page 124: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/124.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
LASSEN (18)
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
104.55 6.97
104.55 6.97
104.55 6.97
104.55 6.97
![Page 125: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/125.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
LASSEN (18)
104.55 6.97
104.55 6.97
104.55 6.97
104.55 6.97
104.55 6.97
104.55 6.97
104.55 6.97
104.55 6.97
![Page 126: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/126.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
LASSEN (18)
84.15 5.61
84.15 5.61
84.15 5.61
84.15 5.61
![Page 127: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/127.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
249.73
101.69
Max Allowed Rate
Per Unit Per Minute
LOS ANGELES (19)
![Page 128: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/128.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
LOS ANGELES (19)
158.73
35.10 2.34
35.10 2.34
35.10 2.34
35.10 2.34
35.10 2.34
35.10 2.34
35.10 2.34
![Page 129: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/129.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
LOS ANGELES (19)
35.10 2.34
45.00 3.00
45.00 3.00
45.00 3.00
45.00 3.00
45.00 3.00
45.00 3.00
45.00 3.00
![Page 130: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/130.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
LOS ANGELES (19)
45.00 3.00
45.00 3.00
45.00 3.00
45.00 3.00
45.00 3.00
45.00 3.00
45.00 3.00
45.00 3.00
![Page 131: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/131.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
LOS ANGELES (19)
45.00 3.00
45.00 3.00
45.00 3.00
45.00 3.00
89.40 5.96
89.40 5.96
89.40 5.96
89.40 5.96
![Page 132: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/132.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
LOS ANGELES (19)
89.40 5.96
89.40 5.96
89.40 5.96
89.40 5.96
89.40 5.96
89.40 5.96
89.40 5.96
89.40 5.96
![Page 133: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/133.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
LOS ANGELES (19)
72.15 4.81
72.15 4.81
72.15 4.81
72.15 4.81
![Page 134: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/134.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
MADERA (20)
![Page 135: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/135.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MADERA (20)
158.73
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
![Page 136: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/136.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MADERA (20)
34.95 2.33
33.45 2.23
33.45 2.23
33.45 2.23
33.45 2.23
33.45 2.23
33.45 2.23
33.45 2.23
![Page 137: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/137.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MADERA (20)
33.45 2.23
33.45 2.23
33.45 2.23
33.45 2.23
33.45 2.23
33.45 2.23
33.45 2.23
33.45 2.23
![Page 138: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/138.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MADERA (20)
33.45 2.23
33.45 2.23
33.45 2.23
33.45 2.23
59.70 3.98
59.70 3.98
59.70 3.98
59.70 3.98
![Page 139: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/139.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MADERA (20)
59.70 3.98
59.70 3.98
59.70 3.98
59.70 3.98
59.70 3.98
59.70 3.98
59.70 3.98
59.70 3.98
![Page 140: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/140.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MADERA (20)
36.45 2.43
36.45 2.43
36.45 2.43
36.45 2.43
![Page 141: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/141.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66165.03165.03
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
MARIN (21)
![Page 142: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/142.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MARIN (21)
158.73
69.15 4.61
69.15 4.61
69.15 4.61
69.15 4.61
69.15 4.61
69.15 4.61
69.15 4.61
![Page 143: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/143.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MARIN (21)
69.15 4.61
88.95 5.93
88.95 5.93
88.95 5.93
88.95 5.93
88.95 5.93
88.95 5.93
88.95 5.93
![Page 144: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/144.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MARIN (21)
88.95 5.93
88.95 5.93
88.95 5.93
88.95 5.93
88.95 5.93
88.95 5.93
88.95 5.93
88.95 5.93
![Page 145: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/145.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MARIN (21)
88.95 5.93
88.95 5.93
88.95 5.93
88.95 5.93
165.30 11.02
165.30 11.02
165.30 11.02
165.30 11.02
![Page 146: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/146.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MARIN (21)
165.30 11.02
165.30 11.02
165.30 11.02
165.30 11.02
165.30 11.02
165.30 11.02
165.30 11.02
165.30 11.02
![Page 147: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/147.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MARIN (21)
108.30 7.22
108.30 7.22
108.30 7.22
108.30 7.22
![Page 148: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/148.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
MARIPOSA (22)
![Page 149: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/149.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MARIPOSA (22)
158.73
45.90 3.06
45.90 3.06
45.90 3.06
45.90 3.06
45.90 3.06
45.90 3.06
45.90 3.06
![Page 150: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/150.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MARIPOSA (22)
45.90 3.06
59.25 3.95
59.25 3.95
59.25 3.95
59.25 3.95
59.25 3.95
59.25 3.95
59.25 3.95
![Page 151: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/151.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MARIPOSA (22)
59.25 3.95
59.25 3.95
59.25 3.95
59.25 3.95
59.25 3.95
59.25 3.95
59.25 3.95
59.25 3.95
![Page 152: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/152.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MARIPOSA (22)
59.25 3.95
59.25 3.95
59.25 3.95
59.25 3.95
109.35 7.29
109.35 7.29
109.35 7.29
109.35 7.29
![Page 153: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/153.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MARIPOSA (22)
109.35 7.29
109.35 7.29
109.35 7.29
109.35 7.29
109.35 7.29
109.35 7.29
109.35 7.29
109.35 7.29
![Page 154: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/154.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MARIPOSA (22)
88.05 5.87
88.05 5.87
88.05 5.87
88.05 5.87
![Page 155: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/155.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
MENDOCINO (23)
![Page 156: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/156.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MENDOCINO (23)
158.73
48.90 3.26
48.90 3.26
48.90 3.26
48.90 3.26
48.90 3.26
48.90 3.26
48.90 3.26
![Page 157: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/157.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MENDOCINO (23)
48.90 3.26
48.15 3.21
48.15 3.21
48.15 3.21
48.15 3.21
48.15 3.21
48.15 3.21
48.15 3.21
![Page 158: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/158.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MENDOCINO (23)
48.15 3.21
48.15 3.21
48.15 3.21
48.15 3.21
48.15 3.21
48.15 3.21
48.15 3.21
48.15 3.21
![Page 159: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/159.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MENDOCINO (23)
48.15 3.21
48.15 3.21
48.15 3.21
48.15 3.21
102.00 6.80
102.00 6.80
102.00 6.80
102.00 6.80
![Page 160: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/160.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MENDOCINO (23)
102.00 6.80
102.00 6.80
102.00 6.80
102.00 6.80
102.00 6.80
102.00 6.80
102.00 6.80
102.00 6.80
![Page 161: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/161.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MENDOCINO (23)
49.50 3.30
