Appendix C

Codes are provided by the service types to align with service tables in section one, and support the ability to
categorize providers in a more standardized way across North Carolina. The codes are base codes and do not include
all the modifiers used by the LME/MCOs in the local system. LME/MCOs will want to use your local modifiers in
addition to the codes provided in this appendix. Some of the SUD services use DHSR licesure type rather than billing
codes.
 support the ability to
es and do not include
cal modifiers in
pe rather than billing
 I) Outpatient Services

Medicaid-funded services
95% of eligible individual
Procedure/ services provider agencie
Gaps Category Service Name Service Code DMA DMH minutes in rural counties
Outpatient Interactive Evaluation with Complexi 90785 X X Medicaid-funded services
Outpatient Clinical Evaluation/Intake 90791 X X Calculate the percent of t
Outpatient Interactive Evaluation 90792 X X providers within 30/45 m
providers inside or outsid
Outpatient Individual Therapy (20-30 min.) 90832 X X miles/minutes of residen
Outpatient Individual Therapy (20-30 min.)--MD 90833 X X total Medicaid enrollees
Outpatient Individual Therapy (45-50 min.) 90834 X X The numerator is the num
Outpatient Individual Therapy (45-50 min.) 90836 X X period with a choice of tw
miles/ minutes of their re
Outpatient Individual Therapy (60 min.) 90837 X X
Outpatient Psychotherapy, 60 minutes with patie 90838 X X Non-Medicaid-funded se
Outpatient Psychotherapy for Crisis First 60 Min 90839 X X 95% of eligible individual
services provider agencie
Outpatient Psychotherapy for Crisis each additi 90840 X X minutes in rural counties
Outpatient Family Therapy without patient 90846 X X
Outpatient Family Therapy with patient 90847 X X Non-Medicaid-funded se
Calculate the percent of c
Outpatient Group Therapy (Multiple Family Grou 90849 X X
had a choice of two provi
Outpatient Group Therapy (non-multiple family 90853 X X residences. Consider pro
Outpatient Psychological Testing 96101 X X within 30/45 miles/minut
Outpatient Aphasia Assessment 96105 X total number of people w
service (consumers) durin
Outpatient Devel Tst Lmt 96110 X X The numerator is the num
Outpatient Devel Tst Ext 96111 X X with a choice of two outp
Outpatient Neurobehavioral Exam 96116 X X minutes of their residenc
Outpatient Neuropsychological testing battery 96118 X X
Outpatient Therapeutic, prophylactic, or diagnost 96372 X
Outpatient Physical Therapy Evaluation 97001 X X
Outpatient Physical Therapy Re-Evaluation 97002 X X
Outpatient Occupational Therapy Evaluation 97003 X X
Outpatient Occupational Therapy Re-Evaluation 97004 X
Outpatient E&M Problem New 99201 X X
Outpatient E&M-Expanded-New Patient 99202 X X
Outpatient E&M-Detailed-New Patient 99203 X X
Outpatient E&M-Moderate-New Patient 99204 X X
Outpatient E&M-High-New Patient 99205 X X
Outpatient E&M-Problem Focused-Established Pa 99211 X X
Outpatient E&M-Expanded-Established Patient 99212 X X
Outpatient E&M-Detailed-Established Patient 99213 X X
Outpatient E&M-Moderate-Established Patient 99214 X X
Outpatient E&M-High-Established Patient 99215 X X
Outpatient Office Consultation 15 99241 X X
Outpatient Office Consultation 30 99242 X X
Outpatient Office Consultation 40 99243 X X
Outpatient Office Consultation 60 99244 X X
Outpatient Office Consultation 80 99245 X X
Outpatient Home Visit Em New Pat-20 99341 X X
Outpatient Home Visit Em New Pat-30 99342 X X
Outpatient Home visit for the evaluation and m 99343 X X
Outpatient Home Visit Em New Pat-60 99344 X X
Outpatient Home Visit Em New Pat-75 99345 X X
Outpatient Home Visit Em Est Pat-15 99347 X X
Outpatient Home Visit Em Est Pat-25 99348 X X
Outpatient Home Visit Em Est Pat-40 99349 X X
Outpatient Home Visit Em Est Pat-60 99350 X X
Outpatient Prolong Md Svc Ofc/Outpt 99354 X
Outpatient Prolong Md Svc Ofc/Opt+30 99355 X
Outpatient Prolonged Physician Service with Dire 99356 X
Outpatient Prolonged Physician Service with Dire 99357 X
Outpatient Prolonged Physician Service with no d 99359 X
Outpatient Tobac Cessat Cnsl 3-10 Mn 99406 X X
Outpatient Tobac Cessat Cnsl >10 Min 99407 X X
Outpatient Alc/Sa Screen <30 99408 X
Outpatient Alc/Sa Screen >30 99409 X
Outpatient Alcohol and/or Drug Assessment H0001 X
Outpatient Behavioral Health Counseling H0004 X
Outpatient Behavioral Health Counseling - Grou H0004HQ X
Outpatient Behavioral Health Counseling - Famil H0004HR X
Outpatient Behavioral Health Counseling - Famil H0004HS X
Outpatient Alcohol and/or Drug Group Counseli H0005 X
Outpatient Mental Health Assessment H0031 X
Outpatient Telehealth Originating Site Facility Fe Q3014 X X
Outpatient Telehealth originating site facility fee Q3014 GT X X
Outpatient Diagnostic Assessment T1023 X X
Outpatient Alcohol and/or Drug Assessment-non- YP830 X
Outpatient Behavioral Health Counseling - non-l YP831 X
Outpatient Behavioral Health Counseling - Group YP832 X
Outpatient Behavioral Health Counseling - Family YP833 X
Outpatient Behavioral Health Counseling - Indivi YP834 X
Outpatient Alcohol and/or Drug Group Counselin YP835 X
Outpatient Mental Health Assessment-non-licen YP836 X
I) Outpatient Services

