ࡱ> ehdg bjbjhh 8:|\|\} @  84d'vvvvv'''''''$v),,5'5'vvHJ'Rvv''Vo$@3%v0} X: FEE RATE ACKNOWLEDGEMENT FORM Discounted Fee Schedule for Mental Health, Substance Abuse, and Wellness Services: SERVICE DESCRIPTIONCPT CODEMD / NP / APRNPSYCHOLOGISTOther Licensed Professionals (LCSW, LPC, etc.)LPN/RNDiagnostic Assessment w/o medical services provided by a covered or participating counselor (required annually)90791$129.00$100.00Diagnostic Assessment with medical services provided by a covered or participating M.D.90792$193.00Service Plan Development provided by a covered or participating counselorH0032$32.25$25.00Evaluation & Management Provided by a covered or participating M.D. 99212$43.00Evaluation & Management Provided by a covered or participating M.D. 99213$65.00Evaluation & Management Provided by a covered or participating M.D.- Presenting Problem Mod to High severity 99214$107.00Evaluation & Management Provided by a covered or participating M.D.- Presenting Problem Mod to High severity 99215$171.00Individual Counseling 30 min - provided by a covered or participating counselor90832$72.00$56.00Individual Counseling 45 min - provided by a covered or participating counselor90834$129.00$100.00Individual Counseling - 60 min - provided by a covered or participating counselor90837$172.00$133.00Crisis Intervention first 60 minutes Crisis Intervention each additional 30 minutes90839/90840$172.00/$86.00$133.00/$67.00$133.00/$67.00Family Counseling without Client present provided by a participating counselor, per session90846$172.00$133.00Family Counseling with Client present provided by a participating counselor, per session90847$172.00$133.00Group Counseling/Skills provided by a covered or participating counselor, per session90853/H2014$ 40.00/$20.00$30.00/$20.00Psychological Testing provided by a participating Psychologist, per hour96101$172.00Nursing Assessment, per 1 hr session by LPN (required annually)T1001$92.00Other Nursing Services, per 15 minutes (Nursing Services, Injections, T1003, 96372, H2010$23.00(LMCS DSPP Fees approximate 60% of Full Standard Rates and 110% of Medicaid Rates). All amounts owed are due at time of service. LMCS Accepts Credit and Debit Cards as well as cash. Charges are based on scheduled services in the amounts listed above. If actual services differ from the scheduled services, a bill or credit will be due/applied at your next appointment. LMCS Appointment Kept Policy: After two consecutive missed appointments without 24 hour notification, the individuals chart is closed. After three consecutive missed appointments, with or without notice, the individual chart is closed. LMCS makes every effort to remind consumers of upcoming appointments. Missed appointments decrease the effectiveness of treatment and delays the care of other individuals due to an unused appointment slot. Individual agrees and understands the services available by LMCS and that certain services are required for proper treatment. Individual agrees to the pricing of services provided based on the fee schedule presented and the requirements to kept appointments.     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