49.50 3.30
49.50 3.30
49.50 3.30
![Page 162: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/162.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
2,230.74368.35368.35179.66179.6660.4160.41
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
MERCED (24)
![Page 163: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/163.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MERCED (24)
158.73
54.60 3.64
54.60 3.64
54.60 3.64
54.60 3.64
54.60 3.64
54.60 3.64
54.60 3.64
![Page 164: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/164.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MERCED (24)
54.60 3.64
62.85 4.19
62.85 4.19
62.85 4.19
62.85 4.19
62.85 4.19
62.85 4.19
62.85 4.19
![Page 165: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/165.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MERCED (24)
62.85 4.19
62.85 4.19
62.85 4.19
62.85 4.19
62.85 4.19
62.85 4.19
62.85 4.19
62.85 4.19
![Page 166: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/166.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MERCED (24)
62.85 4.19
62.85 4.19
62.85 4.19
62.85 4.19
82.65 5.51
82.65 5.51
82.65 5.51
82.65 5.51
![Page 167: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/167.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MERCED (24)
82.65 5.51
82.65 5.51
82.65 5.51
82.65 5.51
82.65 5.51
82.65 5.51
82.65 5.51
82.65 5.51
![Page 168: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/168.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
MERCED (24)
101.55 6.77
101.55 6.77
101.55 6.77
101.55 6.77
![Page 169: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/169.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
MODOC (25)
![Page 170: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/170.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MODOC (25)
158.73
37.35 2.49
37.35 2.49
37.35 2.49
37.35 2.49
37.35 2.49
37.35 2.49
37.35 2.49
![Page 171: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/171.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MODOC (25)
37.35 2.49
43.35 2.89
43.35 2.89
43.35 2.89
43.35 2.89
43.35 2.89
43.35 2.89
43.35 2.89
![Page 172: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/172.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MODOC (25)
43.35 2.89
43.35 2.89
43.35 2.89
43.35 2.89
43.35 2.89
43.35 2.89
43.35 2.89
43.35 2.89
![Page 173: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/173.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MODOC (25)
43.35 2.89
43.35 2.89
43.35 2.89
43.35 2.89
68.40 4.56
68.40 4.56
68.40 4.56
68.40 4.56
![Page 174: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/174.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MODOC (25)
68.40 4.56
68.40 4.56
68.40 4.56
68.40 4.56
68.40 4.56
68.40 4.56
68.40 4.56
68.40 4.56
![Page 175: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/175.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
MODOC (25)
54.15 3.61
54.15 3.61
54.15 3.61
54.15 3.61
![Page 176: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/176.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per MinutePer Unit
Max Allowed Rate
MONO (26)
![Page 177: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/177.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per MinutePer Unit
Max Allowed Rate
MONO (26)
158.73
137.70 9.18
137.70 9.18
137.70 9.18
137.70 9.18
137.70 9.18
137.70 9.18
137.70 9.18
![Page 178: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/178.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per MinutePer Unit
Max Allowed Rate
MONO (26)
137.70 9.18
83.70 5.58
83.70 5.58
83.70 5.58
83.70 5.58
83.70 5.58
83.70 5.58
83.70 5.58
![Page 179: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/179.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per MinutePer Unit
Max Allowed Rate
MONO (26)
83.70 5.58
83.70 5.58
83.70 5.58
83.70 5.58
83.70 5.58
83.70 5.58
83.70 5.58
83.70 5.58
![Page 180: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/180.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per MinutePer Unit
Max Allowed Rate
MONO (26)
83.70 5.58
83.70 5.58
83.70 5.58
83.70 5.58
107.25 7.15
107.25 7.15
107.25 7.15
107.25 7.15
![Page 181: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/181.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per MinutePer Unit
Max Allowed Rate
MONO (26)
107.25 7.15
107.25 7.15
107.25 7.15
107.25 7.15
107.25 7.15
107.25 7.15
107.25 7.15
107.25 7.15
![Page 182: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/182.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per MinutePer Unit
Max Allowed Rate
MONO (26)
149.70 9.98
149.70 9.98
149.70 9.98
149.70 9.98
![Page 183: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/183.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Unit
Max Allowed Rate
Per Minute
MONTEREY (27)
![Page 184: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/184.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Unit
Max Allowed Rate
Per Minute
MONTEREY (27)
158.73
43.50 2.90
43.50 2.90
43.50 2.90
43.50 2.90
43.50 2.90
43.50 2.90
43.50 2.90
![Page 185: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/185.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Unit
Max Allowed Rate
Per Minute
MONTEREY (27)
43.50 2.90
56.25 3.75
56.25 3.75
56.25 3.75
56.25 3.75
56.25 3.75
56.25 3.75
56.25 3.75
![Page 186: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/186.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Unit
Max Allowed Rate
Per Minute
MONTEREY (27)
56.25 3.75
56.25 3.75
56.25 3.75
56.25 3.75
56.25 3.75
56.25 3.75
56.25 3.75
56.25 3.75
![Page 187: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/187.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Unit
Max Allowed Rate
Per Minute
MONTEREY (27)
56.25 3.75
56.25 3.75
56.25 3.75
56.25 3.75
103.80 6.92
103.80 6.92
103.80 6.92
103.80 6.92
![Page 188: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/188.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Unit
Max Allowed Rate
Per Minute
MONTEREY (27)
103.80 6.92
103.80 6.92
103.80 6.92
103.80 6.92
103.80 6.92
103.80 6.92
103.80 6.92
103.80 6.92
![Page 189: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/189.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Unit
Max Allowed Rate
Per Minute
MONTEREY (27)
83.55 5.57
83.55 5.57
83.55 5.57
83.55 5.57
![Page 190: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/190.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
NAPA (28)
![Page 191: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/191.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
NAPA (28)
158.73
85.35 5.69
85.35 5.69
85.35 5.69
85.35 5.69
85.35 5.69
85.35 5.69
85.35 5.69
![Page 192: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/192.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
NAPA (28)
85.35 5.69
76.80 5.12
76.80 5.12
76.80 5.12
76.80 5.12
76.80 5.12
76.80 5.12
76.80 5.12
![Page 193: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/193.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
NAPA (28)
76.80 5.12
76.80 5.12
76.80 5.12
76.80 5.12
76.80 5.12
76.80 5.12
76.80 5.12
76.80 5.12
![Page 194: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/194.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
NAPA (28)
76.80 5.12
76.80 5.12
76.80 5.12
76.80 5.12
100.65 6.71
100.65 6.71
100.65 6.71
100.65 6.71
![Page 195: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/195.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
NAPA (28)
100.65 6.71
100.65 6.71
100.65 6.71
100.65 6.71
100.65 6.71
100.65 6.71
100.65 6.71
100.65 6.71
![Page 196: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/196.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
NAPA (28)
160.95 10.73
160.95 10.73
160.95 10.73
#REF! 10.73
![Page 197: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/197.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35242.49242.49114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