Medicaid-funded services standard

95% of eligible individuals must have a choice of two different outpatient
services provider agencies within 30 miles or 30 minutes (45 miles or 45
minutes in rural counties) of their residences.

Medicaid-funded services instructions

Calculate the percent of total Medicaid enrollees who had a choice of two
providers within 30/45 miles/ minutes of their residences. Consider
providers inside or outside the catchment area, but within 30/45
miles/minutes of residents’ homes. The denominator is the number of
total Medicaid enrollees for the reporting period of 1/1/2020-12/31/2020.
The numerator is the number of Medicaid enrollees during the reporting
period with a choice of two outpatient services providers within 30/45
miles/ minutes of their residences.

Non-Medicaid-funded services standard

95% of eligible individuals have a choice of two different outpatient
services provider agencies within 30 miles or 30 minutes (45 miles or 45
minutes in rural counties) of their residences.

Non-Medicaid-funded services instructions

Calculate the percent of consumers of non-Medicaid-funded services who
had a choice of two providers within 30/45 miles/ minutes of their
residences. Consider providers inside or outside the catchment area, but
within 30/45 miles/minutes of residents’ homes. The denominator is the
total number of people who received at least one non-Medicaid-funded
service (consumers) during the reporting period of 1/1/2020-12/31/2020.
The numerator is the number of consumers during the reporting period
with a choice of two outpatient services providers within 30/45 miles/
minutes of their residences.
 II) Location-Based Servic

Procedure/ Medicaid-funded services

Service Code/ 95% of eligible individual
Gaps Category Service Name Licensure DMA DMH agencies for each location
miles or 45 minutes in ru

Location- Medicaid-funded services

Based Services Psychosocial Rehabilitation H2017 X X Calculate the percent of a
of two providers of each
miles/ minutes of their re
Location- Child and Adolescent Day the catchment area, but w
Based Services Treatment H2012HA X X The denominator is the n
reporting period (1/1/202
each location-based serv
Location- SA Comprehensive Outpatient from the denominator wi
Based Services Treatment Program H2035 X X service within 30/45 mile
below for age-disability g
Location- Non-Medicaid-funded se
Based Services SA Intensive Outpatient Program H0015 X X 95% of eligible individual
each location-based serv
minutes in rural counties
Location- 10A NCAC
Based Services Opioid Treatment 27G.3600 X X Non-Medicaid-funded se
Calculate the percent of c
X X access to at least one pro
Location- SA Non-Medical Community 10A NCAC 27G
miles/ minutes of their re
Based Services Residential Treatment .4100
the catchment area, but w
The denominator is the to
Location- SA Medically Monitored Community 10A NCAC X X group(s) who received an
Based Services Residential Treatment 27G.3400 reporting period (1/1/202
consumers from the deno
each location-based serv
Location- 10A NCAC 27G X residences. See the char
Based Services Sa Halfway House .5600E
II) Location-Based Services

Medicaid-funded services standard

95% of eligible individuals must have a choice of two different provider
agencies for each location-based service within 30 miles or 30 minutes (45
miles or 45 minutes in rural counties) of their residences.

Medicaid-funded services instructions

Calculate the percent of adult, child or total enrollees who have a choice
of two providers of each Medicaid location-based service within 30/45
miles/ minutes of their residences. Consider providers inside or outside
the catchment area, but within 30/45 miles/minutes of residents’ homes.
The denominator is the number of adult, child or total enrollees for the
reporting period (1/1/2020-12/31/2020) who were age-appropriate for
each location-based service. The numerator is the number of enrollees
from the denominator with choice of two providers of each location-based
service within 30/45 miles/ minutes of their residences. See the chart
below for age-disability groups for each service.

Non-Medicaid-funded services standard

95% of eligible individuals have access to at least one provider agency for
each location-based service within 30 miles or 30 minutes (45 miles or 45
minutes in rural counties) of their residences.

Non-Medicaid-funded services instructions

Calculate the percent of consumers of non-Medicaid-funded services with
access to at least one provider of each location-based service within 30/45
miles/ minutes of their residences. Consider providers inside or outside
the catchment area, but within 30/45 miles/minutes of residents’ homes.
The denominator is the total number of people in the same age-disability
group(s) who received any non-Medicaid-funded service during the
reporting period (1/1/2020-12/31/2020). The numerator is the number of
consumers from the denominator with access to at least one provider for
each location-based service within 30/45 miles/ minutes of their
residences. See the chart below for age-disability groups for each service.
 Procedure/
Gaps Category Service Name Service Code DMA DMH

Community-
mobile Assertive Community Treatment
services Team H0040 X X
Community- H2015HT HO,
mobile HF, HN, U1
services Community Support Team and HM X X
Community-
mobile
services Intensive In-Home H2022 X X
Community-
mobile
services Mobile Crisis H2011 X X
Community-
mobile
services Multi-systemic Therapy H2033 X X
H2023 U4
H2023HQU4
H2025 U4
H2025HQU4
H2026
Community- (b)(3) MH Supported Employment U4
mobile Services; Maintenance Supported H2026
services Employment MH HQU4 X
H2023 U4
H2023HQU4
H2025 U4
H2025HQU4
H2026
Community- (b)(3) I/DD Supported Employment U4
mobile Services; Supported Employment to H2026
services Maintain Employment HQU4 X
Community-
mobile
services (b)(3) Waiver Community Guide T2041 U4 X
Community-
mobile (b)(3) Waiver Individual Support
services (Personal Care/Individual Supports) T1019 U4 X
Community-
mobile H0038 HQU4
services Peer Support H0038 U4 X
Community- H0045U4
mobile H4500HQU4
services (b)(3) Waiver Respite T1005 X
Community- I/DD Supported Employment
mobile Services (IP-SE; non-Medicaid-
services funded) YA390 X
Community- I/DD Supported Employment
mobile Services (IP-SE; non-Medicaid-
services funded) YP640 X
Community-
mobile Long-term Vocational Supports
services (non-Medicaid-funded) YA389 X
Community- MH/SA Supported Employment
mobile Services (IP-SE; non-Medicaid-
services funded) YP630 X
Community-
mobile I/DD Non-Medicaid-funded
services Personal Care Services YM050 X
Community-
mobile I/DD Non-Medicaid-funded
services Personal Care Services YP020 X
Community-
mobile
services Day Supports YM850 X
Community-
mobile
services Peer Support H0038 X
Community-
mobile
services Transition Management Service YM120 X
III) Community/Mobile Services