NEVADA (29)
![Page 198: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/198.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
NEVADA (29)
158.73
43.65 2.91
43.65 2.91
43.65 2.91
43.65 2.91
43.65 2.91
43.65 2.91
43.65 2.91
![Page 199: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/199.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
NEVADA (29)
43.65 2.91
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
![Page 200: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/200.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
NEVADA (29)
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
![Page 201: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/201.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
NEVADA (29)
56.40 3.76
56.40 3.76
56.40 3.76
56.40 3.76
104.10 6.94
104.10 6.94
104.10 6.94
104.10 6.94
![Page 202: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/202.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
NEVADA (29)
104.10 6.94
104.10 6.94
104.10 6.94
104.10 6.94
104.10 6.94
104.10 6.94
104.10 6.94
104.10 6.94
![Page 203: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/203.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
NEVADA (29)
83.70 5.58
83.70 5.58
83.70 5.58
83.70 5.58
![Page 204: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/204.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66108.08108.08
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
ORANGE (30)
![Page 205: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/205.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
ORANGE (30)
158.73
53.70 3.58
53.70 3.58
53.70 3.58
53.70 3.58
53.70 3.58
53.70 3.58
53.70 3.58
![Page 206: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/206.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
ORANGE (30)
53.70 3.58
60.90 4.06
60.90 4.06
60.90 4.06
60.90 4.06
60.90 4.06
60.90 4.06
60.90 4.06
![Page 207: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/207.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
ORANGE (30)
60.90 4.06
60.90 4.06
60.90 4.06
60.90 4.06
60.90 4.06
60.90 4.06
60.90 4.06
60.90 4.06
![Page 208: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/208.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
ORANGE (30)
60.90 4.06
60.90 4.06
60.90 4.06
60.90 4.06
126.60 8.44
126.60 8.44
126.60 8.44
126.60 8.44
![Page 209: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/209.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
ORANGE (30)
126.60 8.44
126.60 8.44
126.60 8.44
126.60 8.44
126.60 8.44
126.60 8.44
126.60 8.44
126.60 8.44
![Page 210: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/210.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
ORANGE (30)
103.95 6.93
103.95 6.93
103.95 6.93
103.95 6.93
![Page 211: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/211.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
379.89
101.69
Max Allowed Rate
Per Unit Per Minute
PLACER (31)
![Page 212: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/212.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
PLACER (31)
158.73
77.40 5.16
77.40 5.16
77.40 5.16
77.40 5.16
77.40 5.16
77.40 5.16
77.40 5.16
![Page 213: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/213.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
PLACER (31)
77.40 5.16
55.50 3.70
55.50 3.70
55.50 3.70
55.50 3.70
55.50 3.70
55.50 3.70
55.50 3.70
![Page 214: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/214.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
PLACER (31)
55.50 3.70
55.50 3.70
55.50 3.70
55.50 3.70
55.50 3.70
55.50 3.70
55.50 3.70
55.50 3.70
![Page 215: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/215.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
PLACER (31)
55.50 3.70
55.50 3.70
55.50 3.70
55.50 3.70
73.95 4.93
73.95 4.93
73.95 4.93
73.95 4.93
![Page 216: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/216.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
PLACER (31)
73.95 4.93
73.95 4.93
73.95 4.93
73.95 4.93
73.95 4.93
73.95 4.93
73.95 4.93
73.95 4.93
![Page 217: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/217.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
PLACER (31)
114.30 7.62
114.30 7.62
114.30 7.62
114.30 7.62
![Page 218: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/218.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
PLUMAS (32)
![Page 219: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/219.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
PLUMAS (32)
158.73
22.80 1.52
22.80 1.52
22.80 1.52
22.80 1.52
22.80 1.52
22.80 1.52
22.80 1.52
![Page 220: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/220.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
PLUMAS (32)
22.80 1.52
27.75 1.85
27.75 1.85
27.75 1.85
27.75 1.85
27.75 1.85
27.75 1.85
27.75 1.85
![Page 221: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/221.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
PLUMAS (32)
27.75 1.85
27.75 1.85
27.75 1.85
27.75 1.85
27.75 1.85
27.75 1.85
27.75 1.85
27.75 1.85
![Page 222: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/222.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
PLUMAS (32)
27.75 1.85
27.75 1.85
27.75 1.85
27.75 1.85
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
![Page 223: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/223.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
PLUMAS (32)
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
![Page 224: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/224.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
PLUMAS (32)
41.10 2.74
41.10 2.74
41.10 2.74
41.10 2.74
![Page 225: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/225.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,552.341,552.341,552.34415.95
415.95
415.95
653.20368.35368.35179.66179.6667.7567.75
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
RIVERSIDE (33)
![Page 226: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/226.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
RIVERSIDE (33)
158.73
31.50 2.10
31.50 2.10
31.50 2.10
31.50 2.10
31.50 2.10
31.50 2.10
31.50 2.10
![Page 227: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/227.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
RIVERSIDE (33)
31.50 2.10
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
![Page 228: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/228.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
RIVERSIDE (33)
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
![Page 229: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/229.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
RIVERSIDE (33)
34.95 2.33
34.95 2.33
34.95 2.33
34.95 2.33
75.75 5.05
75.75 5.05
75.75 5.05
75.75 5.05
![Page 230: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/230.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
RIVERSIDE (33)
75.75 5.05
75.75 5.05
75.75 5.05
75.75 5.05
75.75 5.05
75.75 5.05
75.75 5.05
75.75 5.05
![Page 231: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/231.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
RIVERSIDE (33)
50.55 3.37
50.55 3.37
50.55 3.37
50.55 3.37
![Page 232: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/232.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66100.83100.83
174.32
244.84
89.67
Max Allowed Rate
Per Unit Per Minute
SACRAMENTO (34)
![Page 233: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/233.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SACRAMENTO (34)
158.73
32.25 2.15
32.25 2.15
32.25 2.15
32.25 2.15
32.25 2.15
32.25 2.15
32.25 2.15
![Page 234: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/234.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SACRAMENTO (34)
32.25 2.15
41.70 2.78
41.70 2.78
41.70 2.78
41.70 2.78
41.70 2.78
41.70 2.78
41.70 2.78
![Page 235: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/235.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SACRAMENTO (34)
41.70 2.78
41.70 2.78
41.70 2.78
41.70 2.78
41.70 2.78
41.70 2.78
41.70 2.78
41.70 2.78
![Page 236: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/236.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SACRAMENTO (34)
41.70 2.78
41.70 2.78
41.70 2.78
41.70 2.78
77.10 5.14
77.10 5.14
77.10 5.14
77.10 5.14
![Page 237: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/237.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SACRAMENTO (34)
77.10 5.14
77.10 5.14
77.10 5.14
77.10 5.14
77.10 5.14
77.10 5.14
77.10 5.14
77.10 5.14
![Page 238: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/238.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SACRAMENTO (34)
62.10 4.14
62.10 4.14
62.10 4.14
62.10 4.14
![Page 239: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/239.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
SAN BENITO (35)
![Page 240: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/240.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN BENITO (35)
158.73
37.95 2.53
37.95 2.53
37.95 2.53
37.95 2.53
37.95 2.53
37.95 2.53
37.95 2.53
![Page 241: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/241.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN BENITO (35)
37.95 2.53
35.85 2.39
35.85 2.39
35.85 2.39
35.85 2.39
35.85 2.39
35.85 2.39
35.85 2.39
![Page 242: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/242.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN BENITO (35)
35.85 2.39
35.85 2.39
35.85 2.39
35.85 2.39
35.85 2.39
35.85 2.39
35.85 2.39
35.85 2.39
![Page 243: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/243.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN BENITO (35)
35.85 2.39
35.85 2.39
35.85 2.39
35.85 2.39
80.85 5.39
80.85 5.39
80.85 5.39
80.85 5.39
![Page 244: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/244.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN BENITO (35)
80.85 5.39
80.85 5.39
80.85 5.39
80.85 5.39
80.85 5.39
80.85 5.39
80.85 5.39
80.85 5.39
![Page 245: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/245.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN BENITO (35)
36.00 2.40
36.00 2.40
36.00 2.40
36.00 2.40
![Page 246: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/246.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,419.981,419.981,419.98415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
SAN BERNARDINO
(36)
![Page 247: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/247.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN BERNARDINO
(36)
391.53
43.05 2.87
43.05 2.87
43.05 2.87
43.05 2.87
43.05 2.87
43.05 2.87
43.05 2.87
![Page 248: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/248.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN BERNARDINO
(36)
43.05 2.87
43.80 2.92
43.80 2.92
43.80 2.92
43.80 2.92
43.80 2.92
43.80 2.92
43.80 2.92
![Page 249: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/249.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN BERNARDINO
(36)
43.80 2.92
43.80 2.92
43.80 2.92
43.80 2.92
43.80 2.92
43.80 2.92
43.80 2.92
43.80 2.92
![Page 250: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/250.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN BERNARDINO
(36)
43.80 2.92
43.80 2.92
43.80 2.92
43.80 2.92
100.50 6.70
100.50 6.70
100.50 6.70
100.50 6.70
![Page 251: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/251.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN BERNARDINO
(36)
100.50 6.70
100.50 6.70
100.50 6.70
100.50 6.70
100.50 6.70
100.50 6.70
100.50 6.70
100.50 6.70
![Page 252: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/252.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN BERNARDINO
(36)
104.10 6.94
104.10 6.94
104.10 6.94
104.10 6.94
![Page 253: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/253.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,351.421,351.421,351.42415.95
415.95
415.95
653.20368.35368.35179.66179.6656.2156.21
174.32
244.84
101.69
Max Allowed Rate
Per MinutePer Unit
SAN DIEGO (37)
![Page 254: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/254.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
SAN DIEGO (37)
78.03
44.40 2.96
44.40 2.96
44.40 2.96
44.40 2.96
44.40 2.96
44.40 2.96
44.40 2.96
![Page 255: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/255.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
SAN DIEGO (37)
44.40 2.96
57.45 3.83
57.45 3.83
57.45 3.83
57.45 3.83
57.45 3.83
57.45 3.83
57.45 3.83
![Page 256: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/256.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
SAN DIEGO (37)
57.45 3.83
57.45 3.83
57.45 3.83
57.45 3.83
57.45 3.83
57.45 3.83
57.45 3.83
57.45 3.83
![Page 257: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/257.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
SAN DIEGO (37)
57.45 3.83
57.45 3.83
57.45 3.83
#REF! 3.83
105.75 7.05
105.75 7.05
105.75 7.05
105.75 7.05
![Page 258: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/258.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
SAN DIEGO (37)
105.75 7.05
105.75 7.05
105.75 7.05
105.75 7.05
105.75 7.05
105.75 7.05
105.75 7.05
105.75 7.05
![Page 259: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/259.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per MinutePer Unit
SAN DIEGO (37)
85.20 5.68
85.20 5.68
85.20 5.68
85.20 5.68
![Page 260: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/260.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
SAN FRANCISCO (38)
![Page 261: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/261.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SAN FRANCISCO (38)
158.73
49.80 3.32
49.80 3.32
49.80 3.32
49.80 3.32
49.80 3.32
49.80 3.32
49.80 3.32
![Page 262: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/262.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SAN FRANCISCO (38)
49.80 3.32
66.15 4.41
66.15 4.41
66.15 4.41
66.15 4.41
66.15 4.41
66.15 4.41
66.15 4.41
![Page 263: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/263.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SAN FRANCISCO (38)
66.15 4.41
66.15 4.41
66.15 4.41
66.15 4.41
66.15 4.41
66.15 4.41
66.15 4.41
66.15 4.41
![Page 264: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/264.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SAN FRANCISCO (38)
66.15 4.41
66.15 4.41
66.15 4.41
66.15 4.41
130.80 8.72
130.80 8.72
130.80 8.72
130.80 8.72
![Page 265: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/265.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SAN FRANCISCO (38)
130.80 8.72
130.80 8.72
130.80 8.72
130.80 8.72
130.80 8.72
130.80 8.72
130.80 8.72
130.80 8.72
![Page 266: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/266.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SAN FRANCISCO (38)
94.80 6.32
94.80 6.32
94.80 6.32
94.80 6.32
![Page 267: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/267.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
1,120.49368.35368.35179.66179.66138.33138.33
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
SAN JOAQUIN (39)
![Page 268: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/268.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SAN JOAQUIN (39)
158.73
35.40 2.36
35.40 2.36
35.40 2.36
35.40 2.36
35.40 2.36
35.40 2.36
35.40 2.36
![Page 269: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/269.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SAN JOAQUIN (39)
35.40 2.36
50.25 3.35
50.25 3.35
50.25 3.35
50.25 3.35
50.25 3.35
50.25 3.35
50.25 3.35
![Page 270: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/270.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SAN JOAQUIN (39)
50.25 3.35
50.25 3.35
50.25 3.35
50.25 3.35
50.25 3.35
50.25 3.35
50.25 3.35
50.25 3.35
![Page 271: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/271.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SAN JOAQUIN (39)