Medicaid-funded standard
100% of eligible individuals must have a choice of two provider
agencies within the LME/MCO catchment area for each
community/ mobile service.

Medicaid-funded services instructions

For the reporting period (1/1/2020-12/31/2020), the
denominator is the number of adult, child or total enrollees
who were age-appropriate for each specific service according to
the chart below for community/mobile services. The
numerator is the number of enrollees from the denominator
with choice of two providers within the LME/MCO catchment
area for each specific service. See the chart below for age-
disability groups for each service.

Non-Medicaid-funded services standard

95% of eligible individuals have access within the LME/MCO
catchment area to at least one provider agency for each
community/ mobile service.

Non-Medicaid-funded services instructions

The denominator is the total number of people in the same
age-disability group(s) who received any non-Medicaid-funded
service during the reporting period (1/1/2020-12/31/2020).
The numerator is the number of consumers from the
denominator with access to at least one provider within the
LME/MCO catchment area. See the chart below for age-
disability groups for each service.
 Gaps Procedure/ Service
Category Service Name Code DMA DMH
IV) Crisis Services
Crisis X
services Facility-Based Crisis - adults YP485 Medicaid-funded service
Crisis X X 95% of eligible individua
services Facility-Based Crisis - adults S9484 catchment area to at lea
Crisis X
services Facility-Based Respite YA213 Medicaid-funded service
Crisis For the reporting period
X X number of adult, child or
services Detoxification (non-hospital) H0010
each specific service acc
Crisis X X numerator is the numbe
services Facility-Based Crisis - children S9484HA to at least one provider w
Crisis specific service. See the
X X service.
services Ambulatory Detox H0014
Non-Medicaid-funded se
95% of eligible individua
catchment area to at lea

Non-Medicaid-funded se
Calculate the percent of
access within the LME/M
each crisis service. The d
same age-disability grou
service during the reporti
numerator is the numbe
within the LME/MCO cat
crisis service. See the ch
service.
IV) Crisis Services

Medicaid-funded services standard

95% of eligible individuals must have access within the LME/MCO
catchment area to at least one provider agency for each crisis service.

Medicaid-funded services instructions

For the reporting period (1/1/2020-12/31/2020), the denominator is the
number of adult, child or total enrollees who were age-appropriate for
each specific service according to the chart below for crisis services. The
numerator is the number of enrollees from the denominator with access
to at least one provider within the LME/MCO catchment area for each
specific service. See the chart below for age-disability groups for each
service.

Non-Medicaid-funded services standard

95% of eligible individuals must have access within the LME/MCO
catchment area to at least one provider agency for each crisis service.

Non-Medicaid-funded services instructions

Calculate the percent of consumers of non-Medicaid-funded services with
access within the LME/MCO catchment area to at least one provider of
each crisis service. The denominator is the total number of people in the
same age-disability group(s) who received any non-Medicaid-funded
service during the reporting period (1/1/2020-12/31/2020). The
numerator is the number of consumers from the denominator with access
within the LME/MCO catchment area to at least one provider for each
crisis service. See the chart below for age-disability groups for each
service.
 Procedure/
Gaps Category Service Name Service Code DMA DMH
V) Inpatient Services
Inpatient
services Inpatient Hospital - Adult 99221 X X Medicaid-funded services
Inpatient 100% of eligible individua
services Inpatient Hospital - Adult 99222 X X catchment area to at leas
Inpatient Medicaid-funded services
services Inpatient Hospital - Adult 99223 X X For the reporting period (
Inpatient number of adult, child or
services Inpatient Hospital - Adult YP820 X each specific service for i
of enrollees from the den
Inpatient Inpatient Hospital - within the LME/MCO catc
services Child/Adolescent use contracted hospital(s) chart below for age-disab