50.25 3.35
50.25 3.35
50.25 3.35
50.25 3.35
90.15 6.01
90.15 6.01
90.15 6.01
90.15 6.01
![Page 272: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/272.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SAN JOAQUIN (39)
90.15 6.01
90.15 6.01
90.15 6.01
90.15 6.01
90.15 6.01
90.15 6.01
90.15 6.01
90.15 6.01
![Page 273: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/273.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SAN JOAQUIN (39)
52.50 3.50
52.50 3.50
52.50 3.50
52.50 3.50
![Page 274: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/274.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
1,551.42368.35368.35179.66179.66114.35114.35
174.32
250.97
101.69
Per Minute
Max Allowed Rate
Per Unit
SAN LUIS OBISPO (40)
![Page 275: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/275.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN LUIS OBISPO (40)
158.73
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
![Page 276: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/276.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN LUIS OBISPO (40)
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
![Page 277: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/277.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN LUIS OBISPO (40)
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
![Page 278: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/278.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN LUIS OBISPO (40)
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
77.55 5.17
77.55 5.17
77.55 5.17
77.55 5.17
![Page 279: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/279.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN LUIS OBISPO (40)
77.55 5.17
77.55 5.17
77.55 5.17
77.55 5.17
77.55 5.17
77.55 5.17
77.55 5.17
77.55 5.17
![Page 280: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/280.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN LUIS OBISPO (40)
63.15 4.21
63.15 4.21
63.15 4.21
63.15 4.21
![Page 281: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/281.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
2,268.452,268.452,268.45415.95
415.95
415.95
653.20368.35368.35179.66179.6685.0485.04
386.05
542.21
225.21
Per Minute
Max Allowed Rate
Per Unit
SAN MATEO (41)
![Page 282: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/282.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN MATEO (41)
351.53
81.15 5.41
81.15 5.41
81.15 5.41
81.15 5.41
81.15 5.41
81.15 5.41
81.15 5.41
![Page 283: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/283.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN MATEO (41)
81.15 5.41
104.85 6.99
104.85 6.99
104.85 6.99
104.85 6.99
104.85 6.99
104.85 6.99
104.85 6.99
![Page 284: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/284.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN MATEO (41)
104.85 6.99
104.85 6.99
104.85 6.99
104.85 6.99
104.85 6.99
104.85 6.99
104.85 6.99
104.85 6.99
![Page 285: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/285.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN MATEO (41)
104.85 6.99
104.85 6.99
104.85 6.99
104.85 6.99
193.65 12.91
193.65 12.91
193.65 12.91
193.65 12.91
![Page 286: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/286.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN MATEO (41)
193.65 12.91
193.65 12.91
193.65 12.91
193.65 12.91
193.65 12.91
193.65 12.91
193.65 12.91
193.65 12.91
![Page 287: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/287.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SAN MATEO (41)
155.85 10.39
155.85 10.39
155.85 10.39
155.85 10.39
![Page 288: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/288.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,655.011,655.011,655.01415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
SANTA BARBARA (42)
![Page 289: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/289.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA BARBARA (42)
158.73
34.65 2.31
34.65 2.31
34.65 2.31
34.65 2.31
34.65 2.31
34.65 2.31
34.65 2.31
![Page 290: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/290.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA BARBARA (42)
34.65 2.31
44.55 2.97
44.55 2.97
44.55 2.97
44.55 2.97
44.55 2.97
44.55 2.97
44.55 2.97
![Page 291: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/291.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA BARBARA (42)
44.55 2.97
44.55 2.97
44.55 2.97
44.55 2.97
44.55 2.97
44.55 2.97
44.55 2.97
44.55 2.97
![Page 292: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/292.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA BARBARA (42)
44.55 2.97
44.55 2.97
44.55 2.97
44.55 2.97
82.35 5.49
82.35 5.49
82.35 5.49
82.35 5.49
![Page 293: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/293.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA BARBARA (42)
82.35 5.49
82.35 5.49
82.35 5.49
82.35 5.49
82.35 5.49
82.35 5.49
82.35 5.49
82.35 5.49
![Page 294: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/294.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA BARBARA (42)
66.30 4.42
66.30 4.42
66.30 4.42
66.30 4.42
![Page 295: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/295.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
2,183.102,183.102,183.10415.95
415.95
415.95
653.20368.35368.35179.66179.66126.29126.29
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
SANTA CLARA (43)
![Page 296: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/296.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA CLARA (43)
158.73
85.65 5.71
85.65 5.71
85.65 5.71
85.65 5.71
85.65 5.71
85.65 5.71
85.65 5.71
![Page 297: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/297.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA CLARA (43)
85.65 5.71
110.70 7.38
110.70 7.38
110.70 7.38
110.70 7.38
110.70 7.38
110.70 7.38
110.70 7.38
![Page 298: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/298.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA CLARA (43)
110.70 7.38
110.70 7.38
110.70 7.38
110.70 7.38
110.70 7.38
110.70 7.38
110.70 7.38
110.70 7.38
![Page 299: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/299.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA CLARA (43)
110.70 7.38
110.70 7.38
110.70 7.38
110.70 7.38
204.45 13.63
204.45 13.63
204.45 13.63
204.45 13.63
![Page 300: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/300.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA CLARA (43)
204.45 13.63
204.45 13.63
204.45 13.63
204.45 13.63
204.45 13.63
204.45 13.63
204.45 13.63
204.45 13.63
![Page 301: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/301.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA CLARA (43)
164.55 10.97
164.55 10.97
164.55 10.97
164.55 10.97
![Page 302: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/302.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
SANTA CRUZ (44)
![Page 303: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/303.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA CRUZ (44)
158.73
39.45 2.63
39.45 2.63
39.45 2.63
39.45 2.63
39.45 2.63
39.45 2.63
39.45 2.63
![Page 304: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/304.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA CRUZ (44)
39.45 2.63
50.85 3.39
50.85 3.39
50.85 3.39
50.85 3.39
50.85 3.39
50.85 3.39
50.85 3.39
![Page 305: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/305.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA CRUZ (44)
50.85 3.39
50.85 3.39
50.85 3.39
50.85 3.39
50.85 3.39
50.85 3.39
50.85 3.39
50.85 3.39
![Page 306: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/306.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA CRUZ (44)
50.85 3.39
50.85 3.39
50.85 3.39
50.85 3.39
94.05 6.27
94.05 6.27
94.05 6.27
94.05 6.27
![Page 307: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/307.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA CRUZ (44)