Non-Medicaid-funded se
100% of eligible individua
catchment area to at leas

Non-Medicaid-funded se
Calculate the percent of c
access within the LME/M
each inpatient service. T
the same age-disability gr
service during the reporti
numerator is the number
within the LME/MCO catc
inpatient service. See the
service.
V) Inpatient Services

Medicaid-funded services standard

100% of eligible individuals must have access within the LME/MCO
catchment area to at least one provider agency for each inpatient service.

Medicaid-funded services instructions

For the reporting period (1/1/2020-12/31/2020), the denominator is the
number of adult, child or total enrollees who were age-appropriate for
each specific service for inpatient services. The numerator is the number
of enrollees from the denominator with access to at least one provider
within the LME/MCO catchment area for each specific service. See the
chart below for age-disability groups for each service.

Non-Medicaid-funded services standard

100% of eligible individuals must have access within the LME/MCO
catchment area to at least one provider agency for each inpatient service.

Non-Medicaid-funded services instructions

Calculate the percent of consumers of non-Medicaid-funded services with
access within the LME/MCO catchment area to at least one provider of
each inpatient service. The denominator is the total number of people in
the same age-disability group(s) who received any non-Medicaid-funded
service during the reporting period (1/1/2020-12/31/2020). The
numerator is the number of consumers from the denominator with access
within the LME/MCO catchment area to at least one provider for each
inpatient service. See the chart below for age-disability groups for each
service.
 Procedure/ DMA DMH
Gaps Category Service Name Service Code
VI) Specialized Services
Specialized X X Medicaid-funded services
services MH Group Homes H0019 95% of eligible individual
Specialized agency for each specialize
X
services MH Group Homes YP710
Medicaid-funded services
Specialized X Fill out the chart below.
services MH Group Homes YP720 with the LME/MCO as of
Specialized provide the Medicaid-fun
X
services MH Group Homes YP740
Non-Medicaid-funded se
Specialized X 95% of eligible individual
services MH Group Homes YP750 agency for each specialize
Specialized X Non-Medicaid-funded se
services MH Group Homes YP760 Fill out the chart below.
Specialized contracts with the LME/M
X 4/1/2021, to provide the
services MH Group Homes YP770
Specialized X
services MH Group Homes YP780
Specialized Psychiatric Residential Treatment X
services Facility RC 911
Specialized Psychiatric Residential Treatment X
services Facility YA230

Specialized Residential Treatment Level 2: X X

services other than Therapeutic Foster Care H2020
Specialized Residential Treatment Level 2: X X
services Therapeutic Foster Care S5145
Specialized X
services Residential Treatment Level 3 H0019
Specialized X
services Residential Treatment Level 4 H0019 HK
Specialized X
services Child MH Out-of-home respite YA125
Specialized X
services I/DD Respite YP010
Specialized X
services I/DD Respite YP011
Specialized X
services I/DD Respite YP730
Specialized
services I/DD Respite YA125
Specialized X
services (b)(3) I/DD Out-of-home respite H0045
Specialized X
services (b)(3) I/DD Out-of-home respite S5150 HQH4
Specialized X
services (b)(3) I/DD Out-of-home respite S5150 U4
Specialized X
services (b)(3) I/DD Out-of-home respite T2034
Specialized X
services (b)(3) I/DD Facility-based respite S5151
Specialized X
services (b)(3) I/DD Residential supports H2016
Specialized X
services (b)(3) I/DD Residential supports T2020
Specialized X
services (b)(3) I/DD Residential supports T2014
Specialized X
services Intermediate Care Facility/IDD RC 100
Specialized X
services Intermediate Care Facility/IDD RC 183
VI) Specialized Services

Medicaid-funded services standard

95% of eligible individuals must have access to at least one provider
agency for each specialized service.