94.05 6.27
94.05 6.27
94.05 6.27
94.05 6.27
94.05 6.27
94.05 6.27
94.05 6.27
94.05 6.27
![Page 308: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/308.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SANTA CRUZ (44)
75.60 5.04
75.60 5.04
75.60 5.04
75.60 5.04
![Page 309: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/309.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20342.22342.22179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
SHASTA (45)
![Page 310: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/310.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SHASTA (45)
158.73
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
![Page 311: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/311.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SHASTA (45)
39.60 2.64
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
![Page 312: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/312.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SHASTA (45)
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
![Page 313: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/313.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SHASTA (45)
51.15 3.41
51.15 3.41
51.15 3.41
51.15 3.41
56.55 3.77
56.55 3.77
56.55 3.77
56.55 3.77
![Page 314: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/314.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SHASTA (45)
56.55 3.77
56.55 3.77
56.55 3.77
56.55 3.77
56.55 3.77
56.55 3.77
56.55 3.77
56.55 3.77
![Page 315: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/315.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SHASTA (45)
76.05 5.07
76.05 5.07
76.05 5.07
76.05 5.07
![Page 316: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/316.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
SIERRA (46)
![Page 317: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/317.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SIERRA (46)
158.73
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
36.60 2.44
![Page 318: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/318.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SIERRA (46)
36.60 2.44
47.40 3.16
47.40 3.16
47.40 3.16
47.40 3.16
47.40 3.16
47.40 3.16
47.40 3.16
![Page 319: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/319.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SIERRA (46)
47.40 3.16
47.40 3.16
47.40 3.16
47.40 3.16
47.40 3.16
47.40 3.16
47.40 3.16
47.40 3.16
![Page 320: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/320.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SIERRA (46)
47.40 3.16
47.40 3.16
47.40 3.16
47.40 3.16
87.45 5.83
87.45 5.83
87.45 5.83
87.45 5.83
![Page 321: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/321.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SIERRA (46)
87.45 5.83
87.45 5.83
87.45 5.83
87.45 5.83
87.45 5.83
87.45 5.83
87.45 5.83
87.45 5.83
![Page 322: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/322.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SIERRA (46)
70.35 4.69
70.35 4.69
70.35 4.69
70.35 4.69
![Page 323: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/323.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
SISKIYOU (47)
![Page 324: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/324.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SISKIYOU (47)
158.73
44.70 2.98
44.70 2.98
44.70 2.98
44.70 2.98
44.70 2.98
44.70 2.98
44.70 2.98
![Page 325: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/325.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SISKIYOU (47)
44.70 2.98
56.85 3.79
56.85 3.79
56.85 3.79
56.85 3.79
56.85 3.79
56.85 3.79
56.85 3.79
![Page 326: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/326.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SISKIYOU (47)
56.85 3.79
56.85 3.79
56.85 3.79
56.85 3.79
56.85 3.79
56.85 3.79
56.85 3.79
56.85 3.79
![Page 327: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/327.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SISKIYOU (47)
56.85 3.79
56.85 3.79
56.85 3.79
56.85 3.79
86.85 5.79
86.85 5.79
86.85 5.79
86.85 5.79
![Page 328: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/328.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SISKIYOU (47)
86.85 5.79
86.85 5.79
86.85 5.79
86.85 5.79
86.85 5.79
86.85 5.79
86.85 5.79
86.85 5.79
![Page 329: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/329.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SISKIYOU (47)
90.15 6.01
90.15 6.01
90.15 6.01
90.15 6.01
![Page 330: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/330.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
SOLANO (48)
![Page 331: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/331.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SOLANO (48)
158.73
73.35 4.89
73.35 4.89
73.35 4.89
73.35 4.89
73.35 4.89
73.35 4.89
73.35 4.89
![Page 332: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/332.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SOLANO (48)
73.35 4.89
94.95 6.33
94.95 6.33
94.95 6.33
94.95 6.33
94.95 6.33
94.95 6.33
94.95 6.33
![Page 333: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/333.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SOLANO (48)
94.95 6.33
94.95 6.33
94.95 6.33
94.95 6.33
94.95 6.33
94.95 6.33
94.95 6.33
94.95 6.33
![Page 334: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/334.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SOLANO (48)
94.95 6.33
94.95 6.33
94.95 6.33
94.95 6.33
175.05 11.67
175.05 11.67
175.05 11.67
175.05 11.67
![Page 335: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/335.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SOLANO (48)
175.05 11.67
175.05 11.67
175.05 11.67
175.05 11.67
175.05 11.67
175.05 11.67
175.05 11.67
175.05 11.67
![Page 336: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/336.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SOLANO (48)
141.00 9.40
141.00 9.40
141.00 9.40
141.00 9.40
![Page 337: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/337.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.6671.1171.11
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
SONOMA (49)
![Page 338: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/338.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SONOMA (49)
158.73
36.15 2.41
36.15 2.41
36.15 2.41
36.15 2.41
36.15 2.41
36.15 2.41
36.15 2.41
![Page 339: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/339.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SONOMA (49)
36.15 2.41
48.45 3.23
48.45 3.23
48.45 3.23
48.45 3.23
48.45 3.23
48.45 3.23
48.45 3.23
![Page 340: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/340.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SONOMA (49)
48.45 3.23
48.45 3.23
48.45 3.23
48.45 3.23
48.45 3.23
48.45 3.23
48.45 3.23
48.45 3.23
![Page 341: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/341.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SONOMA (49)
48.45 3.23
48.45 3.23
48.45 3.23
48.45 3.23
86.10 5.74
86.10 5.74
86.10 5.74
86.10 5.74
![Page 342: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/342.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SONOMA (49)
86.10 5.74
86.10 5.74
86.10 5.74
86.10 5.74
86.10 5.74
86.10 5.74
86.10 5.74
86.10 5.74
![Page 343: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/343.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
SONOMA (49)
70.80 4.72
70.80 4.72
70.80 4.72
70.80 4.72
![Page 344: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/344.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
778.09368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
STANISLAUS (50)
![Page 345: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/345.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
STANISLAUS (50)
158.73
42.60 2.84
42.60 2.84
42.60 2.84
42.60 2.84
42.60 2.84
42.60 2.84
42.60 2.84