Medicaid-funded services instructions

Fill out the chart below. Count only provider sites with current contracts
with the LME/MCO as of the date of the 2021 gaps report, 4/1/2021, to
provide the Medicaid-funded services listed below.

Non-Medicaid-funded services standard

95% of eligible individuals must have access to at least one provider
agency for each specialized service.

Non-Medicaid-funded services instructions

Fill out the chart below. Count only parent agencies with current
contracts with the LME/MCO as of the date of the 2021 gaps report,
4/1/2021, to provide the non-Medicaid-funded services listed.
 Procedure/
Gaps Service DMA DMH
Category Service Name Code
VII) C-Waiver Services
Community Living and Supports, In
Home Intensive, In Home Skill S5125 X
A. C-Waiver services – choice of
C-Waiver Building, Personal Care services catchment area.
Standard: 95% of eligible individ
Community Living and Supports, In agencies within the LME/MCO c
Home Intensive, In Home Skill T1015 X
C-Waiver Building, Personal Care services Instructions: For the reporting p
Community Living and Supports, In denominator is the number of a
Home Intensive, In Home Skill T2013 X were age-appropriate for each s
C-Waiver Building, Personal Care services below. The numerator is the nu
with choice of two providers wi
Community Living and Supports, In each specific service.
Home Intensive, In Home Skill T2013 HQ X
C-Waiver Building, Personal Care services
Community Living and Supports, In
Home Intensive, In Home Skill T2013 TF X
C-Waiver Building, Personal Care services
Community Living and Supports, In T2013 TF
Home Intensive, In Home Skill X
HQ
C-Waiver Building, Personal Care services
C-Waiver Community Navigator T2041 X
Community Navigator Training for T2041 U1 X
C-Waiver Employer of Record
C-Waiver Community Networking H2015 X
C-Waiver Community Networking H2015 HQ X
Crisis Behavioral Consultation/ Crisis T2025 U3 X
C-Waiver Consultation
Crisis Intervention & Stabilization H2011 HI X
C-Waiver Supports
C-Waiver Residential Supports 1, 2, 3 and 4 H2016 X
C-Waiver Residential Supports 1, 2, 3 and 4 H2016 HI X
C-Waiver Respite Care - Community S5150 X
C-Waiver Respite Care - Community S5150 HQ X
C-Waiver Respite Care Nursing – LPN & RN T1005 TD X
C-Waiver Respite Care Nursing – LPN & RN T1005 TE X
C-Waiver Supported Employment H2025 X
C-Waiver Supported Employment H2025 HQ X
Supported Employment – Long H2025 TS X
C-Waiver Term Follow-up
Supported Employment – Long H2025 TS X
C-Waiver Term Follow-up HQ
C-Waiver Supported Living T2033 X
C-Waiver Supported Living T2033 HI X
C-Waiver Supported Living T2033 TF X
 T2021
T2021HQ X
C-Waiver Day Supports T2027
C-Waiver Consultative Services T2025 U3 X
C-Waiver Financial Supports T2025 X
C-Waiver BCBA T2025HQ X
C-Waiver Out of Home Crisis T2034 X
VII) C-Waiver Services

A. C-Waiver services – choice of at least two providers within the

catchment area.
Standard: 95% of eligible individuals must have a choice of two provider
agencies within the LME/MCO catchment area for each service.

Instructions: For the reporting period (1/1/2020-12/31/2020), the

denominator is the number of adult, child or total C-Waiver enrollees who
were age-appropriate for each specific service according to the chart
below. The numerator is the number of enrollees from the denominator
with choice of two providers within the LME/MCO catchment area for
each specific service.