![Page 346: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/346.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
STANISLAUS (50)
42.60 2.84
54.75 3.65
54.75 3.65
54.75 3.65
54.75 3.65
54.75 3.65
54.75 3.65
54.75 3.65
![Page 347: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/347.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
STANISLAUS (50)
54.75 3.65
54.75 3.65
54.75 3.65
54.75 3.65
54.75 3.65
54.75 3.65
54.75 3.65
54.75 3.65
![Page 348: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/348.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
STANISLAUS (50)
54.75 3.65
54.75 3.65
54.75 3.65
54.75 3.65
101.85 6.79
101.85 6.79
101.85 6.79
101.85 6.79
![Page 349: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/349.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
STANISLAUS (50)
101.85 6.79
101.85 6.79
101.85 6.79
101.85 6.79
101.85 6.79
101.85 6.79
101.85 6.79
101.85 6.79
![Page 350: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/350.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
STANISLAUS (50)
66.30 4.42
66.30 4.42
66.30 4.42
66.30 4.42
![Page 351: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/351.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
1,108.90368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
SUTTER/YUBA (58)
![Page 352: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/352.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SUTTER/YUBA (58)
158.73
53.10 3.54
53.10 3.54
53.10 3.54
53.10 3.54
53.10 3.54
53.10 3.54
53.10 3.54
![Page 353: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/353.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SUTTER/YUBA (58)
53.10 3.54
68.55 4.57
68.55 4.57
68.55 4.57
68.55 4.57
68.55 4.57
68.55 4.57
68.55 4.57
![Page 354: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/354.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SUTTER/YUBA (58)
68.55 4.57
68.55 4.57
68.55 4.57
68.55 4.57
68.55 4.57
68.55 4.57
68.55 4.57
68.55 4.57
![Page 355: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/355.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SUTTER/YUBA (58)
68.55 4.57
68.55 4.57
68.55 4.57
68.55 8.44
126.60 8.44
126.60 8.44
126.60 8.44
126.60 8.44
![Page 356: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/356.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SUTTER/YUBA (58)
126.60 8.44
126.60 8.44
126.60 8.44
126.60 8.44
126.60 8.44
126.60 8.44
126.60 8.44
126.60 8.44
![Page 357: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/357.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
SUTTER/YUBA (58)
101.85 6.79
101.85 6.79
101.85 6.79
101.85 6.79
![Page 358: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/358.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.6695.8395.83
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
TEHAMA (52)
![Page 359: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/359.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TEHAMA (52)
158.73
30.60 2.04
30.60 2.04
30.60 2.04
30.60 2.04
30.60 2.04
30.60 2.04
30.60 2.04
![Page 360: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/360.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TEHAMA (52)
30.60 2.04
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
![Page 361: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/361.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TEHAMA (52)
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
![Page 362: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/362.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TEHAMA (52)
39.60 2.64
39.60 2.64
39.60 2.64
39.60 2.64
73.35 4.89
73.35 4.89
73.35 4.89
73.35 4.89
![Page 363: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/363.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TEHAMA (52)
73.35 4.89
73.35 4.89
73.35 4.89
73.35 4.89
73.35 4.89
73.35 4.89
73.35 4.89
73.35 4.89
![Page 364: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/364.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TEHAMA (52)
58.95 3.93
58.95 3.93
58.95 3.93
58.95 3.93
![Page 365: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/365.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
TRINITY (53)
![Page 366: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/366.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TRINITY (53)
158.73
39.90 2.66
39.90 2.66
39.90 2.66
39.90 2.66
39.90 2.66
39.90 2.66
39.90 2.66
![Page 367: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/367.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TRINITY (53)
39.90 2.66
46.20 3.08
46.20 3.08
46.20 3.08
46.20 3.08
46.20 3.08
46.20 3.08
46.20 3.08
![Page 368: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/368.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TRINITY (53)
46.20 3.08
46.20 3.08
46.20 3.08
46.20 3.08
46.20 3.08
46.20 3.08
46.20 3.08
46.20 3.08
![Page 369: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/369.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TRINITY (53)
46.20 3.08
46.20 3.08
46.20 3.08
46.20 3.08
74.70 4.98
74.70 4.98
74.70 4.98
74.70 4.98
![Page 370: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/370.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TRINITY (53)
74.70 4.98
74.70 4.98
74.70 4.98
74.70 4.98
74.70 4.98
74.70 4.98
74.70 4.98
74.70 4.98
![Page 371: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/371.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TRINITY (53)
53.70 3.58
53.70 3.58
53.70 3.58
53.70 3.58
![Page 372: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/372.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35110.58110.58114.35114.35
174.32
244.84
101.69
Max Allowed Rate
Per Unit Per Minute
TULARE (54)
![Page 373: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/373.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TULARE (54)
158.73
21.45 1.43
21.45 1.43
21.45 1.43
21.45 1.43
21.45 1.43
21.45 1.43
21.45 1.43
![Page 374: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/374.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TULARE (54)
21.45 1.43
67.05 4.47
67.05 4.47
67.05 4.47
67.05 4.47
67.05 4.47
67.05 4.47
67.05 4.47
![Page 375: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/375.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TULARE (54)
67.05 4.47
67.05 4.47
67.05 4.47
67.05 4.47
67.05 4.47
67.05 4.47
67.05 4.47
67.05 4.47
![Page 376: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/376.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TULARE (54)
67.05 4.47
67.05 4.47
67.05 4.47
67.05 4.47
46.65 3.11
46.65 3.11
46.65 3.11
46.65 3.11
![Page 377: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/377.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TULARE (54)
46.65 3.11
46.65 3.11
46.65 3.11
46.65 3.11
46.65 3.11
46.65 3.11
46.65 3.11
46.65 3.11
![Page 378: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/378.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Max Allowed Rate
Per Unit Per Minute
TULARE (54)
34.65 2.31
34.65 2.31
34.65 2.31
34.65 2.31
![Page 379: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/379.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
TUOLUMNE (55)
![Page 380: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/380.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
TUOLUMNE (55)
158.73
43.05 2.87
43.05 2.87
43.05 2.87
43.05 2.87
43.05 2.87
43.05 2.87
43.05 2.87
![Page 381: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/381.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
TUOLUMNE (55)
43.05 2.87
55.65 3.71
55.65 3.71
55.65 3.71
55.65 3.71
55.65 3.71
55.65 3.71
55.65 3.71
![Page 382: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/382.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
TUOLUMNE (55)
55.65 3.71
55.65 3.71
55.65 3.71
55.65 3.71
55.65 3.71
55.65 3.71
55.65 3.71
55.65 3.71
![Page 383: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/383.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
TUOLUMNE (55)
55.65 3.71
55.65 3.71
55.65 3.71
55.65 3.71
102.90 6.86
102.90 6.86
102.90 6.86
102.90 6.86
![Page 384: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/384.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
TUOLUMNE (55)
102.90 6.86
102.90 6.86
102.90 6.86
102.90 6.86
102.90 6.86
102.90 6.86
102.90 6.86
102.90 6.86
![Page 385: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/385.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
TUOLUMNE (55)
82.80 5.52
82.80 5.52
82.80 5.52
82.80 5.52
![Page 386: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/386.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,891.941,891.941,891.94415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
VENTURA (56)
![Page 387: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/387.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
VENTURA (56)
158.73
35.40 2.36
35.40 2.36
35.40 2.36
35.40 2.36
35.40 2.36
35.40 2.36
35.40 2.36
![Page 388: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/388.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
VENTURA (56)
35.40 2.36
45.75 3.05
45.75 3.05
45.75 3.05
45.75 3.05
45.75 3.05
45.75 3.05
45.75 3.05
![Page 389: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/389.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
VENTURA (56)
45.75 3.05
45.75 3.05
45.75 3.05
45.75 3.05
45.75 3.05
45.75 3.05
45.75 3.05
45.75 3.05
![Page 390: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/390.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
VENTURA (56)
45.75 3.05
45.75 3.05
45.75 3.05
45.75 3.05
84.45 5.63
84.45 5.63
84.45 5.63
84.45 5.63
![Page 391: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/391.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
VENTURA (56)
84.45 5.63
84.45 5.63
84.45 5.63
84.45 5.63
84.45 5.63
84.45 5.63
84.45 5.63
84.45 5.63
![Page 392: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/392.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
VENTURA (56)
67.95 4.53
67.95 4.53
67.95 4.53
67.95 4.53
![Page 393: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/393.jpg)
General Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital under age 21 0100 H2015 HE HA 07, 08, 09 05 10 - 18 DayHospital Inpatient - Psychiatric Hospital over age 64 0100 H2015 HE HC 07, 08, 09 05 10 - 18 DayGeneral Hospital - Admin Day 0101 H0046 HE 07, 08, 09 05 19 DayHospital Inpatient - Administrative Day - Psychiatric Hospital Under age 21
0101 H0046 HE HA 07, 08, 09 05 19Day
Hospital Inpatient - Administrative Day - Psychiatric Hospital Over age 64
0101 H0046 HE HC 07, 08, 09 05 19Day
Psychiatric Health Facility H2013 HE 05 05 20 - 29 DayAdult Crisis Residential (Non-Geriatric) H0018 HE HB 05 05 40 - 49 DayAdult Crisis Residential (Geriatric) H0018 HE HC 05 05 40 - 49 DayAdult Residential (Non-Geriatric) H0019 HE HB 05 05 65 - 79 DayAdult Residential (Geriatric) H0019 HE HC 05 05 64 - 79 DayCrisis Stabilization - ER S9484 HE TG 12, 18 10 20 - 24 HourCrisis Stabilization - UC S9484 HE TG 12, 18 10 20 - 29 Hour
Day Treatment Intensive (Half Day) H2012 HE TG 12, 18 10 81 - 84Hour (use Flat Half Day rate for units =
3 and < 4)
Day Treatment Intensive (Full Day) H2012 HE TG 12, 18 10 85 - 89Hour (use Flat Half Day rate for units =
3 and < 4)
Day Rehabilitation (Half Day) H2012 HE 12, 18 10 91 - 94Hour (use Flat Half Day rate for units =
3 and < 4)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
1,313.261,313.261,313.26415.95
415.95
415.95
653.20368.35368.35179.66179.66114.35114.35
174.32
244.84
101.69
Per Minute
Max Allowed Rate
Per Unit
YOLO (57)
![Page 394: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/394.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Day Rehabilitation (Full Day) H2012 HE 12, 18 10 95 - 99Hour (use Flat Half Day rate for units =
3 and < 4)
Linkage(CM)/ Brokerage T1017 HE 12, 18 15 01-0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE GT 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE HQ 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Linkage(CM)/ Brokerage T1017 HE SC 12, 18 15 01- 0915 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK SC 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Care Coordination (ICC) T1017 HK HQ 12, 18 15 0715 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
YOLO (57)
158.73
41.85 2.79
41.85 2.79
41.85 2.79
41.85 2.79
41.85 2.79
41.85 2.79
41.85 2.79
![Page 395: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/395.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Intensive Care Coordination (ICC) T1017 HK GT 12, 18 15 0715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK SC 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK HQ 12, 18 15 5715 minutes (Bill in
one-minute increments)
Intensive Home-Based Services (IHBS) H2015 HK GT 12, 18 15 5715 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) H2015 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
YOLO (57)
41.85 2.79
54.15 3.61
54.15 3.61
54.15 3.61
54.15 3.61
54.15 3.61
54.15 3.61
54.15 3.61
![Page 396: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/396.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) H2015 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS)/Rehabilitation H2017 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE GT 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Mental Health Services (MHS) / Plan Development H0032 HE HQ 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
YOLO (57)
54.15 3.61
54.15 3.61
54.15 3.61
54.15 3.61
54.15 3.61
54.15 3.61
54.15 3.61
54.15 3.61
![Page 397: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/397.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Mental Health Services (MHS) / Plan Development H0032 HE SC 12, 18 15 30 - 56, 5915 minutes (Bill in
one-minute increments)
TBS H2019 HE 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE HQ 12, 18 15 5815 minutes (Bill in
one-minute increments)
TBS H2019 HE SC 12, 18 15 5815 minutes (Bill in
one-minute increments)
Medication Support H2010 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support H2010 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
YOLO (57)
54.15 3.61
54.15 3.61
54.15 3.61
54.15 3.61
99.75 6.65
99.75 6.65
99.75 6.65
99.75 6.65
![Page 398: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/398.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Medication Support / Care Plan Develop and Document G8437 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document G8437 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE GT 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE HQ 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Medication Support / Care Plan Develop and Document H0034 HE SC 12, 18 15 60 - 6915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
YOLO (57)
99.75 6.65
99.75 6.65
99.75 6.65
99.75 6.65
99.75 6.65
99.75 6.65
99.75 6.65
99.75 6.65
![Page 399: County Interim Rate (CIR) Table - California Department … Hospital Inpatient 0100 H2015 HE 07, 08, 09 05 10 - 18 Day 2,136.14 Hospital Inpatient - Psychiatric Hospital under age](https://reader034.vdocument.in/reader034/viewer/2022051509/5b0274f27f8b9ad85d8f944d/html5/thumbnails/399.jpg)
Mode of Service
CR/DC Code
SDMC Claiming
Code
CIR FY 2014-15County Interim Rate (CIR) Table for Short-Doyle Medi-Cal Reimbursement
July 1, 2014 through June 30, 2015
Service Function
Code
Unit Basis Measurement
CodeService Description
Revenue Code
Procedure Code
Procedure Modifier 1
Procedure Modifier 2
Crisis Intervention H2011 HE 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE GT 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE HQ 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Crisis Intervention H2011 HE SC 12, 18 15 70 - 7915 minutes (Bill in
one-minute increments)
Per Minute
Max Allowed Rate
Per Unit
YOLO (57)
80.25 5.35
80.25 5.35
80.25 5.35
80.25 5.35